Outcomes of dysplasia arising in Barrett's esophagus: a dynamic view

Minimally invasive esophagectomy for dysplastic Barrett's esophagus

A substantial portion of patients diagnosed preoperatively with high grade dysplasia (HGD) alone will have occult esophageal adenocarcinoma on analysis of the surgical specimen. Therefore, because of an increased risk of disease progression and malignancy, patients with HGD should be referred for esophagectomy promptly when endoscopic therapy has failed. The required extent of lymphadenectomy in this cohort of patients is unknown because of the variable incidence of submucosal cancer observed. Improvements in perioperative care, adoption of a minimally invasive surgical approach, and centralization of esophageal cancer services have substantially reduced the rates of mortality and morbidity associated with esophagectomy in recent years. Minimally invasive esophagectomy should be considered the treatment of choice in patients with dysplastic Barrett's esophagus that is refractory to endoscopic therapy or those at high risk of invasive cancer.

The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review

OBJECTIVES

Endoscopic eradication therapy is used to treat mucosal neoplasms in Barrett's esophagus, but cannot cure cancers that have metastasized to lymph nodes. The risk of such metastases has been proposed as a reason to consider esophagectomy rather than endoscopic therapy for esophageal mucosal neoplasia. The objective of our study was to determine the frequency of lymph-node metastases in patients with high-grade dysplasia (HGD) and intramucosal carcinoma in Barrett's esophagus.

METHODS

We performed a systematic review using the PRISMA guidelines to identify studies that included patients who had esophagectomy for HGD or intramucosal carcinoma in Barrett's esophagus, and that reported final pathology results after examination of esophagectomy specimens.

RESULTS

We identified 70 relevant reports that included 1,874 patients who had esophagectomy performed for HGD or intramucosal carcinoma in Barrett's esophagus. Lymph-node metastases were found in 26 patients (1.39 % , 95 % CI 0.86 – 1.92). No metastases were found in the 524 patients who had a final pathology diagnosis of HGD, whereas 26 (1.93 % , 95 % CI 1.19 – 2.66 %) of the 1,350 patients with a final pathology diagnosis of intramucosal carcinoma had positive lymph nodes.

CONCLUSIONS

The risk of unexpected lymph-node metastases for patients with mucosal neoplasms in Barrett's esophagus is in the range of 1 – 2 %. Esophagectomy has a mortality rate that often exceeds 2 %, with substantial morbidity and no guarantee of curing metastatic disease. Therefore, the risk of lymph node metastases alone does not warrant the choice of esophagectomy over endoscopic therapy for HGD and intramucosal carcinoma in Barrett's esophagus.

Endoscopic treatments for Barrett's esophagus: a systematic review of safety and effectiveness compared to esophagectomy

BACKGROUND

Recently, several new endoscopic treatments have been used to treat patients with Barrett's esophagus with high grade dysplasia. This systematic review aimed to determine the safety and effectiveness of these treatments compared with esophagectomy.

METHODS

A comprehensive literature search was undertaken to identify studies of endoscopic treatments for Barrett's esophagus or early stage esophageal cancer. Information from the selected studies was extracted by two independent reviewers. Study quality was assessed and information was tabulated to identify trends or patterns. Results were pooled across studies for each outcome. Safety (occurrence of adverse events) and effectiveness (complete eradication of dysplasia) were compared across different treatments.

RESULTS

The 101 studies that met the selection criteria included 8 endoscopic techniques and esophagectomy; only 12 were comparative studies. The quality of evidence was generally low. Methods and outcomes were inconsistently reported. Protocols, outcomes measured, follow-up times and numbers of treatment sessions varied, making it difficult to calculate pooled estimates.The surgical mortality rate was 1.2%, compared to 0.04% in 2831 patients treated endoscopically (1 death). Adverse events were more severe and frequent with esophagectomy, and included anastomotic leaks (9.4%), wound infections (4.1%) and pulmonary complications (4.1%). Four patients (0.1%) treated endoscopically experienced bleeding requiring transfusions. The stricture rate with esophagectomy (5.3%) was lower than with porfimer sodium photodynamic therapy (18.5%), but higher than aminolevulinic acid (ALA) 60 mg/kg PDT (1.4%). Dysphagia and odynophagia varied in frequency across modalities, with the highest rates reported for multipolar electrocoagulation (MPEC). Photosensitivity, an adverse event that occurs only with photodynamic therapy, was experienced by 26.4% of patients who received porfimer sodium.Some radiofrequency ablation (RFA) or argon plasma coagulation (APC) studies (used in multiple sessions) reported rates of almost 100% for complete eradication of dysplasia. But the study methods and findings were not adequately described. The other studies of endoscopic treatments reported similarly high rates of complete eradication.

CONCLUSIONS

Endoscopic treatments offer safe and effective alternatives to esophagectomy for patients with Barrett's esophagus and high grade dysplasia. Unfortunately, shortcomings in the published studies make it impossible to determine the comparative effectiveness of each of the endoscopic treatments.

Treatment for Barrett's oesophagus

BACKGROUND

Treatments for Barrett's oesophagus, the precursor lesion of adenocarcinoma, are available but whether these therapies effectively prevent the development of adenocarcinoma, and in some cases eradicate the Barrett's oesophagus segment, remains unclear.

OBJECTIVES

To summarise, quantify and compare the efficacy of pharmacological, surgical and endoscopic treatments for the eradication of dysplastic and non-dysplastic Barrett's oesophagus and prevention of these states from progression to adenocarcinoma.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2004, issue 4), MEDLINE (1966 to June 2008) and EMBASE (1980 to June 2008).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing medical, endoscopic or non-resectional surgical treatments for Barrett's oesophagus. The primary outcome measures were complete eradication of Barrett's and dysplasia at 12 months, and reduction in the number of patients progressing to cancer at five years or latest time point.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data and assessed the quality of the trials included in the analysis.

MAIN RESULTS

Sixteen studies, including 1074 patients, were included. The mean number of participants in the studies was small (n = 49; range 8 to 208). Most studies did not report on the primary outcomes. Medical and surgical interventions to reduce symptoms and sequelae of gastro-oesophageal reflux disease (GORD) did not induce significant eradication of Barrett's oesophagus or dysplasia. Endoscopic therapies (photodynamic therapy (PDT with aminolevulinic acid or porfimer sodium), argon plasma coagulation (APC) and radiofrequency ablation (RFA)) all induced regression of Barrett's oesophagus and dysplasia. The data for photodynamic therapy were heterogeneous with a mean eradication rate of 51% for Barrett's oesophagus and between 56% and 100% for dysplasia, depending on the treatment regimens. The variation in photodynamic therapy eradication rates for dysplasia was dependent on the drug, source and dose of light. Radiofrequency ablation resulted in eradication rates of 82% and 94% for Barrett's oesophagus and dysplasia respectively, compared to a sham treatment. Endoscopic treatments were generally well tolerated, however all were associated with some buried glands, particularly following argon plasma coagulation and photodynamic therapy, as well as photosensitivity and strictures induced by porfimer sodium based photodynamic therapy in particular.

AUTHORS' CONCLUSIONS

Despite their failure to eradicate Barrett's oesophagus, the role of medical and surgical interventions to reduce the troubling symptoms and sequelae of GORD is not questioned. Whether therapies for GORD reduce the cancer risk is not yet known. Ablative therapies have an increasing role in the management of dysplasia within Barrett's and current data would favour the use of radiofrequency ablation compared with photodynamic therapy. Radiofrequency ablation has been shown to yield significantly fewer complications than photodynamic therapy and is very efficacious at eradicating both dysplasia and Barrett's itself. However, long-term follow-up data are still needed before radiofrequency ablation can be used in routine clinical care without the need for very careful post-treatment surveillance. More clinical trial data and in particular randomised controlled trials are required to assess whether or not the cancer risk is reduced in routine clinical practice.

Preemptive surgery for premalignant foregut lesions

INTRODUCTION

Preemptive surgery is the prophylactic removal of an organ at high risk for malignant transformation or the resection of a precancerous or "early" malignant neoplasm in an individual with a hereditary predisposition to cancer. Recent advances in molecular diagnostic techniques have improved our understanding of the biologic behavior of these conditions. Predictive testing is an emerging field that attempts to assess the potential risk of cancer development in predisposed individuals. Despite substantial improvement in these forms of testing, all results are imperfect. This information often becomes an important tool that is used by healthcare providers to evaluate the risk-benefit ratio of various risk modifying strategies (i.e., intensive surveillance or preemptive surgery).

METHODS

A systematic literature review was performed using Medline and the bibliographies of all referenced publications to identify articles relating to preemptive surgery for premalignant foregut lesions.

RESULTS AND DISCUSSION

In this review, we outline the controversies surrounding predictive risk assessment, surveillance strategies, and preemptive surgery in the management of high-grade dysplasia (HGD) in Barrett's esophagus (BE), hereditary diffuse gastric cancer (HDGC), bile duct cysts, primary sclerosing cholangitis (PSC), and pancreatic cystic neoplasms. Resection of BE is supported by the progressive nature of the disease, the risk of occult carcinoma, and the lethality of esophageal cancer. Prophylactic total gastrectomy for HDGC appears reasonable in the absence of accurate screening tests but must be balanced by the impact of surgical complications and altered quality of life. Surgical resection of biliary cysts theoretically eliminates the exposed epithelium to decrease the lifetime risk of cholangiocarcinoma. Liver transplantation for PSC remains controversial given the scarcity of donor organs and inability to accurately identify high-risk individuals. Given the uncertain natural history of pancreatic cystic neoplasms, the merits of selective versus obligatory resection will continue to be debated.

CONCLUSIONS

Preemptive operations require optimal judgment and surgical precision to maximize function and enhance survival. Ultimately, balancing the risk of surgical intervention with less invasive interventions or observation must be individualized on a case-by-case basis.

The Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol

BACKGROUND & AIMS

The optimal management of high-grade dysplasia in Barrett's esophagus remains controversial. A biopsy protocol consisting of 4 quadrant jumbo biopsies (every 1 cm) with biopsies of mucosal abnormalities (the Seattle protocol) is considered to be the optimal method for detecting early cancers in patients with high-grade dysplasia, although it has never been validated. This study aimed to determine the frequency of unsuspected carcinoma at esophagectomy in Barrett's esophagus patients with high-grade dysplasia who underwent the Seattle protocol and to compare the findings with those of a less rigorous biopsy protocol.

METHODS

Thirty-three patients with high-grade dysplasia underwent esophagectomy. None had obvious mass lesions at preoperative endoscopy. Patients were divided into group 1 (preoperative surveillance biopsies according to Seattle protocol) and group 2 (4 quadrant biopsies every 2 cm). Preoperative and postoperative diagnoses were confirmed by 2 expert gastrointestinal pathologists.

RESULTS

Unsuspected intramucosal cancer was found in 8 of 20 (40%) patients in group 1 versus 4 of 13 (30%) in group 2 (P = .6). Preoperative mucosal nodularity was observed in 4 of 8 (50%) postoperative intramucosal cancers from group 1 versus 3 of 4 (75%) from group 2. Multifocal high-grade dysplasia was seen preoperatively in 7 of 8 (87.5%) postoperative intramucosal cancers in group 1 versus 2 of 4 (50%) in group 2. No patient had submucosal cancer or lymph node metastases at surgery.

CONCLUSIONS

Intense preoperative biopsy sampling by the Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol. This calls into question the concept that extensive sampling with the Seattle protocol consistently detects early cancers arising in Barrett's esophagus patients with high-grade dysplasia.

Is the risk of concomitant invasive esophageal cancer in high-grade dysplasia in Barrett's esophagus overestimated?

BACKGROUND & AIMS

Recent studies have claimed long neoplasia-free survival rates with endoscopic mucosal resection of high-grade dysplasia (HGD) in Barrett's esophagus (BE). However, reports have contended that approximately 40% of patients who have esophagectomy for HGD have occult invasive cancer. The aim of this study was to use explicit criteria to determine the true prevalence of invasive adenocarcinoma in reports of patients who had esophagectomy for HGD in BE.

METHODS

Studies reporting rates of esophageal cancer in patients who underwent esophagectomy for HGD in BE were gathered using MEDLINE and PUBMED. We defined invasive esophageal adenocarcinoma (IEAC) as tumor with submucosal invasion or beyond. Intramucosal carcinoma (IMC) was not considered IEAC.

RESULTS

Twenty-three articles were selected for analysis. Most investigators reported rates of invasive cancer in the esophagectomy specimen, and the pooled average was 39.9% among the 441 patients who underwent an esophagectomy for HGD. Reported rates varied from 0% to 73%. A total of 267 patients had American Joint Committee on Cancer stage 0 postoperatively, 132 patients had stage I, 23 patients had stage IIa, 10 patients had stage IIb, and 9 patients had stage III. Fourteen studies provided differentiation between intramucosal and submucosal invasion. Among 213 patients, only 12.7% had IEAC, whereas 87.3% had HGD or IMC. The IEAC rate of 11% among patients with visible lesions is greater than the rate of 3% among patients with no visible lesion.

CONCLUSIONS

By using strict pathologic definitions of invasive disease, the present study indicates the true prevalence of IEAC in BE and HGD may have been overestimated significantly. Separating IMC from IEAC is clinically relevant because endoscopic techniques potentially may treat IMC.

Esophagectomy for high grade dysplasia is safe, curative, and results in good alimentary outcome

BACKGROUND

The increasing adoption of endoscopic therapies and expectant surveillance for patients with high grade dysplasia (HGD) in Barrett's esophagus has created considerable controversy regarding the ideal treatment choice. Confusion may be due, in part, to a limited understanding of the outcomes associated with surgical resection for HGD and extrapolation of data derived from patients undergoing an esophagectomy for invasive cancer. The purpose of our study was to document the perioperative and symptomatic outcomes and long-term survival after esophagectomy for HGD of the esophagus.

MATERIAL AND METHODS

The study population consisted of 38 patients who underwent esophagectomy for biopsy-proven HGD between 10/1999 and 6/2005. Three patients were excluded from analysis due to obvious tumor on upper endoscopy. Patients were evaluated regarding ten different foregut symptoms and administered a ten-question appraisal of eating and bowel habits. Outcome measures included postoperative morbidity and mortality, the prevalence of invasive cancer in the esophagectomy specimens, symptomatic and functional alimentary results, patient satisfaction, and long-term survival. Median follow-up was 32 months (range, 7-83).

RESULTS

Thirty-day postoperative and in-hospital mortality was zero. Complications occurred in 37% (13/35), and median length of stay was 10 days. Occult adenocarcinoma was found in 29% (10/35) of surgical specimens (intramucosal in four; submucosal in five; and intramuscular in one with a single positive lymph node.) Patients consumed a median of three meals per day, most (76%, 26/34) had no dietary restrictions, and two-thirds (23/34) considered their eating pattern to be normal or only mildly impacted. Meal size, however, was reported to be smaller in the majority (79%, 27/34) of patients. Median body mass index (BMI) decreased slightly after surgery (28.6 vs 26.6, p>0.05), but no patient's BMI went below normal. The number of bowel movements/day was unchanged or less in a majority (82%) of patients after surgery. Fifteen of 34 (44%) patients reported loose bowel movements, which occurred less often than once per week in 10 of the 15. One patient had symptoms of dumping. Mean symptom severity scores improved for all symptoms except dysphagia and choking. Four patients developed foregut symptoms that occurred daily. Most patients (82%) required at least one postoperative dilation for dysphagia. Almost all (97%) patients were satisfied. Disease-free survival was 100%, and overall survival was 97% (34/35) at a median of 32 months.

CONCLUSION

Esophagectomy is an effective and curative treatment for HGD and can be performed with no mortality, acceptable morbidity, and good alimentary outcome. These data provide a gold standard for comparison to alternative therapies.

Surgical aspects of the patient with high-grade dysplasia

The incidence of esophageal cancer has increased dramatically in the Western population in the last 2 decades. In 1975, about three fourths of the esophageal neoplasms were squamous cell carcinomas and the remainder were adenocarcinomas. During the last 2 to 3 decades, this pattern has changed dramatically and the incidence of squamous cell carcinomas has declined while the incidence of adenocarcinomas has increased. The reason for this dramatic increase is not clear, but gastro esophageal reflux disease, obesity and Barrett's esophagus have been identified as risk factors. High grade dysplasia in Barrett's esophagus is a premalignant condition which can progress to invasive adenocarcinoma. In this article, we discuss the natural history of high grade dysplasia (HGD), difficulties in the diagnosis, the incidence of adenocarcinoma in resected specimens and the surgical aspects in the treatment of HGD, including minimally invasive esophagectomy.

Endoscopic mucosal resection for early cancers of the upper gastrointestinal tract

The purpose of this literature review is to examine recent advances in technique and technology of endoscopic mucosal resection of superficial early cancers of the upper gastrointestinal tract. Endoscopic mucosal resection (EMR) of superficial early cancers of the upper gastrointestinal tract is standard technique in Japan and is increasingly used in Western countries. Newer techniques of EMR allow removal of larger lesions en-bloc. These minimally invasive techniques, when applied correctly, allow safe and efficacious treatment in situations that would otherwise require major surgery. Through the establishment of long-term outcomes data, standardization of endoscopic and pathologic reporting, and newer EMR technology and techniques, the future treatment of early cancers in the upper gastrointestinal tract may be achieved primarily through the endoscope.

Endoscopic therapy for Barrett's esophagus

With the increase in the rate of esophageal adenocarcinoma in the United States and the Western world matched with the high morbidity and mortality of esophagectomy, there is an increasing need for new and effective techniques to treat and prevent esophageal adenocarcinoma. A wide variety of endoscopic mucosal ablative techniques have been developed for early esophageal neoplasia. However, long-term control of neoplasic risk has not been demonstrated. Most studies show that specialized intestinal metaplasia may persist underneath neo-squamous mucosa, posing a risk for subsequent neoplastic progression. In this article we review current published literature on endoscopic therapies for the management of Barrett's esophagus.

Accurate discrimination of Barrett's esophagus and esophageal adenocarcinoma using a quantitative three-tiered algorithm and multimarker real-time reverse transcription-PCR

Esophageal adenocarcinoma (EA) is increasing faster than any other cancer in the U.S. In this report, we first show that EA can be distinguished from normal esophagus (NE) and esophageal squamous cell carcinoma by plotting expression values for EpCam, TFF1, and SBEM in three-dimensional Euclidean space. For monitoring progression of Barrett's esophagus (BE) to EA, we developed a highly sensitive assay for limited quantities of tissue whereby 50 ng of RNA are first converted to cDNA using 16 gene-specific primers. Using a set of training tissues, we developed a novel quantitative three-tiered algorithm that allows for accurate (overall accuracy = 61/63, 97%) discrimination of BE versus EA tissues using only three genes. The gene used in the first tier of the algorithm is TSPAN: samples not diagnosed as BE or EA by TSPAN in the first tier are then subjected to a second-tier analysis using ECGF1, followed by a third-tier analysis using SPARC. Addition of TFF1 and SBEM to the first tier (i.e., a five-gene marker panel) increases the overall accuracy of the assay to 98% (62/63) and results in mean molecular diagnostic scores (+/- SD) that are significantly different between EA and BE samples (3.19 +/- 1.07 versus -2.74 +/- 1.73, respectively). Our results suggest that relatively few genes can be used to monitor progression of BE to EA.

Endoscopic treatment of high-grade dysplasia and early cancer in Barrett's oesophagus

Barrett's oesophagus is the premalignant precursor of oesophageal adenocarcinoma. Non-dysplastic metaplasia can progress to low-grade dysplasia, high-grade dysplasia, and finally to invasive cancer. Although the frequency of adenocarcinoma in patients with Barrett's oesophagus is low, surveillance is justified because the outcome of adenocarcinoma is poor. Oesophagectomy remains the standard treatment for patients with high-grade dysplasia and superficial carcinoma. However, it has been associated with substantial morbidity and mortality and some patients are judged unfit for surgery. In this review, the present status of less invasive procedures is discussed. Endotherapy preserves the integrity of the oesophagus and allows a better quality of life to patients at low risk of developing lymph-node metastases. Opposition to endoscopic treatment is based mainly on the identification of undetected foci of cancer and high-grade dysplasia in oesophagectomy samples. The current ablative techniques used are photodynamic therapy, argon plasma coagulation, laser treatment, and endoscopic mucosal resection.

Present status of photodynamic therapy for high-grade dysplasia in Barrett's esophagus

GOALS

Review recent developments in Barrett's dysplasia including regulatory approval of porfimer sodium photodynamic therapy.

BACKGROUND

Barrett's esophagus is thought to be the result of long-standing gastroesophageal reflux disease and is known to be the most important risk factor for the development of esophageal adenocarcinoma. The natural history of Barrett's esophagus is not well known, but the annual incidence of invasive adenocarcinoma is estimated to be 0.5% (reported range, 0.2%-2.0%). This represents an increased risk for esophageal cancer of 30 to 60 times higher than normal subjects. As for colorectal cancer, malignant degeneration is Barrett's esophagus is thought to occur through a continuum of histologic stages: metaplasia, dysplasia and neoplasia. Barrett's high-grade dysplasia (formerly referred to as carcinoma in situ) is the histologic stage of disease that immediately precedes the development of invasive carcinoma.

CONCLUSIONS

Previously, Barrett's high-grade dysplasia patients were routinely referred for esophageal resection surgery based upon the assumption of inevitable progression to cancer, the high rate of undiagnosed synchronous cancers, and few treatment alternatives. Important developments in Barrett's high-grade dysplasia include recent publications regarding the natural history of Barrett's high-grade dysplasia and the regulatory approval for endoscopic ablation therapy using porfimer sodium photodynamic therapy (Photofrin PDT).

Barrett metaplasia: reassessment of treatment and follow-up

PURPOSE OF REVIEW

The incidence of esophageal adenocarcinoma continues to rise in the Western world, with a mean 5-year survival of less than 20%. There has therefore been increasing interest in the precursor lesion, Barrett's esophagus. However, adenocarcinoma will not develop in most patients with Barrett's esophagus. This review summarizes the data on the management of Barrett's esophagus that have been published since January 2003.

RECENT FINDINGS

The control of reflux symptoms significantly improves quality of life, and surgical antireflux therapy may gradually cause regression of the Barrett segment compared with proton pump inhibitor therapy. The data substantiate the claim that the cancer risk in Barrett esophagus is lower than had hitherto been suggested. The risk factors for progression include increasing age and length of segment, macroscopic inflammatory changes, loss of heterozygosity over several genetic loci, and increased proliferation status. The extent of high-grade dysplasia may not accurately predict cancer development, and continued surveillance, rather than intervention, for such patients may decrease the chances of curative treatment. Long-term follow-up data are beginning to accumulate for nonsurgical treatment strategies. Chemoprevention trials are under way to evaluate the role of acid suppression and nonsteroidal anti-inflammatory drugs and their derivatives.

SUMMARY

At this time, endoscopic surveillance and surgical management remain the mainstay, but continued research efforts should enable risk stratification and cancer prevention in the future.

Whole stomach with antro-pyloric nerve preservation as an esophageal substitute: an original technique

The paper describes an original technique of gastric tailoring in which the two-thirds of the lesser curvature proximal to the crow's foot are denuded flush with the gastric wall, leaving both nerves of Latarjet and the hepatic branches of the left vagus nerve intact. Maintenance of the vagal supply to the antro-pyloric segment in two patients resulted in the presence of peristaltic contractions sweeping over the antrum on simple observation of the antral wall at the end of the procedure and on both upper G-I series and intragastric manometry tracings 6 weeks postoperatively. Gastric exposure to bile on 24-h gastric bile monitoring was normal 6 weeks after the operation. Neither patient had any gastrointestinal symptoms with the exception of early sensations of postprandial fullness when overeating.