A critical review of the diagnosis and management of Barrett's esophagus: the AGA Chicago Workshop

Therapeutic implications of signaling pathways and tumor microenvironment interactions in esophageal cancer

Esophageal cancer (EC) is significantly influenced by the tumor microenvironment (TME) and altered signaling pathways. Downregulating these pathways in EC is essential for suppressing tumor development, preventing metastasis, and enhancing therapeutic outcomes. This approach can increase tumor sensitivity to treatments, enhance patient outcomes, and inhibit cancer cell proliferation and spread. The TME, comprising cellular and non-cellular elements surrounding the tumor, significantly influences EC's development, course, and treatment responsiveness. Understanding the complex relationships within the TME is crucial for developing successful EC treatments. Immunotherapy is a vital TME treatment for EC. However, the heterogeneity within the TME limits the application of anticancer drugs outside clinical settings. Therefore, identifying reliable microenvironmental biomarkers that can detect therapeutic responses before initiating therapy is crucial. Combining approaches focusing on EC signaling pathways with TME can enhance treatment outcomes. This integrated strategy aims to interfere with essential signaling pathways promoting cancer spread while disrupting factors encouraging tumor development. Unraveling aberrant signaling pathways and TME components can lead to more focused and efficient treatment approaches, identifying specific cellular targets for treatments. Targeting the TME and signaling pathways may reduce metastasis risk by interfering with mechanisms facilitating cancer cell invasion and dissemination. In conclusion, this integrative strategy has significant potential for improving patient outcomes and advancing EC research and therapy. This review discusses the altered signaling pathways and TME in EC, focusing on potential future therapeutics.

Multimodal integration for Barrett's esophagus

The esophageal adenocarcinoma is facing a worldwide challenge: early prediction and risk assessment in clinical Barrett's esophagus (BE). In recent years, the growing interests have been witnessed in prediction and risk assessment in clinical BE. However, the resolution is limited, and the system is huge and expensive for the existing devices. Inspired by the principle of collaboration between human eye vision and brain cortex in data processing, here we propose multimodal learning framework to tackle tasks from various modalities, which can benefit from each other. To our findings, the experimental result indicates that low-level modality can directly affect high-level modality and form the final risk grading based on contribution, which maximizes the clinical performance of medical professionals based on our findings.

Revisiting Proton Pump Inhibitors as Chemoprophylaxis Against the Progression of Barrett's Esophagus

PURPOSE OF REVIEW

Barrett's esophagus (BE) is associated with chronic gastroesophageal reflux disease and is a known precursor to esophageal adenocarcinoma. While endoscopic surveillance strategies and the role for endoscopic eradication therapy have been well established, there has been much interest in identifying chemopreventive agents to disrupt or halt the metaplasia-dysplasia-carcinoma sequence in patients with BE.

RECENT FINDINGS

No pharmacological agent has held more hope in reducing the risk of neoplastic progression in BE than proton pump inhibitors (PPIs). However, data supporting PPIs for chemoprevention have largely been from observational cohort and case-control studies with mixed results. In this review, we revisit the literature and highlight the role of PPIs in patients with BE as it pertains to chemoprophylaxis against the progression of BE to dysplasia and esophageal adenocarcinoma.

Revolutionizing healthcare by use of artificial intelligence in esophageal carcinoma - a narrative review

Esophageal cancer is a major cause of cancer-related mortality worldwide, with significant regional disparities. Early detection of precursor lesions is essential to improve patient outcomes. Artificial intelligence (AI) techniques, including deep learning and machine learning, have proved to be of assistance to both gastroenterologists and pathologists in the diagnosis and characterization of upper gastrointestinal malignancies by correlating with the histopathology. The primary diagnostic method in gastroenterology is white light endoscopic evaluation, but conventional endoscopy is partially inefficient in detecting esophageal cancer. However, other endoscopic modalities, such as narrow-band imaging, endocytoscopy, and endomicroscopy, have shown improved visualization of mucosal structures and vasculature, which provides a set of baseline data to develop efficient AI-assisted predictive models for quick interpretation. The main challenges in managing esophageal cancer are identifying high-risk patients and the disease's poor prognosis. Thus, AI techniques can play a vital role in improving the early detection and diagnosis of precursor lesions, assisting gastroenterologists in performing targeted biopsies and real-time decisions of endoscopic mucosal resection or endoscopic submucosal dissection. Combining AI techniques and endoscopic modalities can enhance the diagnosis and management of esophageal cancer, improving patient outcomes and reducing cancer-related mortality rates. The aim of this review is to grasp a better understanding of the application of AI in the diagnosis, treatment, and prognosis of esophageal cancer and how computer-aided diagnosis and computer-aided detection can act as vital tools for clinicians in the long run.

Endoscopic Management of Dysplastic Barrett's Oesophagus and Early Oesophageal Adenocarcinoma

Barrett's oesophagus is a pathological condition whereby the normal oesophageal squamous mucosa is replaced by specialised, intestinal-type metaplasia, which is strongly linked to chronic gastro-oesophageal reflux. A correct endoscopic and histological diagnosis is pivotal in the management of Barrett's oesophagus to identify patients who are at high risk of progression to neoplasia. The presence and grade of dysplasia and the characteristics of visible lesions within the mucosa of Barrett's oesophagus are both important to guide the most appropriate endoscopic therapy. In this review, we provide an overview on the management of Barrett's oesophagus, with a particular focus on recent advances in the diagnosis and recommendations for endoscopic therapy to reduce the risk of developing oesophageal adenocarcinoma.

Prospective clinical cohort study: low incidence of Barrett esophagus but high rate of reflux disease at 5-year follow-up after sleeve gastrectomy versus Roux-en-Y gastric bypass

BACKGROUND

Gastroesophageal reflux disease seems more frequent after laparoscopic sleeve gastrectomy (LSG) than Roux-en-Y gastric bypass (LRYGB). Retrospective case series have raised concerns about a high incidence of Barrett esophagus (BE) after LSG.

OBJECTIVE

This prospective clinical cohort study compared the incidence of BE ≥5 years after LSG and LRYGB.

SETTING

St. Clara Hospital, Basel, and University Hospital, Zürich, Switzerland.

METHODS

Patients were recruited from 2 bariatric centers where preoperative gastroscopy is standard practice and LRYGB is preferred for patients with preexisting gastroesophageal reflux disease. At follow-up ≥5 years after surgery, patients underwent gastroscopy with quadrantic biopsies from the squamocolumnar junction and metaplastic segment. Symptoms were assessed using validated questionnaires. Wireless pH measurement assessed esophageal acid exposure.

RESULTS

A total of 169 patients were included, with a median 7.0 ± 1.5 years after surgery. In the LSG group (n = 83), 3 patients had endoscopically and histologically confirmed de novo BE; in the LRYGB group (n = 86), there were 2 patients with BE, 1 de novo and 1 preexisting (de novo BE, 3.6% versus 1.2%; P = .362). At follow-up, reflux symptoms were reported more frequently by the LSG group than by the LRYGB group (51.9% versus 10.5%). Similarly, moderate-to-severe reflux esophagitis (Los Angeles grade B-D) was more common (27.7% versus 5.8%) despite greater use of proton pump inhibitors (49.4% versus 19.7%), and pathologic acid exposure was more frequent in patients who underwent LSG than in patients who underwent LRYGB.

CONCLUSIONS

After at least 5 years of follow-up, a higher incidence of reflux symptoms, reflux esophagitis, and pathologic esophageal acid exposure was found in patients who underwent LSG compared with patients who underwent LRYGB. However, the incidence of BE after LSG was low and not significantly different between the 2 groups.

The Role of microRNAs in Regulating Cancer Cell Response to Oxaliplatin-Containing Regimens

Oxaliplatin (cyclohexane-1,2-diamine; oxalate; platinum [2+]) is a third-generation chemotherapeutic drug with anticancer effects. Oxaliplatin has a role in the treatment of several cancers. It is one of the few drugs which can eliminate the neoplastic cells of colorectal cancer. Also, it has an influential role in breast cancer, lung cancer, bladder cancer, prostate cancer, and gastric cancer. Although oxaliplatin has many beneficial effects in cancer treatment, resistance to this drug is in the way to cure neoplastic cells and reduce treatment efficacy. microRNAs are a subtype of small noncoding RNAs with ∼22 nucleotides that exist among species. They have diverse roles in physiological processes, including cellular proliferation and cell death. Moreover, miRNAs have essential roles in resistance to cancer treatment and can strengthen sensitivity to chemotherapeutic drugs and regimens. In colorectal cancer, the co-treatment of oxaliplatin with anti-miR-19a can partially reverse the oxaliplatin resistance through the upregulation of phosphatase and tensin homolog (PTEN). Moreover, by preventing the spread of gastric cancer cells and downregulating glypican-3 (GPC3), MiR-4510 may modify immunosuppressive signals in the tumor microenvironment. Treatment with oxaliplatin may develop into a specialized therapeutic drug for patients with miR-4510 inhibition and glypican-3-expressing gastric cancer. Eventually, miR-122 upregulation or Wnt/β-catenin signaling suppression boosted the death of HCC cells and made them more sensitive to oxaliplatin. Herein, we have reviewed the role of microRNAs in regulating cancer cells' response to oxaliplatin, with particular attention to gastrointestinal cancers. We also discussed the role of these noncoding RNAs in the pathophysiology of oxaliplatin-induced neuropathic pain.

Hiatal Hernia Associated with Higher Odds of Dysplasia in Patients with Barrett's Esophagus

BACKGROUND

Patients with Barrett's esophagus (BE) are more likely to have associated hiatal hernia (HH) compared to the general population. Studies show that HH are typically longer and wider in patients with BE.

AIMS

To determine whether patients with HH have associated increased odds of coexistence of BE by examining inpatient prevalence, as well as determining other inpatient outcomes.

METHODS

This was a case-control study using the NIS 2016, the largest public inpatient database in the USA. All patients with ICD10CM codes for BE were included. None were excluded. The primary outcome was determining the association between BE and HH in hospitalized patients, stratified by grade of dysplasia. Secondary outcomes included measuring use of endoscopic ablation in patients with BE and HH compared to patients with BE and no HH, determining the degree of association between HH and esophagitis in patients with or without BE, as well as the association between esophagitis and dysplasia in patients with BE and HH.

RESULTS

A total of 118,750 patients with BE were identified, of which 24,030 had associated HH. Adjusted odds of having associated BE in patients with HH was 10.9 (p < 0.01) compared to patients without HH. Patients with HH also displayed significantly higher odds of both low-grade dysplasia (aOR 34.5, p < 0.01) and high-grade dysplasia (aOR 14.7, p < 0.01). For secondary outcomes, the odds of undergoing ablation for BE was higher 4.77 (p < 0.01) in patients with HH.

CONCLUSIONS

Patients with HH have significantly higher odds of having associated BE, regardless of the level of dysplasia. Furthermore, the odds of undergoing ablation are much higher, likely reflecting higher odds of dysplasia. This highlights the importance of BE in patients with HH, and potentially consider these patients as higher risk.

Activation of FXR Suppresses Esophageal Squamous Cell Carcinoma Through Antagonizing ERK1/2 Signaling Pathway

Introduction

Farnesoid X receptor (FXR), a member of nuclear receptors, functionally regulates bile acid, glucose and lipid homeostasis. It is also worth noting that FXR plays a suppressor role in cancer and inflammation. However, the contribution of FXR to esophageal squamous cell carcinoma (ESCC) remains unknown.

Methods

The role of FXR activation in ESCC progression was evaluated in ESCC cell lines KYSE150 and EC109 in vitro and BALB-C nude mice in vivo. In vitro, FXR synthetic ligand GW4064 was used to detect the effects on ESCC cell proliferation, migration, apoptosis and cell cycles. To assess the effects of GW4064 on ESCC development in vivo, a xenograft tumor model was constructed. And ERK1/2 activity was evaluated by immunoblot analysis.

Results

FXR synthetic ligand GW4064 impaired esophageal squamous cell carcinoma (ESCC) proliferation and migration, induced apoptosis and cell cycle arrest in vitro, accompanied by inhibition of some inflammatory genes and promotion of pro-apoptotic genes. We then found that FXR activation decreased the phosphorylation levels of ERK1/2 induced by tumor necrosis factor-α (TNF-α) in ESCC cells. Consistent with these results, GW4064 suppressed ESCC tumorigenesis in a xenograft model and suppressed the phosphorylation of ERK1/2 in tumors.

Discussion

These findings identify that activating FXR may serve as a promising therapy or adjuvant therapeutic tool for controlling ESCC development.

Dual-modality optical coherence tomography and fluorescence tethered capsule endomicroscopy

OCT tethered capsule endomicroscopy (TCE) is an emerging noninvasive diagnostic imaging technology for gastrointestinal (GI) tract disorders. OCT measures tissue reflectivity that provides morphologic image contrast, and thus is incapable of ascertaining molecular information that can be useful for improving diagnostic accuracy. Here, we introduce an extension to OCT TCE that includes a fluorescence (FL) imaging channel for attaining complementary, co-registered molecular contrast. We present the development of an OCT-FL TCE capsule and a portable, plug-and-play OCT-FL imaging system. The technology is validated in phantom experiments and feasibility is demonstrated in a methylene blue (MB)-stained swine esophageal injury model, ex vivo and in vivo.

Endoscopic Submucosal Dissection for Superficial Barrett’s Neoplasia in Korea: a Single-Center Experience

Purpose

While the incidence of Barrett’s neoplasia has been increasing in Western countries, the disease remains rare in Asian countries. Therefore, very few studies have investigated the endoscopic treatment for Barrett’s neoplasia in Korea. Endoscopic submucosal dissection (ESD) enables en bloc and complete resection of gastrointestinal neoplastic lesions. This study aimed to evaluate the therapeutic outcomes of ESD for Barrett’s neoplasia in a single center in Korea and to examine the predictive factors for incomplete resection.

Materials and Methods

We conducted a retrospective observational study of 18 patients who underwent ESD for superficial Barrett’s neoplasia (dysplasia and early cancer) between January 2010 and December 2019 at Pusan National University Hospital. The therapeutic outcomes of ESD and procedure-related complications were analyzed.

Results

En bloc resection, complete resection, and curative resection were performed in 94%, 72%, and 61% of patients, respectively. Histopathology (submucosal or deeper invasion of the tumor) was a significant predictive factor for incomplete resection (P=0.047). Procedure-related bleeding and stenosis were not observed, whereas perforation occurred in one case. During the median follow-up period of 12 months (range, 6–74 months), local recurrence occurred in 2 patients with incomplete resection, one patient underwent repeat ESD, and the other patient received concurrent chemoradiotherapy. The 3-year overall and disease-specific survival rates were 73% and 93%, respectively.

Conclusions

ESD seems to be an effective and safe treatment for superficial Barrett’s neoplasia in Korea. Nevertheless, the suitability of ESD for Barrett’s cancer cases should be determined considering the high risk of deep submucosal invasion.

A Survival Comparison of Mucin-Producing Adenocarcinoma of the Esophagus to Conventional Adenocarcinoma after Esophagectomy

The objective of this study was to test the hypothesis that mucin-producing adenocarcinoma (MA) exhibits a more advanced clinical presentation and worse prognosis than conventional adeno-carcinoma (CA) in patients undergoing esophagectomy. Patient demographic and clinical variables and cancer-specific survival were collected from the U.S. Surveillance Epidemiology and End Results database between 1988 and 2006. Esophagectomy was performed for 105 patients with MA and 5473 patients with CA. The MA cohort exhibited a similar age at presentation, gender, and anatomic location (lower third of the esophagus/abdominal) as the CA cohort. We found trends toward advanced pathologic stage of disease of MA compared with CA (Stage IIB to IV 56 vs 46%), higher grade tumors (Grade III/IV, 44 vs 34%), positive lymph nodes (51 vs 40%), and poorer mean survival. For both groups, after multivariate analysis, age at diagnosis, tumor stage, and grade were negative predictors of survival (hazard ratios 1.02, 1.39, and 1.32, respectively; P < 0.001). Although this study suggests that patients with resected MA of the esophagus have a trend toward worse clinical presentation and survival than patients with resected CA, the observations are not significant and do not support our hypothesis or results from single-institution studies.

Quantitative analysis of p16 methylation in Barrett's carcinogenesis

p16 hypermethylation in Barrett's carcinogenesis has been evaluated in studies which did not take into account sample heterogeneity and yielded qualitative (methylated/unmethylated) instead of accurate quantitative (percentage of CpG methylation) data. We aimed to measure the degree of p16 methylation in pure samples representing all the steps of Barrett's tumorogenesis and to evaluate the influence of sample heterogeneity in methylation analysis.

METHODS

77 paraffin-embedded human esophageal samples were analyzed. Histological grading was established by two pathologists in: negative for dysplasia, indefinite for dysplasia, low-grade dysplasia, high-grade dysplasia and adenocarcinoma. Areas of interest were selected by laser-capture microdissection. p16 methylation was quantified by pyrosequencing. An adjacent section of the whole sample was also analyzed to compare methylation data.

RESULTS

After microdissection, we obtained 15 samples of squamous epithelium, 36 non-dysplastic Barrett's esophagus, 3 indefinite for dysplasia, 24 low-grade dysplasia, 4 high-grade dysplasia and 12 adenocarcinoma. Squamous epithelium showed the lowest methylation rates: 6% (IQR 5-11) vs. 11%(7-39.50) in negative/indefinite for dysplasia, p<0.01; 10.60%(6-24) in low-grade dysplasia, p<0.05; and 44.50%(9-66.75) in high-grade dysplasia/adenocarcinoma, p<0.01. This latter group also exhibited higher methylation rates than Barrett's epithelium with and without low-grade dysplasia (p<0.05). p16 methylation rates of microdissected and non-microdissected samples did not correlate unless the considered histological alteration comprised >71% of the sample.

CONCLUSIONS

p16 methylation is an early event in Barrett's carcinogenesis which increases with the severity of histological alteration. p16 methylation rates are profoundly influenced by sample heterogeneity, so selection of samples is crucial in order to detect differences.

Factors that predict a poor response to radiofrequency ablation for Barrett's oesophagus with dysplasia

BACKGROUND

Radiofrequency ablation (RFA) can eradicate dysplasia and intestinal metaplasia in patients with dysplastic Barrett's oesophagus (BO). This study aimed to determine the factors that affect response to RFA for BO with dysplasia in a tertiary metropolitan referral centre.

METHODS

All patients with dysplastic BO treated with regular proton pump inhibitor twice a day and RFA from November 2008 to July 2019 were identified. These patients were sorted into good responders (GR) (defined as eradication of dysplasia and intestinal metaplasia within three or less treatment sessions) and poor responders (PR) (defined as patients requiring four or more treatment sessions). The following features were compared between the groups: age, gender, presence of hiatus hernia, hiatus hernia size, circumferential and maximal length of BO, grade of dysplasia on histology at referral and presence of endoscopically visible reflux oesophagitis.

RESULTS

A total of 152 patients received RFA for dysplastic BO, of whom 125 (82%) patients were classified as GR and 27 (18%) patients were classified as PR. PR had a longer circumferential length of BO compared to GR (mean length of 8.3 versus 3.3 cm, P < 0.0001). PR also had a longer maximal length of BO compared to GR (mean length of 8.7 versus 4.8 cm, P < 0.0001). More patients had reflux oesophagitis identified on gastroscopy in the PR group compared to GR group (12 (44%) versus 20 (16%), P = 0.001).

CONCLUSION

Factors such as circumferential and maximal length of BO and presence of reflux oesophagitis on gastroscopy are associated with poorer response to RFA.

Estimating neoplasia detection rate (NDR) in patients with Barrett's oesophagus based on index endoscopy: a systematic review and meta-analysis

BACKGROUND

Biopsies are obtained to confirm intestinal metaplasia and rule out prevalent dysplasia and cancer when Barrett's oesophagus (BE) is detected at index upper endoscopy (oesophagogastroduodenoscopy [EGD]).

AIM

The purpose of this systematic review was to obtain summary estimates of the prevalence of high-grade dysplasia (HGD) and oesophageal adenocarcinoma (EAC) associated with BE during index EGD for chronic GERD symptoms, defined as neoplasia detection rate (NDR) which could be used as a quality measure.

METHODS

An extensive search was performed within PUBMED, EMBASE and the Cochrane Library databases to identify studies in which patients underwent index endoscopy for the evaluation of the presence of BE. Two reviewers independently evaluated both the study eligibility and methodological quality and data extraction. A random-effects model (REM) based on the binomial distribution was used to calculate the pooled effects of the prevalence of BE-associated dysplasia and EAC.

RESULTS

For the calculation of dysplasia and EAC prevalence rates, a total of 11 studies with 10 632 patients met the inclusion criteria including 80.4% men with a mean age of 58.7 years and average BE length of 3.5 cm. The pooled prevalence of EAC, HGD and LGD was 3%(95% CI 2 to 5, 9 studies: 396/10 539 patients), 3%(95% CI 2 to 5 [REM], 9 studies: 388/10 539 patients) and 10%(95% CI 7 to 15 [REM], 10 studies: 907/8945 patients), respectively. For NDR, that is, the pooled prevalence of HGD/EAC was 7%(95% CI 4 to 10 [REM], 10 studies: 795/10 632 patients).

CONCLUSION

NDR is approximately 4% and could be used as a quality measure.

Diabetes in relation to Barrett's esophagus and adenocarcinomas of the esophagus: A pooled study from the International Barrett's and Esophageal Adenocarcinoma Consortium

BACKGROUND

Diabetes is positively associated with various cancers, but its relationship with tumors of the esophagus/esophagogastric junction remains unclear.

METHODS

Data were harmonized across 13 studies in the International Barrett's and Esophageal Adenocarcinoma Consortium, comprising 2309 esophageal adenocarcinoma (EA) cases, 1938 esophagogastric junction adenocarcinoma (EGJA) cases, 1728 Barrett's esophagus (BE) cases, and 16,354 controls. Logistic regression was used to estimate study-specific odds ratios (ORs) and 95% CIs for self-reported diabetes in association with EA, EGJA, and BE. Adjusted ORs were then combined using random-effects meta-analysis.

RESULTS

Diabetes was associated with a 34% increased risk of EA (OR, 1.34; 95% CI, 1.00-1.80; I2  = 48.8% [where 0% indicates no heterogeneity, and larger values indicate increasing heterogeneity between studies]), 27% for EGJA (OR, 1.27; 95% CI, 1.05-1.55; I2  = 0.0%), and 30% for EA/EGJA combined (OR, 1.30; 95% CI, 1.06-1.58; I2  = 34.9%). Regurgitation symptoms modified the diabetes-EA/EGJA association (P for interaction = .04) with a 63% increased risk among participants with regurgitation (OR, 1.63; 95% CI, 1.19-2.22), but not among those without regurgitation (OR, 1.03; 95% CI, 0.74-1.43). No consistent association was found between diabetes and BE.

CONCLUSIONS

Diabetes was associated with increased EA and EGJA risk, which was confined to individuals with regurgitation symptoms. Lack of an association between diabetes and BE suggests that diabetes may influence progression of BE to cancer.

New evidence defining the pathology and pathogenesis of lower esophageal sphincter damage

Background

Present diagnosis and management of gastroesophageal reflux disease (GERD) has resulted in a dramatic increase in the incidence of esophageal adenocarcinoma. This is due to failure to identify pathologic changes of early GERD; at present, pathology is limited to management of Barrett esophagus (BE).

Methods

Convincing evidence have confirmed that cardiac mucosa distal to the squamocolumnar junction in the endoscopically normal person is a metaplastic GERD-induced esophageal epithelium, and not a normal proximal gastric epithelium.

Results

When cardiac mucosa is recognized as a metaplastic esophageal epithelium, it becomes self-evident that the present endoscopic definition of the gastro-esophageal junction is incorrect, and there exists a dilated distal esophagus (DDE) in what is incorrectly termed the “gastric cardia” presently mistaken for proximal stomach. It also becomes clear that the length of the DDE correlates with the presence and severity of GERD and represents the pathology of the entire spectrum of GERD. Further, it allows recognition that the DDE, measured as the gap between esophageal squamous epithelium and gastric oxyntic mucosa that is composed of cardiac mucosa, represents the pathologic anatomy of damage to the abdominal segment of the lower esophageal sphincter (LES).

Conclusion

The new understanding of the significance of cardiac mucosa provides a new and highly accurate histologic method of assessment of LES damage, the primary cause of GERD. This opens a new door to complete histologic assessment of GERD from its etiologic standpoint and to new research that permit early diagnosis of GERD at its outset. Ultimately, such early diagnosis has the potential to reverse the increasing trend of esophageal adenocarcinoma.

CAESNet: Convolutional AutoEncoder based Semi-supervised Network for improving multiclass classification of endomicroscopic images

OBJECTIVE

This article presents a novel method of semisupervised learning using convolutional autoencoders for optical endomicroscopic images. Optical endomicroscopy (OE) is a newly emerged biomedical imaging modality that can support real-time clinical decisions for the grade of dysplasia. To enable real-time decision making, computer-aided diagnosis (CAD) is essential for its high speed and objectivity. However, traditional supervised CAD requires a large amount of training data. Compared with the limited number of labeled images, we can collect a larger number of unlabeled images. To utilize these unlabeled images, we have developed a Convolutional AutoEncoder based Semi-supervised Network (CAESNet) for improving the classification performance.

MATERIALS AND METHODS

We applied our method to an OE dataset collected from patients undergoing endoscope-based confocal laser endomicroscopy procedures for Barrett's esophagus at Emory Hospital, which consists of 429 labeled images and 2826 unlabeled images. Our CAESNet consists of an encoder with 5 convolutional layers, a decoder with 5 transposed convolutional layers, and a classification network with 2 fully connected layers and a softmax layer. In the unsupervised stage, we first update the encoder and decoder with both labeled and unlabeled images to learn an efficient feature representation. In the supervised stage, we further update the encoder and the classification network with only labeled images for multiclass classification of the OE images.

RESULTS

Our proposed semisupervised method CAESNet achieves the best average performance for multiclass classification of OE images, which surpasses the performance of supervised methods including standard convolutional networks and convolutional autoencoder network.

CONCLUSIONS

Our semisupervised CAESNet can efficiently utilize the unlabeled OE images, which improves the diagnosis and decision making for patients with Barrett's esophagus.

Overweight Patterns Between Childhood and Early Adulthood and Esophageal and Gastric Cardia Adenocarcinoma Risk

OBJECTIVE

Esophageal adenocarcinoma (EA) and gastric cardia adenocarcinoma (GCA) are among the most rapidly increasing cancers in Western countries. Elevated BMI in adulthood is a known risk factor, but associations in early life are unclear.

METHODS

This study assessed weight change between childhood and early adulthood in relation to EA/GCA. Measured weights and heights during childhood (7-13 years) and early adulthood (17-26 years) were available for 64,695 young men from the Copenhagen School Health Records Register and the Danish Conscription Database. Individuals were categorized as having normal weight or overweight. Linkage with the Danish Cancer Registry identified 275 EA/GCA cases. Hazard ratios (HR) and 95% CI were estimated using Cox proportional hazards regression.

RESULTS

The risk of EA/GCA was 2.5 times higher in men who were first classified as having overweight at age 7 (HR = 2.49; 95% CI: 1.50-4.14) compared with men who were never classified as having overweight. Men who had persistent overweight at ages 7 and 13 and in early adulthood had an EA/GCA risk that was 3.2 times higher (HR = 3.18; 95% CI: 1.57-6.44). However, there was little evidence of increased EA/GCA risk for men with overweight during childhood and subsequent remittance by early adulthood.

CONCLUSIONS

Persistent overweight in early life is associated with increased EA/GCA risk, which declines if body weight is reduced.

Outcome of endoscopic mucosal resection in Barrett's esophagus determined by systematic quantification of epithelial glands using volumetric laser endomicroscopy

BACKGROUND

Dysplastic Barrett's esophagus (BE) lesions ≤2 cm in size can be targeted for en-bloc endoscopic mucosal resection (EMR). White-light endoscopy can underestimate the size of a lesion, limiting complete resection. Volumetric laser endomicroscopy (VLE) provides high-resolution cross-sectional imaging of BE. Epithelial glands are a VLE feature associated with BE dysplasia. We study the association between VLE gland quantification and outcome of resection.

METHODS

EMR specimens of BE lesions targeted for en-bloc resection were imaged with VLE using an established protocol. Manual and automated quantification of epithelial glands was performed blinded to resection outcome. The presence of epithelial glands at the resection margins was recorded. Histologic en-bloc (R0) resection of the targeted lesion was defined by the absence and incomplete (R1) resection by the presence of dysplasia/neoplasia at specimen margins.

RESULTS

Thirty-seven EMRs with a mean (standard deviation) size of 1.04 (0.37) cm were imaged with VLE. The highest grade of dysplasia found was low-grade dysplasia (n = 12), high-grade dysplasia (n = 19), and intramucosal cancer (n = 6). The en-bloc resection rate was 37.8% (R0, n = 14; R1, n = 23). The mean (standard deviation) number of epithelial glands quantified with VLE was 13.0 (6.7) and 28.8 (23.9) for R0 and R1 specimens, respectively, with a significant mean difference of 15.8 glands (95% confidence interval, 2-29; P = .02). The presence of glands at the specimen margin was associated with incomplete resection (P < .001).

CONCLUSION

Systematic quantification of BE epithelial glands using VLE can determine the outcome of endoscopic resection. VLE may have a potential role in assessment of lesion margins.

Enhancing the Detection of Barrett Esophagus

In Western countries, the incidence of esophageal adenocarcinoma has increased rapidly in parallel with its premalignant condition, Barrett esophagus (BE). Unlike colonoscopy, endoscopic screening for BE is not currently recommended for all patients; however, surveillance endoscopy is advocated for patients with established BE. Novel imaging and sampling techniques have been developed and investigated for the purpose of improving the detection of Barrett esophagus, dysplasia, and neoplasia. This article discusses several screening and surveillance techniques, including Seattle protocol, chromoendoscopy, electronic chromoendoscopy, wide area transepithelial sampling with 3-dimensional analysis, nonendoscopic sampling devices, and transnasal endoscopy.

International development and validation of a classification system for the identification of Barrett's neoplasia using acetic acid chromoendoscopy: the Portsmouth acetic acid classification (PREDICT)

BACKGROUND

Barrett's oesophagus is an established risk factor for developing oesophageal adenocarcinoma. However, Barrett's neoplasia can be subtle and difficult to identify. Acetic acid chromoendoscopy (AAC) is a simple technique that has been demonstrated to highlight neoplastic areas but lesion recognition with AAC remains a challenge, thereby hampering its widespread use.

OBJECTIVE

To develop and validate a simple classification system to identify Barrett's neoplasia using AAC.

DESIGN

The study was conducted in four phases: phase 1-development of component descriptive criteria; phase 2-development of a classification system; phase 3-validation of the classification system by endoscopists; and phase 4-validation of the classification system by non-endoscopists.

RESULTS

Phases 1 and 2 led to the development of a simplified AAC classification system based on two criteria: focal loss of acetowhitening and surface patterns of Barrett's mucosa. In phase 3, the application of PREDICT (Portsmouth acetic acid classification) by endoscopists improved the sensitivity and negative predictive value (NPV) from 79.3% and 80.2% to 98.1% and 97.4%, respectively (p<0.001). In phase 4, the application of PREDICT by non-endoscopists improved the sensitivity and NPV from 69.6% and 75.5% to 95.9% and 96.0%, respectively (p<0.001).

CONCLUSION

We developed and validated a classification system known as PREDICT for the diagnosis of Barrett's neoplasia using AAC. The improvement seen in the sensitivity and NPV for detection of Barrett's neoplasia in phase 3 demonstrates the clinical value of PREDICT and the similar improvement seen among non-endoscopists demonstrates the potential for generalisation of PREDICT once proven in real time.

Computer-Aided Analysis of Gland-Like Subsurface Hyposcattering Structures in Barrett’s Esophagus Using Optical Coherence Tomography

(1) Background: Barrett’s esophagus (BE) is a complication of chronic gastroesophageal reflux disease and is a precursor to esophageal adenocarcinoma. The clinical implication of subsurface glandular structures of Barrett’s esophagus is not well understood. Optical coherence tomography (OCT), also known as volumetric laser endomicroscopy (VLE), can assess subsurface glandular structures, which appear as subsurface hyposcattering structures (SHSs). The aim of this study is to develop a computer-aided algorithm and apply it to investigate the characteristics of SHSs in BE using clinical VLE data; (2) Methods: SHSs were identified with an initial detection followed by machine learning. Comprehensive SHS characteristics including the number, volume, depth, size and shape were quantified. Clinical VLE datasets collected from 35 patients with a history of dysplasia undergoing BE surveillance were analyzed to study the general SHS distribution and characteristics in BE. A subset of radiofrequency ablation (RFA) patient data were further analyzed to investigate the pre-RFA SHS characteristics and post-RFA treatment response; (3) Results: SHSs in the BE region were significantly shallower, more vertical, less eccentric, and more regular, as compared with squamous SHSs. SHSs in the BE region which became neosquamous epithelium after RFA were shallower than those in the regions that remained BE. Pre-ablation squamous SHSs with higher eccentricity correlated strongly with larger reduction of post-ablation BE length for less elderly patients; (4) Conclusions: The computer algorithm is potentially a valuable tool for studying the roles of SHSs in BE.

Machine Learning Creates a Simple Endoscopic Classification System that Improves Dysplasia Detection in Barrett's Oesophagus amongst Non-expert Endoscopists

Introduction

Barrett's oesophagus (BE) is a precursor to oesophageal adenocarcinoma (OAC). Endoscopic surveillance is performed to detect dysplasia arising in BE as it is likely to be amenable to curative treatment. At present, there are no guidelines on who should perform surveillance endoscopy in BE. Machine learning (ML) is a branch of artificial intelligence (AI) that generates simple rules, known as decision trees (DTs). We hypothesised that a DT generated from recognised expert endoscopists could be used to improve dysplasia detection in non-expert endoscopists. To our knowledge, ML has never been applied in this manner.

Methods

Video recordings were collected from patients with non-dysplastic (ND-BE) and dysplastic Barrett's oesophagus (D-BE) undergoing high-definition endoscopy with i-Scan enhancement (PENTAX®). A strict protocol was used to record areas of interest after which a corresponding biopsy was taken to confirm the histological diagnosis. In a blinded manner, videos were shown to 3 experts who were asked to interpret them based on their mucosal and microvasculature patterns and presence of nodularity and ulceration as well as overall suspected diagnosis. Data generated were entered into the WEKA package to construct a DT for dysplasia prediction. Non-expert endoscopists (gastroenterology specialist registrars in training with variable experience and undergraduate medical students with no experience) were asked to score these same videos both before and after web-based training using the DT constructed from the expert opinion. Accuracy, sensitivity, and specificity values were calculated before and after training where p < 0.05 was statistically significant.

Results

Videos from 40 patients were collected including 12 both before and after acetic acid (ACA) application. Experts' average accuracy for dysplasia prediction was 88%. When experts' answers were entered into a DT, the resultant decision model had a 92% accuracy with a mean sensitivity and specificity of 97% and 88%, respectively. Addition of ACA did not improve dysplasia detection. Untrained medical students tended to have a high sensitivity but poor specificity as they "overcalled" normal areas. Gastroenterology trainees did the opposite with overall low sensitivity but high specificity. Detection improved significantly and accuracy rose in both groups after formal web-based training although it did it reach the accuracy generated by experts. For trainees, sensitivity rose significantly from 71% to 83% with minimal loss of specificity. Specificity rose sharply in students from 31% to 49% with no loss of sensitivity.

Conclusion

ML is able to define rules learnt from expert opinion. These generate a simple algorithm to accurately predict dysplasia. Once taught to non-experts, the algorithm significantly improves their rate of dysplasia detection. This opens the door to standardised training and assessment of competence for those who perform endoscopy in BE. It may shorten the learning curve and might also be used to compare competence of trainees with recognised experts as part of their accreditation process.

Pathology, Chemoprevention, and Preclinical Models for Target Validation in Barrett Esophagus

Despite esophageal adenocarcinoma (EAC) being the most widespread among gastrointestinal cancers, with an 11-fold increase in the risk of cancer for patients with Barrett esophagus (BE), its prognosis is still poor. There is a critical need to better perceive the biology of cancer progression and identification of specific targets that are the hallmark of BE's progression. This review explores the established animal models of BE, including genetic, surgical and nonsurgical approaches, potential chemoprevention targets, and the reasoning behind their applications to prevent Barrett-related EAC. The key methodological features in the design feasibility of relevant studies are also discussed. Cancer Res; 78(14); 3747-54. ©2018 AACR.

Proton Pump Inhibitors Diminish Barrett's Esophagus Length: Our Experience

AIM

Our main objectives were to evaluate the influence of two-year proton pump inhibitors (PPI) therapy in patients with Barrett's oesophagus on its length, in both types, short and long segment.

METHODS

In this single-centre, prospective interventional controlled study were analysed data collected prospectively over two years from patients with Barrett's oesophagus diagnosed by endoscopy. Patients who received continuous proton pump inhibitors (PPI) for 2 years were included. At each patient visit symptoms were recorded, and at each endoscopy, the length of Barrett's oesophagus (BE) was measured. Biopsies were taken along the length of the oesophagus at intervals of 1 cm. In total, 50 patients with Barrett's oesophagus were included in the study: 10 of whom had long-segment Barrett's oesophagus, and 40 patients had short-segment Barrett's oesophagus. The mean number of endoscopies performed was 3 per patient.

RESULTS

The length of Barrett's esophagus (BE) was influenced by PPI therapy: Circumferential extension in BE patients short-segment Barrett's esophagus (SSBE) (before treatment was 1.5 cm and after treatment was 0.8 cm Maximum proximal extension in SSBE group before treatment was 2.3 cm (SD ± 1.1 cm), and 1.1 cm (SD ± 0.9 cm), respectively. Squamous islands were detected in 25% of patients examined after 2 years on PPIs.

CONCLUSIONS

PPIs achieve a reduction to the length of Barrett's oesophagus, in both types, and the development of squamous islands is commonly associated with their use.

FABP1 and Hepar expression levels in Barrett's esophagus and associated neoplasia in an Asian population

INTRODUCTION

Barrett's esophagus (BE) is a premalignant condition associated with esophageal adenocarcinoma (EAC). Evidence highlights that EAC is associated with an estimated 5-year survival of approximately 10-15%. Therefore, there is a need to determine which biomarkers are of value in the diagnosis of BE and beyond. The aim of our study was to evaluate the clinical significance of markers known to be expressed across BE and associated neoplasia.

METHODS

Retrospective tissues were obtained from columnar lined esophagus (CLE) without goblet cells (n=22), BE (n=29), dysplasia (n=14), and EAC (n=10). Standardised immunohistochemistry for FABP1, Hepar, CDH17, and CDX2 were performed followed by quantitative staining and statistical analysis.

RESULTS

FABP1 expression was negligible in CLE and was highest in BE, with a further decrease in expression in dysplasia and EAC. Hepar expression was also negligible in CLE and was highest in dysplasia and BE, with a reduced expression in EAC. CDH17 and CDX2 showed a significantly higher expression in BE, dysplasia, and EAC compared to CLE.

CONCLUSION

All 4 markers were excellent diagnostic panels to clearly discriminate BE from CLE. Moreover, as FABP1 and Hepar have different expression levels in dysplasia and EAC, these markers could function as key diagnostic aids in helping to determine the state of disease progression.

Diagnosis and treatment of gastroesophageal reflux disease complicated by Barrett's esophagus

The aim of the study was to evaluate the effectiveness of a diagnostic and therapeutic algorithm for gastroesophageal reflux disease complicated by Barrett's esophagus in 46 patients.

MATERIALS AND METHODS

A diagnostic and therapeutic algorithm for complicated GERD was developed. To describe the changes in the esophagus with reflux esophagitis, the Los Angeles classification was used. Intestinal metaplasia of the epithelium in the lower third of the esophagus was assessed using videoendoscopy, chromoscopy, and biopsy. Quality of life was assessed with the Gastro-Intestinal Quality of Life Index. The used methods were modeling, clinical, analytical, comparative, standardized, and questionnaire-based. Results and their discussion. Among the complications of GERD, Barrett's esophagus was diagnosed in 9 (19.6 %), peptic ulcer in the esophagus in 10 (21.7 %), peptic stricture of the esophagus in 4 (8.7 %), esophageal-gastric bleeding in 23 (50.0 %), including Malory-Weiss syndrome in 18, and erosive ulcerous bleeding in 5 people. Hiatal hernia was diagnosed in 171 (87.7 %) patients (sliding in 157 (91.8%), paraesophageal hernia in 2 (1.2%), and mixed hernia in 12 (7.0%) cases). One hundred ninety-five patients underwent laparoscopic surgery. Nissen fundoplication was conducted in 176 (90.2%) patients, Toupet fundoplication in 14 (7.2%), and Dor fundoplication in 5 (2.6%). It was established that the use of the diagnostic and treatment algorithm promoted systematization and objectification of changes in complicated GERD, contributed to early diagnosis, helped in choosing treatment, and improved quality of life.

CONCLUSIONS

Argon coagulation and use of PPIs for 8-12 weeks before surgery led to the regeneration of the mucous membrane in the esophagus. The developed diagnostic and therapeutic algorithm facilitated systematization and objectification of changes in complicated GERD, contributed to early diagnosis, helped in choosing treatment, and improved quality of life.

Endoscopic submucosal dissection for esophagogastric junction tumors: a single-center experience

BACKGROUND

Surgical resection for esophagogastric junction (EGJ) tumors is more aggressive and worsens the quality of life of the patients and leads to poor prognosis even after surgery compared with tumors in other sites of the stomach. Endoscopic submucosal dissection (ESD) is a widely accepted treatment modality for premalignant lesions and early cancers in the stomach. However, EGJ tumor is one of the most technically difficult lesions to resect by ESD. Therefore, this study aimed to evaluate the therapeutic outcomes of ESD for EGJ epithelial neoplasms and to assess the predictive factors for incomplete resection.

METHODS

We conducted a retrospective observational study of 48 patients who underwent ESD for adenomas and early cancers of the EGJ between March 2006 and November 2015 at the Pusan National University Hospital. Therapeutic outcomes of ESD and procedure-related adverse events were analyzed.

RESULTS

En bloc resection, complete resection, and curative resection rates were 96, 77, and 71%, respectively. Multivariate analyses showed that the presence of ulceration was an independent predictive factor for incomplete resection (odds ratio 21.3, 95% confidence interval 1.51-298.49; p = 0.023). The procedure-related bleeding, perforation, and stenosis rates were 8, 4, and 0%, respectively; none of the adverse events required surgical intervention. During a median follow-up period of 25 months (range 6-72 months), local recurrence occurred in four patients with incomplete resection.

CONCLUSION

ESD is an effective, safe, and feasible treatment for EGJ epithelial neoplasms. However, the complete resection rate decreases for tumors with ulceration.

Image assessment of Barrett's esophagus using the simplified narrow band imaging classification

BACKGROUND

A simplified narrow band imaging (NBI) classification has been proposed with the objective of integrating multiple classifications of NBI surface patterns in Barrett's esophagus (BE). Little is known about the impact of the simplified NBI classification on the diagnosis of BE when using high-definition magnification endoscopy with NBI (HM-NBI). This study aimed to evaluate (a) the reproducibility of NBI surface patterns and predicted histology and (b) the diagnostic accuracy of interpreting HM-NBI images by using the simplified NBI classification.

METHODS

Two hundred and forty-eight HM-NBI images from macroscopically normal areas in patients with BE were retrieved from endoscopy databases and randomized for review by four endoscopists (two experts, two non-experts). We evaluated inter- and intra-observer agreement of the interpretation of NBI surface patterns and the predicted histology (dysplasia vs. non-dysplasia), as calculated by using κ statistics, and diagnostic values of the prediction.

RESULTS

The overall inter-observer agreements were substantial for mucosal pattern (κ = 0.73) and vascular pattern (κ = 0.71), and almost perfect for predicting dysplastic histology (κ = 0.80). The overall intra-observer agreements were almost perfect for mucosal (κ = 0.84) and vascular patterns (κ = 0.86), and predicting dysplastic histology (κ = 0.89). The mean accuracy in predicting dysplastic histology for all reviewers was 95 % (experts: 96.8 %, non-experts: 93.1 %).

CONCLUSIONS

The simplified NBI classification has the potential to provide high diagnostic reproducibility and accuracy when using HM-NBI.

Barrett Esophagus and Intramucosal Esophageal Adenocarcinoma

Barrett esophagus (BE) is a precursor lesion for esophageal adenocarcinoma (EAC). Developments in imaging and molecular markers, and endoscopic eradication therapy, are available to curb the increase of EAC. Endoscopic surveillance is recommended, despite lack of data. The cancer risk gets progressively downgraded, raising questions about the understanding of risk factors and molecular biology involved. Recent data point to at least 2 carcinogenic pathways operating in EAC. The use of p53 overexpression and high-risk human papillomavirus may represent the best chance to detect progressors. Genome-wide technology may provide molecular signatures to aid diagnosis and risk stratification in BE.

Body weight trajectories and risk of oesophageal and gastric cardia adenocarcinomas: a pooled analysis of NIH-AARP and PLCO Studies

BACKGROUND

Elevated body mass index (BMI, kg m^-2) has been consistently associated with oesophageal adenocarcinoma (EA) and gastric cardia adenocarcinoma (GCA) incidence. However, effects of adiposity over the life course in relation to EA/GCA have not been thoroughly explored.

METHODS

We pooled two prospective cohort studies: NIH-AARP Diet and Health Study and Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, with data on 409 796 individuals (633 EA, 415 GCA). At baseline, participants reported their height and weight at ages 20 and 50 years, and current. Body mass index trajectories were determined using latent class analysis. Hazard ratios (HRs) and 95% confidence intervals (CI) were estimated using proportional hazards regression.

RESULTS

Compared with individuals with a BMI<25 kg m^-2 at all time points, exceeding a BMI of 25 kg m^-2 at age 20 was associated with increased risks of EA (HR=1.76, 95% CI: 1.35-2.29) and GCA (HR=1.62, 95% CI: 1.16-2.25). Similarly, a BMI trajectory of overweight (⩾25-<30 kg m^-2) at age 20 progressing to obesity (⩾30 kg m^-2) by age 50 was associated with increased risks of EA (HR=2.90, 95% CI: 1.67-5.04) and GCA (HR=4.07, 95% CI: 2.32-7.15), compared with individuals with a normal weight (⩾18.5-<25 kg m^-2) trajectory. Weight gain of ⩾20 kg between age 20 and baseline was also associated with a two times increased risk of EA (HR=1.97, 95% CI: 1.43-2.73) and more modestly with GCA (HR=1.40, 95% CI: 0.96-2.05).

CONCLUSIONS

Being overweight in early adulthood and weight gain later in life were each associated with increased risks of EA and GCA. This underscores the potential of weight control programs for reducing EA and GCA risk.

Esophageal cancer: Risk factors, genetic association, and treatment

The poor prognosis and rising incidence of esophageal cancer highlight the need for improved detection and prediction methods that are essential prior to treatment. Esophageal cancer is one of the most fatal malignancies worldwide, with a dramatic increase in incidence in the Western world occurring over the past few decades. Despite improvements in the management and treatment of esophageal cancer patients, the general outcome remains very poor for overall 5-year survival rates (∼10%) and 5-year postesophagectomy survival rates (∼15-40%). Esophageal cancer is often diagnosed during its advanced stages, the main reason being the lack of early clinical symptoms. In an attempt to improve the outcome of patients after surgery, such patients are often treated with neoadjuvent concurrent chemoradiotherapy (CCRT) in order to decrease tumor size. However, CCRT may enhance toxicity levels and possibly cause a delay in surgery for patients who respond poorly to CCRT. Thus, precise biomarkers that could predict or identify patients who may or may not respond well to CCRT can assist physicians in choosing the appropriate therapy for patients. Identifying susceptible gene and biomarkers can help in predicting the treatment response of patients while improving their survival rates.

Esophageal adenocarcinoma and Barrett esophagus in a neurologically impaired teenager

Esophageal adenocarcinoma (EAC) accompanied by Barrett esophagus (BE) is rare in patients younger than 20 years old. EAC in the upper esophagus is also rare. We report a rare case of EAC with BE that developed in the upper esophagus after chronic, untreated gastroesophageal reflux disease in a neurologically impaired teenager. A 19-year-old neurologically impaired man underwent endoscopy for evaluation of dysphagia and vomiting, and was diagnosed with EAC with BE. He underwent transthoracic esophagectomy, extensive lymph node dissection, and cervical esophagogastric anastomosis, but the prognosis was poor. Pathology indicated poorly differentiated adenocarcinoma with BE.

Diagnosis and Surveillance of Barrett's Esophagus: Addressing the Transatlantic Divide

BACKGROUND

Barrett's esophagus is a premalignant condition of the esophagus leading to esophageal adenocarcinoma. No consensus exists between the UK and USA concerning the diagnosis of Barrett's esophagus. Although the diagnostic procedure is common, the required findings and diagnostic criteria vary. Both guidelines require endoscopy showing columnar epithelia lining the esophagus, but the US guidelines require the additional finding of intestinal metaplasia on biopsy to confirm diagnosis. Achievement of a consensus is of particular importance due to the established progression from Barrett's esophagus to esophageal adenocarcinoma. Of further importance is the increasing incidence of esophageal adenocarcinoma, a condition with poor overall survival, leading to various opinions on the utility of surveillance in patients.

DISCUSSION

A review of the vast array of literature revealed that substantial evidence exists in favor of both diagnostic criteria; hence, there is no easy way to identify the "correct" method of diagnosing Barrett's esophagus. USA recommends surveillance of Barrett's esophagus, whereas UK does not advocate it unless dysplasia is present. Surveillance was found to be effective, but this varied as did cost-effectiveness. Further research into diagnostic methods for Barrett's esophagus is needed to address areas of limited understanding, such that agreement can be reached and practice standardized. Surveillance was generally advocated, but with different criteria and time intervals, and new methods are being evaluated.

Dietary fruit, vegetable, fat, and red and processed meat intakes and Barrett's esophagus risk: a systematic review and meta-analysis

The relationships between dietary fruit, vegetable, fat, and red and processed meat intakes and Barrett’s esophagus (BE) risk remain inconclusive. We conducted a systematic review and meta-analysis to summarize the available evidence on these issues. PubMed, EMBASE and the Cochrane Library were searched for studies published from inception through October 2015. A total of eight studies were included in this analysis. Fruit intake was not associated with BE risk (OR = 0.65, 95% CI = 0.37–1.13), but vegetable intake was strongly associated with BE risk (OR = 0.45, 95% CI = 0.29–0.71). Saturated fat, red meat and processed meat intakes were not associated with BE risk with OR = 1.25 (95% CI = 0.82–1.91), OR = 0.85 (95% CI = 0.61–1.17) and OR = 1.03 (95% CI = 0.73–1.46), respectively. Dietary vegetable not fruits intake may be associated with decreased BE risk. Fat and red and processed meat intakes may not contribute to an increased BE risk. Well-designed, large prospective studies with better established dose-response relationships are needed to further validate these issues.

A meta-analysis of confocal laser endomicroscopy for the detection of neoplasia in patients with Barrett's esophagus

BACKGROUND AND AIMS

Barrett's esophagus (BE) is considered the most important risk factor for development of esophageal adenocarcinoma. Confocal laser endomicroscopy (CLE) is a recently developed technique used to diagnose neoplasia in BE. This meta-analysis was performed to assess the accuracy of CLE for diagnosis of neoplasia in BE.

METHODS

We searched EMBASE, PubMed, Cochrane Library, and Web of Science to identify relevant studies for all articles published up to June 27, 2015 in English. The quality of included studies was assessed using QUADAS-2. Per-patient and per-lesion pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with 95% confidence intervals (CIs) were calculated.

RESULTS

In total, 14 studies were included in the final analysis, covering 789 patients with 4047 lesions. Seven studies were included in the per-patient analysis. Pooled sensitivity and specificity were 89% (95% CI: 0.82-0.94) and 83% (95% CI: 0.78-0.86), respectively. Ten studies were included in the per-lesion analysis. Compared with the PP analysis, the corresponding pooled sensitivity declined to 77% (95% CI: 0.73-0.81) and specificity increased to 89% (95% CI: 0.87-0.90). Subgroup analysis showed that probe-based CLE (pCLE) was superior to endoscope-based CLE (eCLE) in pooled specificity [91.4% (95% CI: 89.7-92.9) vs 86.1% (95% CI: 84.3-87.8)] and AUC for the sROC (0.885 vs 0.762).

CONCLUSION

Confocal laser endomicroscopy is a valid method to accurately differentiate neoplasms from non-neoplasms in BE. It can be applied to BE surveillance and early diagnosis of esophageal adenocarcinoma.

Oesophageal adenocarcinoma and gastric cancer: should we mind the gap?

Over recent decades we have witnessed a shift in the anatomical distribution of gastric cancer (GC), which increasingly originates from the proximal stomach near the junction with the oesophagus. In parallel, there has been a dramatic rise in the incidence of oesophageal adenocarcinoma (OAC) in the lower oesophagus, which is associated with antecedent Barrett oesophagus (BO). In this context, there has been uncertainty regarding the characterization of adenocarcinomas spanning the area from the lower oesophagus to the distal stomach. Most relevant to this discussion is the distinction, if any, between OAC and intestinal-type GC of the proximal stomach. It is therefore timely to review our current understanding of OAC and intestinal-type GC, integrating advances from cell-of-origin studies and comprehensive genomic alteration analyses, ultimately enabling better insight into the relationship between these two cancers.

An Analysis of Weight Gains and Body Mass Index in Patients with Barrett's Esophagus

BACKGROUND

Obesity is a risk factor for developing Barrett's esophagus (BE), a precursor to esophageal cancer. Long BE lengths are associated with greater risk for malignancy. How weight gains from young adulthood (defined as ages 19 to 29 years) affect BE length is unknown.

OBJECTIVE

To examine current body mass index (BMI), weight gains from young adulthood, and evening snacking near bedtime during young adulthood in BE patients.

DESIGN

Cross-sectional analysis of 71 patients from 2001 to 2008 from a 600-bed tertiary care center in the United States who were newly diagnosed with BE by endoscopy and mucosal biopsies.

MAIN OUTCOME MEASURES

Barrett's esophagus length and age at presentation.

STATISTICAL ANALYSES PERFORMED

Pearson's correlation coefficient (r) measured the linear association between continuous variables. The Kruskal-Wallis test was used to compare medians by segment length and the chi-squared test or Fisher's exact test for categorical data. Quantile regression was used for multivariable adjustment.

RESULTS

Younger patients had higher BMIs at diagnosis (r=-0.32, P=0.007). Patients who gained more than 23 kg from young adulthood were diagnosed at an adjusted median age of 18.0 years younger 95% CI (6.1-29.9, P=0.004) than patients with no weight gains. BMI was not correlated with BE length (r=-0.12, P=0.33). Weight gains from young adulthood were not associated with BE length after multivariable adjustment (P=0.19). Patients whose late evening snack or bedtime was less than 4 hours from dinner had longer median BE lengths than those who went to bed later (5 vs 2 cm, P=0.02).

CONCLUSIONS

Longer BE lengths were associated with shorter dinner-bedtime intervals during young adulthood but not with current BMI or weight gains from young adulthood.

The Prevalence of Barrett Esophagus Diagnosed in the Second Endoscopy: A Retrospective, Observational Study at a Tertiary Center

At present, we do not know the exact prevalence of Barrett esophagus (BE) developing later in patients without BE in their first endoscopic screening. The purpose of this study was to determine the prevalence of BE on the second endoscopic examination of patients who had no BE in their first endoscopic examination.The data of the patients older than 18 years who had undergone upper gastrointestinal system endoscopy more than once at the endoscopy unit of our clinic during the last 6 years were retrospectively analyzed.During the last 6 years, 44,936 patients had undergone at least one endoscopic examination. Among these patients, 2701 patients who had more than one endoscopic screening were included in the study. Of the patients, 1276 (47.3%) were females and 1425 (52.7%) were males, with an average age of 54.9 (18-94) years. BE was diagnosed in 18 (0.66%) of the patients who had no BE in the initial endoscopic examination. The patients with BE had reflux symptoms in their medical history and in both endoscopies, they revealed a higher prevalence of lower esophageal sphincter laxity, hiatal hernia, and reflux esophagitis when compared to patients without BE (P < 0.001).Our study showed that in patients receiving no diagnosis of BE on their first endoscopic examination performed for any reason, the prevalence of BE on their second endoscopy within 6 years was very low (0.66%).

Linkage and related analyses of Barrett's esophagus and its associated adenocarcinomas

Background

Familial aggregation and segregation analysis studies have provided evidence of a genetic basis for esophageal adenocarcinoma (EAC) and its premalignant precursor, Barrett's esophagus (BE). We aim to demonstrate the utility of linkage analysis to identify the genomic regions that might contain the genetic variants that predispose individuals to this complex trait (BE and EAC).

Methods

We genotyped 144 individuals in 42 multiplex pedigrees chosen from 1000 singly ascertained BE/EAC pedigrees, and performed both model‐based and model‐free linkage analyses, using S.A.G.E. and other software. Segregation models were fitted, from the data on both the 42 pedigrees and the 1000 pedigrees, to determine parameters for performing model‐based linkage analysis. Model‐based and model‐free linkage analyses were conducted in two sets of pedigrees: the 42 pedigrees and a subset of 18 pedigrees with female affected members that are expected to be more genetically homogeneous. Genome‐wide associations were also tested in these families.

Results

Linkage analyses on the 42 pedigrees identified several regions consistently suggestive of linkage by different linkage analysis methods on chromosomes 2q31, 12q23, and 4p14. A linkage on 15q26 is the only consistent linkage region identified in the 18 female‐affected pedigrees, in which the linkage signal is higher than in the 42 pedigrees. Other tentative linkage signals are also reported.

Conclusion

Our linkage study of BE/EAC pedigrees identified linkage regions on chromosomes 2, 4, 12, and 15, with some reported associations located within our linkage peaks. Our linkage results can help prioritize association tests to delineate the genetic determinants underlying susceptibility to BE and EAC.

Development and Validation of a Classification System to Identify High-Grade Dysplasia and Esophageal Adenocarcinoma in Barrett's Esophagus Using Narrow-Band Imaging

BACKGROUND & AIMS

Although several classification systems have been proposed for characterization of Barrett's esophagus (BE) surface patterns based on narrow-band imaging (NBI), none have been widely accepted. The Barrett's International NBI Group (BING) aimed to develop and validate an NBI classification system for identification of dysplasia and cancer in patients with BE.

METHODS

The BING working group, composed of NBI experts from the United States, Europe, and Japan, met to develop a validated, consensus-driven NBI classification system for identifying dysplasia and cancer in BE. The group reviewed 60 NBI images of nondysplastic BE, high-grade dysplasia, and esophageal adenocarcinoma to characterize mucosal and vascular patterns visible by NBI; these features were used to develop the BING criteria. We then recruited adult patients undergoing surveillance or endoscopic treatment for BE at 4 institutions in the United States and Europe, obtaining high-quality NBI images and performing histologic analysis of biopsies. Experts individually reviewed 50 NBI images to validate the BING criteria, and then evaluated 120 additional NBI images (not previously viewed) to determine whether the criteria accurately predicted the histology results.

RESULTS

The BING criteria identified patients with dysplasia with 85% overall accuracy, 80% sensitivity, 88% specificity, 81% positive predictive value, and 88% negative predictive value. When dysplasia was identified with a high level of confidence, these values were 92%, 91%, 93%, 89%, and 95%, respectively. The overall strength of inter-observer agreement was substantial (κ = 0.681).

CONCLUSIONS

The BING working group developed a simple, internally validated system to identify dysplasia and EAC in patients with BE based on NBI results. When images are assessed with a high degree of confidence, the system can classify BE with >90% accuracy and a high level of inter-observer agreement.

The role of endoscopy in the management of GERD

We recommend that uncomplicated GERD be diagnosed on the basis of typical symptoms without the use of diagnostic testing, including EGD. We recommend EGD for patients who have symptoms suggesting complicated GERD or alarm symptoms. We recommend that EGD not be routinely performed solely for the assessment of extraesophageal GERD symptoms. We recommend that endoscopic findings of reflux esophagitis be classified according to an accepted grading scale or described in detail. We suggest that repeat EGD be performed in patients with severe erosive esophagitis after at least an 8-week course of PPI therapy to exclude underlying BE or dysplasia. 44BB We recommend against obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude BE in adults. We suggest that endoscopy be considered in patients with multiple risk factors for Barrett’s esophagus. We recommend that tissue samples be obtained to confirm endoscopically suspected Barrett’s esophagus. We suggest that endoscopic antireflux therapy be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options.

The management of gastro-oesophageal reflux disease

If there are no features of serious disease, suspected gastro-oesophageal reflux disease can be initially managed with a trial of a proton pump inhibitor for 4-8 weeks. This should be taken 30-60 minutes before food for optimal effect. Once symptoms are controlled, attempt to withdraw acid suppression therapy. If symptoms recur, use the minimum dose that controls symptoms. Patients who have severe erosive oesophagitis, scleroderma oesophagus or Barrett's oesophagus require long-term treatment with a proton pump inhibitor. Lifestyle modification strategies can help gastro-oesophageal reflux disease. Weight loss has the strongest evidence for efficacy. Further investigation and a specialist referral are required if there is no response to proton pump inhibitor therapy. Atypical symptoms or signs of serious disease also need investigation.

Oesophageal biopsies are insufficient to predict final histology after endoscopic resection in early Barrett's neoplasia

BACKGROUND

Endoscopic resection (ER) with or without ablation is the first choice treatment for early Barrett's neoplasia. Adequate staging is important to assure a good oncological outcome.

OBJECTIVE

The purpose of this study was to investigate the diagnostic accuracy of pre-operative biopsies in patients who undergo ER for high-grade dysplasia (HGD) or early adenocarcinoma (EAC) in Barrett's oesophagus (BE) and the cardia.

METHODS

Between November 2005-May 2012, 142 ERs performed in 137 patients were obtained. Worst pre-ER and ER histology were compared. Upgrading/downgrading was defined as any more/less severe histological grading on the ER specimen.

RESULTS

The accuracy of pre-ER biopsies in predicting final histology was 61%. ER changed the pre-treatment diagnosis in 55 of the 142 procedures (39%) with downgrading in 23 cases (16%) and upgrading from HGD to T1a or T1b in 32 cases (23%). In the majority of upgraded cases, a visible lesion according to the Paris classification could be detected (26/32, 81%).

CONCLUSION

The diagnostic accuracy of oesophageal biopsies alone in predicting final pathology in Barrett's dysplasia is only 61%. The majority of upgraded lesions are detectable. When ablative therapy is considered in HGD Barrett's dysplasia a meticulous inspection for and removal of all small visible lesions is mandatory.

Yield of Repeat Endoscopy in Barrett's Esophagus with No Dysplasia and Low-Grade Dysplasia: A Population-Based Study

BACKGROUND

The yield of early repeat endoscopy in patients with Barrett's esophagus (BE) is not well established.

AIMS

To determine how often early repeat endoscopy detected missed dysplasia or esophageal adenocarcinoma (EAC) in a population-based cohort of patients with BE. Secondary aims were to identify risk factors for missed dysplasia/EAC and compare detection of prevalent versus incident HGD/EAC.

METHODS

A population-based cohort of BE subjects in Olmsted County, MN, was studied. Patients with initial non-dysplastic BE or low-grade dysplasia (LGD) who underwent repeat endoscopy within 24 months were included. Those with a worse histologic diagnosis on repeat endoscopy were considered to have missed dysplasia/EAC. Baseline characteristics among patients with and without missed dysplasia/EAC were compared. The absolute numbers of asymptomatic prevalent or missed, and incident HGD/EAC in the entire cohort were ascertained.

RESULTS

Of 488 BE cases, 210 were included for the primary aim of this study. Repeat endoscopy revealed four HGD/EAC (1.9 %) and 16 LGD (8.8 %) for a combined miss rate of 9.5 %. Long-segment BE (LSBE) and lack of PPI use were predictors of missed dysplasia/EAC (P = 0.008), but adherence to biopsy protocol was not. Increased prevalent HGD/EAC (n = 30) rather than incident HGD/EAC (n = 22) was identified during a median 4.8 years of follow-up in this cohort.

CONCLUSIONS

Dysplasia/EAC is commonly missed at initial BE diagnosis, particularly in patients with LSBE and no PPI use. Efforts should be made to enhance the sensitivity of detecting dysplasia/neoplasia around the time of initial BE diagnosis.