Endoscopic treatment of high-grade dysplasia and early cancer in Barrett's oesophagus. Lancet Oncol. 2005;6:311-321. [PMID: 15863379 DOI: 10.1016/s1470-2045(05)70167-4]

Risk factor analysis of malignant adenomas detected during colonoscopy

Background

Several studies have shown that colorectal adenomas are the most important precancerous lesions. The colonoscopic identification of groups with the high risk of malignant colorectal adenomas remains a controversial issue for clinicians.

Aims

To evaluate the basic characteristics of colorectal adenomas with malignancy risk using high-grade dysplasia (HGD) as an alternative marker for malignant transformation.

Methods

Data from Shanghai General Hospital between January 2017 and December 2021 were retrospectively analyzed. The primary outcome was the incidence of HGD in adenomas, which was used as a surrogate marker for the risk of malignancy. Odds ratios (ORs) for the HGD rate in adenomas were analyzed in relation to adenoma-related factors.

Results

A total of 9,646 patients identified with polyps during 57,445 screening colonoscopies were included in the study. Patients with flat polyps, sessile polyps, and pedunculated polyps represented 27.3% (N = 2,638), 42.7% (N = 4,114), and 30.0% (N = 2,894) of the total number, respectively. HGD was found in 2.41% (N = 97), 0.92% (N = 24), and 3.51% (N = 98) of sessile adenomas, flat adenomas, and pedunculated adenomas, respectively (P < 0.001). Multivariable logistic regression showed that polyp size (P < 0.001) but not shape (P > 0.8), was an independent predictor of HGD. Contrast to the diameter ≤1 cm, the OR value for diameters 1-2, 2-3, and >3 cm was 13.9, 49.3, and 161.6, respectively. The HGD incidence also increased in multiple adenomas (>3 vs. >1, ORs 1.582) and distal adenomas (distal vs. proximal adenomas, OR 2.252). Adenoma morphology (pedunculated vs. flat) was statistically significant in univariate analysis but not when size was included in the multivariate analysis. Besides, the incidence of HGD was also significantly higher in older patients (>64 vs. <50 years old, OR = 2.129). Sex (P = 0.681) was not statistically significant. All these associations were statistically significant (P < 0.05).

Conclusion

The malignant potential of polyps is mostly affected by their size but not by their shape. In addition, distal location, multiple adenomas, and advanced age were also correlated with malignant transformation.

Visceral Obesity, Metabolic Syndrome, and Esophageal Adenocarcinoma

Esophageal adenocarcinoma (EAC) represents an exemplar of obesity-associated carcinogenesis, with a progressive increase in EAC risk with increased body mass index. In this context, there is increased focus on visceral adipose tissue and associated metabolic dysfunction, including hypertension, diabetes mellitus and hyperlipidemia, or combinations of these in the metabolic syndrome. Visceral obesity (VO) may promote EAC via both directly impacting on gastro-esophageal reflux disease and Barrett's esophagus, as well as via reflux-independent effects, involving adipokines, growth factors, insulin resistance, and the microbiome. In this review these pathways are explored, including the impact of VO on the tumor microenvironment, and on cancer outcomes. The current evidence-based literature regarding the role of dietary, lifestyle, pharmacologic and surgical interventions to modulate the risk of EAC is explored.

Blocking NFATc3 ameliorates azoxymethane/dextran sulfate sodium induced colitis-associated colorectal cancer in mice via the inhibition of inflammatory responses and epithelial-mesenchymal transition

Ulcerative colitis-associated colorectal cancer (UC-CRC) is the most serious complication of ulcerative colitis (UC). Nuclear factor of activated T cells 3 (NFATc3) is participated in inflammation and cancer. In this study, we investigated the effects of NFATc3 on experimental UC-CRC in vivo and in vitro, and explored the underlying mechanisms. Administration of azoxymethane (AOM) and dextran sulfate sodium (DSS) induced UC-CRC model in C57BL/6 mice. Body weight was monitored weekly. Colon tissues were harvested at week 14. We examined changes in the histopathology, inflammatory cytokines, carcinogenesis factors, and epithelial-mesenchymal transition (EMT) markers in colon tissues. We found that NFATc3 expression was significantly up-regulated in AOM/DSS treated mice compared with control. Mice lacking NFATc3 showed decreased tumor number and size, decreased mucosal damage, and increased survival rate. Moreover, down-regulation of NFATc3 could inhibit the proliferation and EMT of UC-CRC, decrease the levels of pro-inflammatory cytokines, reduce the colonic infiltration by neutrophils and macrophages, and suppress the activation of P38 and JNK signal pathway in mice. In In vitro experiments, silencing NFATc3 suppressed the proliferation and EMT of CRC cells, and reduced the activation of P38 and JNK. In addition, miR-370-3p could bind to NFATc3. Down-regulation of miR-370-3p promoted proliferation and EMT of CRC cells, while silencing NFATc3 could reverse these effects. In conclusion, NFATc3 was involved in the pathogenesis of experimental UC-CRC and NFATc3 knockdown ameliorated experimental UC-CRC progression via the inhibition of inflammatory responses and EMT. NFATc3 mediated the inhibitory effects of miR-370-3p on CRC cells proliferation and EMT. Targeting NFATc3 may be effective in treating UC-CRC.

Early-stage adenocarcinoma of the esophagus with mid to deep submucosal invasion (pT1b sm2-3): the frequency of lymph-node metastasis depends on macroscopic and histological risk patterns

The rate of lymph-node (LN) metastasis in early adenocarcinoma (EAC) of the esophagus with mid to deep submucosal invasion (pT1b sm2/3) has not yet been precisely defined. The aim of the this study was to evaluate the rate of LN metastasis in pT1b sm2/3 EAC depending on macroscopic and histological risk patterns to find out whether there may also be options for endoscopic therapy as in cancers limited to the mucosa and the upper third of the submucosa. A total of 1.718 pt with suspicion of EAC were referred for endoscopic treatment (ET) to the Dept. of Internal Medicine II at HSK Wiesbaden 1996-2010. In 230/1.718 pt, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of pT1b EAC (ER/surgery) was made. Of these, 38 pt had sm2 lesions, and 69 sm3. Rate of LN metastasis was analyzed depending on risk patterns: histologically low-risk (hisLR): G1-2, L0, V0; histologically high-risk (hisHR): ≥1 criterion not fulfilled; macroscopically low-risk (macLR): gross tumor type I-II, tumor size ≤2 cm; macroscopically high-risk (macHR): ≥1 criterion not fulfilled; combined low-risk (combLR): hisLR+macLR; combined high-risk (combHR): at least 1 risk factor. LN rate was only evaluated in pt who had proven maximum invasion depth of sm2/sm3, and who in case of ET had a follow-up (FU) by EUS of at least 24 months. 23/38 pt with pT1b sm2 lesions and 39/69 pt with sm3 lesions fulfilled our inclusion criteria. In the pT1b sm2 group, rate of LN metastasis in the hisLR, hisHR, combLR, and combHR groups were 8.3% (1/12), 36.3% (4/11), 0% (0/5), and 27.8% (5/18). In the pT1b sm3 group, rate of LN metastasis in the hisLR, hisHR, combLR and combHR groups were 28.6% (2/7), 37.5% (12/32), 25% (1/4), and 37.1% (13/35). 30-day mortality of surgery was 1.7% (1/58 pt). In EAC with pT1b sm2/3 invasion, the frequency of LN metastasis depends on macroscopic and histological risk patterns. Surgery remains the standard treatment, because the rate of LN metastasis appears to be higher than the mortality risk of surgery. Whether a highly selected group of pT1b sm2 patients with a favourable risk pattern may be candidates for endoscopic therapy cannot be decided until the results of larger case volumes are available.

Treatment allocation in patients with early-stage esophageal adenocarcinoma: Prevalence and predictors of lymph node involvement

BACKGROUND

In considering treatment allocation for patients with early esophageal adenocarcinoma, the incidence of lymph node metastasis is a critical determinant; however, this has not been well defined or stratified by the relevant clinical predictors of lymph node spread.

METHODS

Data from the Surveillance, Epidemiology, and End Results database of the National Cancer Institute were abstracted from 2004 to 2010 for patients with early-stage esophageal adenocarcinoma. The incidence of lymph node involvement for patients with Tis, T1a, and T1b tumors was examined and was stratified by predictors of spread.

RESULTS

A total of 13,996 patients with esophageal adenocarcinoma were evaluated. Excluding those with advanced, metastatic, and/or invasive (T2-T4) disease, 715 patients with Tis, T1a, and T1b tumors were included. On multivariate analysis, tumor grade (odds ratio [OR], 2.76; 95% confidence interval [95% CI], 1.58-4.82 [P<.001]), T classification (OR, 0.47; 95% CI, 0.24-0.91 [P =.025]), and tumor size (OR, 2.68; 95% CI, 1.48-4.85 [P = .001]) were found to be independently associated with lymph node metastases. There was no lymph node spread noted with Tis tumors. For patients with low-grade (well or moderately differentiated) tumors measuring <2 cm in size, the risk of lymph node metastasis was 1.7% for T1a (P<.001) and 8.6% for T1b (P = .001) tumors.

CONCLUSIONS

For patients with low-grade Tis or T1 tumors measuring ≤2 cm in size, the incidence of lymph node metastasis appears to be comparable to the mortality rate associated with esophagectomy. For highly selected patients with early esophageal adenocarcinomas, the results of the current study support the recommendation that local endoscopic resection can be considered as an alternative to surgical management when followed by rigorous endoscopic and radiographic surveillance. Cancer 2016;122:2150-7. © 2016 American Cancer Society.

Surgical Therapy of Early Carcinoma of the Esophagus

Background

The modern therapy of early esophageal carcinomas (pT1) requires an excellent cooperation between experienced gastroenterologists, pathologists, and esophageal surgeons. While endoscopic resection (ER) is accepted as the standard curative treatment for mucosal esophageal carcinomas, submucosal tumors are regarded as a strict indication for surgery. There is an ongoing discussion about the operative approach and the extent of lymph node dissection in these cases.

Methods

A literature review was performed to evaluate the operative treatment of early esophageal cancer. In view of oncological risk factors, treatment strategies, and operative procedures, current studies are summarized and compared to the results of our own center.

Results and Conclusion

In early esophageal cancer, lymph node involvement is the only independent risk factor for survival and recurrence rates. There is evidence that infiltrated lymph nodes (N+) are significantly correlated with tumor infiltration depth, lymphovascular (L1) and microvascular invasion (V1), and poor tumor differentiation (G3). Several studies suggest that early squamous cell carcinomas (eSCCs) and early adenocarcinomas (eACs) have a different tumor biology and therefore need a different treatment strategy. While eSCCs in stage m1 and m2 can be cured by ER, tumors infiltrating the submucosal layer (sm1-3) show a high rate of lymph node metastasis (LNM); thus, surgical resection (SR) is clearly indicated. In tumors with invasion into the deep mucosa (m3) the risk of LNM is up to 11%; however, reliable data are rare and the type of therapy should be discussed with the patients individually. In eACs, ER is the standard curative treatment for all mucosal tumors (m1-m4) and sm1 tumors with low-risk constellation (G1, L0, VO, R0). All high-risk sm1 tumors and those with deeper submucosal infiltration (sm2, sm3) show a high rate of LNM and require SR. The standard operative procedure for early esophageal carcinomas is an Ivor-Lewis esophagectomy with radical, at least two-field lymphadenectomy.

Genetic susceptibility to Barrett's oesophagus: Lessons from early studies

Barrett’s oesophagus (BO) is a common condition, predisposing strongly to the development of oesophageal adenocarcinoma (OAC). Consequently, there has been considerable effort to determine the processes involved in the development of BO metaplasia, and ultimately develop markers of patients at risk. Whilst a number of robust acquired risk factors have been identified, a genetic component to these and the apparent increased susceptibility of certain individuals has long been suspected. This has been evidenced in part by linkage studies, but subsequently two recent genome-wide association studies (GWAS) have suggested mechanisms underlying the heritability of BO, as well as providing the first direct evidence at modern levels of statistical significance. This review discusses BO heritability, in addition to that of individual variants and genes reported to be associated with BO to date. Through this, we identify a number of plausible associations, although often tempered by issues of methodology, and discuss the priorities and need for future research.

Obesity and increased risk of esophageal adenocarcinoma

There has been a substantial increase in the incidence of esophageal adenocarcinoma over the past 40 years. Meta-analyses of large prospective cohorts and population-based case-control studies demonstrate consistent associations between obesity and the development of adenocarcinoma of the esophagus and esophago-gastric junction, with an approximate doubling of risk of esophageal adenocarcinoma among patients who are obese, and an almost five-fold increased risk among those with BMI >40 kg/m². The pathologic precursor, specialized intestinal metaplasia in Barrett's esophagus, is also associated with increased adiposity. Epidemiologic evidence suggests that this cancer risk is not solely due to increased gastro-esophageal reflux, and that adipose tissue itself, in particular visceral adipose, may fuel carcinogenesis through the production of adipokines, cytokines, growth factors, and increased inflammation. The robust epidemiologic evidence linking obesity with esophageal adenocarcinoma makes it an exemplar model for investigating the molecular mechanisms underpinning obesity-associated malignant progression, which are discussed in this review.

The frequency of lymph node metastasis in early-stage adenocarcinoma of the esophagus with incipient submucosal invasion (pT1b sm1) depending on histological risk patterns

BACKGROUND

A prerequisite for endoscopic treatment (ET) of not only mucosal, but also submucosal early adenocarcinoma of the esophagus (EAC) would be a rate of lymph node (LN) metastasis below the mortality rate of esophagectomy (2-5%). The aim of the present study was to evaluate the rate of LN metastasis in patients with pT1b sm1 EAC.

METHODS

1996-2010, 1,718 patients with suspicion of EAC were referred to the Department of Internal Medicine II at HSK Wiesbaden. In 123/1718 patients, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of sm1 EAC (ER/surgery) was made. Rate of LN metastasis was analyzed separately for low-risk (LR; G1-2, L0, V0) and high-risk lesions (HR; G3, L1, V1; ≥ 1 risk factor). LN metastasis was only evaluated in patients who had a proven maximum invasion depth of sm1 (ER and/or surgery), and who in case of ET had a follow-up (FU) by EUS of at least 24 months.

RESULTS

Of the 72/123 patients included into the study, 49 patients had LR (68%) and 23 HR lesions (32%). In endoscopically treated LR patients (37/49), mean EUS-FU was 60 ± 30 mo (range 25-146); in HR patients undergoing ET (6/23), it was 63 ± 17 mo (46-86; p = 0.4). Mean number of resected LN was 27 ± 16 (12-62) in operated LR patients and 27 ± 10 (12-47) in HR-patients. The rate of LN metastasis was 2% in the LR (1 patient) and 9% in the HR group (2 patients; p = 0.24). Mortality of esophagectomy was 3%.

CONCLUSIONS

The rate of LN metastasis in pT1b sm1 early adenocarcinoma with histological LR pattern was lower than the mortality rate of esophagectomy. ER may therefore be used alternatively to surgery in this group of patients.

Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion

BACKGROUND & AIMS

Patients with early-stage mucosal (T1a) esophageal adenocarcinoma (EAC) are increasingly treated by endoscopic resection. EACs limited to the upper third of the submucosa (pT1b sm1) could also be treated by endoscopy. We assessed the efficacy, safety, and long-term effects of endoscopic therapy for these patients.

METHODS

We analyzed data from 66 patients with sm1 low-risk lesions (macroscopically polypoid or flat, with a histologic pattern of sm1 invasion, good-to-moderate differentiation [G1/2], and no invasion into lymph vessels or veins) treated by endoscopic therapy at the HSK Hospital Wiesbaden from 1996 through 2010. The efficacy of endoscopic therapy was assessed on the basis of rates of complete endoluminal remission (CER), metachronous neoplasia, lymph node events, and long-term remission (LTR). Safety was assessed on the basis of rate of complications.

RESULTS

Remissions were assessed in 61 of the 66 patients; 53 of the 61 achieved CER (87%). Of patients with small focal neoplasias ≤2 cm, 97% achieved CER (for those with tumors ≥2 cm, 77%; P = .026). Metachronous neoplasias were observed in 10 of 53 patients (19%; 9 of the 10 underwent repeat endoscopic resection). One patient developed a lymph node metastasis (1.9%). Fifty-one patients achieved LTR (84%); 90% of those with focal lesions ≤2 cm achieved LTR after a mean follow-up period of 47 ± 29.1 months (range, 8-120 months). No tumor-associated deaths were observed, and the estimated 5-year survival rate was 84%. The rate of major complications from endoscopic resection was 1.5%, and no patients died.

CONCLUSIONS

Endoscopic therapy appears to be a good alternative to esophagectomy for patients with pT1b sm1 EAC, on the basis of macroscopic and histologic analyses. The risk of developing lymph node metastases after endoscopic resection for sm1 EAC is lower than the risk of surgery.

Effectiveness, safety, and cost-effectiveness of photodynamic therapy in Barrett's esophagus: a systematic review

Barrett's esophagus, the management of which remains controversial, is the precursor condition to esophageal adenocarcinoma. A number of endoscopic treatments have been designed as an alternative to surgical resection for patients with high-grade dysplasia. One of these, photodynamic therapy, involves the light activation of a photosensitizer that causes local tissue destruction via oxidation reactions. The present work reviews the effectiveness, safety, and cost-effectiveness of this treatment. A systematic review of the literature recorded in the Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database, and the National Health Service Economic Evaluation Database was undertaken. Articles reporting randomized clinical trials of photodynamic therapy for the treatment of Barrett's esophagus, and economic assessments of the procedure, were selected. The quality of the articles was checked. Twelve articles were included in this review: eight randomized, controlled clinical trials and four economic assessments. The clinical trials suffered from methodological limitations, but the economic assessments were considered to be good quality. Photodynamic therapy is effective for the ablation of dysplasia in Barrett's esophagus, although the frequency of adverse events is quite high. The procedure is presented as a cost-effective alternative to intense endoscopic monitoring and esophagectomy. However, the evidence regarding its effectiveness in reducing the number of patients who go on to develop cancer is only incipient. Rigorous, controlled studies with longer follow-up times, in which photodynamic therapy is compared with surgical resection and other endoscopic techniques, are needed.

Imaging of subsquamous Barrett's epithelium with ultrahigh-resolution optical coherence tomography: a histologic correlation study

BACKGROUND

Optical coherence tomography (OCT) is being developed as a potentially valuable method for high-resolution cross-sectional imaging of the esophageal mucosal and submucosal layers. One potential application of OCT imaging is to identify subsquamous Barrett's epithelium in patients who have undergone ablative therapy, which is not visible on standard endoscopic examination. However, histologic correlation confirming the ability of OCT to image subsquamous Barrett's epithelium has yet to be performed.

DESIGN

Histologic correlation study.

OBJECTIVE

To perform histologic correlation of ultrahigh-resolution optical coherence tomography (UHR-OCT) imaging for identification of subsquamous Barrett's epithelium.

SETTING

Academic Medical Center (University of Washington, Seattle, WA).

PATIENTS

Fourteen patients with pathologic biopsy specimens, proven to be high-grade dysplasia or adenocarcinoma underwent esophagectomy.

INTERVENTIONS

UHR-OCT imaging was performed on ex vivo esophagectomy specimens immediately after resection.

MAIN OUTCOME MEASUREMENTS

Correlation of UHR-OCT images with histologic images.

RESULTS

Subsquamous Barrett's epithelium was clearly identified by using UHR-OCT images and was confirmed by corresponding histology.

LIMITATIONS

Difficulty distinguishing some subsquamous Barrett's glands from blood vessels in ex vivo tissue (because of the lack of blood flow) in some cases. Imaging was performed with a bench-top system.

CONCLUSIONS

Results from this study demonstrate that UHR-OCT imaging is capable of identifying subsquamous Barrett's epithelium.

Endoluminal therapy for esophageal disease: an introduction

This introductory article summarizes decades of research from many dedicated gastrointestinal endoscopists. It provides a background to Barrett esophagus (BE), exploring the risk of progression to dysplasia and esophageal adenocarcinoma. Two premalignant conditions, BE and colon adenoma, are compared, including their progression to esophageal adenocarcinoma and colon and rectal carcinoma, respectively. A comparison of the risks of surgical treatment and post-surgical complications of these cancers and of the strikingly different paradigms for their prevention is presented. The article concludes with the rationale for endoscopic treatment of Barrett disease.

Meta-analysis and systematic review of colorectal endoscopic mucosal resection

AIM: To evaluate the proportion of successful complete cure en-bloc resections of large colorectal polyps achieved by endoscopic mucosal resection (EMR).

METHODS: Studies using the EMR technique to resect large colorectal polyps were selected. Successful complete cure en-bloc resection was defined as one piece margin-free polyp resection. Articles were searched for in Medline, Pubmed, and the Cochrane Control Trial Registry, among other sources.

RESULTS: An initial search identified 2620 reference articles, from which 429 relevant articles were selected and reviewed. Data was extracted from 25 studies (n = 5221) which met the inclusion criteria. All the studies used snares to perform EMR. Pooled proportion of en-bloc resections using a random effect model was 62.85% (95% CI: 51.50-73.52). The pooled proportion for complete cure en-bloc resections using a random effect model was 58.66% (95% CI: 47.14-69.71). With higher patient load (> 200 patients), this complete cure en-bloc resection rate improves from 44.19% (95% CI: 24.31-65.09) to 69.17% (95% CI: 51.11-84.61).

CONCLUSION: EMR is an effective technique for the resection of large colorectal polyps and offers an alternative to surgery.

Treatment of gastrointestinal diseases with second-generation argon plasma coagulation: an analysis of 260 cases

AIM: To investigate the safety and efficacy of the second-generation argon plasma coagulation (VIO APC) for gastrointestinal diseases.

METHODS: During 2007-09-14/2008-10-22, 260 patients were treated using VIO APC in a total of 289 sessions. For various indications, the new VIO APC device was used. Safety and efficacy of VIO APC were recorded after each individual treatment session.

RESULTS: The mean number of treatment sessions required using VIO APC in various indications was 1.11 ± 0.31. In the palliative treatment of gastric adenocarcinoma, it was 2.50; in endoscopic hemostasis, it was 1.23; in the treatment of colorectal polypi, it was 1.15, in the treatment of upper gastrointestinal polypi, it was 1.03, in the management of self-expand stent overgrowth or tumor stenosis, it was 1.17; in the ablation of Barrett's esophagus, it was 1.13; in the ablation of gastric dysplasia, gastritis verrucosa, gastric xanthelasma and gastric or duodenal liparomphalus, only 1 session was needed. Minor complications (pain, dysphagia/odynophagia, asymptomatic gas accumulation in the intestinal wall) were observed in 10.1%-20% sessions, but no major complications (hemorrhage, perforation, stenosis) were observed.

CONCLUSION: VIO APC is effective and safe for various gastrointestinal conditions. It can be widely applied to daily endoscopic treatment.

Radiofrequency ablation of Barrett's esophagus: short-term results

BACKGROUND

The presence of Barrett's esophagus (BE) increases the risk of esophageal cancer. Total regression of BE is uncommon with medication or laparoscopic fundoplication, and endoscopic techniques to obliterate BE have varied results. This study evaluated the early results of a balloon-based catheter radiofrequency ablation (RFA) system in patients with medically refractory reflux symptoms and biopsy-proven BE.

METHODS

The medical records of 27 consecutive patients who underwent RFA for BE from March 2005 through January 2007 were reviewed. Esophagogastroduodenoscopy was performed before ablation to document presence of BE and no cancer and at 8 weeks after the RFA to assess the presence of residual BE.

RESULTS

Mean patient age was 53.6 +/- 12.5 years; 16 (59%) were men. The average length of the Barrett segment treated was 4.6 +/- 4.7 cm. Two patients (7.4%) had low-grade dysplasia. No patient had high-grade dysplasia and cancer. There was no periprocedural morbidity or at follow-up, no postprocedure dysphagia or stricture. In all patients, the BE was completely replaced with normal squamous epithelium. Symptoms regressed in 16 patients (60%) with RFA and proton pump inhibitor therapy. Eleven required an antireflux procedure for persistent symptoms.

CONCLUSIONS

Short-term results show that RFA for BE is safe and achieves 100% replacement of intestinal metaplasia. RFA of BE combined with fundoplication may be offered to patients with BE and medically refractory reflux symptoms. Long-term endoscopic surveillance is needed to determine if the risk of cancer is reduced with this bimodality therapy.

Endoscopic submucosal dissection of a minute intramucosal adenocarcinoma in Barrett's esophagus

A 73-year-old man with short segmental Barrett's esophagus underwent esophagoscopy, and a slightly depressed, discolored lesion was found on the anterior wall of the lower esophagus. Under a provisional diagnosis of differentiated adenocarcinoma without local lymph node metastasis, endoscopic submucosal dissection (ESD) was carried out. En bloc resection with tumor-free lateral/basal margins was accomplished without complication. The resected area was 12 x 15 mm in size, whereas the neoplastic lesion was 4 x 4 mm. Histopathological examination confirmed intramucosal well-differentiated tubular adenocarcinoma without angiolymphatic invasion adjacent to the muscularis mucosae. Repeated esophagoscopy 6 months after ESD showed neither locally recurrent nor metachronous lesions. Considering that Barrett's esophagus is a precancerous condition, one may recommend eradication of both the neoplastic and non-neoplastic lesion with using ESD.

Histological assessment of oesophageal columnar mucosa

This review presents the pathological features of Barrett's oesophagus, with an emphasis on the role of pathologists in the diagnosis, surveillance and treatment of the disease. The diagnosis of Barrett's oesophagus is based both on endoscopy and histology. The surveillance of patients relies on systematic biopsy sampling, looking for dysplasia - intraepithelial neoplasia. Well established classifications of dysplasia are now used by pathologists, but there remain problems with this marker. Therefore, many alternative biomarkers have been proposed, that remain of limited interest in daily practice, including DNA-ploidy, proliferation markers, and p53 abnormalities. Endoscopic improvements already allow a better selection of biopsies, and it may be that new technologies will allow 'virtual biopsies'. The role of pathologists is now extended to the evaluation of new therapeutic modalities of early neoplastic lesions in Barrett's oesophagus, especially endoscopic mucosal resection.

Depth of resection using two different endoscopic mucosal resection techniques

BACKGROUND AND STUDY AIMS

Endoscopic mucosal resection (EMR) has been carried out for high-grade dysplasia (HGD) and intramucosal carcinoma (IMCA) in Barrett's esophagus using two different cap-assisted techniques, the "inject, suck, and cut" and the "band and snare." Previous work has demonstrated comparable specimen diameters. However, the two techniques have not been previously compared with respect to depth of resection.

PATIENTS AND METHODS

From a database of patients with Barrett's esophagus, we identified 40 consecutive specimens removed using EMR from patients with HGD or IMCA, 20 each from the "inject, suck, and cut" and the "band and snare" techniques. Specimens were evaluated and measured separately by two pathologists for greatest diameter and depth, and for the presence of submucosa and muscularis propria at the deepest margin of resection. Follow-up data were collected regarding clinical outcome and stricture formation.

RESULTS

The mean depth of the specimens from the two techniques was not significantly different (0.51 cm vs. 0.50 cm, P = 0.76). All specimens contained substantial submucosa, allowing accurate staging of the neoplastic lesions resected. Muscularis propria was identified at the base of 65% of the "band and snare" and 50% of the "inject, suck, and cut" specimens (P = 0.52).

CONCLUSIONS

The "inject, suck, and cut" and "band and snare" techniques both yield equivalent adequate depth of histological specimens from Barrett's esophagus with HGD or IMCA, and both provide accurate pathological staging.

Endoscopic mucosal resection in the upper gastrointestinal tract

Endoscopic mucosal resection (EMR) is a technique used to locally excise lesions confined to the mucosa. Its main role is the treatment of advanced dysplasia and early gastrointestinal cancers. EMR was originally described as a therapy for early gastric cancer. Recently its use has expanded as a therapeutic option for ampullary masses, colorectal cancer, and large colorectal polyps. In the Western world, the predominant indication for EMR in the upper gastrointestinal tract is the staging and treatment of advance dysplasia and early neoplasia in Barrett’s esophagus. This review will describe the basis, indications, techniques, and complications of EMR, and its role in the management of Barrett’s esophagus.

Endoscopic endoluminal radiofrequency ablation of Barrett's esophagus in patients with fundoplications

BACKGROUND

Endoscopic endoluminal radiofrequency ablation using the Barrx device is a new technique to treat Barrett's esophagus. This procedure has been used in patients who have not had antireflux surgery. This report is presents an early experience of the effects of endoluminal ablation on the reflux symptoms and completeness of ablation in post-fundoplication patients.

METHODS

Seven patients who have had either a laparoscopic or open Nissen fundoplication and Barrett's esophagus underwent endoscopic endoluminal ablation of the Barrett's metaplasia using the Barrx device (Barrx Medical, Sunnyvale, CA). Preprocedure, none of the patients had significant symptoms related to gastroesophageal reflux disease. One to two weeks after the ablation, patients were questioned as to the presence of symptoms. Preprocedure and postprocedure, they completed the GERD-HRQL symptom severity questionnaire (best possible score, 0; worst possible score, 50). Patients had follow-up endoscopy to assess completeness of ablation 3 months after the original treatment.

RESULTS

All patients completed the ablation without complications. No patients reported recurrence of their GERD symptoms. The median preprocedure total GERD-HRQL score was 2, compared to a median postprocedure score of 1. One patient had residual Barrett's metaplasia at 3 months follow-up, requiring re-ablation.

CONCLUSIONS

This preliminary report of a small number of patients demonstrates that endoscopic endoluminal ablation of Barrett's metaplasia using the Barrx device is safe and effective in patients who have already undergone antireflux surgery. There appears to be no disruption in the fundoplication or recurrence of GERD-related symptoms. Nevertheless, longer-term follow-up with more patients is needed.

Barrett's oesophagus?a pathologist's view

Barrett's oesophagus, a precancerous condition for oesophageal adenocarcinoma, detected on endoscopy and confirmed on histology, shows intestinal metaplasia of the lower oesophagus. The significance of microscopic foci of intestinal metaplasia at the gastro-oesophageal junction, corresponding either to so-called 'ultrashort' segment Barrett's oesophagus, or to carditis with intestinal metaplasia, is still a matter of debate. The surveillance of patients with Barrett's oesophagus is still based on systematic biopsy sampling of Barrett's mucosa on endoscopy, looking for dysplasia. Although well-established classifications of dysplasia are now used by most pathologists, there remain numerous problems with this subjective marker (sampling, diagnostic reproducibility, natural history, etc). Therefore, many alternative biomarkers have been proposed, but only DNA aneuploidy, proliferation markers and p53 loss of heterozygosity/overexpression have been shown to be of some use at the present time. Some endoscopic improvements already allow a better selection of biopsies, and it may be that in future new technologies will allow 'virtual biopsies'. On the other hand, the role of pathologists now extends to the evaluation of new therapeutic modalities of early neoplastic lesions in Barrett's oesophagus, especially endoscopic mucosal resection.

Endoluminal therapy for Barrett's esophagus

This article reviews methods to minimize the complications associated with endoscopic therapy for patients with Barrett's esophagus. To place this discussion in context, the natural history of Barrett's esophagus and the risks associated with progression to dysplasia and invasive carcinoma are reviewed. Operative esophageal resection traditionally is recommended for patients with Barrett's high-grade dysplasia and early carcinoma, and these surgical risks also are reviewed. Finally, all currently approved and commercially available methods for endoscopic ablation and resection of Barrett's disease are categorized according to their application methods of ablation: focal ablation, field ablation, and mucosal resection. The clinical experience with these devices is reviewed with their associated adverse events and complications. Caveats, concerns, and recommendations are discussed to help minimize the complications associated with the use of these important technologies that hold the promise of removing or destroying Barrett's disease to prevent the development of invasive carcinoma.

Clinical use of p53 in Barrett's esophagus

Barrett's esophagus is an established precursor to esophageal adenocarcinoma. Whereas most patients with Barrett's esophagus do not progress to adenocarcinoma, patients with progression have a poor prognosis. Current management strategies use frequent endoscopic surveillance and multiple nontargeted biopsies. This approach, however, may miss dysplastic areas. Furthermore, given the relatively high prevalence of Barrett's esophagus but low incidence of progression, this invasive and expensive approach has not been shown to be cost-effective. Thus, there is intense interest in using biomarkers to identify patients at increased risk of progressing to adenocarcinoma. This has included examination of mutations in the tumor suppressor gene, p53. In this report, we discuss the biology of p53 and the incidence of p53 mutations in Barrett's esophagus and review relevant studies regarding the ability of p53 to predict neoplastic progression. Additionally, we report our results of the expression of p53 by immunohistochemistry in a group of 18 patients that have undergone endoscopic esophageal mucosal resection for dysplasia. Although the presence of a p53 mutation increases the risk of neoplastic progression, the absence of this mutation does not abrogate the risk. Continuing efforts, therefore, are needed to define and prospectively validate a panel of biomarkers to risk-stratify patients with Barrett's esophagus. Determination of p53 mutational status may ultimately be a component of such a panel.

Endoscopic mucosal resection of large hyperplastic polyps in 3 patients with Barrett’s esophagus

AIM: To report the endoscopic treatment of large hyperplastic polyps of the esophagus and esophago-gastric junction (EGJ) associated with Barrett’s esophagus (BE) with low-grade dysplasia (LGD), by endoscopic mucosal resection (EMR).

METHODS: Cap fitted EMR (EMR-C) was performed in 3 patients with hyperplastic-inflammatory polyps (HIPs) and BE.

RESULTS: The polyps were successfully removed in the 3 patients. In two patients, with short segment BE (SSBE) (≤ 3 cm), the metaplastic tissue was completely excised. A 2 cm circumferential EMR was performed in one patient with a polyp involving the whole EGJ. A simultaneous EMR-C of a BE-associated polypoid dysplastic lesion measuring 1 cm x 10 cm, was also carried out. In the two patients, histologic assessment detected LGD in BE. No complications occurred. Complete neosquamous re-epithelialization occurred in the two patients with SSBE. An esophageal recurrence occurred in the remaining one and was successfully retreated by EMR.

CONCLUSION: EMR-C appears to be a safe and effective method for treating benign esophageal mucosal lesions, allowing also the complete removal of SSBE.

Endoprevention of esophageal cancer: endoscopic ablation of Barrett's metaplasia and dysplasia

This review describes the use of endoscopic therapy for the treatment of Barrett's disease and the prevention of esophageal carcinoma, predominantly a disease of older white men. While the term endoprevention may be novel, gastroenterologists have been using endoscopic techniques to prevent colon cancer for decades. For the endoprevention of Barrett's carcinoma, the regulatory approval for the use of porfimer sodium photodynamic therapy was an important milestone, as this treatment has been proven to safely ablate Barrett's glandular epithelium, including high-grade dysplasia, and significantly decrease the risk for the development of invasive cancer in several single-center studies, a prospective multicenter randomized controlled study using expert centralized histopathology analysis and long-term single-center results. Newer methods of mucosal ablation, such as the radiofrequency balloon, have been developed for the treatment of patients with Barrett's metaplasia or dysplasia. These newly developed techniques are able to treat large fields of glandular epithelium in a short treatment procedure using safe, effective, durable methods for the complete ablation of Barrett's metaplasia and low-grade dysplasia. These techniques may finally allow the interventional gastrointestinal endoscopist to prevent the development of esophageal carcinoma, just as colonoscopy with polypectomy has prevented colon cancer. However, it will be critically important to document the safety, durability and efficacy of these devices. Ultimately, the impact of successful Barrett's ablation on the incidence of Barrett's carcinoma, and the need for postablation surveillance endoscopy must be determined.