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Iyer PG, Slettedahl SW, Mahoney DW, Giakoumopoulos M, Olson MC, Krockenberger M, Taylor WR, Foote P, Berger C, Leggett C, Wu TT, Antpack E, Falk GW, Ginsberg GG, Abrams JA, Lightdale CJ, Ramirez F, Kahn A, Wolfsen H, Konda V, Trindade AJ, Kisiel JB. Algorithm Training and Testing for a Nonendoscopic Barrett's Esophagus Detection Test in Prospective Multicenter Cohorts. Clin Gastroenterol Hepatol 2024; 22:1596-1604.e4. [PMID: 38513982 PMCID: PMC11272429 DOI: 10.1016/j.cgh.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND & AIMS Endoscopic Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) detection is invasive and expensive. Nonendoscopic BE/EAC detection tools are guideline-endorsed alternatives. We previously described a 5-methylated DNA marker (MDM) panel assayed on encapsulated sponge cell collection device (CCD) specimens. We aimed to train a new algorithm using a 3-MDM panel and test its performance in an independent cohort. METHODS Algorithm training and test samples were from 2 prospective multicenter cohorts. All BE cases had esophageal intestinal metaplasia (with or without dysplasia/EAC); control subjects had no endoscopic evidence of BE. The CCD procedure was followed by endoscopy. From CCD cell lysates, DNA was extracted, bisulfite treated, and MDMs were blindly assayed. The algorithm was set and locked using cross-validated logistic regression (training set) and its performance was assessed in an independent test set. RESULTS Training (N = 352) and test (N = 125) set clinical characteristics were comparable. The final panel included 3 MDMs (NDRG4, VAV3, ZNF682). Overall sensitivity was 82% (95% CI, 68%-94%) at 90% (79%-98%) specificity and 88% (78%-94%) sensitivity at 84% (70%-93%) specificity in training and test sets, respectively. Sensitivity was 90% and 68% for all long- and short-segment BE, respectively. Sensitivity for BE with high-grade dysplasia and EAC was 100% in training and test sets. Overall sensitivity for nondysplastic BE was 82%. Areas under the receiver operating characteristic curves for BE detection were 0.92 and 0.94 in the training and test sets, respectively. CONCLUSIONS A locked 3-MDM panel algorithm for BE/EAC detection using a nonendoscopic CCD demonstrated excellent sensitivity for high-risk BE cases in independent validation samples. (Clinical trials.gov: NCT02560623, NCT03060642.).
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Affiliation(s)
- Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Seth W Slettedahl
- Division of Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Douglas W Mahoney
- Division of Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - William R Taylor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Patrick Foote
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Calise Berger
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Cadman Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Tsung-Teh Wu
- Department of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Eduardo Antpack
- Department of Surgery, Mayo Clinic Health System, Austin, Minnesota
| | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Gregory G Ginsberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York
| | - Charles J Lightdale
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York
| | - Francisco Ramirez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona
| | - Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona
| | - Herbert Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Vani Konda
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Dallas, Texas
| | - Arvind J Trindade
- Division of Gastroenterology and Hepatology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York
| | - John B Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Yoon JY, Lim F, Shah SC, Rubenstein JH, Abrams JA, Katzka D, Inadomi J, Kim MK, Hur C. Endoscopic Surveillance of Intestinal Metaplasia of the Esophagogastric Junction: A Decision Modeling Analysis. Am J Gastroenterol 2024; 119:1289-1297. [PMID: 38275234 PMCID: PMC11222037 DOI: 10.14309/ajg.0000000000002672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024]
Abstract
INTRODUCTION The incidence of esophagogastric junction adenocarcinoma (EGJAC) has been rising. Intestinal metaplasia of the esophagogastric junction (EGJIM) is a common finding in gastroesophageal reflux (irregular Z-line) and may represent an early step in the development of EGJAC in the West. Worldwide, EGJIM may represent progression along the Correa cascade triggered by Helicobacter pylori . We sought to evaluate the cost-effectiveness of endoscopic surveillance of EGJIM. METHODS We developed a decision analytic model to compare endoscopic surveillance strategies for 50-year-old patients after diagnosis of non-dysplastic EGJIM: (i) no surveillance (standard of care), (ii) endoscopy every 3 years, (iii) endoscopy every 5 years, or (iv) 1-time endoscopy at 3 years. We modeled 4 progression scenarios to reflect uncertainty: A (0.01% annual cancer incidence), B (0.05%), C (0.12%), and D (0.22%). RESULTS Cost-effectiveness of endoscopic surveillance depended on the progression rate of EGJIM to cancer. At the lowest progression rate (scenario A, 0.01%), no surveillance strategies were cost-effective. In moderate progression scenarios, 1-time surveillance at 3 years was cost-effective, at $30,989 and $16,526 per quality-adjusted life year for scenarios B (0.05%) and C (0.12%), respectively. For scenario D (0.22%), surveillance every 5 years was cost-effective at $77,695 per quality-adjusted life year. DISCUSSION Endoscopic surveillance is costly and can cause harm; however, low-intensity longitudinal surveillance (every 5 years) is cost-effective in populations with higher EGJAC incidence. No surveillance or 1-time endoscopic surveillance of patients with EGJIM was cost-effective in low-incidence populations. Future studies to better understand the natural history of EGJIM, identify risk factors of progression, and inform appropriate surveillance strategies are required.
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Affiliation(s)
- Ji Yoon Yoon
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Shailja C. Shah
- Division of Gastroenterology, University of California San Diego, La Jolla, CA
- Gastroenterology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Joel H. Rubenstein
- Center for Clinical Management Research, LTC Charles S Kettles Veterans Affairs Medical Center, Ann Arbor, MI
- Barrett’s Esophagus Program, Division of Gastroenterolgy, University of Michigan Medical School, Ann Arbor, MI
| | - Julian A. Abrams
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - David Katzka
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - John Inadomi
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT
| | - Michelle K. Kim
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Chin Hur
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer center, Columbia University Irving Medical Center, New York, NY
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Saha B, Verma A, Dierkhising R, Canning R, Kisiel JB, Iyer PG. Barrett's Esophagus Risk Factors in Patients Without Gastroesophageal Reflux: A Large Population-Based Study. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00391-4. [PMID: 38670476 DOI: 10.1016/j.cgh.2024.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/14/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
Esophageal adenocarcinoma (EAC) is a lethal malignancy with an abysmal 5-year survival rate of <20%.1 Barrett's esophagus (BE) is the only known precursor to EAC.1,2 BE is characterized by intestinal metaplasia of the distal esophagus, typically arising in the setting of gastroesophageal reflux disease (GERD).1 Hence, chronic GERD symptoms are an essential criterion for BE screening in most gastroenterology guidelines, alongside other BE risk factors including age >50 years, male sex, White race, history of tobacco smoking, hiatal hernia (HH) diagnosis, obesity, and family history of BE/EAC in first-degree relatives.1,3 Dysplastic BE and early stage EAC are amenable to endoscopic eradication therapy, highlighting the importance of BE/EAC screening and surveillance.4.
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Affiliation(s)
- Bibek Saha
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anjul Verma
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ross Dierkhising
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Rachel Canning
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - John B Kisiel
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Shaheen NJ, Odze RD, Singer ME, Salyers WJ, Srinivasan S, Kaul V, Trindade AJ, Aravapalli A, Herman RD, Smith MS, McKinley MJ. Adjunctive Use of Wide-Area Transepithelial Sampling-3D in Patients With Symptomatic Gastroesophageal Reflux Increases Detection of Barrett's Esophagus and Dysplasia. Am J Gastroenterol 2024:00000434-990000000-01127. [PMID: 38635377 DOI: 10.14309/ajg.0000000000002818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Patients with gastroesophageal reflux (GERD) symptoms undergoing screening upper endoscopy for Barrett's esophagus (BE) frequently demonstrate columnar-lined epithelium, with forceps biopsies (FBs) failing to yield intestinal metaplasia (IM). Repeat endoscopy is then often necessary to confirm a BE diagnosis. The aim of this study was to assess the yield of IM leading to a diagnosis of BE by the addition of wide-area transepithelial sampling (WATS-3D) to FB in the screening of patients with GERD. METHODS We performed a prospective registry study of patients with GERD undergoing screening upper endoscopy. Patients had both WATS-3D and FB. Patients were classified by their Z line appearance: regular, irregular (<1 cm columnar-lined epithelium), possible short-segment BE (1 to <3 cm), and possible long-segment BE (≥3 cm). Demographics, IM yield, and dysplasia yield were calculated. Adjunctive yield was defined as cases identified by WATS-3D not detected by FB, divided by cases detected by FB. Clinicians were asked if WATS-3D results affected patient management. RESULTS Of 23,933 patients, 6,829 (28.5%) met endoscopic criteria for BE. Of these, 2,878 (42.1%) had IM identified by either FB or WATS-3D. Among patients fulfilling endoscopic criteria for BE, the adjunctive yield of WATS-3D was 76.5% and absolute yield was 18.1%. One thousand three hundred seventeen patients (19.3%) who fulfilled endoscopic BE criteria had IM detected solely by WATS-3D. Of 240 patients with dysplasia, 107 (44.6%) were found solely by WATS-3D. Among patients with positive WATS-3D but negative FB, the care plan changed in 90.7%. DISCUSSION The addition of WATS-3D to FB in patients with GERD being screened for BE resulted in confirmation of BE in an additional one-fifth of patients. Furthermore, dysplasia diagnoses approximately doubled.
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Affiliation(s)
- Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Robert D Odze
- Department of Pathology, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Mendel E Singer
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - William J Salyers
- Department of Internal Medicine, Division of Gastroenterology University of Kansas School of Medicine-Wichita, Kansas, USA
| | | | - Vivek Kaul
- Division of Gastroenterology & Hepatology, University of Rochester School of Medicine, Rochester, New York, USA
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | | | - Robert D Herman
- Allied Digestive Health, Great Neck, New York and Division of Gastroenterology, Northwell Health, Manhasset, New York, USA
| | - Michael S Smith
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Vantanasiri K, Kamboj AK, Kisiel JB, Iyer PG. Advances in Screening for Barrett Esophagus and Esophageal Adenocarcinoma. Mayo Clin Proc 2024; 99:459-473. [PMID: 38276943 PMCID: PMC10922282 DOI: 10.1016/j.mayocp.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 01/27/2024]
Abstract
Esophageal adenocarcinoma (EAC), the primary form of esophageal cancer in the United States, is a lethal cancer with exponentially increasing incidence. Screening for Barrett esophagus (BE), the only known precursor to EAC, followed by endoscopic surveillance to detect dysplasia and early-stage EAC and subsequent endoscopic treatment (to prevent progression of dysplasia to EAC and to treat early-stage EAC effectively) is recommended by several society guidelines. Sedated endoscopy (the primary current tool for BE screening) is both invasive and expensive, limiting its widespread use. In this review, we aim to provide a comprehensive review of recent innovations in the nonendoscopic detection of BE and EAC. These include swallowable cell sampling devices combined with protein and epigenetic biomarkers (which are now guideline endorsed as alternatives to sedated endoscopy), tethered capsule endomicroscopy, emerging peripheral blood-sampled molecular biomarkers, and exhaled volatile organic compounds. We also summarize progress and challenges in assessing BE and EAC risk, which is an important complementary component of the process for the clinical implementation of these innovative nonendoscopic tools, and propose a new paradigm for the strategy to reduce EAC incidence and mortality.
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Affiliation(s)
- Kornpong Vantanasiri
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Amrit K Kamboj
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John B Kisiel
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Agarwal S, Bell MG, Dhaliwal L, Codipilly DC, Dierkhising RA, Lansing R, Gibbons EE, Leggett CL, Kisiel JB, Iyer PG. Population Based Time Trends in the Epidemiology and Mortality of Gastroesophageal Junction and Esophageal Adenocarcinoma. Dig Dis Sci 2024; 69:246-253. [PMID: 37914889 PMCID: PMC10926253 DOI: 10.1007/s10620-023-08126-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/02/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Limited data are available on the epidemiology of gastroesophageal junction adenocarcinoma (GEJAC), particularly in comparison to esophageal adenocarcinoma (EAC). With the advent of molecular non-endoscopic Barrett's esophagus (BE) detection tests which sample the esophagus and gastroesophageal junction, early detection of EAC and GEJAC has become a possibility and their epidemiology has gained importance. AIMS We sought to evaluate time trends in the epidemiology and survival of patients with EAC and GEJAC in a population-based cohort. METHODS EAC and GEJAC patients from 1976 to 2019 were identified using ICD 9 and 10 diagnostic codes from the Rochester Epidemiology Project (REP). Clinical data and survival status were abstracted. Poisson regression was used to calculate incidence rate ratios (IRR). Survival analysis and Cox proportional models were used to assess predictors of survival. RESULTS We included 443 patients (287 EAC,156 GEJAC). The incidence of EAC and GEJAC during 1976-2019 was 1.40 (CI 1.1-1.74) and 0.83 (CI 0.61-1.11) per 100,000 people, respectively. There was an increase in the incidence of EAC (IRR = 2.45, p = 0.011) and GEJAC (IRR = 3.17, p = 0.08) from 2000 to 2004 compared to 1995-1999, plateauing in later time periods. Most patients had associated BE and presented at advanced stages, leading to high 5-year mortality rates (66% in EAC and 59% in GEJAC). Age and stage at diagnosis were predictors of mortality. CONCLUSION The rising incidence of EAC/GEJAC appears to have plateaued somewhat in the last decade. However, both cancers present at advanced stages with persistently poor survival, underscoring the need for early detection.
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Affiliation(s)
- Siddharth Agarwal
- Division of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, MN, USA
| | - Matthew G Bell
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lovekirat Dhaliwal
- Division of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, MN, USA
| | - D Chamil Codipilly
- Division of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, MN, USA
| | - Ross A Dierkhising
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Ramona Lansing
- Division of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, MN, USA
| | - Erin E Gibbons
- Division of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, MN, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, MN, USA
| | - John B Kisiel
- Division of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, MN, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Barrett's Esophagus Unit, Mayo Clinic, Rochester, MN, USA.
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Lu H, Cao LL, Ballout F, Belkhiri A, Peng D, Chen L, Chen Z, Soutto M, Wang TC, Que J, Giordano S, Washington MK, Chen S, McDonald OG, Zaika A, El-Rifai W. Reflux conditions induce E-cadherin cleavage and EMT via APE1 redox function in oesophageal adenocarcinoma. Gut 2023; 73:47-62. [PMID: 37734913 PMCID: PMC10872865 DOI: 10.1136/gutjnl-2023-329455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE Chronic gastro-oesophageal reflux disease, where acidic bile salts (ABS) reflux into the oesophagus, is the leading risk factor for oesophageal adenocarcinoma (EAC). We investigated the role of ABS in promoting epithelial-mesenchymal transition (EMT) in EAC. DESIGN RNA sequencing data and public databases were analysed for the EMT pathway enrichment and patients' relapse-free survival. Cell models, pL2-IL1β transgenic mice, deidentified EAC patients' derived xenografts (PDXs) and tissues were used to investigate EMT in EAC. RESULTS Analysis of public databases and RNA-sequencing data demonstrated significant enrichment and activation of EMT signalling in EAC. ABS induced multiple characteristics of the EMT process, such as downregulation of E-cadherin, upregulation of vimentin and activation of ß-catenin signalling and EMT-transcription factors. These were associated with morphological changes and enhancement of cell migration and invasion capabilities. Mechanistically, ABS induced E-cadherin cleavage via an MMP14-dependent proteolytic cascade. Apurinic/apyrimidinic endonuclease (APE1), also known as redox factor 1, is an essential multifunctional protein. APE1 silencing, or its redox-specific inhibitor (E3330), downregulated MMP14 and abrogated the ABS-induced EMT. APE1 and MMP14 coexpression levels were inversely correlated with E-cadherin expression in human EAC tissues and the squamocolumnar junctions of the L2-IL1ß transgenic mouse model of EAC. EAC patients with APE1high and EMThigh signatures had worse relapse-free survival than those with low levels. In addition, treatment of PDXs with E3330 restrained EMT characteristics and suppressed tumour invasion. CONCLUSION Reflux conditions promote EMT via APE1 redox-dependent E-cadherin cleavage. APE1-redox function inhibitors can have a therapeutic role in EAC.
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Affiliation(s)
- Heng Lu
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Long Long Cao
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Farah Ballout
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Abbes Belkhiri
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - DunFa Peng
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Lei Chen
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Zheng Chen
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Mohammed Soutto
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Veterans Affairs, VA Miami Healthcare System, Miami, FL, USA
| | - Timothy C Wang
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Jianwen Que
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Silvia Giordano
- Department of Oncology, University of Torino and Candiolo Cancer Institute, Candiolo, Italy
| | - Mary Kay Washington
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steven Chen
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Oliver Gene McDonald
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Pathology and Laboratory Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Alexander Zaika
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Veterans Affairs, VA Miami Healthcare System, Miami, FL, USA
| | - Wael El-Rifai
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Veterans Affairs, VA Miami Healthcare System, Miami, FL, USA
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Ashktorab H, Geramfard S, Rashid M, Rashid R, Mynedi SM, Nouraie M, Nezamloo A, Brim H. Exploring the Incidence and Associated Risk Factors of Barrett's Esophagus in African Americans: A Retrospective Study. REPORTS ON GLOBAL HEALTH RESEARCH 2023; 6:164. [PMID: 38044960 PMCID: PMC10691964 DOI: 10.29011/2690-9480.100164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Background The prevalence of Barrett's esophagus (BE) in African Americans (AA) is uncertain. However, several potential risk factors, includes family history, male sex, ethnicity, chronic heartburn and acid reflux, age over 60, current or past smoking, and obesity are associated with BE. The aim of this study is to determine the incidence of BE in AA patients who underwent Esophageal Gastro Endoscopy (EGD). Methods Medical and demographic data of 1,253 AA patients with various symptoms, including BE, Esophageal adenocarcinoma (EAC), esophageal squamous adenocarcinoma (SCC), hiatal hernia, H. pylori infection, Gastro-Esophageal Reflux Disease (GERD), Gastritis, and esophagitis, were collected from January 2004 to December 2014 at Howard University Hospital. Results Among the 1,253 patients, the median age was 61 and 49% were male out of the total. The frequencies of EAC (p= 0.05), and SCC (p= 0.002) were significantly high in males, along with SCC frequency significantly increased with older age (p<0.001). Furthermore, esophageal polyps with hiatal hernia (p=0.008) and H. pylori (p=<0.001) were found to be associated with esophagitis, and its presence may contribute to the development of BE. Conclusion The findings highlighted the high prevalence of GERD symptoms and pathologic gastritis along with EAC was less common than SCC and both types of esophageal cancer were associated with male gender and older age whereas, H. pylori infection was identified as a risk factor for pathologic gastritis in AA. Overall data emphasize the need for extensive research, increased awareness, diagnosis, and management of GERD, gastritis, and related conditions to uncover the underlying mechanisms and factors contributing to these conditions in the AA population.
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Affiliation(s)
- Hassan Ashktorab
- Department of Medicine and Cancer Center, Department of Pathology, Howard University College of Medicine, Washington DC, USA
| | - Sahar Geramfard
- Department of Medicine and Cancer Center, Department of Pathology, Howard University College of Medicine, Washington DC, USA
| | - Mudasir Rashid
- Department of Medicine and Cancer Center, Department of Pathology, Howard University College of Medicine, Washington DC, USA
| | - Rumaisa Rashid
- Department of Medicine and Cancer Center, Department of Pathology, Howard University College of Medicine, Washington DC, USA
| | - Swetha M Mynedi
- Department of Medicine and Cancer Center, Department of Pathology, Howard University College of Medicine, Washington DC, USA
| | - Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine University of Pittsburgh, PA, USA
| | - Ali Nezamloo
- Department of Medicine and Cancer Center, Department of Pathology, Howard University College of Medicine, Washington DC, USA
| | - Hassan Brim
- Department of Medicine and Cancer Center, Department of Pathology, Howard University College of Medicine, Washington DC, USA
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Why Has Screening and Surveillance for Barrett's Esophagus Fallen Short in Stemming the Rising Incidence of Esophageal Adenocarcinoma? Am J Gastroenterol 2023; 118:590-592. [PMID: 36728873 DOI: 10.14309/ajg.0000000000002159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/20/2022] [Indexed: 02/03/2023]
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10
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Kasiri K, Sherwin CM, Rostamian S, Heidari-Soureshjani S. Assessment of the Relationship Between Gastric-Acid Suppressants and the Risk of Esophageal Adenocarcinoma: A Systematic Review and Meta-Analysis. CURRENT THERAPEUTIC RESEARCH 2023; 98:100692. [PMID: 36798525 PMCID: PMC9925855 DOI: 10.1016/j.curtheres.2023.100692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/15/2023] [Indexed: 01/26/2023]
Abstract
Background Esophageal cancer is a cancerous tumor that develops in the esophagus. It is the 10th most common cancer and has a low survival rate. Esophageal adenocarcinoma (EAC) is increasing in incidence globally. Those with EAC are affected by Barrett's esophagus metaplasia, which is attributed to genetic predisposition and is more common in men. Studies suggest that gastric acid suppressants, like proton pump inhibitors and histamine-2 receptor antagonists, have anticancer properties and reduce EAC. However, other research has suggested that they are not cancer-protective, and the use of antisecretory drugs is a risk factor for developing EAC. Objective This systematic review and meta-analysis investigated the properties and risk factors associated with using gastric acid suppressants in patients with EAC. Methods This meta-analysis used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Information from selected articles, including the lead author's name, year of publication, study setting, sample size, and gender, was extracted and recorded into an Excel (Microsoft, Redmond, Washington) form. Statistical data included odds ratio, hazard ratio, and/or risk ratio, with a 95% CI associated with patients with EAC and receiving gastric acid suppressants. Data were compared with individuals not receiving treatment. Publication bias was assessed using Begg's and Egger's tests. Statistical analyzes used Stata 14.0 (Stata LLC, College Station, Texas). Results The initial electronic literature search retrieved 3761 titles/abstracts. Extensive screening selected 20 articles for analysis. Odds ratios associated with EAC in the individuals using gastric acid suppressants were 0.77 (95% CI, 0.49-1.22; P = 0.274) and 0.67 (95% CI, 0.39-1.29; P = 0.240) for proton pump inhibitors and 1.02 (95% CI, 0.44-2.36; P = 0.967) for histamine-2 receptor antagonists. Conclusions The results found that gastric acid suppressants do not have a protective role in EAC and are not risk factors. Future studies of confounding variables and risk factors are needed to understand what affects EAC development.
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Affiliation(s)
- Karamali Kasiri
- Department of Pediatrics, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Catherine M.T. Sherwin
- Pediatric Clinical Pharmacology and Toxicology, Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio
| | - Sahar Rostamian
- Shahrekord University of Medical Science, Student Research Committee, Shahrekord, Iran
| | - Saeid Heidari-Soureshjani
- Modeling in Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran,Address correspondence to: Saeid Heidari-Soureshjani, Kashani street, Shahrekord University of Medical Sciences, Shahrekord, Iran.
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11
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High rate of missed Barrett's esophagus when screening with forceps biopsies. Esophagus 2023; 20:143-149. [PMID: 35864425 PMCID: PMC9813185 DOI: 10.1007/s10388-022-00943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Screening for Barrett's esophagus (BE) with endoscopy plus forceps biopsy (FB) has poor compliance with the recommended Seattle protocol and fails to sample large areas of mucosa. This statistical modeling study estimates, for the first time, the actual frequency of missed BE cases by FB. METHODS Published, calibrated models in the literature were combined to calculate the age-specific prevalence of BE in white males with gastroesophageal reflux disease (GERD). We started with estimates of the prevalence of BE and GERD, and applied the relative risk for BE in patients with GERD based on the literature. This created estimates of the true prevalence of BE in white males with GERD by decade of life. The proportion of BE missed was calculated as the difference between the prevalence and the proportion with a positive screen. RESULTS The prevalence of BE in white males with GERD was 8.9%, 12.1%, 15.3%, 18.7% and 22.0% for the third through eighth decades of life. Even after assuming no false positives, missed cases of BE were about 50% when estimated for patients of ages 50 or 60 years, and over 60% for ages of 30, 40 or 70 years. Sensitivity analysis was done for all variables in the model calculations. For ages 50 and 60 years, this resulted in values from 30.3 to 57.3% and 36.4 to 60.9%. CONCLUSION Screening for BE with endoscopy and FB misses approximately 50% of BE cases. More sensitive methods of BE detection or better adherence to the Seattle protocol are needed.
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12
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Frederiks CN, van Munster SN, Nieuwenhuis EA, Alvarez Herrero L, Alkhalaf A, Schenk BE, Schoon EJ, Curvers WL, Koch AD, de Jonge PJF, Tang T, Nagengast WB, Westerhof J, Houben MHMG, Bergman JJGHM, Pouw RE, Weusten BLAM. Clinical Relevance of Random Biopsies From the Esophagogastric Junction After Complete Eradication of Barrett's Esophagus is Low. Clin Gastroenterol Hepatol 2022:S1542-3565(22)01091-6. [PMID: 36423874 DOI: 10.1016/j.cgh.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND & AIMS Although random histological sampling from the esophagogastric junction (EGJ) after complete eradication of Barrett's esophagus (BE) is recommended, its clinical relevance is questionable. This study aimed to assess the incidence and long-term outcomes of findings from random EGJ biopsies in a nationwide cohort with long-term follow-up. METHODS We included all patients with successful endoscopic eradication therapy (EET), defined as complete endoscopic eradication of all visible BE (CE-BE), for early BE neoplasia from the Dutch registry. Patients were treated and followed-up in 9 expert centers according to a joint protocol. Outcomes included the incidence of intestinal metaplasia (IM) at the EGJ (EGJ-IM) and the association between IM and visible (dysplastic) BE recurrence. RESULTS A total of 1154 patients were included with a median follow-up of 43 months (interquartile range, 22-69 months). At the time of CE-BE, persisting EGJ-IM was found in 7% of patients (78/1154), which was reproduced during further follow-up in 46% of patients (42/78). No significant association existed between persisting EGJ-IM at CE-BE and recurrent non-dysplastic or dysplastic BE (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.63-2.13 and HR, 0.73; 95% CI, 0.17-3.06, respectively). Among patients with no EGJ-IM at the time of CE-BE (1043/1154; 90%), EGJ-IM recurred in 7% (72/1043) after a median of 21 months (interquartile range, 15-36 months), and was reproduced during further follow-up in 26% of patients (19/72). No association was found between recurrent EGJ-IM and non-dysplastic or dysplastic recurrence (HR, 1.18; 95% CI, 0.67-2.06 and HR, 0.27; 95% CI, 0.04-1.96, respectively). CONCLUSION Because EGJ-IM was not associated with a higher risk for recurrent disease, we recommend to consider abandoning random EGJ sampling after successful EET, under the condition that care is provided in expert centers, and the esophagus, including the EGJ, is carefully inspected (Netherlands Trial Register, NL7309).
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Affiliation(s)
- Charlotte N Frederiks
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sanne N van Munster
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Boudewijn E Schenk
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter-Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Thjon Tang
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Cappelle a/d IJssel, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Souza RF, Spechler SJ. Mechanisms and pathophysiology of Barrett oesophagus. Nat Rev Gastroenterol Hepatol 2022; 19:605-620. [PMID: 35672395 DOI: 10.1038/s41575-022-00622-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 01/10/2023]
Abstract
Barrett oesophagus, in which a metaplastic columnar mucosa that can predispose individuals to cancer development lines a portion of the distal oesophagus, is the only known precursor of oesophageal adenocarcinoma, the incidence of which has increased profoundly over the past several decades. Most evidence suggests that Barrett oesophagus develops from progenitor cells at the oesophagogastric junction that proliferate and undergo epithelial-mesenchymal transition as part of a wound-healing process that replaces oesophageal squamous epithelium damaged by gastroesophageal reflux disease (GERD). GERD also seems to induce reprogramming of key transcription factors in the progenitor cells, resulting in the development of the specialized intestinal metaplasia that is characteristic of Barrett oesophagus, probably through an intermediate step of metaplasia to cardiac mucosa. Genome-wide association studies suggest that patients with GERD who develop Barrett oesophagus might have an inherited predisposition to oesophageal metaplasia and that there is a shared genetic susceptibility to Barrett oesophagus and to several of its risk factors (such as GERD, obesity and cigarette smoking). In this Review, we discuss the mechanisms, pathophysiology, genetic predisposition and cells of origin of Barrett oesophagus, and opine on the clinical implications and future research directions.
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Affiliation(s)
- Rhonda F Souza
- Division of Gastroenterology, Center for Oesophageal Diseases, Baylor University Medical Center, Dallas, TX, USA. .,Center for Oesophageal Research, Baylor Scott & White Research Institute, Dallas, TX, USA.
| | - Stuart J Spechler
- Division of Gastroenterology, Center for Oesophageal Diseases, Baylor University Medical Center, Dallas, TX, USA.,Center for Oesophageal Research, Baylor Scott & White Research Institute, Dallas, TX, USA
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14
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Guideline to Practice: Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol 2022; 117:1177-1180. [PMID: 35467555 DOI: 10.14309/ajg.0000000000001788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 12/11/2022]
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15
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Paiji C, Sedarat A. Endoscopic Management of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14153583. [PMID: 35892840 PMCID: PMC9329770 DOI: 10.3390/cancers14153583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.
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16
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Emura F, Chandrasekar VT, Hassan C, Armstrong D, Messmann H, Arantes V, Araya R, Barrera-Leon O, Bergman JJGHM, Bandhari P, Bourke MJ, Cerisoli C, Chiu PWY, Desai M, Dinis-Ribeiro M, Falk GW, Fujishiro M, Gaddam S, Goda K, Gross S, Haidry R, Ho L, Iyer PG, Kashin S, Kothari S, Lee YY, Matsuda K, Neuhaus H, Oyama T, Ragunath K, Repici A, Shaheen N, Singh R, Sobrino-Cossio S, Wang KK, Waxman I, Sharma P. Rio de Janeiro Global Consensus on Landmarks, Definitions, and Classifications in Barrett's Esophagus: World Endoscopy Organization Delphi Study. Gastroenterology 2022; 163:84-96.e2. [PMID: 35339464 DOI: 10.1053/j.gastro.2022.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND & AIMS Despite the significant advances made in the diagnosis and treatment of Barrett's esophagus (BE), there is still a need for standardized definitions, appropriate recognition of endoscopic landmarks, and consistent use of classification systems. Current controversies in basic definitions of BE and the relative lack of anatomic knowledge are significant barriers to uniform documentation. We aimed to provide consensus-driven recommendations for uniform reporting and global application. METHODS The World Endoscopy Organization Barrett's Esophagus Committee appointed leaders to develop an evidence-based Delphi study. A working group of 6 members identified and formulated 23 statements, and 30 internationally recognized experts from 18 countries participated in 3 rounds of voting. We defined consensus as agreement by ≥80% of experts for each statement and used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to assess the quality of evidence and the strength of recommendations. RESULTS After 3 rounds of voting, experts achieved consensus on 6 endoscopic landmarks (palisade vessels, gastroesophageal junction, squamocolumnar junction, lesion location, extraluminal compressions, and quadrant orientation), 13 definitions (BE, hiatus hernia, squamous islands, columnar islands, Barrett's endoscopic therapy, endoscopic resection, endoscopic ablation, systematic inspection, complete eradication of intestinal metaplasia, complete eradication of dysplasia, residual disease, recurrent disease, and failure of endoscopic therapy), and 4 classification systems (Prague, Los Angeles, Paris, and Barrett's International NBI Group). In round 1, 18 statements (78%) reached consensus, with 12 (67%) receiving strong agreement from more than half of the experts. In round 2, 4 of the remaining statements (80%) reached consensus, with 1 statement receiving strong agreement from 50% of the experts. In the third round, a consensus was reached on the remaining statement. CONCLUSIONS We developed evidence-based, consensus-driven statements on endoscopic landmarks, definitions, and classifications of BE. These recommendations may facilitate global uniform reporting in BE.
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Affiliation(s)
- Fabian Emura
- Gastroenterology Division, Universidad de La Sabana, Chía, Colombia; Advanced GI Endoscopy, EmuraCenter LatinoAmerica, Bogotá DC, Colombia.
| | | | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy; Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - David Armstrong
- Division of Gastroenterology & Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Vitor Arantes
- Endoscopy Division, Hospital das Clınicas e Mater Dei Contorno, Belo Horizonte, Brazil; Alfa Institute of Gastroenterology, Medical School, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Raul Araya
- Clinic Los Andes University, Division of Gastroenterology and Endoscopy, Army Hospital of Santiago, Santiago, Chile
| | - Oscar Barrera-Leon
- Gastroenterology Division, Universidad de La Sabana, Chía, Colombia; Advanced GI Endoscopy, EmuraCenter LatinoAmerica, Bogotá DC, Colombia
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Pradeep Bandhari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Cecilio Cerisoli
- Gastroenterology and Diagnostic and Therapeutic Endoscopy (GEDYT), Buenos Aires, Argentina
| | | | - Madhav Desai
- Division of Gastroenterology, VA Medical Center and University of Kansas School of Medicine, Kansas City, Missouri
| | - Mário Dinis-Ribeiro
- MEDCIDS-Department of Community Medicine, Information and Decision in Health, Faculty of Porto, University of Medicine, Porto, Portugal
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Srinivas Gaddam
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kenichi Goda
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Seth Gross
- Division of Gastroenterology, NYU Langone Medical Center, New York, New York
| | - Rehan Haidry
- Department of Gastrointestinal and Endoscopy, University College London Hospital, London, UK
| | - Lawrence Ho
- Division of Gastroenterology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Sergey Kashin
- Department of Gastroenterology, Yaroslavl Oncology Hospital, Yaroslavl, Russian Federation
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center and Strong Memorial Hospital, Rochester, New York; Developmental Endoscopy, Lab at University of Rochester (DELUR), University of Rochester Medical, Rochester, New York
| | - Yeong Yeh Lee
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Koji Matsuda
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, Kawasaki, Japan
| | - Horst Neuhaus
- Department of Internal Medicine, Gastroenterology and Interventional Endoscopy, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan
| | - Krish Ragunath
- Department of Gastroenterology, Curtin University Medical School, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy; Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Nicholas Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rajvinder Singh
- Department of Gastroenterology, The Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Sergio Sobrino-Cossio
- Unidad de Endoscopia y Fisiología Digestiva, Hospital Ángeles del Pedregal, México DF, México
| | - Kenneth K Wang
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Irving Waxman
- Division of Gastroenterology, University of Chicago Medical Center, Chicago, Illinois
| | - Prateek Sharma
- Division of Gastroenterology, VA Medical Center and University of Kansas School of Medicine, Kansas City, Missouri
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Tubularized and Effaced Gastric Cardia Mimicking Barrett Esophagus following Sleeve Gastrectomy: Protocolized Endoscopic and Histological Assessment with High-Resolution Manometry Analysis. Ann Surg 2022; 276:119-127. [PMID: 35703462 DOI: 10.1097/sla.0000000000005493] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To describe expected endoscopic and histological changes at gastro-esophageal junction (GEJ) and define diagnostic paradigms for Barrett esophagus (BE) post-sleeve gastrectomy (SG). SUMMARY BACKGROUND DATA De novo incidence of BE post-SG was reported as high as 18.8%. A confounding factor is the lack of standardized definition of BE post-SG, which may differ from the general population due to procedure-induced alterations of GEJ. METHODS Part 1 involved evaluating endoscopic changes of GEJ post-SG (N = 567) compared to pre-SG (N = 320), utilizing protocolized pre-operative screening, post-operative surveillance and synoptic reporting. Part 2 involved dedicated studies examining causes of altered anatomical and mucosal GEJ appearance using histopathology (N = 55) and high-resolution manometry (HRM) (N = 15). RESULTS Part 1 - A characteristic tubularized cardia segment projecting supra-diaphragmatically was identified and almost exclusive to post-SG (0.6%vs.26.6%, p < 0.001). True BE prevalence was low (4.1%pre-SG vs. 3.8%post-SG, p = 0.756), esophagitis was comparable (32.1%vs.25.9%, p = 0.056).Part 2 - Histologically-confirmed BE was found in 12/55 patients, but 70.8% had glandular-type gastric mucosa implying tubularized cardia herniation. HRM of tubularized cardia demonstrated concordance of supra-diaphragmatic cardia herniation between endoscopy and HRM (3cmvs.3.2 cm, p = 0.168), with frequent elevated isobaric intraluminal pressurizations in supra- and infra-diaphragmatic cardia compartments. CONCLUSION A novel appearance of tubularized cardia telescoping supra-diaphragmatically with flattening of gastric folds is common post-SG, likely associated with isobaric hyper-pressurization of proximal stomach. Incidence of true BE post-SG is low in short-intermediate term. These provided a clear framework for approaching endoscopic screening and surveillance, with correct anatomical and mucosal identifications, and clarified key issues of SG and BE.
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Fukuda S, Watanabe K, Yoshida T, Takahashi S, Fujimori S, Horikawa Y, Komatsu T, Shirane K, Shimodaira Y, Matsuhashi T, Iijima K. Low risk of esophageal adenocarcinoma among patients with ultrashort-segment Barrett's esophagus in Japan. Dig Endosc 2022; 34:757-765. [PMID: 34437742 DOI: 10.1111/den.14118] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/22/2021] [Accepted: 08/25/2021] [Indexed: 12/13/2022]
Abstract
OBJECTS Ultrashort-segment Barrett's esophagus (USSBE; length of <1 cm) is very frequently diagnosed in Japan, but the cancer risk of USSBE is unknown. In this study, by retrieving endoscopic images, we retrospectively investigated the incidence of esophageal adenocarcinoma (EAC) by the grade of Barrett's esophagus (BE) and compared the findings with those of gastric cancer by the degree of endoscopic gastric atrophy in the same population. METHODS Among consecutive participants who had undergone endoscopy for an annual health checkup in 2014, the 9121 who had received at least one follow-up endoscopy by December 2020 were enrolled in this study. Using the retrieved endoscopic images, we retrospectively evaluated BE and gastric atrophy. Information on the subsequent occurrence of EAC and gastric cancer as of December 2020 was also collected. The incidence of cancer by the extent of BE and gastric atrophy was calculated and expressed as the percentage per year. RESULTS On reviewing the endoscopic image in 2014, 4190 (45.9%) were found to have been diagnosed with BE, of whom 3318 (36.4%) were judged to have USSBE. During an observation period of 54.1 (17.9) months, 89 gastric cancers and only two EACs were identified. The incidence of EAC in USSBE was 0.0068%/year, which was nearly as low as the incidence of gastric cancer in atrophy-free patients (0.0068% vs. 0.0059%/year). CONCLUSIONS Although the prevalence of USSBE is quite high (36.4%), the incidence of EAC in USSBE is very low (0.0068%/year). Accordingly, USSBE can be excluded from targets for endoscopic surveillance in Japan.
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Affiliation(s)
- Sho Fukuda
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Kenta Watanabe
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tatsuki Yoshida
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - So Takahashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Shusei Fujimori
- Department of Gastroenterology, Yokote Municipal Hospital, Akita, Japan
| | - Yohei Horikawa
- Department of Gastroenterology, Hiraka General Hospital, Akita, Japan
| | - Taiga Komatsu
- Department of Anesthesiology, Honjo-Daiichi Hospital, Akita, Japan
| | | | - Yosuke Shimodaira
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
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Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol 2022; 117:559-587. [PMID: 35354777 DOI: 10.14309/ajg.0000000000001680] [Citation(s) in RCA: 158] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 02/04/2022] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus (BE) is a common condition associated with chronic gastroesophageal reflux disease. BE is the only known precursor to esophageal adenocarcinoma, a highly lethal cancer with an increasing incidence over the last 5 decades. These revised guidelines implement Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the definition and diagnosis of BE, screening for BE and esophageal adenocarcinoma, surveillance of patients with known BE, and the medical and endoscopic treatment of BE and its associated early neoplasia. Important changes since the previous iteration of this guideline include a broadening of acceptable screening modalities for BE to include nonendoscopic methods, liberalized intervals for surveillance of short-segment BE, and volume criteria for endoscopic therapy centers for BE. We recommend endoscopic eradication therapy for patients with BE and high-grade dysplasia and those with BE and low-grade dysplasia. We propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia. We could not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data.
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Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.
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Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
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21
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van Munster S, Nieuwenhuis E, Weusten BLAM, Alvarez Herrero L, Bogte A, Alkhalaf A, Schenk BE, Schoon EJ, Curvers W, Koch AD, van de Ven SEM, de Jonge PJF, Tang TJ, Nagengast WB, Peters FTM, Westerhof J, Houben MHMG, Bergman JJ, Pouw RE. Long-term outcomes after endoscopic treatment for Barrett's neoplasia with radiofrequency ablation ± endoscopic resection: results from the national Dutch database in a 10-year period. Gut 2022; 71:265-276. [PMID: 33753417 PMCID: PMC8762001 DOI: 10.1136/gutjnl-2020-322615] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Radiofrequency ablation (RFA)±endoscopic resection (ER) is the preferred treatment for early neoplasia in Barrett's oesophagus (BE). We aimed to report short-term and long-term outcomes for all 1384 patients treated in the Netherlands (NL) from 2008 to 2018, with uniform treatment and follow-up (FU) in a centralised setting. DESIGN Endoscopic therapy for early BE neoplasia in NL is centralised in nine expert centres with specifically trained endoscopists and pathologists that adhere to a joint protocol. Prospectively collected data are registered in a uniform database. Patients with low/high-grade dysplasia or low-risk cancer, were treated by ER of visible lesions followed by trimonthly RFA sessions of any residual BE until complete eradication of BE (CE-BE). Patients with ER alone were not included. RESULTS After ER (62% of cases; 43% low-risk cancers) and median 1 circumferential and 2 focal RFA (p25-p75 0-1; 1-2) per patient, CE-BE was achieved in 94% (1270/1348). Adverse events occurred in 21% (268/1386), most commonly oesophageal stenosis (15%), all were managed endoscopically. A total of 1154 patients with CE-BE were analysed for long-term outcomes. During median 43 months (22-69) and 4 endoscopies (1-5), 38 patients developed dysplastic recurrence (3%, annual recurrence risk 1%), all were detected as endoscopically visible abnormalities. Random biopsies from a normal appearing cardia showed intestinal metaplasia (IM) in 14% and neoplasia in 0%. A finding of IM in the cardia was reproduced during further FU in only 33%, none progressed to neoplasia. Frequent FU visits in the first year of FU were not associated with recurrence risk. CONCLUSION In a setting of centralised care, RFA±ER is effective for eradication of Barrett's related neoplasia and has remarkably low rates of dysplastic recurrence. Our data support more lenient FU intervals, with emphasis on careful endoscopic inspection. Random biopsies from neosquamous epithelium and cardia are of questionable value. NETHERLANDS TRIAL REGISTER NUMBER NL7039.
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Affiliation(s)
- Sanne van Munster
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Esther Nieuwenhuis
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Bas L A M Weusten
- Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Auke Bogte
- Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alaa Alkhalaf
- Gastroenterology and Hepatology, Isala Klinieken, Zwolle, Overijssel, The Netherlands
| | - B E Schenk
- Gastroenterology and Hepatology, Isala Klinieken, Zwolle, Overijssel, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Wouter Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Arjun D Koch
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Tjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Ziekenhuis, Capelle aan den IJssel, Zuid-Holland, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frans T M Peters
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H M G Houben
- Gastroenterology and Hepatology, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Jacques Jghm Bergman
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Roos E Pouw
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
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22
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Yao H, Wang L, Li H, Xu S, Bai Z, Wu Y, Chen H, Goyal H, Qi X. Proton pump inhibitors may reduce the risk of high-grade dysplasia and/or esophageal adenocarcinoma in Barrett's esophagus: a systematic review and meta-analysis. Expert Rev Clin Pharmacol 2022; 15:79-88. [PMID: 34806503 DOI: 10.1080/17512433.2022.2008909] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Barrett's esophagus (BE) is an important risk factor for high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC). The effect of proton pump inhibitors (PPIs) on the chemoprevention of HGD and/or EAC arising from BE remains controversial. RESEARCH DESIGN AND METHODS PubMed, EMBASE, and Cochrane Library databases were systematically searched. Risk ratios (RRs) or odds ratios (ORs) with 95% confidence intervals (CIs) were pooled by a random-effect model. Heterogeneity and its potential source were assessed. RESULTS Fifteen studies with 26,291 BE patients were included. Meta-analysis of eight cohort studies showed that PPIs can significantly reduce the risk of HGD and/or EAC in BE patients (RR = 0.46; P < 0.001), but meta-analysis of six case-control studies showed no significant benefit of PPIs (OR = 0.64; P = 0.334). Heterogeneity was significant among both cohort and case-control studies, which might be attributed to the information sources of PPIs. There was no significant protective effect of high-dose PPIs on HGD and/or EAC in one RCT (RR = 0.84; P = 0.21), meta-analysis of two cohort studies (RR = 0.61; P = 0.28), or meta-analysis of two case-control studies (OR = 0.32; P = 0.08). CONCLUSIONS Chemoprevention of HGD and/or EAC by PPIs may be considered in BE patients. However, there might not be further preventive effect of high-dose PPIs.
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Affiliation(s)
- Haijuan Yao
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, P.R. China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Shixue Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Yanyan Wu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Hongxin Chen
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, P.R. China
| | - Hemant Goyal
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
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23
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Abstract
BACKGROUND Identification of Barrett's esophagus (BE) with the treatment of dysplasia is essential to prevent esophageal adenocarcinoma (EAC). Moreover, determination of BE prevalence is important to define subsequent management strategies. However, precise estimates on BE prevalence from several European countries are lacking. We aimed to determine BE prevalence in a Southern European country. METHODS A cross-sectional, multicenter study from November 2019 to February 2020 was performed defining BE as a columnar extent in the distal esophagus greater than or equal to 1 cm with intestinal metaplasia. RESULTS A total of 1550 individuals, 51% male with a mean age of 62 (SD = 15) years undergoing upper endoscopy were included. The overall BE prevalence was 1.29% (95% confidence interval: 0.73-1.85); significantly higher in men [2.05% (1.06-3.04)] vs. women [0.53% (0.01-1.04)]. Of the 20 BE patients, eight were newly diagnosed and 12 were under surveillance. The median extent was C3 (min 0; max 16) M4.5 (min 2; max 16). One patient each had EAC (0.06%) and high-grade dysplasia (0.06%) at the time of endoscopy. There was no difference in prevalence between geographical regions, centers, use of sedation or experience of endoscopists. Considering all reports, 93% used standardized terminology, 23% accurate photodocumentation and 69% photodocumented the esophagogastric junction (EGJ). Furthermore, 80% used Prague classification, 55% Seattle protocol, 60% distance to the squamocolumnar junction, 75% to the EGJ and 40% to the hiatal pinch. When considering only reports with EGJ photodocumentation or Prague classification, the prevalence was 1.78% (0.91-2.64) or 1.03% (0.53-1.53). CONCLUSION We report for the first time BE prevalence in Southern Europe and report a low overall prevalence in an unselected population. Future studies need to determine progression rates and how to improve quality metrics.
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24
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Chang K, Jackson CS, Vega KJ. Barrett's Esophagus: Diagnosis, Management, and Key Updates. Gastroenterol Clin North Am 2021; 50:751-768. [PMID: 34717869 DOI: 10.1016/j.gtc.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Barrett's esophagus (BE) is the precursor lesion for esophageal adenocarcinoma (EAC) development. Unfortunately, BE screening/surveillance has not provided the anticipated EAC reduction benefit. Noninvasive techniques are increasingly available or undergoing testing to screen for BE among those with/without known risk factors, and the use of artificial intelligence platforms to aid endoscopic screening and surveillance will likely become routine, minimizing missed cases or lesions. Management of high-grade dysplasia and intramucosal EAC is clear with endoscopic eradication therapy preferred to surgery. BE with low-grade dysplasia can be managed with removal of visible lesions combined with endoscopic eradication therapy or endoscopic surveillance at present.
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Affiliation(s)
- Karen Chang
- Department of Internal Medicine, University of California, Riverside School of Medicine, 900 University Avenue, Riverside, CA 92521, USA
| | - Christian S Jackson
- Section of Gastroenterology, Loma Linda VA Healthcare System, 11201 Benton Street, 2A-38, Loma Linda, CA 92357, USA
| | - Kenneth J Vega
- Division of Gastroenterology & Hepatology, Augusta University-Medical College of Georgia, 1120 15th Street, AD-2226, Augusta, GA 30912, USA.
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25
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Ventre S, Shahid H. Endoscopic therapies for Barrett's esophagus. Transl Gastroenterol Hepatol 2021; 6:62. [PMID: 34805584 DOI: 10.21037/tgh.2020.02.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/23/2020] [Indexed: 11/06/2022] Open
Abstract
The management of Barrett's esophagus (BE) has evolved as newer technologies and novel methods are developed. Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are the initial interventions of choice for nodular BE, with ESD reserved for endoscopists highly trained in the technique and for larger lesions that would warrant en bloc resection. Resection should then be followed by ablative therapy, which remains first line in the treatment of BE with dysplasia. Although there is a myriad of ablation techniques available to the endoscopist, this review has found that radiofrequency ablation (RFA) continues to have the most robust safety and efficacy data to support its use despite a relatively high rate of recurrence. Cryotherapy and Hybrid-APC appear to be safe and effective as RFA alternatives, but further trials are still needed to directly compare their outcomes to RFA and ultimately guide changes in treatment decisions.
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Affiliation(s)
- Scott Ventre
- Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Haroon Shahid
- Division of Gastroenterology & Hepatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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26
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Jung HK, Tae CH, Song KH, Kang SJ, Park JK, Gong EJ, Shin JE, Lim HC, Lee SK, Jung DH, Choi YJ, Seo SI, Kim JS, Lee JM, Kim BJ, Kang SH, Park CH, Choi SC, Kwon JG, Park KS, Park MI, Lee TH, Kim SY, Cho YS, Lee HH, Jung KW, Kim DH, Moon HS, Miwa H, Chen CL, Gonlachanvit S, Ghoshal UC, Wu JCY, Siah KTH, Hou X, Oshima T, Choi MY, Lee KJ. 2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2021; 27:453-481. [PMID: 34642267 PMCID: PMC8521465 DOI: 10.5056/jnm21077] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.
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Affiliation(s)
- Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyung Ho Song
- Division of Gastroenterology, Department of Internal Medicine, CHA Ilsan Medical Center, CHA University School of Medicine, Ilsan, Jeollabuk-do, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Gangnam Center, Seoul, Korea
| | - Jong Kyu Park
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Chungcheongnam-do, Korea
| | - Hyun Chul Lim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Jin Choi
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung In Seo
- Division of Gastroenterology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jung Min Lee
- Digestive Disease Center, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sun Hyung Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Suck Chei Choi
- Department of Internal Medicine and Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Jeollabuk-do, Korea
| | - Joong Goo Kwon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Seung Young Kim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan, Hospital, Cheonan, Chungcheongnamdo, Korea
| | - Han Hong Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hirota Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Chien-Lin Chen
- Institute of Medical Sciences, Tzu Chi University, and Department of Public Health, College of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Sutep Gonlachanvit
- Center of Excellence on Neurogastroenterology and Motility, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Uday C Ghoshal
- Departments of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India
| | - Justin C Y Wu
- Institute of Digestive Disease, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, China
| | - Kewin T H Siah
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Hospital, Singapore
| | - Xiaohua Hou
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Mi-Young Choi
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
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Condon A, Muthusamy VR. The evolution of endoscopic therapy for Barrett's esophagus. Ther Adv Gastrointest Endosc 2021; 14:26317745211051834. [PMID: 34708204 PMCID: PMC8543722 DOI: 10.1177/26317745211051834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/21/2021] [Indexed: 12/20/2022] Open
Abstract
Barrett’s esophagus is the condition in which a metaplastic columnar epithelium
replaces the stratified squamous epithelium that normally lines the distal
esophagus. The condition develops as a consequence of chronic gastroesophageal
reflux disease and predisposes the patient to the development of esophageal
adenocarcinoma. The diagnosis and management of Barrett’s esophagus have
undergone dramatic changes over the years and continue to evolve today.
Endoscopic eradication therapy has revolutionized the management of dysplastic
Barrett’s esophagus and early esophageal adenocarcinoma by significantly
reducing the morbidity and mortality associated with the prior gold standard of
therapy, esophagectomy. The purpose of this review is to highlight current
principles in the management and endoscopic treatment of this disease.
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Affiliation(s)
- Ashwinee Condon
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - V Raman Muthusamy
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
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28
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Salimian KJ, Birkness-Gartman J, Waters KM. The path(ology) from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. Pathology 2021; 54:147-156. [PMID: 34711413 DOI: 10.1016/j.pathol.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
This review seeks to summarise the steps in the path from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. The epidemiology, clinical presentation, definitions, pathological features, diagnostic pitfalls, and emerging concepts are reviewed for each entity. The histological features of reflux oesophagitis can be variable and are not specific. Cases of reflux oesophagitis with numerous eosinophils are difficult to distinguish from eosinophilic oesophagitis and other oesophagitides with eosinophils (Crohn's disease, medication effect, and connective tissue disorders). In reflux oesophagitis, the findings are often most pronounced in the distal oesophagus, the eosinophils are randomly distributed throughout the epithelium, and eosinophilic abscesses and degranulated eosinophils are rare. For reflux oesophagitis with prominent lymphocytes, clinical history and ancillary clinical studies are paramount to distinguish reflux oesophagitis from other causes of lymphocytic oesophagitis pattern. For Barrett oesophagus, the definition remains a hotly debated topic for which the requirement for intestinal metaplasia to make the diagnosis is not applied unanimously across the globe. Assessing for dysplasia is a challenging aspect of the histological interpretation that guides clinical management. We describe the histological features that we find useful in making this evaluation. Oesophageal adenocarcinoma has been steadily increasing in incidence and has a poor prognosis. The extent of invasion can be overdiagnosed due to a duplicated muscularis mucosae. We also describe the technical factors that can lead to challenges in distinguishing the mucosal and deep margins of endoscopic resections. Lastly, we give an overview of targeted therapies with emerging importance and the ancillary tests that can identify the cases best suited for each therapy.
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Affiliation(s)
- Kevan J Salimian
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Kevin M Waters
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA.
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29
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Validation of a methylated DNA marker panel for the nonendoscopic detection of Barrett's esophagus in a multisite case-control study. Gastrointest Endosc 2021; 94:498-505. [PMID: 33857451 PMCID: PMC8380660 DOI: 10.1016/j.gie.2021.03.937] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS We previously identified a 5 methylated DNA marker (MDM) panel for the detection of nonendoscopic Barrett's esophagus (BE). In this study, we aimed to recalibrate the performance of the 5 MDM panel using a simplified assay in a training cohort, validate the panel in an independent test cohort, and explore the accuracy of an MDM panel with only 3 markers. METHODS Participants were recruited from 3 medical centers. The sponge on a string device (EsophaCap; CapNostics, Concord, NC, USA) was swallowed and withdrawn, followed by endoscopy, in BE cases and control subjects. A 5 MDM panel was blindly assayed using a simplified assay. Random forest modeling analysis was performed, in silico cross-validated in the training set, and then locked down, before test set analysis. RESULTS The training set had 199 patients: 110 BE cases and 89 control subjects, and the test set had 89 patients: 60 BE cases and 29 control subjects. Sensitivity of the 5 MDM panel for BE diagnosis was 93% at 90% specificity in the training set and 93% at 93% specificity in the test set. Areas under the receiver operating characteristic curves were .96 and .97 in the training and test sets, respectively. Model accuracy was not influenced by age, sex, or smoking history. Multiple 3 MDM panels achieved similar accuracy. CONCLUSIONS A 5 MDM panel for BE is highly accurate in training and test sets in a blinded multisite case-control analysis using a simplified assay. This panel may be reduced to only 3 MDMs in the future. (Clinical trial registration number: NCT02560623.).
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Sami SS, Moriarty JP, Rosedahl JK, Borah BJ, Katzka DA, Wang KK, Kisiel JB, Ragunath K, Rubenstein JH, Iyer PG. Comparative Cost Effectiveness of Reflux-Based and Reflux-Independent Strategies for Barrett's Esophagus Screening. Am J Gastroenterol 2021; 116:1620-1631. [PMID: 34131096 PMCID: PMC8315187 DOI: 10.14309/ajg.0000000000001336] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/12/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Minimally invasive tests for Barrett's esophagus (BE) detection have raised the prospect of broader nonreflux-based testing. Cost-effectiveness studies have largely studied men aged 50 years with chronic gastroesophageal reflux disease (GERD) symptoms. We evaluated the comparative cost effectiveness of BE screening tests in GERD-based and GERD-independent testing scenarios. METHODS Markov modeling was performed in 3 scenarios in 50 years old individuals: (i) White men with chronic GERD (GERD-based); (ii) GERD-independent (all races, men and women), BE prevalence 1.6%; and (iii) GERD-independent, BE prevalence 5%. The simulation compared multiple screening strategies with no screening: sedated endoscopy (sEGD), transnasal endoscopy, swallowable esophageal cell collection devices with biomarkers, and exhaled volatile organic compounds. A hypothetical cohort of 500,000 individuals followed for 40 years using a willingness to pay threshold of $100,000 per quality-adjusted life year (QALY) was simulated. Incremental cost-effectiveness ratios (ICERs) comparing each strategy with no screening and comparing screening strategies with each other were calculated. RESULTS In both GERD-independent scenarios, most non-sEGD BE screening tests were cost effective. Swallowable esophageal cell collection devices with biomarkers were cost effective (<$35,000/QALY) and were the optimal screening tests in all scenarios. Exhaled volatile organic compounds had the highest ICERs in all scenarios. ICERs were low (<$25,000/QALY) for all tests in the GERD-based scenario, and all non-sEGD tests dominated no screening. ICERs were sensitive to BE prevalence and test costs. DISCUSSION Minimally invasive nonendoscopic tests may make GERD-independent BE screening cost effective. Participation rates for these strategies need to be studied.
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Affiliation(s)
- Sarmed S. Sami
- Division of Surgery and Interventional Science, University College London, London, UK;
| | - James P. Moriarty
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jordan K. Rosedahl
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan J. Borah
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - David A. Katzka
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K. Wang
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John B. Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Joel H. Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Prasad G. Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Ishikawa K, Okimoto K, Matsumura T, Hirotsu Y, Amemiya K, Kishimoto T, Akizue N, Ohta Y, Saito K, Maruoka D, Nishimura M, Matsushita K, Mochizuki H, Arai M, Kato J, Yokosuka O, Omata M, Kato N. Comprehensive Analysis of Barrett's Esophagus: Focused on Carcinogenic Potential for Barrett's Cancer in Japanese Patients. Dig Dis Sci 2021; 66:2674-2681. [PMID: 32840705 DOI: 10.1007/s10620-020-06563-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/12/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND/AIM Barrett's esophagus (BE) is a precursor of esophageal adenocarcinoma (EAC). Therefore, an accurate diagnosis of BE is important for the subsequent follow-up and early detection of EAC. However, the definitions of BE have not been standardized worldwide; columnar-lined epithelium (CLE) without intestinal metaplasia (IM) and/or < 1 cm is not diagnosed as BE in most countries. This study aimed to clarify the malignant potential of CLE without IM and/or < 1 cm genetically. METHOD A total of 96 consecutive patients (including nine patients with EAC) who had CLE were examined. Biopsies for CLE were conducted, and patients were divided into those with IM and > 1 cm (Group A) and those without IM and/or < 1 cm (Group B). Malignant potential was assessed using immunochemical staining for p53. Moreover, causative genes were examined using next-generation sequencing (NGS) on ten patients without Helicobacter pylori infection and without atrophic gastritis. RESULT Of the 96 patients, 66 were in Group B. The proportion of carcinoma/dysplasia in Group A was significantly higher than that in Group B (26.7% in Group A and 1.5% in Group B; p < 0.01). However, one EAC patient was found in Group B. In the immunostaining study for non-EAC patients, an abnormal expression of p53 was not observed in Group A, whereas p53 loss was observed in three patients (4.6%) in Group B. In the NGS study, a TP53 mutation was found in Group B. CONCLUSION CLE without IM and/or < 1 cm has malignant potential. This result suggests that patients with CLE as well as BE need follow-up.
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Affiliation(s)
- Kentaro Ishikawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan. .,Department of Medical Oncology, Chiba University Hospital, Chiba, Japan.
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Yosuke Hirotsu
- Genome Analysis Center, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi, Japan
| | - Kenji Amemiya
- Genome Analysis Center, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi, Japan
| | - Takashi Kishimoto
- Department of Molecular Pathology, Graduate School of Medicine, Chiba University Hospital, Chiba, Japan
| | - Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Keiko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan.,Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Motoi Nishimura
- Division of Laboratory Medicine, Chiba University Hospital, Chiba, Japan
| | | | - Hitoshi Mochizuki
- Genome Analysis Center, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi, Japan
| | - Makoto Arai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan.,Department of Medical Oncology, Chiba University Hospital, Chiba, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Osamu Yokosuka
- Graduate School of Medicine, University of Chiba, Chiba, Japan
| | - Masao Omata
- Genome Analysis Center, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi, Japan.,Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University Hospital, Inohana 1-8-1, Chiba-City, 260-8670, Japan
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Klaver E, Bureo Gonzalez A, Mostafavi N, Mallant-Hent R, Duits LC, Baak B, Böhmer CJM, van Oijen AHAM, Naber T, Scholten P, Meijer SL, Bergman JJGHM, Pouw RE. Barrett's esophagus surveillance in a prospective Dutch multi-center community-based cohort of 985 patients demonstrates low risk of neoplastic progression. United European Gastroenterol J 2021; 9:929-937. [PMID: 34228885 PMCID: PMC8498404 DOI: 10.1002/ueg2.12114] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/18/2021] [Indexed: 12/20/2022] Open
Abstract
Background and Aims Barrett's esophagus (BE) is accompanied by an increased risk of developing esophageal cancer. Accurate risk‐stratification is warranted to improve endoscopic surveillance. Most data available on risk factors is derived from tertiary care centers or from cohorts with limited surveillance time or surveillance quality. The aim of this study was to assess endoscopic and clinical risk factors for progression to high‐grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in a large prospective cohort of BE patients from community hospitals supported by an overarching infrastructure to ensure optimal surveillance quality. Methods A well‐defined prospective multicenter cohort study was initiated in six community hospitals in the Amsterdam region in 2003. BE patients were identified by PALGA search and included in a prospective surveillance program with a single endoscopist performing all endoscopies at each hospital. Planning and data collection was performed by experienced research nurses who attended all endoscopies. Endpoint was progression to HGD/EAC. Results Nine hundred eighty‐five patients were included for analysis. During median follow‐up of 7.9 years (IQR 4.1–12.5) 67 patients were diagnosed with HGD (n = 28) or EAC (n = 39), progression rate 0.78% per patient‐year. As a clinical risk factor age at time of endoscopy was associated with neoplastic progression (HR 1.05; 95% CI 1.03–1.08). Maximum Barrett length and low‐grade dysplasia (LGD) at baseline were endoscopic predictors of progression (HR 1.15; 95% CI 1.09–1.21 and HR 2.36; 95% CI 1.29–4.33). Conclusion Risk of progression to HGD/EAC in a large, prospective, community‐based Barrett's cohort was low. Barrett's length, LGD and age were important risk factors for progression. (www.trialregister.nl NTR1789)
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Affiliation(s)
- Esther Klaver
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Angela Bureo Gonzalez
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nahid Mostafavi
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rosalie Mallant-Hent
- Department of Gastroenterology and Hepatology, Flevohospital, Almere, The Netherlands
| | - Lucas C Duits
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert Baak
- Department of Gastroenterology and Hepatology, OLVG Oost, Amsterdam, The Netherlands
| | - Clarisse J M Böhmer
- Department of Gastroenterology and Hepatology, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Arnoud H A M van Oijen
- Department of Gastroenterology and Hepatology, Nothwest Clinics, Alkmaar, The Netherlands
| | - Ton Naber
- Department of Internal Medicine, Tergooi Hospitals, Hilversum, The Netherlands
| | - Pieter Scholten
- Department of Gastroenterology and Hepatology, OLVG West, Amsterdam, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Iyer PG, Katzka DA. Nonendoscopic Detection of Barrett Esophagus and Esophageal Adenocarcinoma: Recent Advances and Implications. Ann Intern Med 2021; 174:1006-1007. [PMID: 33939476 PMCID: PMC8292209 DOI: 10.7326/m20-7164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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How extent of Barrett's metaplasia influences the risk of esophageal adenocarcinoma. Curr Opin Gastroenterol 2021; 37:378-383. [PMID: 33883421 DOI: 10.1097/mog.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW This review will focus on how the extent of Barrett's metaplasia influences the risk of esophageal adenocarcinoma (EAC). More specifically, this review will discuss the concepts of long and short-segment Barrett's metaplasia and irregular Z line as they relate to EAC risk. RECENT FINDINGS The Prague classification can standardize reporting of Barrett's metaplasia. Recent literature has found significant associations between the length of Barrett's metaplasia and increased progression risk to EAC in multiple geographically distinct populations. Length of Barrett's metaplasia has been incorporated into the Progression of Barrett's esophagus (PIB) model that can predict individualized life-time risks of progression. The risk of malignant transformation appears to be very low in patients with irregular Z line. SUMMARY Length of Barrett's metaplasia has emerged as an important predictor that can influence the risk of EAC and should be reported using the Prague classification. The PIB model, if further validated, could help a practicing gastroenterologist to inform patients with Barrett's metaplasia about their personal risk of progression to tailor surveillance intervals. Current guidelines do not recommend surveillance in patients with irregular Z line, but careful examination is recommended.
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Solfisburg QS, Sami SS, Gabre J, Soroush A, Dhaliwal L, Beveridge C, Jin Z, Poneros JM, Falk GW, Ginsberg GG, Wang KK, Lightdale CJ, Iyer PG, Abrams JA. Clinical significance of recurrent gastroesophageal junction intestinal metaplasia after endoscopic eradication of Barrett's esophagus. Gastrointest Endosc 2021; 93:1250-1257.e3. [PMID: 33144238 DOI: 10.1016/j.gie.2020.10.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS After endoscopic eradication of Barrett's esophagus (BE), recurrence of intestinal metaplasia at the gastroesophageal junction (GEJIM) is common. The clinical significance of this finding is unclear. We assessed whether recurrent GEJIM is associated with increased risk of subsequent dysplasia and whether endoscopic treatment lowers this risk. METHODS A retrospective, multicenter, cohort study was performed of treated BE patients who achieved complete eradication of intestinal metaplasia (IM). Postablation follow-up was performed at standard intervals. Recurrent GEJIM was defined as nondysplastic IM on gastroesophageal junction biopsy specimens without endoscopic evidence of BE. Patients were categorized as "never-GEJIM," "GEJIM-observed," or "GEJIM-treated." Endoscopic treatment for recurrent GEJIM was at the endoscopists' discretion. The primary outcome was dysplasia recurrence. Analyses were performed using log-rank tests and Cox proportional hazards modeling. RESULTS Six hundred thirty-three patients were analyzed; median follow-up was 47 months (interquartile range, 24-69). Most patients (81%) had high-grade dysplasia or intramucosal adenocarcinoma before treatment. Dysplasia recurrence was 2.2% per year. GEJIM-observed patients had the lowest rate of recurrence (.6%/y) followed by GEJIM-treated (2.2%/y) and never-GEJIM (2.6%/y) (log-rank P = .07). In multivariate analyses, compared with never-GEJIM, the risk of dysplasia recurrence was significantly lower in GEJIM-observed patients (adjusted hazard ratio, .19; 95% confidence interval, .05-.81) and not different in GEJIM-treated patients (adjusted hazard ratio, .81; 95% confidence interval, .39-1.67). Older age and longer initial BE length were independently associated with recurrence. CONCLUSIONS Recurrent GEJIM after endoscopic eradication of BE was not associated with an increased risk of subsequent dysplasia. Future studies are warranted to determine if observation is appropriate for this finding.
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Affiliation(s)
- Quinn S Solfisburg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Sarmed S Sami
- Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Joel Gabre
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ali Soroush
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Lovekirat Dhaliwal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Claire Beveridge
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zhezhen Jin
- Departments of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - John M Poneros
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Gary W Falk
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory G Ginsberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles J Lightdale
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
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Dhaliwal L, Codipilly DC, Gandhi P, Johnson ML, Lansing R, Wang KK, Leggett CL, Katzka DA, Iyer PG. Neoplasia Detection Rate in Barrett's Esophagus and Its Impact on Missed Dysplasia: Results from a Large Population-Based Database. Clin Gastroenterol Hepatol 2021; 19:922-929.e1. [PMID: 32707339 PMCID: PMC7854811 DOI: 10.1016/j.cgh.2020.07.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/12/2020] [Accepted: 07/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS It is a challenge to detect dysplasia in Barrett's esophagus (BE) and esophageal adenocarcinomas (EACs) are missed in 25%-33% of cases. The neoplasia detection rate (NDR), defined as the rate of high-grade dysplasia (HGD) or EAC detection during initial surveillance endoscopy, has been proposed as a quality metric for endoscopic evaluation of patients with BE. However, current estimates are from referral center cohorts, which might overestimate NDR. Effects on rates of missed dysplasia are also unknown. We analyzed data from a large cohort of patients with BE to estimate the NDR and factors associated with it, and assess the effects of the NDR on the rate of missed dysplasia. METHODS We analyzed data from 1066 patients in the Rochester Epidemiology Project-linked medical record system, a population-based cohort of patients with BE (confirmed by review of the endoscopic and histologic reports) from 11 southeastern Minnesota counties from 1991 through 2019. Biopsies reported to contain dysplasia were confirmed by expert gastrointestinal pathologists. The NDR was calculated as the rate of HGD or EAC detected by histologic analyses of biopsies collected during the first surveillance endoscopy. Patients without HGD or EAC at their initial endoscopy (n = 391) underwent repeat endoscopy within 12 months; HGD or EAC detected at the repeat endoscopy were considered to be missed on index endoscopy. Factors associated with NDR and missed dysplasia were identified using univariate and multivariate logistic regression models. RESULTS The NDR was 4.9% (95% CI, 3.8-6.4); 3.1% of patients had HGD, 1.8% had EAC, and 10.6% had low-grade dysplasia. Factors associated with higher rates of detection of neoplasia included older age, male sex, smoking, increasing length of BE, and surveillance endoscopies by gastroenterologists. This NDR was associated with a substantially lower rate of missed dysplasia (13%). CONCLUSIONS In an analysis of 1066 patients with BE in a population-based cohort, we found a lower NDR and lower rate of missed dysplasia than previously reported. NDR may have value as a quality metric in BE surveillance if validated in other cohorts.
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Affiliation(s)
- Lovekirat Dhaliwal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - D Chamil Codipilly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Parth Gandhi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michele L Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ramona Lansing
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Do proton pump inhibitors prevent Barrett's esophagus progression to high-grade dysplasia and esophageal adenocarcinoma? An updated meta-analysis. J Cancer Res Clin Oncol 2021; 147:2681-2691. [PMID: 33575855 DOI: 10.1007/s00432-021-03544-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/21/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Previous research on the association between proton pump inhibitor (PPI) use and the risk of progression to high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) in Barrett's Esophagus (BE) patients has generated inconsistent findings. This meta-analysis was performed to clarify the association. METHODS We performed a comprehensive search strategy to select relevant studies up to September 2020. Heterogeneity was assessed using the I-squared statistic. Odds ratios (OR) and 95% confidence intervals (CI) were calculated through either fixed-effects or random-effects model. Duration-response was also performed to assess the gain effects of different PPI intake duration. Sensitivity analysis, subgroup analyses, and tests for publication bias or other small-study effects were conducted. RESULTS Twelve studies with 155,769 subjects were included. The PPI use was associated with the reduced risk of BE progression to HGD/EAC (OR = 0.47, 95% CI = 0.32-0.71). In the duration-response analysis, the estimated OR for decreased risk of HGD/EAC with PPI intake duration of 12 months was 0.81 (95% CI = 0.71-0.91). Sensitivity analysis suggested the results of this meta-analysis were stable. No publication bias was detected. CONCLUSIONS PPI use is associated with a decreased risk of HGD/EAC in patients with BE. For further investigation, that more well-designed studies are still needed to elucidate the protective effect of PPI usage on BE patients to prevent HGD/EAC.
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Kamboj AK, Katzka DA, Iyer PG. Endoscopic Screening for Barrett's Esophagus and Esophageal Adenocarcinoma: Rationale, Candidates, and Challenges. Gastrointest Endosc Clin N Am 2021; 31:27-41. [PMID: 33213798 PMCID: PMC8127641 DOI: 10.1016/j.giec.2020.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer with increasing incidence and poor survival. Risk of EAC in patients with BE is higher compared with the general population. Endoscopic screening for BE is performed to identify patients earlier in the metaplasia-dysplasia-carcinoma sequence from BE to EAC to enable eradication therapy. BE screening should be considered in individuals with multiple risk factors for BE and EAC. Challenges to BE screening include the absence of a cost-effective, widely applicable minimally invasive screening tool, gastroesophageal reflux disease centric screening recommendations, and limitations of current endoscopic surveillance practice.
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Loughrey MB, Shepherd NA. The indications for biopsy in routine upper gastrointestinal endoscopy. Histopathology 2020; 78:215-227. [PMID: 33382487 DOI: 10.1111/his.14213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022]
Abstract
This review describes the indications and contraindications for endoscopic biopsy, in routine practice, of the upper gastrointestinal (GI) tract. We accept that this review provides grounds for controversy, as our stance in certain situations is counter to some national guidelines. Nevertheless, we provide evidence to support our viewpoints, especially on efficiency and economic grounds. We describe the particular controversies concerning the biopsy assessment of Barrett's oesophagus, chronic gastritis and the duodenum in the investigation of coeliac disease. We accept that there are indications for more extensive upper GI biopsy protocols in children than in adults; the latter constitute our main focus in this article. We would encourage detailed discussion between pathologists and their endoscopy colleagues about the indications, or lack of them, for routine upper GI endoscopic biopsy, as studies have shown that adherence to agreed guidelines has resulted in a very considerable diminution in the biopsy workload without compromising patient management. Furthermore, where biopsy is indicated, we emphasise the importance of accompanying clinical information provided to the pathologist, in particular regarding biopsy site(s), and regular feedback to endoscopists to improve and maintain the quality of such information. Finally, local dialogue is also advised, when necessary, to indicate to endoscopists the need to appropriately segregate biopsies into separate, individually labelled specimens, to maximise the information that can be derived by pathological evaluation and thereby improve the quality of the final pathology report.
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Affiliation(s)
- Maurice B Loughrey
- Department of Cellular Pathology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Cheltenham, UK
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Chang C, Worrell SG. Viruses and esophageal cancer. Dis Esophagus 2020; 33:5847897. [PMID: 32462190 DOI: 10.1093/dote/doaa036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 12/11/2022]
Abstract
Esophageal adenocarcinoma (EAC) has had the fastest increasing incidence of any solid tumor in the United States in the last 30 years. Long standing gastroesophageal reflux disease is a well-established risk factor with strong associations with obesity, alcohol and tobacco. However, there are likely additional contributing factors. Viruses such as human papillomavirus, ebstein-barr virus and herpes simplex virus have been implicated in the pathogenesis of esophageal cancer. This review will discuss the known literature linking viruses to esophageal adenocarcinoma and consider future relationships such as identifying prognostic and predictive molecular biomarkers to guide therapies.
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Affiliation(s)
- Carolyn Chang
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Case Western Reserve School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Spechler SJ. Screening for Barrett's oesophagus: are we looking for the right thing? Gut 2020; 70:gutjnl-2020-323378. [PMID: 33239343 DOI: 10.1136/gutjnl-2020-323378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/13/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Stuart J Spechler
- Department of Medicine, Baylor University Medical Center at Dallas, Dallas, Texas, USA
- Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, USA
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Marques de Sá I, Marcos P, Sharma P, Dinis-Ribeiro M. The global prevalence of Barrett's esophagus: A systematic review of the published literature. United European Gastroenterol J 2020; 8:1086-1105. [PMID: 32631176 PMCID: PMC7724547 DOI: 10.1177/2050640620939376] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Determining the prevalence of Barrett's esophagus is important for defining screening strategies. We aimed to synthesize the available data, determine Barrett's esophagus prevalence, and assess variability. METHODS Three databases were searched. Subgroup, sensitivity, and meta-regression analyses were conducted and pooled prevalence was computed. RESULTS Of 3510 studies, 103 were included. In the general population, we estimated a prevalence for endoscopic suspicion of Barrett's esophagus of (a) any length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.85-1.07), (b) ≥1 cm of length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.75-1.18) and (c) for any length with histologic confirmation of columnar metaplasia as 3.89% (95% confidence interval: 2.25-5.54) . By excluding studies with high-risk of bias, the prevalence decreased to: (a) 0.70% (95% confidence interval: 0.61-0.79) and (b) 0.82% (95% confidence interval: 0.63-1.01). In gastroesophageal reflux disease patients, we estimated the prevalence with afore-mentioned criteria to be: (a) 7.21% (95% confidence interval: 5.61-8.81) (b) 6.72% (95% confidence interval: 3.61-9.83) and (c) 7.80% (95% confidence interval: 4.26-11.34). The Barrett's esophagus prevalence was significantly influenced by time period, region, Barrett's esophagus definition, Seattle protocol, and study design. There was a significant gradient East-West and North-South. There were minimal to no data available for several countries. Moreover, there was significant heterogeneity between studies. CONCLUSION There is a need to reassess the true prevalence of Barrett's esophagus using the current guidelines in most regions. Having knowledge about the precise Barrett's esophagus prevalence, diverse attitudes from educational to screening programs could be taken.
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Affiliation(s)
- Inês Marques de Sá
- Department of Gastroenterology, Portuguese Oncology Institute of
Porto, Porto, Portugal
| | - Pedro Marcos
- Department of Gastroenterology, Centro Hospitalar de Leiria,
Leiria, Portugal
| | - Prateek Sharma
- University of Kansas School of Medicine, Kansas City, USA
- Department of Gastroenterology, Veterans Affairs Medical Center,
Kansas City, USA
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of
Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS),
University of Porto, Porto, Portugal
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Wani S, Williams JL, Falk GW, Komanduri S, Muthusamy VR, Shaheen NJ. An Analysis of the GIQuIC Nationwide Quality Registry Reveals Unnecessary Surveillance Endoscopies in Patients With Normal and Irregular Z-Lines. Am J Gastroenterol 2020; 115:1869-1878. [PMID: 33156106 DOI: 10.14309/ajg.0000000000000960] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Population-based estimates of adherence to Barrett's esophagus (BE) guidelines are not available. Using a national registry, we assessed surveillance intervals for patients with normal and irregular Z-lines based on the presence or absence of intestinal metaplasia (IM) and among patients with suspected or confirmed BE. METHODS We analyzed data from the GI Quality Improvement Consortium Registry. Endoscopy data, including procedure indication, demographics, endoscopy and histology findings, and recommendations for further endoscopy, were assessed from January 2013 through December 2019. Patients with an indication of BE screening or surveillance or an endoscopic finding of BE were included. Biopsy and surveillance practices were assessed based on the length of columnar epithelium (0 cm, <1 cm, 1-3 cm, and >3 cm) and diagnosis based on histology findings. RESULTS A total of 1,907,801 endoscopies were assessed; 135,704 endoscopies (7.1%) performed in 114,894 patients met the inclusion criteria (men 61.4%, Whites 91%, and mean age of 61.7 years [SD 12.5]). Among patients with normal Z-lines, surveillance endoscopy was recommended for 81% of patients with IM and 20% of individuals without IM. Among patients with irregular Z-lines, surveillance endoscopy was recommended for 81% with IM and 24% without IM. Approximately 30% of patients with confirmed nondysplastic BE (lengths 1-3 and >3 cm) had recommended surveillance intervals of <3 years. DISCUSSION An analysis of data from a nationwide quality registry demonstrated that patients without BE are receiving recommendations for surveillance endoscopies and many patients with nondysplastic BE are reexamined too soon.
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Affiliation(s)
- Sachin Wani
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Scarpignato C, Sloan JA, Wang DH, Hunt RH. Gastrointestinal pharmacology: practical tips for the esophagologist. Ann N Y Acad Sci 2020; 1481:90-107. [PMID: 32822080 DOI: 10.1111/nyas.14447] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/19/2020] [Accepted: 07/05/2020] [Indexed: 12/22/2022]
Abstract
Gastroesophageal reflux disease (GERD) is primarily a motor disorder, and its pathogenesis is multifactorial. As a consequence, treatment should be able to address the underlying pathophysiology. Proton pump inhibitors (PPIs) are the mainstay of medical therapy for GERD, but these drugs only provide the control of symptoms and lesions without curing the disease. However, continuous acid suppression with PPIs is recommended for patients with Barrett's esophagus because of their potential chemopreventive effects. In addition to the antisecretory activity, these compounds display several pharmacological properties, often overlooked in clinical practice. PPIs can indeed affect gastric motility, exert a mucosal protective effect, and an antioxidant, anti-inflammatory, and antineoplastic activity, also protecting cancer cells from developing chemo- or radiotherapeutic resistance. Even in the third millennium, current pharmacologic approaches to address GERD are limited. Reflux inhibitors represent a promise unfulfilled, effective and safe prokinetics are lacking, and antidepressants, despite being effective in selected patients, give rise to adverse events in a large proportion of them. While waiting for new drug classes (like potassium-competitive acid blockers), reassessing old drugs (namely alginate-containing formulations), and paving the new avenue of esophageal mucosal protection are, at the present time, the only reliable alternatives to acid suppression.
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Affiliation(s)
- Carmelo Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta.,Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - Joshua A Sloan
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David H Wang
- Division of Hematology and Oncology, UT Southwestern Medical Center and VA North Texas Health Care System, Dallas, Texas
| | - Richard H Hunt
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Snider EJ, Kaz AM, Inadomi JM, Grady WM. Chemoprevention of esophageal adenocarcinoma. Gastroenterol Rep (Oxf) 2020; 8:253-260. [PMID: 32843972 PMCID: PMC7434588 DOI: 10.1093/gastro/goaa040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/12/2022] Open
Abstract
Esophageal adenocarcinoma (EAC) is a major cause of cancer-related death, particularly in Western populations, and is rapidly rising in Asian populations at this time. Virtually all EACs develop from the precursor lesion Barrett's esophagus (BE), which is the most significant risk factor for EAC. However, the rates of progression from BE to EAC are low and patients with BE are asymptomatic. Thus, any strategy for EAC prevention must carry a low risk of harm in order to be clinically useful. Since current EAC-screening and BE-surveillance methods carry some procedural risk and are burdensome, there is an opportunity for chemoprevention, i.e. medications or dietary factors that may prevent BE from progressing to EAC. A variety of candidate chemoprevention therapies have been assessed to date. Proton-pump inhibitors (PPIs) are the best studied and have modest EAC-chemoprevention efficacy in BE patients, with a recent randomized trial showing that high-dose PPI may be more effective than low-dose PPI. Aspirin and other non-steroidal anti-inflammatory drugs have moderate quality observational and randomized-trial evidence for preventing progression of BE to EAC, but their risks for harm have precluded their routine clinical use. Other therapies (statins, metformin, female sex hormones) generally do not have strong evidence to support their use in EAC chemoprevention. Although progress has been made in this field, there is still a need for more effective and safe chemoprevention therapies for EAC.
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Affiliation(s)
- Erik J Snider
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Andrew M Kaz
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Gastroenterology Section, VA Puget Sound Health Care System, Seattle, WA, USA
| | - John M Inadomi
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - William M Grady
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Abstract
Because of the rising incidence and lethality of esophageal adenocarcinoma, Barrett's esophagus (BE) is an increasingly important premalignant target for cancer prevention. BE-associated neoplasia can be safely and effectively treated with endoscopic eradication therapy (EET), incorporating tissue resection and ablation. Because EET has proliferated, managing patients after complete eradication of intestinal metaplasia has taken on increasing importance. Recurrence after complete eradication of intestinal metaplasia occurs in 8%-10% of the patients yearly, and the incidence may remain constant over time. Most recurrences occur at the gastroesophageal junction, whereas those in the tubular esophagus are endoscopically visible and distally located. A simplified biopsy protocol limited to the distal aspect of the BE segment, in addition to gastroesophageal junction sampling, may enhance efficiency and cost without significantly reducing recurrence detection. Similarly, research suggests that current surveillance intervals may be excessively frequent, failing to reflect the cancer risk reduction of EET. If validated, longer surveillance intervals could reduce the burden of resource-intensive endoscopic surveillance. Several important questions in post-EET management remain unanswered, including surveillance duration, the significance of gastric cardia intestinal metaplasia, and the role of advanced imaging and nonendoscopic sampling techniques in detecting recurrence. These merit further research to enhance quality of care and promote a more evidence-based approach.
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Barrett Esophagus and Intestinal Metaplasia of the Gastroesophageal Junction in Children: A Clinicopathologic Study. J Pediatr Gastroenterol Nutr 2020; 70:562-567. [PMID: 31977949 DOI: 10.1097/mpg.0000000000002640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Barrett esophagus (BE) and intestinal metaplasia of gastroesophageal junction (IMGEJ) are rare in the pediatric population. This multi-institutional retrospective study evaluated the clinicopathologic characteristics and natural history of BE and IMGEJ in children. METHODS Data from 20 BE patients (70% boys, mean age: 14.9 years) and 17 IMGEJ patients (71% boys, mean age: 14 years) were retrospectively obtained from chart review. Endoscopic and pathologic findings from index and follow-up endoscopies were analyzed. RESULTS Most patients (70% BE and 59% IMGEJ) had underlying conditions which put them at risk for gastroesophageal reflux disease. Increased body mass index (BMI) was observed in patients without underlying conditions (BE: 30.1 ± 9.8; IMGEJ: 23.9 ± 6.3) compared with those with underlying conditions (BE: 19.6 ± 7.8; IMGEJ: 16.4 ± 2.1) (BE, P = 0.02; IMGEJ, P = 0.01). Incomplete intestinal metaplasia (IM) was the predominant histology seen in BE (80%) and IMGEJ patients (75%). Dysplasia and malignancy were not identified in the initial and follow-up biopsies. Concurrent gastric biopsies showed various findings (79% BE and 40% IMGEJ were normal), with 1 IMGEJ patient showing coexisting gastric IM (7%). Follow-up in 12 BE patients (mean follow-up time 51.6 months) showed 100% persistent endoscopic disease and 58% persistent IM histologically. Three of 6 IMGEJ patients (mean follow-up time 24 months) demonstrated endoscopic and histologic features consistent with BE on subsequent procedures. Moreover, a subset of BE (57%) and IMGEJ patients (67%) who underwent endoscopy before initial diagnosis showed nongoblet columnar mucosa above the anatomic gastroesophageal junction. CONCLUSIONS Increased BMI may be a risk factor for BE and IMGEJ in pediatric patients without underlying conditions. Nongoblet columnar metaplasia and IMGEJ might represent incomplete forms of BE. Our data suggest that these patients should be closely monitored.
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Tan WK, Shaheen NJ. Random biopsy of the neosquamous epithelium is a waste of time and money. Gastrointest Endosc 2019; 90:404-406. [PMID: 31439129 DOI: 10.1016/j.gie.2019.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/05/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Wei Keith Tan
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom; Department of Gastroenterology, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Abstract
Barrett esophagus is a metaplastic change in the lining of the distal esophageal epithelium, characterized by replacement of the normal squamous epithelium by specialized intestinal metaplasia. The presence of Barrett esophagus increases the risk of esophageal adenocarcinoma several-fold. Esophageal adenocarcinoma is a malignancy with rapidly rising incidence and persistently poor outcomes when diagnosed after the onset of symptoms. Risk factors for Barrett esophagus include chronic gastroesophageal reflux, central obesity, white race, male gender, older age, smoking, and a family history of Barrett esophagus or esophageal adenocarcinoma. Screening for Barrett esophagus in those with several risk factors followed by endoscopic surveillance to detect dysplasia or adenocarcinoma is currently recommended by society guidelines. Minimally invasive nonendoscopic tools for the early detection of Barrett esophagus are currently being developed. Multimodality endoscopic therapy-using a combination of endoscopic resection and ablation techniques-for the treatment of dysplasia and early adenocarcinoma is successful in eliminating intestinal metaplasia and preventing progression to adenocarcinoma, with outcomes comparable to those after esophagectomy. Risk stratification of those diagnosed with Barrett esophagus is a challenge at present, with active research focused on identifying clinical and biomarker panels to identify those with low and high risk of progression. This narrative review highlights some of the challenges and recent progress in this field.
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Affiliation(s)
- Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY.
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Que J, Garman KS, Souza RF, Spechler SJ. Pathogenesis and Cells of Origin of Barrett's Esophagus. Gastroenterology 2019; 157:349-364.e1. [PMID: 31082367 PMCID: PMC6650338 DOI: 10.1053/j.gastro.2019.03.072] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/22/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023]
Abstract
In patients with Barrett's esophagus (BE), metaplastic columnar mucosa containing epithelial cells with gastric and intestinal features replaces esophageal squamous mucosa damaged by gastroesophageal reflux disease. This condition is estimated to affect 5.6% of adults in the United States, and is a major risk factor for esophageal adenocarcinoma. Despite the prevalence and importance of BE, its pathogenesis is incompletely understood and there are disagreements over the cells of origin. We review mechanisms of BE pathogenesis, including transdifferentiation and transcommitment, and discuss potential cells of origin, including basal cells of the squamous epithelium, cells of esophageal submucosal glands and their ducts, cells of the proximal stomach, and specialized populations of cells at the esophagogastric junction (residual embryonic cells and transitional basal cells). We discuss the concept of metaplasia as a wound-healing response, and how cardiac mucosa might be the precursor of the intestinal metaplasia of BE. Finally, we discuss shortcomings in current diagnostic criteria for BE that have important clinical implications.
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Affiliation(s)
- Jianwen Que
- Division of Digestive and Liver Diseases and Center for Human Development, Department of Medicine, Columbia University, New York, New York.
| | - Katherine S. Garman
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine. Durham, NC
| | - Rhonda F. Souza
- Center for Esophageal Diseases, Department of Medicine, Baylor University Medical Center at Dallas, and Center for Esophageal Research, Department of Medicine, Baylor Scott & White Research Institute, Dallas, TX
| | - Stuart Jon Spechler
- Center for Esophageal Diseases, Department of Medicine, Baylor University Medical Center at Dallas, Dallas, Texas; Center for Esophageal Research, Department of Medicine, Baylor Scott & White Research Institute, Dallas, Texas.
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