Low-grade dysplasia in Barrett's esophagus

Clinical and Endoscopic Differences Between Patients With Barrett's Esophagus With and Without Dysplasia/Adenocarcinoma

INTRODUCTION

Barrett's esophagus (BE) is the main precursor of esophageal adenocarcinoma (EAC). This study aimed to identify the risk factors associated with BE progression to dysplasia or EAC in a Latin population.

METHODS

The study is a retrospective analysis of a single-center cohort of patients with BE, evaluated from 2002 to 2012.

RESULTS

We identified 420 patients with BE; 281 (66.9%) of them were men with a mean age of 57.2 ± 15.3 years. Among all BE patients evaluated, 81 (19.3%) had progression to some degree of dysplasia/EAC. The mean follow-up was 5.6 years. Multivariate analysis showed that age (OR = 1.03), cigarette smoking (OR = 3.05), long-segment BE (OR = 4.81), and a visible lesion on BE (OR = 6.94) were associated with progression to dysplasia/EAC.

CONCLUSION

In Latin patients with BE, age, cigarette smoking, long-segment BE, and the presence of lesions were associated with the presence of dysplasia/EAC.

Current state of prognostication, therapy and prospective innovations for Barrett's-related esophageal adenocarcinoma: a literature review

Objective

Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), which has one of the lowest 5-year survival rates in oncology. The reasons for poor survival are twofold: the large majority of diagnoses are in advanced stages (~80%) and limited treatment options, with a deficit of biology-guided therapies. As a rapidly growing public health concern with poor prognosis, research into the molecular progression for BE and novel therapeutics for EAC currently has high clinical utility. Review of the literature reveals that innovative analysis of metaplastic progression from BE to EAC at a molecular level can shed light on the underlying transformative probabilities of BE into malignant pathologies and may impact current of future therapeutic modalities for management of these diseases.

Background

EAC is the fastest increasing cancer in the United States with a 600% increase over the past 25 years. This cancer arises from dysplastic tissue of BE, a complication of gastroesophageal reflux disease (GERD). Chronic acid and bile reflux in the distal esophagus initiates a metaplastic conversion of normal squamous epithelium to premalignant intestinalized columnar epithelium. Patients with BE have a 125-fold higher risk of cancer compared to the general population.

Methods

We critically reviewed the current status of BE monitoring, and subsequent therapeutic strategies being used in patients who have progressed to cancer. Also, new diagnostic tools and therapeutic candidates for BE-related EAC are discussed. Highly-targeted searches of databases containing recent original peer-reviewed papers were utilized for this review.

Conclusions

Novel and well-described biomarkers analyzed in the patient's diseased tissue will provide for more powerful diagnostics, but also possess the potential to develop strategies for personalized management and identify targets for intervention to either cease disease progression or treat BE and/or EAC. Since millions of Americans develop BE without progressing to cancer, there is a critical need to identify the small percentage of Barrett's patients who possess hallmarks of disease progression or carcinogenesis with novel screening techniques. Incorporation of such tools into standard screening protocols for BE surveillance and/or therapy would be critical to detect malignant transformations before clinically obvious cancer ever develops.

Aberrant p53 Immunostaining in Barrett's Esophagus Predicts Neoplastic Progression: Systematic Review and Meta-Analyses

Risk stratification of patients with Barrett's esophagus (BE) presently relies on the histopathologic grade of dysplasia found in esophageal biopsies, which is limited by sampling error and inter-pathologist variability. p53 immunostaining of BE biopsies has shown promise as an adjunct tool but is not recommended by American gastroenterology societies, who cite insufficient evidence of its prognostic value. We have conducted a systematic review and meta-analyses to clarify this value. We searched for studies that: (1) used immunohistochemistry to assess p53 expression in esophageal biopsies of BE patients and (2) reported subsequent neoplastic progression. We performed separate meta-analyses of case-control studies and cohort studies. We identified 14 relevant reports describing 8 case-control studies comprising 1435 patients and 7 cohort studies comprising 582 patients. In the case-control study meta-analysis of the risk of neoplasia with aberrant p53 expression, the fixed- and random-effect estimates of average effect size with aberrant p53 expression were OR 3.84, p < .001 (95% CI 2.79-5.27) and OR 5.95, p < .001 (95% CI 2.68-13.22), respectively. In the cohort study meta-analysis, the fixed- and random-effect estimates of average effect size were RR = 17.31, p < .001 (95% CI 9.35-32.08) and RR = 14.25, p < .001 (95% CI 6.76-30.02), respectively. Separate meta-analyses of case-control and cohort studies of BE patients who had baseline biopsies with p53 immunostaining revealed consistent, strong, and significant associations between aberrant p53 immunostaining and progression to high-grade dysplasia or esophageal adenocarcinoma. These findings support the use of p53 immunostaining as an adjunct to routine clinical diagnosis for dysplasia in BE patients.

Barrett's esophagus: Ten years of experience at a tertiary care hospital center in Mexico

INTRODUCTION

The prevalence of Barrett's esophagus has been calculated at between 1.3 and 1.6%. There is little information with respect to this in Mexico.

AIM

To determine the frequency and characteristics of Barrett's esophagus in patients that underwent endoscopy at a national referral center, within a 10-year time frame.

MATERIAL AND METHODS

The databases of the pathology and gastrointestinal endoscopy departments of the Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán" were analyzed, covering the period of January 2002 to December 2012. Patients with a histologic diagnosis of Barrett's esophagus were included. The variables of age, sex, the presence of dysplasia/esophageal adenocarcinoma, Barrett's esophagus length, and follow-up were analyzed.

RESULTS

Of 43,639 upper gastrointestinal endoscopies performed, 420 revealed Barrett's esophagus, corresponding to a frequency of 9.6 patients for every 1,000 endoscopies. Of those patients, 66.9% (n=281) were men, mean patient age±SD was 57.2±15.3 years, 223 patients (53%) presented with long-segment Barrett's esophagus, and 197 (47%) with short-segment Barrett's esophagus. Dysplasia was not present in 339 patients (80.7%). Eighty-one (19.3%) patients had some grade of dysplasia or cancer: 48/420 (11.42%) presented with low-grade dysplasia, 20/420 (4.76%) with high-grade dysplasia, and 13/420 (3.1%) were diagnosed with esophageal cancer arising from Barrett's esophagus. Mean follow-up time was 5.6 years.

CONCLUSIONS

The frequency of Barrett's esophagus was 9.6 cases for every 1,000 upper gastrointestinal endoscopies performed. Dysplasia was not documented in the majority of the patients with Barrett's esophagus and they had no histopathologic changes during follow-up. A total of 19.3% of the patients presented with dysplasia or cancer.

Healthcare Cost of Over-Diagnosis of Low-Grade Dysplasia in Barrett's Esophagus

INTRODUCTION

Published reports have demonstrated that many Barrett's esophagus patients are over-diagnosed as low-grade dysplasia (BE-LGD). We performed an analysis of the surveillance and treatment costs associated with the over-diagnosis of BE-LGD.

METHODS

As the principal cost variables, we used endoscopic and histologic procedures performed during the recommended surveillance intervals for patients with BE-LGD, the national average Medicare reimbursement for the Current Procedural Terminology codes of the procedures performed, and a spreadsheet-based tool we created to determine the overall healthcare cost associated with the over-diagnosis of BE-LGD in the US population.

RESULTS

The average excess cost (range) for every patient in the US who is over-diagnosed with BE-LGD is estimated to be $5557 ($3115 to $8072). The principal contributors to the excess cost of over-diagnosis of BE-LGD in these patients are: endoscopy ($2626 to $4639), pathologist biopsy review ($275 to $2185), and esophagogastroduodenoscopy-guided endoscopic ablation ($214 to $1249).

CONCLUSIONS

The healthcare cost of over-diagnosis of BE-LGD is significant. To reduce the overall healthcare cost impact of over-diagnosis of BE-LGD, strict adherence to the recommendations of the American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy that pathology review of all BE biopsy specimens be performed by a gastrointestinal pathologist is warranted.

Barrett's oesophagus: epidemiology, cancer risk and implications for management

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.

Risk factors for rising incidence of esophageal and gastric cardia adenocarcinoma

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.

Differential expression of the nuclear receptors farnesoid X receptor (FXR) and pregnane X receptor (PXR) for grading dysplasia in patients with Barrett's oesophagus

AIMS

To investigate expression of nuclear receptors farnesoid X receptor (FXR) and pregnane X receptor (PXR) as a diagnostic tool to improve grading of dysplasia in Barrett's oesophagus patients.

METHODS AND RESULTS

Immunostaining was analysed on a total of 192 biopsy samples of 22 Barrett's patients with no dysplasia (ND), 17 with low-grade dysplasia (LGD), 20 high-grade dysplasia (HGD) and 24 with adenocarcinoma (AC). Nuclear FXR expression was observed in 15 of 22 (68%) ND cases versus none of 19 HGD; 3 of 17 (18%); LGD; 5 of 60 (8%) patients with AC (P<0.001). FXR expression was highly specific for non-dysplastic tissue. Nuclear PXR was expressed in 16 of 20 (80%) HGD cases versus two of 16 (13%) LGD cases (PPV 89%). Upon examining adjacent tissue taken from HGD and AC patients, PXR expression was high in samples of all tissue types.

CONCLUSIONS

Nuclear receptors are expressed differentially during neoplastic progression, with FXR positivity being useful to distinguish ND from dysplasia and AC. PXR nuclear expression is able to separate HGD from LGD and ND. The combination of FXR and PXR also appears to have diagnostic and possibly prognostic value, but future prospective studies are required to investigate their predictive power for neoplastic progression in Barret's oesophagus.

Treatment of GERD complications (Barrett's, peptic stricture) and extra-oesophageal syndromes

Apart from typical reflux symptoms and oesophagitis, the clinical presentation of GERD can be dominated by mucosal complications of reflux (Barrett's oesophagus, oesophageal adenocarcinoma, Peptic structure) or by extra-oesophageal syndromes, most notably asthma, laryngitis, or chronic cough. Managing these entities is much less straightforward than with oesophagitis. With respect to adenocarcinoma, metaplasia and dysplasia are recognised precursors, but the potential of these lesions to evolve to cancer has not been shown to lessen as a result of treatment, medical or surgical. Consequently, management focuses on strategies to identify and eliminate high-grade dysplasia and intramucosal cancer, lesions that are potentially curable by endoscopic ablation or surgical resection. With respect to the extra-oesophageal GERD syndromes, these are increasingly recognised as multifactorial conditions with reflux as an exacerbating factor. Treatment trials have been generally disappointing and the clinical challenge remains in accurately identifying afflicted patients who might benefit from more intensive medical or surgical reflux treatment.

Barrett's esophagus and Cornelia de Lange Syndrome

AIM

To review the records of Cornelia de Lange Syndrome (CDLS) children, affected by Gastro-oesophageal reflux disease (GERD), to detect the presence of Barrett's Esophagus (BE).

METHODS

A total of 62 CDLS patients were investigated for GERD (1 month-35 years). In all of them a pH-metry, an upper endoscopy with multiple biopsies and a complete radiologic digestive evaluation were carried out. BE was diagnosed in case of replacement of oesophageal mucosa by specialized intestinal-type columnar mucosa. Anti-reflux surgery was considered in case of persistence of BE after medical therapy. Follow-up (mean 3.5 years) consisted in endoscopy every 6 months .

RESULTS

Gastro-oesophageal reflux disease was found in 50 CDLS patients (80%) and BE in six of them (12% of the GERD group, 9.6% of the entire population, mean age 17 years, range 6-32 years). A short segment BE was observed in three patients, a long one in two patients and an infiltrating adenocarcinoma of the lower oesophagus in one patient.

CONCLUSIONS

A higher frequency of BE in CDLS patients than in a normal population is found. A delayed diagnosis because of atypical GERD symptoms and an altered intestinal motility as a result of neurological impairment can be recognized as the main cause.

Predictors of progression in Barrett's esophagus: current knowledge and future directions

Barrett's esophagus (BE) is the strongest risk factor for esophageal adenocarcinoma (EAC), a malignancy with persistently poor long-term outcomes. EAC is thought to develop through progression of metaplasia to dysplasia to invasive carcinoma. Identification of factors predicting progression to EAC would help in focusing surveillance, chemoprevention, or ablation for those deemed to be at highest risk of progression. We performed a comprehensive review of the literature and summarized current evidence on risk factors for progression in subjects with known BE. Clinical and demographic factors (age, male gender, length of BE segment) are associated with modestly increased odds of progression to EAC in some studies. Biomarkers such as aneuploidy and p53 loss of heterozygosity have been associated with increased risk of progression to high-grade dysplasia and/or EAC in single-center prospective cohort studies. Promising newer techniques and markers have been recently reported with the potential to help risk stratify BE subjects. Development of a comprehensive BE risk progression score comprised of both clinical and biomarker variables should be the ultimate goal and can be achieved by multicenter prospective collaborative efforts. Although it would be challenging, creation of such a score has the potential to improve outcomes and make the management of patients with BE more cost-effective.

Low-grade dysplasia in Barrett's esophagus: overdiagnosed and underestimated

OBJECTIVES

Published data on the natural history of low-grade dysplasia (LGD) in Barrett's esophagus (BE) are inconsistent and difficult to interpret. We investigated the natural history of LGD in a large community-based cohort of BE patients after reviewing the original histological diagnosis by an expert panel of pathologists.

METHODS

Histopathology reports of all patients diagnosed with LGD between 2000 and 2006 in six non-university hospitals were reviewed by two expert pathologists. This panel diagnosis was subsequently compared with the histological outcome during prospective endoscopic follow-up.

RESULTS

A diagnosis of LGD was made in 147 patients. After pathology review, 85% of the patients were downstaged to non-dysplastic BE (NDBE) or to indefinite for dysplasia. In only 15% of the patients was the initial diagnosis LGD. Endoscopic follow-up was carried out in 83.6% of patients, with a mean follow-up of 51.1 months. For patients with a consensus diagnosis of LGD, the cumulative risk of progressing to high-grade dysplasia or carcinoma (HGD or Ca) was 85.0% in 109.1 months compared with 4.6% in 107.4 months for patients downstaged to NDBE (P<0.0001). The incidence rate of HGD or Ca was 13.4% per patient per year for patients in whom the diagnosis of LGD was confirmed. For patients downstaged to NDBE, the corresponding incidence rate was 0.49%.

CONCLUSIONS

LGD in BE is an overdiagnosed and yet underestimated entity in general practice. Patients diagnosed with LGD should undergo an expert pathology review to purify this group. In case the diagnosis of LGD is confirmed, patients should undergo strict endoscopic follow-up or should be considered for endoscopic ablation therapy.

Risk factors for esophageal cancer development

The incidence of esophageal adenocarcinoma is increasing at a rate greater than that of any other cancer in the Western world today. Barrett's esophagus is a clearly recognized risk factor for the development of esophageal adenocarcinoma, but the overwhelming majority of patients with Barrett's esophagus will never develop esophageal cancer. To date, dysplasia remains the only factor useful for identifying patients at increased risk for the development of esophageal adenocarcinoma in clinical practice. Other epidemiologic risk factors include aging, gender, race, obesity, reflux symptoms, smoking, and diet. Factors that may protect against the development of adenocarcinoma include infection with Helicobacter pylori, a diet rich in fruits and vegetables, and consumption of aspirin and NSAIDs.

Screening and surveillance of Barrett's esophagus

Esophageal adenocarcinoma (EAC) is the most rapidly increasing cancer in the Western world and Barrett's esophagus (BE) is the only known precursor lesion for this lethal cancer. Long-term survival may be improved if EAC is diagnosed early, providing an opportunity for early intervention. Screening for BE in patients with gastroesophageal reflux disease is not routinely recommended; however, if diagnosed, enrollment into a surveillance program may be beneficial. Surveillance of all patients with known BE is probably not cost-effective and factors predictive of BE progression to dysplasia/EAC are poorly understood. Screening and surveillance examinations are also faced with challenges in the endoscopic detection of intestinal metaplasia and dysplasia. Future application of molecular biomarkers may help identify the patients with BE most likely to progress, and the use of novel imaging methods may improve outcomes of BE screening and surveillance.

The characteristics of Barrett's esophagus: an analysis of 4120 cases in China

Our objective was to investigate the endoscopic and clinico-pathological characteristics in patients with Barrett's esophagus (BE) in China. Using the terms 'Barrett's esophagus' and 'Barrett's esophagus, China' as key words, literatures published in Chinese and English journals were searched in Chinese data banks, as well as PubMed and ISI Web of Science from 1989 to 2007. An analysis was carried out with the standard inclusion and exclusion criteria. A total of 4120 cases were included in this study. BE was found in 2.44% of patients undergoing endoscopy for various symptoms of upper gastrointestinal tract diseases; the male : female ratio was 2.09 : 1, the average age of detection of BE was 53.15 years old, and 51% of patients with BE had typical symptoms for gastroesophageal reflux disease (GERD). The island-type BE was predominant (56.80%), and the occurrence of BE with special intestinal metaplasia (SIM) was 36.58%, but SIM was more common in tongue-type BE than island-type and circumferential-type BE (both P < 0.001), as well as in long segment BE (LSBE) than in short segment BE (SSBE) (P < 0.001). A total of 46.39% of patients had Helicobacter pylori infection. The mean length of follow up was 2 years in 492 patients. The incidence of adenocarcinoma was 0.61% patient-years of total follow up. In China, the endoscopic prevalence of BE is lower, but the average age of diagnosis is younger; a high proportion of H. pylori infection is found in patients with BE, and about half of the patients have no typical symptoms of GERD; the tongue-type BE and the LSBE are apt to SIM.

Quality of Barrett's surveillance in The Netherlands: a standardized review of endoscopy and pathology reports

OBJECTIVE

The quality of Barrett's surveillance relies on an adequate endoscopic inspection, obtaining a sufficient number of biopsy specimens, good communication of the endoscopic findings to the pathologist, and an accurate description of the histological findings by the pathologist. The aim of this study was to assess the quality of Barrett's surveillance in daily practice in The Netherlands.

MATERIALS AND METHODS

A structured scoring list was developed to evaluate systematically the quality of endoscopy and pathology reports. From 15 hospitals, endoscopy reports and corresponding pathology reports were selected randomly and evaluated by two observers. In case of disagreement, the observers re-evaluated the reports in a consensus meeting.

RESULTS

One hundred and fifty cases were evaluated. The adherence to current standard biopsy protocols (four quadrant biopsies every 2 cm) decreased with increasing Barrett's length: 0-5 cm: 79%; 5-10 cm: 50%; 10-15 cm: 30%. The indication for the endoscopy was mentioned in 28% of the pathology reports, in 4% the presence/absence of oesophagitis was communicated, and in 19% the location and/or aetiology of biopsies was described. The presence/absence of dysplasia was mentioned in 93% of pathology reports.

CONCLUSION

Endoscopy reports and pathology reports in current practice do not include all relevant information for an adequate Barrett's surveillance. In short Barrett's oesophagus, the adherence to current standard biopsy protocols is acceptable, but in longer segments (with a higher risk for neoplastic progression) this is clearly insufficient. The communication between endoscopists and pathologist is suboptimal.

Extent of low-grade dysplasia is a risk factor for the development of esophageal adenocarcinoma in Barrett's esophagus

OBJECTIVES

Previous studies that evaluated extent of high-grade dysplasia (HGD) as a risk factor for esophageal adenocarcinoma (EA) in Barrett's esophagus (BE) were conflicting, and no prior study has evaluated extent of low-grade dysplasia (LGD) as a risk factor. The aim of this discovery study was to evaluate the hypothesis that extent of LGD and HGD are risk factors for progression to EA.

METHODS

We evaluated baseline biopsies from 77 BE patients with dysplasia including 44 who progressed to EA and 33 who did not progress during follow-up. The total numbers of LGD and HGD crypts were determined separately by counting all crypts and the extent of LGD, HGD, and total dysplasia were correlated with EA outcome.

RESULTS

Thirty-one and 46 patients had a maximum diagnosis of LGD and HGD, respectively. When the crypts were stratified by dysplasia grade, the mean number of LGD crypts per patient was borderline higher in progressors (93.9) compared with nonprogressors (41.2, P= 0.07), and the mean proportion of LGD crypts per patient was significantly higher in progressors (46.4%vs 26.0%, P= 0.037). Neither the mean number of HGD crypts per patient (P= 0.14) nor the mean proportion of HGD crypts per patient (P= 0.20) was significantly associated with EA outcome.

CONCLUSIONS

The extent of LGD is a significant risk factor for the development of EA in BE in this study. Although the presence of HGD is significantly associated with a greater relative risk for development of EA, the extent of HGD was not an independent risk factor for progression.

Extent of low-grade dysplasia in Barrett's esophagus: is it useful for risk stratification?

Low-grade dysplasia remains one of the great enigmas of Barrett's esophagus. Limited information is available on the natural history of this lesion, and studies suggest that cancer risk in patients with low-grade dysplasia is intermediate between that of intestinal metaplasia without dysplasia and high-grade dysplasia. Natural history studies of low-grade dysplasia are hampered by problems with interobserver variability among pathologists and sampling variability among endoscopists. To date, the extent of low-grade dysplasia has not been examined as a potential risk factor for the subsequent development of adenocarcinoma. Srivastava et al., in this issue of the American Journal of Gastroenterology, found that the extent of low-grade dysplasia, as measured by several different methods, was a risk factor for progression to cancer. While these findings are novel and provocative, it is premature to request your pathologist to count the number of crypts or biopsies with low-grade dysplasia just yet. However, these findings, if confirmed by studies utilizing a simpler measure of the extent of low-grade dysplasia, may help us determine the prognostic significance of this lesion in the future.

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

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

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

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

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

The utility of a novel narrow band imaging endoscopy system in patients with Barrett's esophagus

BACKGROUND

A narrow band imaging (NBI) endoscopy system has been developed that allows superficial surface imaging of esophageal tissue in vivo.

OBJECTIVE

The objective was to assess the potential of NBI for prediction of histology during screening and surveillance endoscopy in patients with Barrett's esophagus (BE).

DESIGN

A prospective cohort study.

SETTING

Veterans Affairs Medical Center.

PATIENTS

Fifty-one patients with known or suspected BE.

METHODS

NBI images were graded according to mucosal pattern (ridge/villous, circular and irregular/distorted) and vascular pattern (normal and abnormal), and correlated with histology in a prospective, blinded manner.

MAIN OUTCOME MEASUREMENTS

Biopsy-confirmed intestinal metaplasia (IM) and dysplasia were used as the outcome measures.

RESULTS

Of 51 patients (mean BE length 3.5 cm), 28 had IM without dysplasia, 8 had low-grade dysplasia (LGD), 7 had high-grade dysplasia (HGD), and 8 had cardiac-type mucosa. The sensitivity, specificity, and positive predictive value of ridge/villous pattern for diagnosis of IM without HGD were 93.5%, 86.7%, and 94.7%, respectively. The sensitivity, specificity, and positive predictive value of irregular/distorted pattern for HGD were 100%, 98.7%, and 95.3%, respectively. If biopsies were limited to areas with irregular/distorted pattern, no patient with HGD would have been missed. However, NBI was unable to distinguish areas of IM from those with LGD.

LIMITATIONS

The open study design without a control group was the main limitation.

CONCLUSIONS

NBI is a novel diagnostic tool with a high degree of accuracy for the detection of metaplastic and dysplastic tissue within the BE segment.

The rationale for screening and surveillance of Barrett's metaplasia

Oesophageal adenocarcinoma is a rare cancer; however, it is the most rapidly increasing cancer in the western world. Barrett's oesophagus is the only recognised precursor and is associated with the majority of cases of adenocarcinoma. The role of screening and surveillance in patients with Barrett's oesophagus remains controversial. There is insufficient evidence to show that screening improves survival and is cost-effective. Indirect evidence suggests that patients diagnosed with cancer while undergoing surveillance endoscopy are diagnosed at an earlier stage and have an improved survival. The problems with current surveillance techniques include lack of data on natural history of Barrett's oesophagus, test invasiveness, costs, lack of standardisation and validation of biopsy and treatment protocols, and endoscopy intervals. The use of novel endoscopic techniques and biomarkers combined with better identification of high-risk groups could make screening and surveillance a cost-effective practice in the future.