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Menon S, Norman R, Iyer PG, Ragunath K. Stratification of Barrett's esophagus surveillance based on p53 immunohistochemistry: a cost-effectiveness analysis by an international collaborative group. Endoscopy 2024. [PMID: 38698618 DOI: 10.1055/a-2317-8184] [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: 05/05/2024]
Abstract
BACKGROUND Surveillance of nondysplastic Barrett's esophagus (NDBE) is recommended to identify progression to dysplasia; however, the most cost-effective strategy remains unclear. Mutation of TP53 or aberrant expression of p53 have been associated with the development of dysplasia in BE. We sought to determine if surveillance intervals for BE could be stratified based on p53 expression. METHODS A Markov model was developed for NDBE. Patients with NDBE underwent p53 immunohistochemistry (IHC) and those with abnormal p53 expression underwent surveillance endoscopy at 1 year, while patients with normal p53 expression underwent surveillance in 3 years. Patients with dysplasia underwent endoscopic therapy and surveillance. RESULTS On base-case analysis, the strategy of stratifying surveillance based on abnormal p53 IHC was cost-effective relative to conventional surveillance and a natural history model, with an incremental cost-effectiveness ratio (ICER) of $8258 for p53 IHC-based surveillance. Both the conventional and p53-stratified surveillance strategies dominated the natural history model. On probabilistic sensitivity analysis, the p53 IHC strategy ($28 652; 16.78 quality-adjusted life years [QALYs]) was more cost-effective than conventional surveillance ($25 679; 16.17 QALYs) with a net monetary benefit of $306 873 compared with conventional surveillance ($297 642), with an ICER <$50 000 in 96% of iterations. The p53-stratification strategy was associated with a 14% reduction in the overall endoscopy burden and a 59% increase in dysplasia detection. CONCLUSION A surveillance strategy for BE based on abnormal p53 IHC is cost-effective relative to a conventional surveillance strategy and is likely to be associated with higher rates of dysplasia diagnosis.
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Affiliation(s)
- Shyam Menon
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom of Great Britain and Northern Ireland
| | - Richard Norman
- Health Economist, School of Population Health, Curtin University, Perth, Australia
| | - Prasad G Iyer
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
| | - Krish Ragunath
- Curtin Medical School, Curtin University, Perth, Australia
- Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Australia
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2
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Patil DT, Odze RD. Barrett's Esophagus and Associated Dysplasia. Gastroenterol Clin North Am 2024; 53:1-23. [PMID: 38280743 DOI: 10.1016/j.gtc.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Early detection of dysplasia and effective management are critical steps in halting neoplastic progression in patients with Barrett's esophagus (BE). This review provides a contemporary overview of the BE-related dysplasia, its role in guiding surveillance and management, and discusses emerging diagnostic and therapeutic approaches that might further enhance patient management. Novel, noninvasive techniques for sampling and surveillance, adjunct biomarkers for risk assessment, and their limitations are also discussed.
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Affiliation(s)
- Deepa T Patil
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Robert D Odze
- Department of Pathology and Lab Medicine, Tufts University School of Medicine, Boston, MA, USA
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3
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Kaul V, Gross S, Corbett FS, Malik Z, Smith MS, Tofani C, Infantolino A. Clinical utility of wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) in identifying Barrett's esophagus and associated neoplasia. Dis Esophagus 2020; 33:5865411. [PMID: 32607543 DOI: 10.1093/dote/doaa069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/30/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022]
Abstract
Sampling error during screening and surveillance endoscopy is a well-recognized problem. Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D), used adjunctively to forceps biopsy (FB), has been shown to increase the detection of Barrett's esophagus (BE) and BE-associated neoplasia. We evaluated the clinical utility of WATS3D and its impact on the management of patients with BE and dysplasia. Between 2013 and 2018, 432 consecutive patients who had a WATS3D positive and an accompanying FB negative result were identified. Physicians were contacted to determine if the WATS3D result impacted their decision to enroll patients in surveillance or increase the frequency of surveillance, recommend ablation, and/or initiate or increase the dose of proton pump inhibitors (PPIs). WATS3D directly impacted the management of 97.8% of 317 BE patients; 96.2% were enrolled in surveillance and 60.2% were started on PPIs or their dose was increased. WATS3D impacted the management of 94.9% and 94.1% of the 98 low-grade dysplasia and 17 high-grade dysplasia patients, respectively. As a result of WATS3D, 33.7% of low-grade dysplasia and 70.6% of high-grade dysplasia patients underwent endoscopic therapy. More than 37% of all dysplasia patients were enrolled in a surveillance program, and nearly 30% were scheduled to be surveilled more frequently. PPIs were either initiated, or the dose was increased in more than 54% of all dysplasia patients. We demonstrate that WATS3D has high clinical utility. By prompting physicians to change their clinical management in patients with negative FB results, WATS3D, used adjunctively to FB, directly impacts patient management, and improves patient outcomes.
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Affiliation(s)
- Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, New York
| | - Seth Gross
- Division of Gastroenterology, NYU Langone Medical Center, New York, New York
| | - F Scott Corbett
- Suncoast Endoscopy of Sarasota, Gastroenterology Associates of Sarasota, Sarasota, Florida
| | - Zubair Malik
- Division of Gastroenterology, Temple University, Philadelphia, Pennsylvania
| | - Michael S Smith
- Division of Gastroenterology, Temple University, Philadelphia, Pennsylvania
| | - Christina Tofani
- Department of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anthony Infantolino
- Department of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Amano Y, Ishimura N, Ishihara S. Is Malignant Potential of Barrett's Esophagus Predictable by Endoscopy Findings? Life (Basel) 2020; 10:E244. [PMID: 33081277 PMCID: PMC7602941 DOI: 10.3390/life10100244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/01/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
Given that endoscopic findings can be used to predict the potential of neoplastic progression in Barrett's esophagus (BE) cases, the detection rate of dysplastic Barrett's lesions may become higher even in laborious endoscopic surveillance because a special attention is consequently paid. However, endoscopic findings for effective detection of the risk of neoplastic progression to esophageal adenocarcinoma (EAC) have not been confirmed, though some typical appearances are suggestive. In the present review, endoscopic findings that can be used predict malignant potential to EAC in BE cases are discussed. Conventional results obtained with white light endoscopy, such as length of BE, presence of esophagitis, ulceration, hiatal hernia, and nodularity, are used as indicators of a higher risk of neoplastic progression. However, there are controversies in some of those findings. Absence of palisade vessels may be also a new candidate predictor, as that reveals degree of intense inflammation and of cyclooxygenase-2 protein expression with accelerated cellular proliferation. Furthermore, an open type of mucosal pattern and enriched stromal blood vessels, which can be observed by image-enhanced endoscopy, including narrow band imaging, have been confirmed as factors useful for prediction of neoplastic progression of BE because they indicate more frequent cyclooxygenase-2 protein expression along with accelerated cellular proliferation. Should the malignant potential of BE be shown predictable by these endoscopic findings, that would simplify methods used for an effective surveillance, because patients requiring careful monitoring would be more easily identified. Development in the near future of a comprehensive scoring system for BE based on clinical factors, biomarkers and endoscopic predictors is required.
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Affiliation(s)
- Yuji Amano
- Department of Endoscopy, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan
| | - Norihisa Ishimura
- Department of Internal Medicine II, Faculty of Medicine, Shimane University, Shimane 693-8501, Japan; (N.I.); (S.I.)
| | - Shunji Ishihara
- Department of Internal Medicine II, Faculty of Medicine, Shimane University, Shimane 693-8501, Japan; (N.I.); (S.I.)
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5
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Maitra I, Date RS, Martin FL. Towards screening Barrett's oesophagus: current guidelines, imaging modalities and future developments. Clin J Gastroenterol 2020; 13:635-649. [PMID: 32495144 PMCID: PMC7519897 DOI: 10.1007/s12328-020-01135-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma (OAC). Although guidelines on the screening and surveillance exist in Barrett's oesophagus, the current strategies are inadequate. Oesophagogastroduodenoscopy (OGD) is the gold standard method in screening for Barrett's oesophagus. This invasive method is expensive with associated risks negating its use as a current screening tool for Barrett's oesophagus. This review explores current definitions, epidemiology, biomarkers, surveillance, and screening in Barrett's oesophagus. Imaging modalities applicable to this condition are discussed, in addition to future developments. There is an urgent need for an alternative non-invasive method of screening and/or surveillance which could be highly beneficial towards reducing waiting times, alleviating patient fears and reducing future costs in current healthcare services. Vibrational spectroscopy has been shown to be promising in categorising Barrett's oesophagus through to high-grade dysplasia (HGD) and OAC. These techniques need further validation through multicentre trials.
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Affiliation(s)
- Ishaan Maitra
- School of Pharmacy and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE UK
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6
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Bennett C, Green S, DeCaestecker J, Almond M, Barr H, Bhandari P, Ragunath K, Singh R, Jankowski J. Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus. Cochrane Database Syst Rev 2020; 5:CD007334. [PMID: 32442322 PMCID: PMC7390331 DOI: 10.1002/14651858.cd007334.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). OBJECTIVES We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). SEARCH METHODS We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. SELECTION CRITERIA Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. TYPES OF PARTICIPANTS patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. DATA COLLECTION AND ANALYSIS Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. MAIN RESULTS We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. AUTHORS' CONCLUSIONS This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.
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Affiliation(s)
- Cathy Bennett
- Centre for Innovative Research Across the Life Course (CIRAL), Coventry University, Coventry, UK
| | - Susi Green
- Gastroenterology, Portsmouth Hospitals Trust, Cosham, UK
| | | | - Max Almond
- Department of Oesphogastric Surgery, Gloucestershire Royal Hospital, Gloucester, UK
| | - Hugh Barr
- Surgery, Gloucester Royal Hospital, Gloucester, UK
| | - Pradeep Bhandari
- Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Krish Ragunath
- Wolfson Digestive Diseases Centre, Queens Medical Centre, Nottingham University NHS Trust, Nottingham, UK
| | - Rajvinder Singh
- Gastroenterology, The Lyell McEwin Hospital, Elizabeth Vale, Australia
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7
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Clinical Outcomes Based on the Timing of Appearance of Visible Lesions in Barrett's Esophagus During Endoscopic Eradication Therapy. J Clin Gastroenterol 2020; 54:144-149. [PMID: 30614938 PMCID: PMC7050469 DOI: 10.1097/mcg.0000000000001165] [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] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND GOALS Visible lesions (VLs) in Barrett's esophagus (BE) are seen in 70% to 90% of patients presenting for endoscopic eradication therapy (EET). It is not known if there are any differences in outcomes of patients with flat dysplasia versus patients with VL. Our aim was to assess outcomes of EET in BE patients with VL and BE patients with flat dysplasia. STUDY This is a single center study with data drawn from a prospective registry of patients referred for EET of BE between 2011 and 2015. Demographic data, endoscopic findings, histologic findings, and response to EET were analyzed. RESULTS There were 264 patients of which 34 had flat dysplasia, 180 had VL before initiating EET (prevalent lesions) and 50 who developed VL during EET (incident lesions). Compared with patients with flat dysplasia, patients with VL had longer segments of BE (5 vs. 4 cm, P=0.002) and greater prevalence of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) (63.6% vs. 29.4%, P<0.001). Incident lesions are less likely to harbor HGD/EAC compared with prevalent lesions (28.1% vs. 61.8%, P<0.001). There were no significant differences in eradication of metaplasia/dysplasia between the groups. No progression or recurrences were observed in flat dysplasia group. In VL group, 14 patients progressed (prevalent VL=11, incident VL=3) and 15 had recurrences (prevalent VL=11, incident VL=4). CONCLUSIONS About 19% of BE patients developed VL during EET. There is higher prevalence of HGD/EAC in prevalent VL compared with incident VL. However, the outcomes did not differ.
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8
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Yalaki S, Pulat H, Ilhan A. Localization of Helicobacter pylori gastritis and the relation of existing histopathological features with reflux esophagitis. Scand J Gastroenterol 2020; 55:27-33. [PMID: 31865819 DOI: 10.1080/00365521.2019.1701071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background/aims: Interactions between Helicobacter pylori (Hp) and gastroesophageal reflux disease (GERD), which are common diseases worldwide, are confusing. In this study, the aim was to compare and evaluate the relationship between reflux esophagitis (RE) and Hp infection in adult patients with both the gastric localization of Hp and its histopathologic features.Materials and methods: 248 patients with RE were compared with 249 age and sex matched control groups. Biopsy specimens obtained from the gastric antrum and corpus were histologically evaluated.Findings: The incidence of Hp infection was significantly lower in patients with RE than in the control group (Ratio 1.53, 95% CI 1.07-2.20; p = .02, p < .05). Corpus Hp colonization and corpus gastritis scores were notably lower in the study group (p = .01, p < .05), whereas there was no significant difference in Hp colonization and antrum gastritis scores in the antrum. Corpus Hp colonization and gastritis scores were found to be negatively correlated with esophagitis development (r = -0.11; p = .01; (r = -0.14; p = .00 respectively, p < .05). There was no difference between the groups in terms of atrophy development (p > .05).Conclusion: This study showed that the presence of Hp infection in the corpus and corpus gastritis score was significantly lower in patients with erosive reflux esophagitis than in the control group. It also showed that Hp colonization and corpus gastritis scores were negatively correlated with esophagitis development. This inverse relationship was independent of atrophy.
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Affiliation(s)
- Serkan Yalaki
- Department of Gastroenterology, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Hüseyin Pulat
- Department of General Surgery, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Aysu Ilhan
- Pediatrics Department, Mersin City Training and Research Hospital, Mersin, Turkey
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9
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Alnasser S, Agnihotram R, Martel M, Mayrand S, Franco E, Ferri L. Predictors of dysplastic and neoplastic progression of Barrett’s esophagus. Can J Surg 2019; 62:93-99. [PMID: 30907564 DOI: 10.1503/cjs.008716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background It is unknown why some cases of Barrett’s esophagus progress to invasive malignant disease rapidly while others do so more slowly or not at all. The aim of this study was to identify demographic and endoscopic factors that predict dysplastic and neoplastic progression in patients with Barrett’s esophagus. Methods Patients with Barrett’s esophagus who were assessed in 2000–2010 were assessed for inclusion in this retrospective study. Demographic and endoscopic variables were collected from an endoscopy database and the medical chart. Dysplastic and neoplastic progression was examined by time-to-event analysis. We used Cox proportional hazard regression modelling and generalized estimating equation methods to identify variables that were most predictive of neoplastic progression. Results A total of 518 patients had Barrett’s esophagus confirmed by endoscopy and pathology and at least 2 surveillance visits. Longer Barrett’s esophagus segment (≥ 3 cm) (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.1–1.3) and increased age (≥ 60 yr) (OR 3.5, 95% CI 1.7–7.4) were independent predictors of progression from nondysplasia to dysplastic or neoplastic grades. Presence of mucosal irregularities (OR 8.6, 95% CI 2.4–30.4) and increased age (OR 5.1, 95% CI 1.6–16.6) were independent predictors of progression from nondysplasia to high-grade dysplasia or adenocarcinoma. Conclusion Increased age, longer Barrett’s segment and presence of mucosal irregularities were associated with increased risk of dysplastic and neoplastic progression. In addition to dysplasia, these factors may help stratify patients according to risk of neoplastic progression and be used to individualize surveillance. More prospective studies with larger samples are required to validate these results.
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Affiliation(s)
- Saleh Alnasser
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Raman Agnihotram
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Myriam Martel
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Serge Mayrand
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Eduardo Franco
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Lorenzo Ferri
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
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Hall M, Wenner J, Scherman P, Öberg S. Intestinal metaplasia at the gastroesophageal junction is associated with gastroesophageal reflux but not with Helicobacter pylori infection. Scand J Gastroenterol 2019; 53:1179-1185. [PMID: 30516400 DOI: 10.1080/00365521.2018.1526967] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Studies of the etiology of intestinal metaplasia (IM) at a normal appearing gastroesophageal junction (GEJ) are conflicting as associations with both H. Pylori (HP) infection and gastroesophageal reflux has been reported. The aim of this study was to investigate whether IM at the GEJ is associated with gastroesophageal reflux or HP infection. MATERIAL AND METHODS Fifty asymptomatic volunteers and 149 patients with reflux symptoms underwent endoscopy with biopsies obtained from the gastric antrum and the squamocolumnar junction (SCJ). All subjects underwent wireless 48 h pH monitoring with the electrode placed immediately above the SCJ and a fecal antigen test for HP infection. Clinical characteristics and the pattern of reflux were compared in subjects with and without IM. RESULTS Three asymptomatic volunteers and 35 patients who had clearly irregular SCJs with short extensions of columnar mucosa were excluded from the study. In the remaining 47 asymptomatic volunteers and 114 patients, variables that reached a significance level of 0.1 or less on univariate analyses were used in a binomial regression analysis to assess their relative importance for the finding of IM. IM at the GEJ was significantly associated with abnormal distal esophageal acid exposure (5.5 (1.2-24.6), p = .026), the frequency of reflux episodes/hour (1.5 (1.1-2.2), p = .031), and an endoscopic appearance of the SCJ corresponding to ZAP grade I (4.6 (1.4-15.6), p = .013). There was no association with HP infection. CONCLUSION The finding of IM at an endoscopically normal-appearing GEJ is associated with gastroesophageal reflux but not with HP infection.
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Affiliation(s)
- Mats Hall
- a Department of Gastroenterology, Skåne University Hospital , Clinical Sciences Lund, Lund University , Lund , Sweden
| | - Jörgen Wenner
- a Department of Gastroenterology, Skåne University Hospital , Clinical Sciences Lund, Lund University , Lund , Sweden.,b Department of Surgery & Urology , Division of Surgery, Helsingborg Hospital , Helsingborg , Sweden
| | - Peter Scherman
- a Department of Gastroenterology, Skåne University Hospital , Clinical Sciences Lund, Lund University , Lund , Sweden.,b Department of Surgery & Urology , Division of Surgery, Helsingborg Hospital , Helsingborg , Sweden
| | - Stefan Öberg
- a Department of Gastroenterology, Skåne University Hospital , Clinical Sciences Lund, Lund University , Lund , Sweden.,b Department of Surgery & Urology , Division of Surgery, Helsingborg Hospital , Helsingborg , Sweden
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11
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Pecere S, Costamagna G. Endoscopic therapy for confirmed low-grade dysplasia in Barrett's esophagus. Transl Gastroenterol Hepatol 2018; 3:83. [PMID: 30505970 DOI: 10.21037/tgh.2018.10.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/28/2018] [Indexed: 12/24/2022] Open
Abstract
Barrett's esophagus (BE) is a premalignant condition characterized by replacement of the esophageal lining with metastatic columnar epithelium. To date, the management in case of confirmed low-grade dysplasia (LGD) remains controversial. In this article we summarize the available endoscopic options and their results in terms of efficacy and safety in the treatment of confirmed LGD in BE.
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Affiliation(s)
- Silvia Pecere
- Unità Operativa Complessa di Endoscopia Digestiva Chirurgica, Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche Istituto di Clinica Chirurgica Generale e Terapia Chirurgica Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Guido Costamagna
- Unità Operativa Complessa di Endoscopia Digestiva Chirurgica, Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche Istituto di Clinica Chirurgica Generale e Terapia Chirurgica Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Roma, Italia
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12
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Abstract
Barrett's esophagus is the only known pre-cancerous lesion for esophageal adenocarcinoma and is diagnosed by high-definition white light endoscopy demonstrating a columnar-lined esophagus along with biopsy evidence of intestinal metaplasia. With accurate performance and reporting of the endoscopic procedure, an evidence-based management strategy can be developed for treatment of Barrett's dysplasia. However, cross-sectional data demonstrate that there is still inconsistency among gastroenterologists in performance and reporting of endoscopic findings in patients with Barrett's esophagus. Here, we present an evidence-based review of how to report endoscopic findings in Barrett's esophagus.
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13
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Choi WT, Tsai JH, Rabinovitch PS, Small T, Huang D, Mattis AN, Kakar S. Diagnosis and risk stratification of Barrett's dysplasia by flow cytometric DNA analysis of paraffin-embedded tissue. Gut 2018. [PMID: 28642331 DOI: 10.1136/gutjnl-2017-313815] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The diagnosis of dysplasia in Barrett's oesophagus (BO) can be challenging, and reliable ancillary techniques are not available. This study examines if DNA content abnormality detected by flow cytometry can serve as a diagnostic marker of dysplasia and facilitate risk stratification of low-grade dysplasia (LGD) and indefinite for dysplasia (IND) patients using formalin-fixed paraffin-embedded (FFPE) BO samples with varying degrees of dysplasia. DESIGN DNA flow cytometry was performed on 80 FFPE BO samples with high-grade dysplasia (HGD), 38 LGD, 21 IND and 14 negative for dysplasia (ND). Three to four 60-micron thick sections were cut from each tissue block, and the area of interest was manually dissected. RESULTS DNA content abnormality was identified in 76 HGD (95%), 8 LGD (21.1%), 2 IND (9.5%) and 0 ND samples. As a diagnostic marker of HGD, the estimated sensitivity and specificity of DNA content abnormality were 95% and 85%, respectively. For patients with DNA content abnormality detected at baseline LGD or IND, the univariate HRs for subsequent detection of HGD or oesophageal adenocarcinoma (OAC) were 7.0 and 20.0, respectively (p =<0.001). CONCLUSIONS This study demonstrates the promise of DNA flow cytometry using FFPE tissue in the diagnosis and risk stratification of dysplasia in BO. The presence of DNA content abnormality correlates with increasing levels of dysplasia, as 95% of HGD samples showed DNA content abnormality. DNA flow cytometry also identifies a subset of patients with LGD and IND who are at higher risk for subsequent detection of HGD or OAC.
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Affiliation(s)
- Won-Tak Choi
- Department of Pathology, University of California at San Francisco, San Francisco, California, USA
| | - Jia-Huei Tsai
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Thomas Small
- Department of Pathology, University of Washington, Seattle, Washington, USA
| | - Danning Huang
- Department of Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Aras N Mattis
- Department of Pathology, University of California at San Francisco, San Francisco, California, USA
| | - Sanjay Kakar
- Department of Pathology, University of California at San Francisco, San Francisco, California, USA
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Kinra P, Gahlot GPS, Yadav R, Baloda V, Makharia GK, Gupta SD, Das P. Histological assessment & use of immunohistochemical markers for detection of dysplasia in Barrett's esophageal mucosa. Pathol Res Pract 2018; 214:993-999. [PMID: 29764708 DOI: 10.1016/j.prp.2018.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/16/2018] [Accepted: 05/05/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Histological assessment of dysplasia in Barrett's esophagus (BE) has high inter-observer variability. Hence, use of ancillary markers for early detection of dysplasia in BE is an important clinical question. METHODS In this retrospective study consecutive cases of BE (n = 59), over a period of 4 years were included. Hematoxylin and eosin stained sections were reviewed independently by 3 senior qualified pathologists, who graded the dysplasia according to the Vienna Classification system and inter-observer agreement was analysed using the Kappa statistics. Subsequently Alpha-Methyl Acyl-CoA Racemase (AMACR), p53, CyclinD1, β-catenin, H2AX and M30 immunohistochemical (IHC) stains were examined on the following disease categories: BE with no dysplasia [NFD] (45), BE with indefinite for dysplasia (IFD) (4), low grade dysplasia (LGD) (3), high grade dysplasia (HGD) (2) and in adenocarcinomas (5). H score was calculated by adding up products of different grades of stain distribution and stain intensities (range of scores 0-300). RESULTS Among the 3 pathologists, overall agreement was poor (k 0.06; 95% CI -0.089 to 0.145), with highest disagreement noted for differentiating the LGD and IFDs (k = 0.21). After revising the histological criteria, the kappa improved to 0.53. Among the IHC stains performed, p53, β-catenin, H2AX and M30 stains were significantly useful to differentiate between IFD and LGD (P values: 0.04, 0.004, 0.05 & 0.04, respectively). AMACR and β-catenin stains though were up-regulated in HGD/adenocarcinomas than in other categories, their expression were not statistically different between the IFD and LGDs. CONCLUSIONS A detail histological scoring system may bring uniformity in histological interpretation of dysplasia in BE. Using a combined panel of IHC stains seems helpful in detection of dysplasia in BE, especially to differentiate the IFD and LGD changes in BE.
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Affiliation(s)
- Prateek Kinra
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Gaurav P S Gahlot
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Rajni Yadav
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vandana Baloda
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Govind K Makharia
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Siddhartha Datta Gupta
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
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Subramaniam S, Kandiah K, Chedgy F, Meredith P, Longcroft-Wheaton G, Bhandari P. The safety and efficacy of radiofrequency ablation following endoscopic submucosal dissection for Barrett's neoplasia. Dis Esophagus 2018; 31:4683665. [PMID: 29211875 DOI: 10.1093/dote/dox133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 12/11/2022]
Abstract
The current standard of treating early Barrett's neoplasia is resection of visible lesions using endoscopic mucosal resection (EMR) followed by ablative therapy to the Barrett's segment. There is increasing evidence to support the use of endoscopic submucosal dissection (ESD) where en-bloc resection and lower recurrence rates may be achieved. However, ESD is associated with deep submucosal dissection when compared to EMR. This may increase the risk of complications including stricture formation with subsequent radiofrequency ablation (RFA) therapy. The aim of this study is to compare the safety and efficacy of RFA following EMR and ESD as well as when RFA was used without prior endoscopic resection. The primary outcome measure was complication rates. Clearance of dysplasia (CRD) and clearance of intestinal metaplasia (CRIM) were secondary outcomes. A retrospective analysis of a cohort of 91 patients referred for RFA from a single academic tertiary center was performed. The choice of endoscopic resection method was tailored according to the lesion type and morphology. Focal and circumferential ablation was performed after initial follow up endoscopy postresection. Patients proceeded straight to RFA in the absence of any visible lesions. In this study, the ESD group had a higher proportion of cancers compared to the EMR cohort (74.1% vs. 30.2%, P < 0.01) prior to RFA. All complications post RFA occurred in the groups with previous endoscopic resection. There was no significant difference in the total complication rate (7.4% vs. 9.3%, P = 0.78) and stricture formation rate (3.7% vs. 9.3%, P = 0.38) between the ESD and EMR groups. CRD was achieved in 96.3% in the ESD group, 88.4% in the EMR group, and all patients in the RFA alone group. CRIM rates were similar in the EMR and ESD groups (81.4% vs. 85.2%) but higher in the RFA alone group (90.5%). In conclusion, RFA following ESD is very effective and not associated with an increased risk of complications compared to EMR. This supports the application of RFA in the treatment algorithm of patients undergoing ESD for Barrett's neoplasia.
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Affiliation(s)
| | | | | | - P Meredith
- Research & Innovation, Queen Alexandra Hospital, Portsmouth, United Kingdom
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Lee HC, Ahsen OO, Liang K, Wang Z, Figueiredo M, Giacomelli MG, Potsaid B, Huang Q, Mashimo H, Fujimoto JG. Endoscopic optical coherence tomography angiography microvascular features associated with dysplasia in Barrett's esophagus (with video). Gastrointest Endosc 2017; 86:476-484.e3. [PMID: 28167119 PMCID: PMC5545067 DOI: 10.1016/j.gie.2017.01.034] [Citation(s) in RCA: 28] [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: 09/16/2016] [Accepted: 01/27/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Angiogenesis is associated with neoplastic progression of Barrett's esophagus (BE). Volumetric optical coherence tomography angiography (OCTA) visualizes subsurface microvasculature without exogenous contrast agents. We investigated the association of OCTA microvascular features with low-grade dysplasia (LGD) and high-grade dysplasia (HGD). METHODS Fifty-two patients undergoing BE surveillance or endoscopic eradication therapies for dysplasia were imaged using volumetric OCTA and corresponding histologic diagnoses wre obtained to yield 97 data sets (nondysplastic BE [NDBE], 74; LGD, 10; HGD, 13). After evaluating OCTA image quality, 54 datasets (NDBE, 35; LGD, 8; HGD, 11) from 32 patients were used to develop a training and reading protocol. The association of abnormal vessel branching and heterogeneous vessel size with LGD/HGD and a regular honeycomb vessel pattern with NDBE were investigated. RESULTS Blinded OCTA reading of 41 OCTA datasets (NDBE, 27; LGD, 7; HGD, 7) was performed by readers with various levels of OCT/OCTA experience including 3 OCT trainees, 1 gastroenterologist, and 2 gastroenterology fellows. Among the 6 readers, OCTA features of abnormal vessel branching and heterogeneous vessel size had an overall 94% sensitivity (95% CI, 89-99) and 69% specificity (95% CI, 62-76) for differentiating LGD/HGD versus NDBE with a mean reading time of 45 seconds per data set and moderate (kappa = .58) interobserver agreement. CONCLUSIONS Volumetric en face OCTA imaging enables rapid examination of depth resolved microvascular features with near-microscopic resolution. OCTA can visualize microvascular features associated with LGD/HGD with high accuracy, which motivates new technologic advances and future studies investigating the diagnostic performance of OCTA.
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Affiliation(s)
- Hsiang-Chieh Lee
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Osman O Ahsen
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Kaicheng Liang
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Zhao Wang
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | | | - Michael G Giacomelli
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Benjamin Potsaid
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA; Advanced Imaging Group, Thorlabs, Inc, Newton, New Jersey, USA
| | - Qin Huang
- VA Boston Healthcare System, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Hiroshi Mashimo
- VA Boston Healthcare System, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - James G Fujimoto
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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Filby A, Taylor M, Lipman G, Lovat L, Haidry R. Cost–effectiveness analysis of endoscopic eradication therapy for treatment of high-grade dysplasia in Barrett’s esophagus. J Comp Eff Res 2017; 6:425-436. [DOI: 10.2217/cer-2016-0089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aim: The aim was to evaluate the cost–effectiveness of endoscopic eradication therapy (EET) with combined endoscopic mucosal resection and radiofrequency ablation for the treatment of high-grade dysplasia (HGD) arising in patients with Barrett’s esophagus compared with endoscopic surveillance alone in the UK. Materials & methods: The cost–effectiveness model consisted of a decision tree and modified Markov model. A lifetime time horizon was adopted with the perspective of the UK healthcare system. Results: The base case analysis estimates that EET for the treatment of HGD is cost-effective at a GB£20,000 cost–effectiveness threshold compared with providing surveillance alone for HGD patients (incremental cost–effectiveness ratio: GB£1272). Conclusion: EET is likely to be a cost-effective treatment strategy compared with surveillance alone in patients with HGD arising in Barrett’s esophagus in the UK.
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Affiliation(s)
- Alex Filby
- York Health Economic Consortium (YHEC), Enterprise House, Innovation Way, University of York, York, UK
| | - Matthew Taylor
- York Health Economic Consortium (YHEC), Enterprise House, Innovation Way, University of York, York, UK
| | - Gideon Lipman
- Department of Gastroenterology, University College Hospital, 235 Euston Rd, Fitzrovia, London, UK
| | - Laurence Lovat
- Department of Gastroenterology, University College Hospital, 235 Euston Rd, Fitzrovia, London, UK
- Department of Surgery & Interventional Sciences, University College London, London, UK
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, 235 Euston Rd, Fitzrovia, London, UK
- Department of Surgery & Interventional Sciences, University College London, London, UK
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Eluri S, Shaheen NJ. Barrett's esophagus: diagnosis and management. Gastrointest Endosc 2017; 85:889-903. [PMID: 28109913 PMCID: PMC5392444 DOI: 10.1016/j.gie.2017.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 01/07/2017] [Indexed: 02/08/2023]
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Yamashita DT, Li C, Bethune D, Henteleff H, Ellsmere J. Endoscopic mucosal resection for high-grade dysplasia and intramucosal carcinoma: a Canadian experience. Can J Surg 2017; 60:129-133. [PMID: 28338468 DOI: 10.1503/cjs.013515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is increasingly being used as a first-line treatment for Barrett esophagus (BE) with high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC). We reviewed our experience with endoscopic treatment of BE with HGD and IMC at our institution with respect to eradication rates, complications and long-term recurrence. METHODS We performed a single-centre retrospective review of all patients referred between October 2010 and August 2014 for EMR with dysplastic BE or IMC. We performed EMR using a cap-fitted endoscope, and the procedure was repeated every 3 months until eradication or progression of disease. RESULTS A total of 28 patients were identified: 16 with dysplastic BE (14 HGD, 1 low-grade dysplasia, 1 intermediate dysplasia) and 12 with IMC. Complete eradication of HGD was achieved in 11 of 14 (79%) patients. Three of 12 (25%) patients initially referred with suspected IMC were found to have invasive adenocarcinoma on EMR. Eradication was successful in 8 of 9 (89%) patients with true IMC, with 1 patient progressing to salvage esophagectomy. Complications occurred in 2 of 28 (7%) patients; both had esophageal strictures managed with dilatation. Median duration of follow-up was 371 days. CONCLUSION Our experience supports the safety of EMR as a first-line treatment for patients with BE with dysplasia and IMC in early short-term follow-up.
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Affiliation(s)
- Denise Tami Yamashita
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Chao Li
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Drew Bethune
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Harry Henteleff
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - James Ellsmere
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
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Moole H, Patel J, Ahmed Z, Duvvuri A, Vennelaganti S, Moole V, Dharmapuri S, Boddireddy R, Yedama P, Bondalapati N, Uppu A, Vennelaganti P, Puli S. Progression from low-grade dysplasia to malignancy in patients with Barrett's esophagus diagnosed by two or more pathologists. World J Gastroenterol 2016; 22:8831-8843. [PMID: 27818599 PMCID: PMC5075558 DOI: 10.3748/wjg.v22.i39.8831] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/04/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate annual incidence of low grade dysplasia (LGD) progression to high grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC) when diagnosis was made by two or more expert pathologists. METHODS Studies evaluating the progression of LGD to HGD or EAC were included. The diagnosis of LGD must be made by consensus of two or more expert gastrointestinal pathologists. Articles were searched in Medline, Pubmed, and Embase. Pooled proportions were calculated using fixed and random effects model. Heterogeneity among studies was assessed using the I2 statistic. RESULTS Initial search identified 721 reference articles, of which 53 were selected and reviewed. Twelve studies (n = 971) that met the inclusion criteria were included in this analysis. Among the total original LGD diagnoses in the included studies, only 37.49% reached the consensus LGD diagnosis after review by two or more expert pathologists. Total follow up period was 1532 patient-years. In the pooled consensus LGD patients, the annual incidence rate (AIR) of progression to HGD and or EAC was 10.35% (95%CI: 7.56-13.13) and progression to EAC was 5.18% (95%CI: 3.43-6.92). Among the patients down staged from original LGD diagnosis to No-dysplasia Barrett's esophagus, the AIR of progression to HGD and EAC was 0.65% (95%CI: 0.49-0.80). Among the patients down staged to Indefinite for dysplasia, the AIR of progression to HGD and EAC was 1.42% (95%CI: 1.19-1.65). In patients with consensus HGD diagnosis, the AIR of progression to EAC was 28.63% (95%CI: 13.98-43.27). CONCLUSION When LGD is diagnosed by consensus agreement of two or more expert pathologists, its progression towards malignancy seems to be at least three times the current estimates, however it could be up to 20 times the current estimates. Biopsies of all Barrett's esophagus patients with LGD should be reviewed by two expert gastroenterology pathologists. Follow-up strict surveillance programs should be in place for these patients.
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Abstract
This review provides a summary of our current understanding of, and the controversies surrounding, the diagnosis, pathogenesis, histopathology, and molecular biology of Barrett's esophagus (BE) and associated neoplasia. BE is defined as columnar metaplasia of the esophagus. There is worldwide controversy regarding the diagnostic criteria of BE, mainly with regard to the requirement to histologically identify goblet cells in biopsies. Patients with BE are at increased risk for adenocarcinoma, which develops in a metaplasia-dysplasia-carcinoma sequence. Surveillance of patients with BE relies heavily on the presence and grade of dysplasia. However, there are significant pathologic limitations and diagnostic variability in evaluating dysplasia, particularly with regard to the more recently recognized unconventional variants. Identification of non-morphology-based biomarkers may help risk stratification of BE patients, and this is a subject of ongoing research. Because of recent achievements in endoscopic therapy, there has been a major shift in the treatment of BE patients with dysplasia or intramucosal cancer away from esophagectomy and toward endoscopic mucosal resection and ablation. The pathologic issues related to treatment and its complications are also discussed in this review article.
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Comparative Effectiveness of Esophagectomy Versus Endoscopic Treatment for Esophageal High-grade Dysplasia. Ann Surg 2016; 263:719-26. [PMID: 26672723 DOI: 10.1097/sla.0000000000001387] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study is to determine the comparative effectiveness of esophagectomy versus endoscopic mucosal resection followed by radiofrequency ablation (EMR-RFA) for the treatment of Barrett esophagus with high-grade dysplasia (HGD). BACKGROUND HGD of the esophagus may be managed by surgical resection or EMR-RFA. National guidelines suggest that EMR-RFA is effective at eradicating HGD. The comparative effectiveness and cost-effectiveness of EMR-RFA versus esophagectomy for HGD remains unclear. METHODS A decision-analysis model was constructed to represent 3 management strategies for HGD: (1) esophagectomy, (2) EMR-RFA, and (3) endoscopic surveillance. Estimates for model variables were obtained from literature review, and costs were estimated from Medicare fee schedules. Costs and utilities were discounted at an annual rate of 3%. The baseline model was adjusted for alternative age groups and high-risk dysplastic variants. One-way and multivariable probabilistic sensitivity analyses were conducted. RESULTS For a 65-year-old patient, compared to esophagectomy, EMR-RFA yields equivalent utility (11.5 vs 11.4 discounted quality-adjusted life years) with lower total cost ($52.5K vs $74.3K) over the first 20 years. Dominance of EMR-RFA over esophagectomy persists for all age groups. Patients with diffuse or ulcerated HGD are more effectively treated with esophagectomy. Model outcomes are sensitive to estimated rates of disease progression and postintervention utility parameters. CONCLUSIONS Existing evidence supports EMR-RFA over esophagectomy for the treatment of esophageal HGD. Long-term outcomes and more definitive quality-of-life studies for both interventions are crucial to better inform decision-making.
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Kaye PV, Ilyas M, Soomro I, Haider SA, Atwal G, Menon S, Gill S, Richards C, Harrison R, West K, Ragunath K. Dysplasia in Barrett's oesophagus: p53 immunostaining is more reproducible than haematoxylin and eosin diagnosis and improves overall reliability, while grading is poorly reproducible. Histopathology 2016; 69:431-40. [PMID: 26918780 DOI: 10.1111/his.12956] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 02/22/2016] [Indexed: 12/20/2022]
Abstract
AIMS p53 immunostaining in Barrett's oesophagus (BO) has been shown to be predictive of progression, but data regarding its generalizability to routine practice are lacking. This study compared the reliability of p53 and dysplasia interpretation and grading. METHODS AND RESULTS Seventy-two cases encompassing the full spectrum of BO were circulated to 10 pathologists from four institutions after a brief training session in p53 interpretation. Each pathologist classified cases on haematoxylin and eosin (H&E) alone using the Vienna classification and assessed the p53 staining using a qualitative system. Agreement was assessed using kappa statistics. For the four-tier Vienna system, the average unweighted kappa was 0.30. Weighted kappa values varied from 0.27 to 0.69 with an average of 0.47. When grouped into definite dysplasia versus no definite dysplasia the average kappa was 0.55, but the kappa for low-grade dysplasia (LGD) versus high-grade dysplasia (HGD) was only 0.31. For p53, using the three recognized patterns, the unweighted kappa was 0.6 (confidence interval 0.58-0.63). When cases were evaluated with both H&E and p53 the average kappa was 0.61 for definite dysplasia versus the rest. CONCLUSIONS p53 immunohistochemistry interpretation is more reliable than dysplasia diagnosis, even with limited training. As it is predictive of prognosis and improves diagnostic reproducibility, it is suitable for routine use by pathologists as an adjunct to dysplasia diagnosis. The distinction of LGD versus HGD was poor. This study supports simplifying dysplasia diagnosis into 'present', 'indefinite' or 'absent', and the use of p53 as an ancillary marker in difficult cases. This should help to prevent overdiagnosis of dysplasia and inappropriate treatment.
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Affiliation(s)
- Philip V Kaye
- Department of Histopathology, Nottingham University Hospitals, University of Nottingham, Nottingham Digestive Diseases BRU, Nottingham, UK
| | - Mohammad Ilyas
- Department of Histopathology, Nottingham University Hospitals, University of Nottingham, Nottingham Digestive Diseases BRU, Nottingham, UK
| | - Irshad Soomro
- Department of Histopathology, Nottingham University Hospitals, University of Nottingham, Nottingham Digestive Diseases BRU, Nottingham, UK
| | - Syeda A Haider
- Department of Histopathology, Nottingham University Hospitals, University of Nottingham, Nottingham Digestive Diseases BRU, Nottingham, UK
| | - Gurprit Atwal
- Department of Histopathology, Royal Derby Hospitals, Derby, UK
| | - Sindhu Menon
- Department of Histopathology, Royal Derby Hospitals, Derby, UK
| | - Shafiq Gill
- Department of Histopathology, Sherwood Forest Hospitals, Mansfield, UK
| | - Cathy Richards
- Department of Histopathology, University Hospitals of Leicester, Leicester, UK
| | - Rebecca Harrison
- Department of Histopathology, University Hospitals of Leicester, Leicester, UK
| | - Kevin West
- Department of Histopathology, University Hospitals of Leicester, Leicester, UK
| | - Krish Ragunath
- Department of Histopathology, Nottingham University Hospitals, University of Nottingham, Nottingham Digestive Diseases BRU, Nottingham, UK
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Ortiz-Fernández-Sordo J, Sami S, Mansilla-Vivar R, De Caestecker J, Cole A, Ragunath K. Incidence of metachronous visible lesions in patients referred for radiofrequency ablation (RFA) therapy for early Barrett's neoplasia: a single-centre experience. Frontline Gastroenterol 2016; 7:24-29. [PMID: 26834956 PMCID: PMC4717434 DOI: 10.1136/flgastro-2015-100561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/05/2015] [Accepted: 02/09/2015] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Evaluate the incidence of metachronous visible lesions (VLs) in patients referred for radiofrequency ablation (RFA) for early Barrett's neoplasia. DESIGN This study was conducted as part of the service evaluation audit. SETTING Tertiary referral centre. PATIENTS All patients with dysplastic Barrett's oesophagus referred for RFA were included for analysis. White light high-resolution endoscopy (HRE), autofluorescence imaging and narrow band imaging were sequentially performed. Endoscopic mucosal resection (EMR) was performed for all VL. Three to six months after EMR, all patients underwent initial RFA and then repeat RFA procedures at three monthly intervals. INTERVENTIONS All endoscopy reports and final staging by EMR/surgery were evaluated and included for analysis. RESULTS Fifty patients were analysed; median age 73 years, 84% men. 38/50 patients (76%) had a previous EMR due to the presence of VL before referred for ablation; twelve patients had no previous treatment. In total, 151 ablation procedures were performed, median per patient 2.68. Twenty metachronous VL were identified in 14 patients before the first ablation or during the RFA protocol; incidence was 28%. All metachronous lesions were successfully resected by EMR. Upstaging after rescue EMR compared with the initial histology was observed in four patients (28%). CONCLUSIONS In total, 28% of patients enrolled in the RFA programme were diagnosed to have metachronous lesions. This high-incidence rate highlights the importance of a meticulous examination to identify and resect any VL before every ablation session. RFA treatment for early Barrett's neoplasia should be performed in tertiary referral centres with HRE and EMR facilities and expertise.
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Affiliation(s)
- J Ortiz-Fernández-Sordo
- Nottingham Digestive Diseases Centre and NIHR Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham , UK
| | - S Sami
- Nottingham Digestive Diseases Centre and NIHR Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham , UK
| | - R Mansilla-Vivar
- Nottingham Digestive Diseases Centre and NIHR Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham , UK
| | - J De Caestecker
- Digestive Diseases Centre, University Hospitals of Leicester NHS Trust , Leicester , UK
| | - A Cole
- Gastroenterology and Hepatology Department , Derby Hospitals NHS Foundation Trust , Derby , UK
| | - K Ragunath
- Nottingham Digestive Diseases Centre and NIHR Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham , UK
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Vance RB, Dunbar KB. Endoscopic options for treatment of dysplasia in Barrett’s esophagus. World J Gastrointest Endosc 2015; 7:1311-1317. [PMID: 26722612 PMCID: PMC4689793 DOI: 10.4253/wjge.v7.i19.1311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/17/2015] [Accepted: 11/11/2015] [Indexed: 02/05/2023] Open
Abstract
Recent advances in the endoscopic treatment of dysplasia in Barrett’s esophagus (BE) have allowed endoscopists to provide effective and durable eradication therapies. This review summarizes the available endoscopic eradication techniques for dysplasia in patients with BE including endoscopic mucosal resection, endoscopic submucosal dissection, photodynamic therapy, argon plasma coagulation, radiofrequency ablation and cryotherapy.
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Sharma P, Katzka DA, Gupta N, Ajani J, Buttar N, Chak A, Corley D, El-Serag H, Falk GW, Fitzgerald R, Goldblum J, Gress F, Ilson DH, Inadomi JM, Kuipers EJ, Lynch JP, McKeon F, Metz D, Pasricha PJ, Pech O, Peek R, Peters JH, Repici A, Seewald S, Shaheen NJ, Souza RF, Spechler SJ, Vennalaganti P, Wang K. Quality indicators for the management of Barrett's esophagus, dysplasia, and esophageal adenocarcinoma: international consensus recommendations from the American Gastroenterological Association Symposium. Gastroenterology 2015; 149:1599-606. [PMID: 26296479 PMCID: PMC4820399 DOI: 10.1053/j.gastro.2015.08.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The development of and adherence to quality indicators in gastroenterology, as in all of medicine, is increasing in importance to ensure that patients receive consistent high-quality care. In addition, government-based and private insurers will be expecting documentation of the parameters by which we measure quality, which will likely affect reimbursements. Barrett's esophagus remains a particularly important disease entity for which we should maintain up-to-date guidelines, given its commonality, potentially lethal outcomes, and controversies regarding screening and surveillance. To achieve this goal, a relatively large group of international experts was assembled and, using the modified Delphi method, evaluated the validity of multiple candidate quality indicators for the diagnosis and management of Barrett's esophagus. Several candidate quality indicators achieved >80% agreement. These statements are intended to serve as a consensus on candidate quality indicators for those who treat patients with Barrett's esophagus.
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Affiliation(s)
- Prateek Sharma
- University of Kansas School of Medicine, Kansas City, Kansas; Veterans Affairs Medical Center, Kansas City, Missouri.
| | | | - Neil Gupta
- Department of Gastroenterology and Hepatology, Loyola University Medical Center, Maywood, Illinois
| | - Jaffer Ajani
- University of Texas, Anderson Cancer Center, Houston, Texas
| | | | - Amitabh Chak
- Case Western Reserve University, Cleveland, Ohio
| | - Douglas Corley
- Kaiser Permanente Northern California, Oakland, California
| | | | - Gary W. Falk
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca Fitzgerald
- MRC Cancer Cell Unit, Hutchison-MRC Research Center and University of Cambridge, Cambridge, UK
| | - John Goldblum
- Anatomic Pathology, The Cleveland Clinic, Cleveland, Ohio
| | - Frank Gress
- State University of New York at Downstate Medical Center, New York, New York
| | - David H. Ilson
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - John M. Inadomi
- University of Washington Medical Center, Seattle, Washington
| | | | - John P. Lynch
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank McKeon
- National University Health System, Singapore and University of Connecticut, Farmington, Connecticut
| | - David Metz
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Oliver Pech
- Kranhenhaus Barmherzige Brüder, Regensburg, Germany
| | - Richard Peek
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Nicholas J. Shaheen
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Rhonda F. Souza
- University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Texas
| | - Stuart J. Spechler
- University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Texas
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Haidry R, Lovat L, Sharma P. Radiofrequency ablation for Barrett's dysplasia: past, present and the future? Curr Gastroenterol Rep 2015; 17:13. [PMID: 25740248 DOI: 10.1007/s11894-015-0433-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Barrett's oesophagus is the only know pre-cursor to oesophageal adenocarcinoma. The incidence of OAC is growing rapidly in the western world with a poor prognosis for most with a 5-year survival of only 15%. The approach to treating patients with neoplasia arising within BE has dramatically changed in the past 5 years. Resection of visible lesions with endoscopic mucosal resection followed by field ablation with radio-frequency ablation is now the accepted standard of care in these patients worldwide. This combined approach has shown high rates of disease reversal in several high quality clinical trials but also large volume registry studies. As well as being a minimally invasive and oesophageal sparing interventions compared to surgery with oesophagectomy, endoscopic therapy has proved to be safe and emerging long-term data show sustained benefit in the majority of patients and low rates of cancer progression. However, in a sub-group of patients, recurrences have been reported after successful endoscopic therapy making it mandatory to follow these patients post therapy. Improvements in endoscopic imaging continue to aid early diagnosis, and in turn, this will allow clinicians the ability to offer patient's treatment at an early stage.
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Affiliation(s)
- Rehan Haidry
- Department of Gastroenterology, University College Hospital NHS foundation Trust, London, UK,
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30
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Small AJ, Araujo JL, Leggett CL, Mendelson AH, Agarwalla A, Abrams JA, Lightdale CJ, Wang TC, Iyer PG, Wang KK, Rustgi AK, Ginsberg GG, Forde KA, Gimotty PA, Lewis JD, Falk GW, Bewtra M. Radiofrequency Ablation Is Associated With Decreased Neoplastic Progression in Patients With Barrett's Esophagus and Confirmed Low-Grade Dysplasia. Gastroenterology 2015; 149:567-76.e3; quiz e13-4. [PMID: 25917785 PMCID: PMC4550488 DOI: 10.1053/j.gastro.2015.04.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 04/15/2015] [Accepted: 04/19/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) with low-grade dysplasia (LGD) can progress to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). Radiofrequency ablation (RFA) has been shown to be an effective treatment for LGD in clinical trials, but its effectiveness in clinical practice is unclear. We compared the rate of progression of LGD after RFA with endoscopic surveillance alone in routine clinical practice. METHODS We performed a retrospective study of patients who either underwent RFA (n = 45) or surveillance endoscopy (n = 125) for LGD, confirmed by at least 1 expert pathologist, from October 1992 through December 2013 at 3 medical centers in the United States. Cox regression analysis was used to assess the association between progression and RFA. RESULTS Data were collected over median follow-up periods of 889 days (interquartile range, 264-1623 days) after RFA and 848 days (interquartile range, 322-2355 days) after surveillance endoscopy (P = .32). The annual rates of progression to HGD or EAC were 6.6% in the surveillance group and 0.77% in the RFA group. The risk of progression to HGD or EAC was significantly lower among patients who underwent RFA than those who underwent surveillance (adjusted hazard ratio = 0.06; 95% confidence interval: 0.008-0.48). CONCLUSIONS Among patients with BE and confirmed LGD, rates of progression to a combined end point of HGD and EAC were lower among those treated with RFA than among untreated patients. Although selection bias cannot be excluded, these findings provide additional evidence for the use of endoscopic ablation therapy for LGD.
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Affiliation(s)
- Aaron J. Small
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James L. Araujo
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY
| | - Cadman L. Leggett
- Department of Medicine, Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | - Aaron H. Mendelson
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Anant Agarwalla
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Julian A. Abrams
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY
| | - Charles J. Lightdale
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY
| | - Timothy C. Wang
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY
| | - Prasad G. Iyer
- Department of Medicine, Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | - Kenneth K. Wang
- Department of Medicine, Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | - Anil K. Rustgi
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gregory G. Ginsberg
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly A. Forde
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Phyllis A. Gimotty
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James D. Lewis
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gary W. Falk
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meenakshi Bewtra
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Abstract
Although there are many unanswered questions with Barrett esophagus, we can safely say that the incidence is increasing, chemoprevention strategies for the prevention of Barrett metaplasia and its progression to adenocarcinoma may be in the offing, surveillance should be considered for all patients who are discovered to have Barrett esophagus, RFA is the treatment of choice for those with HGD and strongly considered in those with LGD, EMR should be the treatment of choice for patients with nodular high-grade Barrett esophagus, and, finally, vagal-sparing esophagectomy reserved for patients with persistent HGD or a strong suspicion of carcinoma, with consideration of a concomitant fundoplication.
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Affiliation(s)
- Mark Splittgerber
- Division of General Surgery, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, FL, USA.
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Haidry RJ, Butt MA, Dunn JM, Gupta A, Lipman G, Smart HL, Bhandari P, Smith L, Willert R, Fullarton G, Di Pietro M, Gordon C, Penman I, Barr H, Patel P, Kapoor N, Hoare J, Narayanasamy R, Ang Y, Veitch A, Ragunath K, Novelli M, Lovat LB. Improvement over time in outcomes for patients undergoing endoscopic therapy for Barrett's oesophagus-related neoplasia: 6-year experience from the first 500 patients treated in the UK patient registry. Gut 2015; 64:1192-9. [PMID: 25539672 PMCID: PMC4515987 DOI: 10.1136/gutjnl-2014-308501] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 11/29/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Barrett's oesophagus (BE) is a pre-malignant condition leading to oesophageal adenocarcinoma (OAC). Treatment of neoplasia at an early stage is desirable. Combined endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) is an alternative to surgery for patients with BE-related neoplasia. METHODS We examined prospective data from the UK registry of patients undergoing RFA/EMR for BE-related neoplasia from 2008 to 2013. Before RFA, visible lesions were removed by EMR. Thereafter, patients had RFA 3-monthly until all BE was ablated or cancer developed (endpoints). End of treatment biopsies were recommended at around 12 months from first RFA treatment or when endpoints were reached. Outcomes for clearance of dysplasia (CR-D) and BE (CR-IM) at end of treatment were assessed over two time periods (2008-2010 and 2011-2013). Durability of successful treatment and progression to OAC were also evaluated. RESULTS 508 patients have completed treatment. CR-D and CR-IM improved significantly between the former and later time periods, from 77% and 56% to 92% and 83%, respectively (p<0.0001). EMR for visible lesions prior to RFA increased from 48% to 60% (p=0.013). Rescue EMR after RFA decreased from 13% to 2% (p<0.0001). Progression to OAC at 12 months is not significantly different (3.6% vs 2.1%, p=0.51). CONCLUSIONS Clinical outcomes for BE neoplasia have improved significantly over the past 6 years with improved lesion recognition and aggressive resection of visible lesions before RFA. Despite advances in technique, the rate of cancer progression remains 2-4% at 1 year in these high-risk patients. TRIAL REGISTRATION NUMBER ISRCTN93069556.
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Affiliation(s)
- R J Haidry
- Research Department of Tissue and Energy, Division of Surgery and Interventional Science, University College London, London, UK,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - M A Butt
- Research Department of Tissue and Energy, Division of Surgery and Interventional Science, University College London, London, UK
| | - J M Dunn
- Guy's and St Thomas’ NHS foundation Trust, London, UK,Institute for Cancer Genetics and Informatics, Oslo University, Oslo, Norway
| | - A Gupta
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - G Lipman
- Research Department of Tissue and Energy, Division of Surgery and Interventional Science, University College London, London, UK
| | - H L Smart
- Department of Gastroenterology and Hepatology, Royal Liverpool University Hospital, Liverpool, UK
| | - P Bhandari
- Princess Alexandra Hospital, Portsmouth, UK
| | - L Smith
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - R Willert
- Central Manchester University Hospitals NHS Foundation Trust, Manchester,UK
| | | | | | - C Gordon
- Royal Bournemouth Hospital, Bournemouth, UK
| | - I Penman
- Royal Infirmary Edinburgh, Edinburgh, UK
| | - H Barr
- Oesophagogastric Surgery, Gloucestershire Hospital NHS Trust, Birmingham, UK
| | - P Patel
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - N Kapoor
- Digestive Diseases Centre, Aintree University Hospital, Liverpool, UK
| | - J Hoare
- St Mary's Hospital NHS Trust, London, UK
| | | | - Y Ang
- Centre of Gastrointestinal Sciences, University of Manchester, Salford Royal Foundation NHS Trust, Salford, UK
| | - A Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - K Ragunath
- Department of Gastroenterology, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - M Novelli
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - L B Lovat
- Research Department of Tissue and Energy, Division of Surgery and Interventional Science, University College London, London, UK,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
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33
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Hopcroft SA, Shepherd NA. The changing role of the pathologist in the management of Barrett's oesophagus. Histopathology 2015; 65:441-55. [PMID: 24809428 DOI: 10.1111/his.12457] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 05/04/2014] [Indexed: 02/06/2023]
Abstract
Pathological specimens from columnar-lined oesophagus (CLO) comprise a considerable proportion of the workload of gastrointestinal pathologists in Western countries. There remain controversies concerning the diagnostic role of pathology. More recently, in the UK at least, the diagnosis has been regarded as primarily an endoscopic endeavour, with pathology being corroborative and only diagnostic when endoscopic features are equivocal or when there are additional features that make the endoscopic diagnosis unclear. There is also recognition that demonstration of intestinalisation or 'goblet cells' is not paramount, and should not be required for the diagnosis. There have been notable changes in the management of CLO neoplasia: pathologists are centrally involved in its management. Pathological assessment of endoscopic mucosal resection (EMR) specimens provides the most useful means of determining the management of early neoplasia and of determining indications for surgery. This represents an extraordinarily rapid change in management, in that, <10 years ago, laborious Seattle-type biopsy protocols were recommended, and high grade dysplasia was an indication for resectional surgery. Now, individual patient management is paramount: multi-professional meetings determine management after biopsy and EMR assessment. One significant change is that major resections are undertaken less often, in Western countries, for CLO neoplasia.
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Affiliation(s)
- Suzanne A Hopcroft
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Cheltenham, UK
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34
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Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection for Endoscopic Therapy of Barrett's Esophagus-related Neoplasia. Gastroenterol Clin North Am 2015; 44:317-35. [PMID: 26021197 DOI: 10.1016/j.gtc.2015.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A major paradigm shift has occurred in the management of dysplastic Barrett's esophagus (BE) and early esophageal carcinoma. Endoscopic therapy has now emerged as the standard of care for this disease entity. Endoscopic resection techniques like endoscopic mucosal resection and endoscopic submucosal dissection combined with ablation techniques help achieve long-term curative success comparable with surgical outcomes, in this subgroup of patients. This article is an in-depth review of these endoscopic resection techniques, highlighting their role and value in the overall management of BE-related dysplasia and neoplasia.
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35
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Runge TM, Abrams JA, Shaheen NJ. Epidemiology of Barrett's Esophagus and Esophageal Adenocarcinoma. Gastroenterol Clin North Am 2015; 44:203-31. [PMID: 26021191 PMCID: PMC4449458 DOI: 10.1016/j.gtc.2015.02.001] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [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 precursor to esophageal adenocarcinoma (EAC), a disease with increasing burden in the Western world, especially in white men. Risk factors for BE include obesity, tobacco smoking, and gastroesophageal reflux disease (GERD). EAC is the most common form of esophageal cancer in the United States. Risk factors include GERD, tobacco smoking, and obesity, whereas nonsteroidal antiinflammatory drugs and statins may be protective. Factors predicting progression from nondysplastic BE to EAC include dysplastic changes on esophageal histology and length of the involved BE segment. Biomarkers have shown promise, but none are approved for clinical use.
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Affiliation(s)
- Thomas M. Runge
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - Julian A. Abrams
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY
| | - Nicholas J. Shaheen
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
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36
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Chak A, Buttar NS, Foster NR, Seisler DK, Marcon NE, Schoen R, Cruz-Correa MR, Falk GW, Sharma P, Hur C, Katzka DA, Rodriguez LM, Richmond E, Sharma AN, Smyrk TC, Mandrekar SJ, Limburg PJ. Metformin does not reduce markers of cell proliferation in esophageal tissues of patients with Barrett's esophagus. Clin Gastroenterol Hepatol 2015; 13:665-72.e1-4. [PMID: 25218668 PMCID: PMC4362887 DOI: 10.1016/j.cgh.2014.08.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/14/2014] [Accepted: 08/19/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Obesity is associated with neoplasia, possibly via insulin-mediated cell pathways that affect cell proliferation. Metformin has been proposed to protect against obesity-associated cancers by decreasing serum insulin. We conducted a randomized, double-blind, placebo-controlled, phase 2 study of patients with Barrett's esophagus (BE) to assess the effect of metformin on phosphorylated S6 kinase (pS6K1), a biomarker of insulin pathway activation. METHODS Seventy-four subjects with BE (mean age, 58.7 years; 58 men [78%; 52 with BE >2 cm [70%]) were recruited through 8 participating organizations of the Cancer Prevention Network. Participants were randomly assigned to groups given metformin daily (increasing to 2000 mg/day by week 4, n = 38) or placebo (n = 36) for 12 weeks. Biopsy specimens were collected at baseline and at week 12 via esophagogastroduodenoscopy. We calculated and compared percent changes in median levels of pS6K1 between subjects given metformin vs placebo as the primary end point. RESULTS The percent change in median level of pS6K1 did not differ significantly between groups (1.4% among subjects given metformin vs -14.7% among subjects given placebo; 1-sided P = .80). Metformin was associated with an almost significant reduction in serum levels of insulin (median -4.7% among subjects given metformin vs 23.6% increase among those given placebo, P = .08) as well as in homeostatic model assessments of insulin resistance (median -7.2% among subjects given metformin vs 38% increase among those given placebo, P = .06). Metformin had no effects on cell proliferation (on the basis of assays for KI67) or apoptosis (on the basis of levels of caspase 3). CONCLUSIONS In a chemoprevention trial of patients with BE, daily administration of metformin for 12 weeks, compared with placebo, did not cause major reductions in esophageal levels of pS6K1. Although metformin reduced serum levels of insulin and insulin resistance, it did not discernibly alter epithelial proliferation or apoptosis in esophageal tissues. These findings do not support metformin as a chemopreventive agent for BE-associated carcinogenesis. ClinicalTrials.gov number, NCT01447927.
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Affiliation(s)
- Amitabh Chak
- Department of Gastroenterology and Hepatology, University Hospitals Case Medical Center, Cleveland, Ohio.
| | - Navtej S Buttar
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Nathan R Foster
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Drew K Seisler
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Norman E Marcon
- Department of Medicine, Gastroenterology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Robert Schoen
- Department of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marcia R Cruz-Correa
- Department of Gastroenterology Oncology at UPR Cancer Center, University of Puerto Rico, San Juan, Puerto Rico
| | - Gary W Falk
- Department of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Prateek Sharma
- Department of Gastroenterology, Hepatology and Motility, Kansas City VA, Kansas City, Missouri
| | - Chin Hur
- Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David A Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Luz M Rodriguez
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ellen Richmond
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Anamay N Sharma
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Thomas C Smyrk
- Department of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Sumithra J Mandrekar
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Paul J Limburg
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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"Indefinite for Dysplasia" in Barrett's Esophagus: Inflammation and DNA Content Abnormality are Significant Predictors of Early Detection of Neoplasia. Clin Transl Gastroenterol 2015; 6:e81. [PMID: 25761942 PMCID: PMC4459537 DOI: 10.1038/ctg.2015.7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 02/07/2015] [Indexed: 12/16/2022] Open
Abstract
Background: Dysplasia arising from Barrett's esophagus precedes esophageal adenocarcinoma (EAC). Cases that are difficult to diagnose as dysplastic, especially in the setting of inflammation, may be designated “indefinite for dysplasia (IND).” Although flow cytometric analysis of DNA content has shown some promise in detecting EAC, there are few reports that have specifically evaluated the outcome of IND. Aims and methods: We analyzed a series of 96 IND patients seen at the University of Washington between 2005 and 2013 to determine the outcome of IND and to identify factors (including histologic features and DNA flow cytometric data) associated with subsequent detection of neoplasia. Results: Twenty-five percent of IND cases were found to have low-grade dysplasia, high-grade dysplasia (HGD), or EAC within 1 year, with 37% and 47% detected within 2 and 3 years, respectively. The 1-, 2-, and 3-year detection rates of HGD or EAC were 10%, 13%, and 20%, respectively. Active inflammation (hazard ratio (HR)=3.4, P=0.0005) and abnormal DNA content (HR=5.7, P=0.003) were significant risk factors of neoplasia. When active inflammation and DNA flow cytometric results were considered together, the HR for the combined markers was 18.8 (P<0.0001). The sensitivity and specificity of the combined markers for predicting detection of subsequent neoplasia within 3 years were 100% and 60%, respectively, with 100% negative and 89% positive predictive values. Conclusions: Histology with the support of DNA flow cytometry can identify a subset of IND patients who may have a higher risk for subsequent detection of neoplasia.
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Zapletal C, Heesen C, Origer J, Pauthner M, Pech O, Ell C, Lorenz D. Quality of life after surgical treatment of early Barrett's cancer: a prospective comparison of the Ivor-Lewis resection versus the modified Merendino resection. World J Surg 2015; 38:1444-52. [PMID: 24378548 DOI: 10.1007/s00268-013-2410-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The Merendino (MER) procedure has been evaluated as an alternative to transthoracic esophageal resection (TER) for early stage Barrett's carcinoma. Apart from reducing morbidity and mortality, improvements concerning postoperative health-related quality of life (HRQL) have been postulated. The aim of our study was to compare HRQL between these procedures. MATERIALS AND METHODS Between July 2000 and July 2007, 117 patients with early Barrett's carcinoma underwent surgery. Patients with tumor recurrence were excluded from the study. HRQL was assessed 1 and 2 years after surgery using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (EORTC-QLQ-C30) and the QLQ-OES18 module. Patients recently diagnosed with early Barrett's carcinoma served as controls. Symptoms that showed a difference of more than ten between the control and the study groups were considered clinically relevant and were tested for significant differences between the study groups using the Mann-Whitney U test (p < 0.05). RESULTS The response rates for the questionnaires ranged between 70 and 93 %. In the MER group, more items reflected a clinical relevant impairment of HRQL than in the TER group. Significant complaints in the MER group included nausea/vomiting, appetite loss, local pain, difficulties with social eating, and choking. Moreover, we found a significant restriction concerning global health and emotional and social functioning in this group 1 year after surgery. 2 years postoperatively, hardly any differences between the operative techniques could be detected. The only symptom in favor of the MER procedure was a better dysphagia score postoperatively. CONCLUSION Our study suggests that MER procedure is not superior to subtotal esophagectomy with regard to HRQL.
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Affiliation(s)
- Ch Zapletal
- Department of Surgery, Dr. Horst-Schmidt-Klinik, Ludwig-Erhard-Str. 100, 65199, Wiesbaden, Germany,
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Perry KA, Walker JP, Salazar M, Suzo A, Hazey JW, Melvin WS. Endoscopic management of high-grade dysplasia and intramucosal carcinoma: experience in a large academic medical center. Surg Endosc 2014; 28:777-82. [PMID: 24122245 DOI: 10.1007/s00464-013-3240-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 09/21/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Esophagectomy has been the standard treatment for Barrett's esophagus (BE) with high-grade dysplasia (HGD) and intramucosal cancer (IMC). Recently, endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) have become the preferred treatment for these patients in some centers. We report a single institution series of patients undergoing endoscopic management of HGD and IMC. METHODS Nineteen patients underwent endoscopic treatment for HGD or IMC between 2009 and 2012. The primary outcome measure was progression of BE necessitating esophagectomy. Secondary outcomes included complete eradication of intestinal metaplasia (CE-IM), complete eradication of dysplasia (CE-D), recurrence or progression of BE or dysplasia, and complications. Patients were followed for a median follow-up interval of 19 months following completion of RFA treatment. RESULTS Three patients (16 %) had a presenting diagnosis of IMC, and 16 (84 %) were treated for HGD. Twelve (63 %) had long-segment BE; the median length of BE was 5 cm. Ten (53 %) patients underwent EMR prior to RFA. CE-D was achieved in 88 % of patients, and CE-IM was achieved in 65 % of patients. A median of 2 (1-7) treatments were required, and there were no immediate post-procedure complications. Two patients developed recurrent dysplasia following complete eradication of BE, and each case was successfully managed with repeat RFA. Three patients (16 %) required esophagectomy within 6 months following RFA. A complete surgical resection was achieved in each case, and none of the patients developed lymph node metastases. CONCLUSIONS Complete eradication of HGD and IMC can be achieved via endoscopic therapy, thus avoiding esophagectomy in the majority of patients. However, a subset of patients will fail this treatment approach and will require surgical resection. With aggressive endoscopic treatment and surveillance, these patients can be identified at an early stage while curative resection is still possible.
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Anaparthy R, Sharma P. Progression of Barrett oesophagus: role of endoscopic and histological predictors. Nat Rev Gastroenterol Hepatol 2014; 11:525-34. [PMID: 24860927 DOI: 10.1038/nrgastro.2014.69] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Barrett oesophagus is an important precursor lesion for the development of oesophageal adenocarcinoma (OAC). Upper gastrointestinal endoscopy is the modality most widely used to visualize and biopsy the oesophagus to establish a diagnosis. Additional clues are available at the time of endoscopy that can identify high-risk features known to increase the risk of progression to OAC, such as the length of the Barrett oesophagus segment, length of hiatal hernia and the presence of nodularity or visible endoscopic lesions in this segment. Until molecular biomarkers are identified and validated as adjunctive tools for risk stratification, knowledge of endoscopic features could complement dysplasia grading for risk stratification of patients with Barrett oesophagus and identify subgroups at risk of progression to OAC. This approach would, in turn, facilitate more rational tailoring of endoscopic surveillance. This Review summarizes the current role of endoscopic and histological factors involved in neoplastic progression of Barrett oesophagus to OAC, and provides an overview of the risk-prediction models that have utilized endoscopic and histological factors for risk stratification in patients with Barrett oesophagus.
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Affiliation(s)
- Rajeswari Anaparthy
- Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, MO 64128, USA
| | - Prateek Sharma
- Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, MO 64128, USA
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Abstract
A substantial portion of patients diagnosed preoperatively with high grade dysplasia (HGD) alone will have occult esophageal adenocarcinoma on analysis of the surgical specimen. Therefore, because of an increased risk of disease progression and malignancy, patients with HGD should be referred for esophagectomy promptly when endoscopic therapy has failed. The required extent of lymphadenectomy in this cohort of patients is unknown because of the variable incidence of submucosal cancer observed. Improvements in perioperative care, adoption of a minimally invasive surgical approach, and centralization of esophageal cancer services have substantially reduced the rates of mortality and morbidity associated with esophagectomy in recent years. Minimally invasive esophagectomy should be considered the treatment of choice in patients with dysplastic Barrett's esophagus that is refractory to endoscopic therapy or those at high risk of invasive cancer.
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Zaninotto G, Bennett C. Surveillance for low-grade dysplastic Barrett's oesophagus: one size fits all? World J Surg 2014; 39:578-85. [PMID: 24919861 DOI: 10.1007/s00268-014-2661-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This paper reviews the role of low-grade dysplasia (LGD) as a marker of progression in Barrett's oesophagus (BO). Albeit with its limits due to the difficulty of its diagnosis and the low agreement among pathologists, LGD remains the most relevant single prognostic factor of progression, and, when the diagnosis is confirmed by two or three pathologists, the chances of progression to high-grade dysplasia or invasive adenocarcinoma are as high as 40%. On the other hand, BO patients who remain dysplasia free at several follow-up examinations seem to have a very low likelihood of progression. The diagnosis of LGD should be confirmed by two pathologists, and surveillance programs should be tailored depending on the presence or persistent absence of LGD. Ablative therapy should be also considered for cases where LGD persists in a series of follow-ups.
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Affiliation(s)
- Giovanni Zaninotto
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK,
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Occurrence of invasive cancer after endoscopic treatment of Barrett's esophagus with high-grade dysplasia and intramucosal cancer in physiologically fit patients: time for a review of surveillance and treatment guidelines. Gastrointest Endosc 2014; 79:839-44. [PMID: 24447341 DOI: 10.1016/j.gie.2013.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 11/15/2013] [Indexed: 02/08/2023]
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Verbeek RE, van Oijen MGH, ten Kate FJ, Vleggaar FP, van Baal JWPM, Siersema PD. Consistency of a high-grade dysplasia diagnosis in Barrett's oesophagus: a Dutch nationwide cohort study. Dig Liver Dis 2014; 46:318-22. [PMID: 24388501 DOI: 10.1016/j.dld.2013.11.010] [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: 06/17/2013] [Revised: 11/04/2013] [Accepted: 11/22/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Consistency of high-grade dysplasia in Barrett's oesophagus is incompletely known and the clinical course may vary between patients. AIMS To evaluate the consistency of high-grade dysplasia diagnosis in a Dutch nationwide cohort and to identify predictors for (re-)detecting high-grade dysplasia or oesophageal adenocarcinoma when ≥ 1 follow-up evaluations after an initial high-grade dysplasia diagnosis were scored with a lower histological grade. METHODS In this retrospective cohort study, all patients diagnosed with high-grade dysplasia in Barrett's oesophagus between 1999 and 2008 in the Netherlands were selected using the nationwide histopathology registry. Multivariate analysis was performed to identify predictors for (re-)detecting high-grade dysplasia or oesophageal adenocarcinoma in patients with ≥ 1 follow-up evaluations scored with a lower grade. RESULTS In total, 512 high-grade dysplasia patients were included, of whom 53% had ≥ 1 follow-up evaluations scored with a lower grade. The (re-)detection risk was increased when follow-up was performed in a university hospital and when endoscopic/surgical resection was performed and decreased with an increasing number of follow-up evaluations scored with a lower grade. CONCLUSION High-grade dysplasia diagnosis was inconsistent in more than half of patients. (Endoscopic) resection in an expert centre is recommended to (re-)detect high-grade dysplasia or oesophageal adenocarcinoma when an endoscopic follow-up protocol with biopsies repeatedly shows a lower histological grade.
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Affiliation(s)
- Romy E Verbeek
- Departments of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Martijn G H van Oijen
- Departments of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Fiebo J ten Kate
- Departments of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Departments of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jantine W P M van Baal
- Departments of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter D Siersema
- Departments of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
The management of Barrett's oesophagus and associated neoplasia has evolved considerably in recent years. Modern endoscopic strategies including endoscopic resection and mucosal ablation can eradicate dysplastic Barrett's and prevent progression to invasive oesophageal cancer. However, several aspects of Barrett's management remain controversial including the stage in the disease process at which to intervene, and the choice of endoscopic or surgical therapy. A review of articles pertaining to the management of Barrett's oesophagus with or without associated neoplasia, was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, Embase and Cochrane databases were searched to identify literature relevant to eight pre-defined areas of clinical controversy. The following search terms were used: Barrett's oesophagus; dysplasia; intramucosal carcinoma; endotherapy; endoscopic resection; ablation; oesophagectomy. A significant body of evidence exists to support early endoscopic therapy for high-grade dysplasia (HGD). Although not supported by randomised controlled trial evidence, endoscopic therapy is now favoured ahead of oesophagectomy for most patients with HGD. Focal intramucosal (T1a) carcinomas can be managed effectively using endoscopic and surgical therapy, however surgery should be considered the first line therapy where there is submucosal invasion (T1b). Treatment of low grade dysplasia is not supported at present due to widespread over-reporting of the disease. The role of surveillance endoscopy in non-dysplastic Barrett's remains controversial.
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Espino A, Cirocco M, Dacosta R, Marcon N. Advanced imaging technologies for the detection of dysplasia and early cancer in barrett esophagus. Clin Endosc 2014; 47:47-54. [PMID: 24570883 PMCID: PMC3928491 DOI: 10.5946/ce.2014.47.1.47] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 12/30/2013] [Accepted: 12/30/2013] [Indexed: 12/14/2022] Open
Abstract
Advanced esophageal adenocarcinomas arising from Barrett esophagus (BE) are tumors with an increasing incidence and poor prognosis. The aim of endoscopic surveillance of BE is to detect dysplasia, particularly high-grade dysplasia and intramucosal cancers that can subsequently be treated endoscopically before progression to invasive cancer with lymph node metastases. Current surveillance practice standards require the collection of random 4-quadrant biopsy specimens over every 1 to 2 cm of BE (Seattle protocol) to detect dysplasia with the assistance of white light endoscopy, in addition to performing targeted biopsies of recognizable lesions. This approach is labor-intensive but should currently be considered state of the art. Chromoendoscopy, virtual chromoendoscopy (e.g., narrow band imaging), and confocal laser endomicroscopy, in addition to high-definition standard endoscopy, might increase the diagnostic yield for the detection of dysplastic lesions. Until these modalities have been demonstrated to enhance efficiency or cost effectiveness, the standard protocol will remain careful examination using conventional off the shelf high-resolution endoscopes, combined with as longer inspection time which is associated with increased detection of dysplasia.
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Affiliation(s)
- Alberto Espino
- Division of Gastroenterology, Department of Medicine, The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Maria Cirocco
- Division of Gastroenterology, Department of Medicine, The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Ralph Dacosta
- Department of Medical Biophysics, Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Norman Marcon
- Division of Gastroenterology, Department of Medicine, The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
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Bronner MP. Barrett's Esophagus. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2014. [DOI: 10.7704/kjhugr.2014.14.3.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Mary P. Bronner
- Division of Anatomic Pathology & Molecular Oncology, University of Utah and ARUP Laboratories, Huntsman Cancer Institute, Salt Lake City, UT, USA
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de Jonge PJF, van Blankenstein M, Grady WM, Kuipers EJ. Barrett's oesophagus: epidemiology, cancer risk and implications for management. Gut 2014; 63:191-202. [PMID: 24092861 PMCID: PMC6597262 DOI: 10.1136/gutjnl-2013-305490] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although endoscopic surveillance of patients with Barrett's oesophagus has been widely implemented, its effectiveness is debateable. The recently reported low annual oesophageal adenocarcinoma risk in population studies, the failure to identify most Barrett's patients at risk of disease progression, the poor adherence to surveillance and biopsy protocols, and the significant risk of misclassification of dysplasia all tend to undermine the effectiveness of current management, in particular, endoscopic surveillance programmes, to prevent or improve the outcomes of patients with oesophageal adenocarcinoma. The ongoing increase in incidence of Barrett's oesophagus and consequent growth of the surveillance population, together with the associated discomfort and costs of endoscopic surveillance, demand improved techniques for accurately determining individual risk of oesophageal adenocarcinoma. More accurate techniques are needed to run efficient surveillance programmes in the coming decades. In this review, we will discuss the current knowledge on the epidemiology of Barrett's oesophagus, and the challenging epidemiological dilemmas that need to be addressed when assessing the current screening and surveillance strategies.
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Affiliation(s)
- Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, , Rotterdam, The Netherlands
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Carr JS, Zafar SF, Saba N, Khuri FR, El-Rayes BF. Risk factors for rising incidence of esophageal and gastric cardia adenocarcinoma. J Gastrointest Cancer 2013; 44:143-51. [PMID: 23435833 DOI: 10.1007/s12029-013-9480-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION In the last 30 years, the incidence of esophageal and gastric cardia adenocarcinoma has steadily increased. The increase in incidence is approximately seven-fold, which is a more substantial increase than that of several malignancies, including melanoma, breast cancer, and prostate cancer. DISCUSSION The rising incidence has led to a steady increase in mortality from 2 to 15 deaths per 100,000 in the last three decades. The etiologic factors involved in the development of these malignancies include gastroesophageal reflux disease, Barrett's esophagus, acid-suppressive medication use, obesity, and tobacco use. This article discusses the contribution of these etiologic risk factors to this increase in incidence.
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Affiliation(s)
- Jacquelyn S Carr
- Department of Surgery, University of North Carolina, Chapel Hill, NC 300322, USA
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