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Sachdeva K, Natarajan K, Iyer PG. Improving esophageal cancer screening across the globe: Translating knowledge into action. Indian J Gastroenterol 2024:10.1007/s12664-024-01543-z. [PMID: 38848004 DOI: 10.1007/s12664-024-01543-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/26/2024] [Indexed: 08/02/2024]
Abstract
Esophageal cancer (EC) is a pressing global health concern, ranking as the eighth most common cancer and the sixth leading cause for cancer-related deaths worldwide. Esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC) are the two major histological types of esophageal cancer associated with distinct risk factors and geographical distributions. Unfortunately, the outcomes for both types of EC remain discouraging, with a five-year survival rate of less than 20% when diagnosed at advanced stages. Advanced endoscopic techniques have the potential to vastly enhance patient outcomes and impede the progression of pre-malignant lesions to cancer. However, low screening rates with endoscopy due to its invasive nature and high cost hinder its effectiveness. Despite extensive research on risk predictors, a significant number of cases still go undiagnosed, highlighting the need for improved screening techniques that can be implemented at the population level. To increase uptake, a shift towards minimally invasive, well-tolerated and cost-effective non-endoscopic technologies is crucial. The implementation of such devices in primary care settings, specifically targeting high-risk populations, can be a promising strategy. With early detection and enrollment in surveillance programs, there is hope for substantial improvement in morbidity and mortality rates through modern minimally invasive endoscopic and surgical techniques.
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Affiliation(s)
- Karan Sachdeva
- Division of Internal Medicine, Louisiana State University Health Science, Shreveport, LA, USA
| | | | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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An L, Zheng R, Zeng H, Zhang S, Chen R, Wang S, Sun K, Li L, Wei W, He J. The survival of esophageal cancer by subtype in China with comparison to the United States. Int J Cancer 2022; 152:151-161. [PMID: 35913753 DOI: 10.1002/ijc.34232] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/30/2022] [Accepted: 07/12/2022] [Indexed: 11/11/2022]
Abstract
Adenocarcinoma (AC) and squamous cell carcinoma (SCC) are the main subtypes of esophageal cancer (EC), but nationwide survival of both EC subtypes has never been reported in China. This study aimed to estimate the survival trends of EC by subtype in China and compare them with those in the USA for the same period. We used data from 64 Chinese cancer registries, which included EC patients diagnosed during 2008 and 2015 and followed up until 31st December 2017. The 5-year age-standardized relative survival by subtype, sex, age group, and urban or rural area between 2008 and 2017 were analyzed. We stratified survival estimates by calendar period (2008-09, 2010-11, 2012-14, and 2015-17). Data from the SEER 18 programme were calculated to estimate the survival of EC in the USA. A further comparison between the survivals in areas covered and not covered by population-based endoscopic screening programmes in China was conducted. A total of 129 962 records were included in the survival analyses. Results revealed that age-standardised 5-year relative survivals for AC and SCC increased in both China and USA from 2008 to 2017. In 2015-17, 5-year survival from both subtypes in China was better than the USA (SCC: 36.9% vs 18.5%, AC: 34.8% vs 22.3%). The survival for both subtypes was significantly higher in screening areas than in non-screening areas in China (SCC: 40.6% vs 32.8%; AC: 43.0% vs 31.3%). A survival gap in EC by subtype exists between China and USA. Our results may support the beneficial effect of population-based endoscopic screening for survival, and may be poised to inform national policy-making in both countries. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Lan An
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rongshou Zheng
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongmei Zeng
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siwei Zhang
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ru Chen
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shaoming Wang
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kexin Sun
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Li
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenqiang Wei
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Development and Validation of a Risk Prediction Model for Esophageal Squamous Cell Carcinoma Using Cohort Studies. Am J Gastroenterol 2021; 116:683-691. [PMID: 33982937 DOI: 10.14309/ajg.0000000000001094] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Esophageal squamous cell carcinoma (ESCC) carries a poor prognosis, but earlier tumor detection would improve survival. We aimed to develop and externally validate a risk prediction model based on exposure to readily available risk factors to identify high-risk individuals of ESCC. METHODS Competing risk regression modeling was used to develop a risk prediction model. Individuals' absolute risk of ESCC during follow-up was computed with the cumulative incidence function. We used prospectively collected data from the Nord-Trøndelag Health Study (HUNT) for model derivation and the UK Biobank cohort for validation. Candidate predictors were age, sex, tobacco smoking, alcohol consumption, body mass index (BMI), education, cohabitation, physical exercise, and employment. Model performance was validated internally and externally by evaluating model discrimination using the area under the receiver-operating characteristic curve (AUC) and model calibration. RESULTS The developed risk prediction model included age, sex, smoking, alcohol, and BMI. The AUC for 5-year risk of ESCC was 0.76 (95% confidence interval [CI], 0.58-0.93) in the derivation cohort and 0.70 (95% CI, 0.64-0.75) in the validation cohort. The calibration showed close agreement between the predicted cumulative risk and observed probabilities of developing ESCC. Higher net benefit was observed when applying the risk prediction model than considering all participants as being at high risk, indicating good clinical usefulness. A web tool for risk calculation was developed: https://sites.google.com/view/escc-ugis-ki. DISCUSSION This ESCC risk prediction model showed good discrimination and calibration and validated well in an independent cohort. This readily available model can help select high-risk individuals for preventive interventions.
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Fountoulakis A, Souglakos J, Vini L, Douridas GN, Koumarianou A, Kountourakis P, Agalianos C, Alexandrou A, Dervenis C, Gourtsoyianni S, Gouvas N, Kalogeridi MA, Levidou G, Liakakos T, Sgouros J, Sgouros SN, Triantopoulou C, Xynos E. Consensus statement of the Hellenic and Cypriot Oesophageal Cancer Study Group on the diagnosis, staging and management of oesophageal cancer. Updates Surg 2019; 71:599-624. [DOI: 10.1007/s13304-019-00696-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
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Kahn A, Crowell MD, Fleischer DE. Reducing the risk of esophageal squamous cell carcinoma: out with the old; in with the new. Gastrointest Endosc 2019; 89:733-735. [PMID: 30902201 DOI: 10.1016/j.gie.2018.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/17/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Michael D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - David E Fleischer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
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Abstract
This article reviews the pathophysiology, risk factors, clinical presentation/diagnosis, and management of SCC.
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Affiliation(s)
- Rishi Batra
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198, USA
| | - Gautam K Malhotra
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198, USA
| | - Shailender Singh
- Internal Medicine, Division of Gastroenterology-Hepatology, 982000 Nebraska Medical Center, Omaha, NE 68198-2000, USA
| | - Chandrakanth Are
- Department of Surgery, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE 68198-6880, USA.
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FOXO1 overexpression and loss of pSerine256-FOXO1 expression predicts clinical outcome in esophageal adenocarcinomas. Sci Rep 2018; 8:17370. [PMID: 30478420 PMCID: PMC6255784 DOI: 10.1038/s41598-018-35459-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 11/01/2018] [Indexed: 12/17/2022] Open
Abstract
The function of Forkhead box O 1 (FOXO1) and pSerine256-FOXO1 immunostaining in esophageal cancer is unclear. To clarify the prognostic role of nuclear FOXO1 and cytoplasmic pSerine256-FOXO1 immunostaining, a tissue microarray containing more than 600 esophageal cancers was analyzed. In non-neoplastic esophageal mucosae, FOXO1 expression was detectable in low and pSerine256-FOXO1 expression in high intensities. Increased FOXO1 and decreased pSerine256-FOXO1 expression were linked to advanced tumor stage and high UICC stage in esophageal adenocarcinomas (EACs) (tumor stage: p = 0.0209 and p < 0.0001; UICC stage: p = 0.0201 and p < 0.0001) and squamous cell carcinomas (ESCCs) (tumor stage: p = 0.0003 and p = 0.0016; UICC stage: p = 0.0026 and p = 0.0326). Additionally, overexpression of FOXO1 and loss of pSerine256-FOXO1 expression predicted shortened survival of patients with EACs (p = 0.0003 and p = 0.0133) but were unrelated to outcome in patients with ESCCs (p = 0.7785 and p = 0.8426). In summary, our study shows that overexpression of nuclear FOXO1 and loss of cytoplasmic pSerine256-FOXO1 expression are associated with poor prognosis in patients with EACs. Thus, evaluation of FOXO1 and pSerine256-FOXO1 protein expression - either alone or in combination with other markers - might be useful for prediction of clinical outcome in patients with EAC.
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Codipilly DC, Qin Y, Dawsey SM, Kisiel J, Topazian M, Ahlquist D, Iyer PG. Screening for esophageal squamous cell carcinoma: recent advances. Gastrointest Endosc 2018; 88:413-426. [PMID: 29709526 PMCID: PMC7493990 DOI: 10.1016/j.gie.2018.04.2352] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 04/20/2018] [Indexed: 02/08/2023]
Abstract
Esophageal squamous cell carcinoma (ESCC) is the most common type of esophageal cancer worldwide, with a high mortality due to advanced stage at diagnosis. Although most common in an area known as the Asian Esophageal Cancer Belt, which extends from the Caspian Sea to northern China, and in parts of Africa, high-risk populations also exist elsewhere in the world. Screening for ESCC has been practiced in a few geographic areas and high-risk populations, with varying levels of success. Esophageal squamous dysplasia is recognized as the precursor lesion for ESCC. Endoscopic screening for ESCC/esophageal squamous dysplasia is expensive and not sufficiently available in many high-risk regions. Recent advances in non-endoscopic screening enhanced by biomarker-based disease detection have raised the prospect of improved accuracy and availability of screening for esophageal squamous dysplasia and early stage ESCC. Development of a cost-effective, accurate, and well-tolerated screening test, if applied in endemic areas and high-risk populations, has the potential to reduce mortality from this deadly disease worldwide. In this review, we summarize recent developments in endoscopic and non-endoscopic screening modalities.
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Affiliation(s)
- DC Codipilly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester
| | - Y Qin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester
| | - Sanford M. Dawsey
- Division of Cancer Epidemiology and Genetics, National Cancer Institute
| | - John Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester
| | - David Ahlquist
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester
| | - PG Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester
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Bohle W, Kasper M, Zoller WG. Prognostic relevance of serial endoscopic ultrasound after chemoradiation in esophageal cancer. Dis Esophagus 2017; 30:1-8. [PMID: 28859390 DOI: 10.1093/dote/dox065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/18/2017] [Indexed: 12/11/2022]
Abstract
The objective of this study is the feasibility of sequential endoscopic and endosonographic measurement of locoregional tumor load for the prediction of tumor recurrence in patients after neoadjuvant or definitive chemoradiotherapy, treated in curative intent for locally advanced esophageal carcinoma. In 67 patients with esophageal cancer, serial endoscopic ultrasound was performed before and after neoadjuvant (25) or definitive (42) chemoradiotherapy. Rate of complete endoscopic and endosonographic tumor response, reduction in tumor length or circumferential tumorous extension, maximal tumor thickness, lymph node size, and endosonographic uT- and uN-stage shift was measured. Results were correlated with tumor recurrence rate. After chemoradiotherapy, endosonography revealed a complete response of the primary tumor in 27 patients, and complete resolution of suspicious lymph nodes in 24 patients. According to uTN-stage, 43 patients showed a therapeutic response, with stage shift to a lower tumor stage. In patients with macroscopic residual disease, mean tumor thickness decreased from 13 to 9 mm, with nine patients presenting with a decrease of >50%. Mean tumor length decreased from 5.6 to 4.6 cm, with 10 patients showing a decrease of >50%. Mean lymph node size decreased from 14.5 to 12 mm, with four patients having a reduction in size of >50%. Tumor response was generally more pronounced after definitive than after neoadjuvant chemoradiotherapy. During follow-up, 33 patients developed a tumor recurrence. None of the endoscopic and endosonographic parameter analyzed was predictive for patient's prognosis, irrespective of the kind of chemoradiotherapy (neoadjuvant or definitive). Sequential measurement of locoregional tumor load with endoscopic ultrasound before and after chemoradiotherapy is not suitable for the prediction of tumor recurrence risk.
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Bohle W, Kasper M, Zoller WG. Different accuracy of endosonographic tumor staging after neoadjuvant chemotherapy and chemoradiotherapy in esophageal cancer. Surg Endosc 2015; 30:2922-8. [PMID: 26487231 DOI: 10.1007/s00464-015-4578-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/19/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Treatment response to neoadjuvant therapy is histologically associated with more or less intensive inflammation and fibrosis. In consequence, accuracy of endosonographic TN-tumor staging after neoadjuvant treatment is hampered. We analyzed whether the kind of treatment chosen [chemoradiotherapy (CRT) or chemotherapy (CT)] differently influences the accuracy of endoscopic ultrasound after neoadjuvant therapy in esophageal cancer. METHODS We performed serial endoscopic ultrasound examinations in 18 patients after neoadjuvant CRT and 30 patients after neoadjuvant CT. TN-stage was classified according to the standard parameter. Histological examination of the surgical resection specimen served as gold standard. RESULTS The most frequent error was overstaging, especially in patients with complete tumor response or minimal residual disease. Accuracy of T-staging was significantly worse after CRT (0.16) than after CT (0.43), obviously due to difficulty in distinguishing residual tumor from treatment-associated fibrosis and inflammation. Accuracy of N-staging was also hampered, but to a less extent (sensitivity/specificity 0.85/0.36 after CRT, and 0.5/0.42 after CT). CONCLUSIONS Accuracy of endosonographic TN-tumor staging is significantly more hampered by neoadjuvant CRT than after CT. However, endoscopic ultrasound is insufficient for TN-staging irrespective of the kind of neoadjuvant therapy performed.
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Affiliation(s)
- Wolfram Bohle
- Department of Gastroenterology, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany
| | - Michaela Kasper
- Department of Gastroenterology, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany
| | - Wolfram G Zoller
- Department of Gastroenterology, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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The case for ablating nondysplastic Barrett's esophagus. Gastrointest Endosc 2014; 80:866-72. [PMID: 25436398 DOI: 10.1016/j.gie.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/03/2014] [Indexed: 02/08/2023]
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12
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The society of thoracic surgeons guidelines on the diagnosis and staging of patients with esophageal cancer. Ann Thorac Surg 2013; 96:346-56. [PMID: 23752201 DOI: 10.1016/j.athoracsur.2013.02.069] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 02/15/2013] [Accepted: 02/25/2013] [Indexed: 12/17/2022]
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Patil DT, Bennett AE, Mahajan D, Bronner MP. Distinguishing Barrett gastric foveolar dysplasia from reactive cardiac mucosa in gastroesophageal reflux disease. Hum Pathol 2013; 44:1146-53. [PMID: 23332925 DOI: 10.1016/j.humpath.2012.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 10/03/2012] [Accepted: 10/10/2012] [Indexed: 11/17/2022]
Abstract
Morphologic dysplasia remains the criterion standard of cancer risk in Barrett esophagus but poses many challenges including distinction from reactive inflammatory change. Gastric foveolar dysplasia, a newly described subtype comprising 15% to 20% of Barrett dysplasia, overlaps with reactive cardiac mucosa in gastroesophageal reflux disease (GERD). Despite the clinical importance of accurate distinction, the issue has not been studied. Review of 3698 biopsies from 461 Barrett patients yielded 160 biopsies with Barrett gastric foveolar dysplasia (74 low grade and 86 high grade). These were compared with inflamed cardia from 80 patients with GERD. Immunohistochemistry was performed for Lgl2, MUC2, MUC5AC, and MUC6. Comparing GERD with Barrett gastric foveolar dysplasia, surface nuclear stratification (85% versus 0%, P < .00001), upper mucosa-limited atypia (80% versus 0%, P < .0001), villiform architecture (52% versus 4%; P < .0001), full-thickness mucosal atypia (0% versus 100%, P < .00001), and crowded glandular architecture (0% versus 75%, P < .00001) all proved useful. Cytologic features were less helpful. Comparing low-grade gastric dysplasia alone, because its distinction from reactive cardia may be even more challenging, the listed features all remained significant. Loss or aberrant Lgl2 expression was much more typical of dysplasia (12% versus 99%; P = .0001). MUC proteins did not distinguish the groups. Surface nuclear stratification, "top-heavy" atypia, and noncrowded, villiform architecture were highly characteristic of reactive cardiac atypia in GERD, in comparison with the monolayered nuclei in crowded glands occupying the full mucosal thickness in Barrett gastric foveolar dysplasia. Loss or aberrant Lgl2 staining was useful in identifying Barrett gastric foveolar dysplasia.
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Affiliation(s)
- Deepa T Patil
- Department of Anatomic Pathology, Cleveland Clinic Foundation, 9500 Euclid Av, L-25, Cleveland, OH 44195, USA.
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Yang S, Wu S, Huang Y, Shao Y, Chen XY, Xian L, Zheng J, Wen Y, Chen X, Li H, Yang C. Screening for oesophageal cancer. Cochrane Database Syst Rev 2012; 12:CD007883. [PMID: 23235651 PMCID: PMC11091427 DOI: 10.1002/14651858.cd007883.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Oesophageal cancer is a global heath problem. The prognosis for advanced oesophageal cancer is generally unfavourable, but early-stage asymptomatic oesophageal cancer is basically curable and could achieve better survival rates. The two most commonly used tests are cytologic examination and endoscopy with mucosal iodine staining. The efficacy of the screening tests is controversial, and the true benefit and efficacy of screening remains uncertain because of the potential lead-time and length-time biases. This review was conducted to examine the evidence for the efficacy of screening for oesophageal cancer (squamous cell carcinoma and adenocarcinoma). OBJECTIVES To determine the efficacy of early screening, using endoscopy with iodine staining or cytologic examination, in reducing mortality from oesophageal cancer in asymptomatic individuals from high-risk and general populations. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 8), The Cochrane Library (2012, Issue 8), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012), Allied and Complementary Medicine (AMED) (1985 to August 2012), Chinese Biomedical Database (CBM) (January 1975 to August 2012), VIP Database (January 1989 to August 2012), China National Knowledge Infrastructure (CNKI) (January 1979 to August 2012), and the Internet. We also searched reference lists, conference proceedings, and databases of ongoing trials. There was no restriction on language or publication status in the search for trials. SELECTION CRITERIA We included only randomised controlled trials (RCT) of screening versus no screening for oesophageal cancer. Randomisation of groups or clusters of individuals was acceptable. DATA COLLECTION AND ANALYSIS Two review authors independently scanned the titles and abstracts from the initial search for potential trials for inclusion. We did not find any trials that met the inclusion criteria. MAIN RESULTS The electronic search identified 3482 studies. Two authors independently reviewed the references. The reports of 18 studies were retrieved for further investigation. None met the eligibility criteria for a RCT investigation of the effects of screening versus no screening for oesophageal cancer. AUTHORS' CONCLUSIONS There were no RCTs that determined the efficacy of screening for oesophageal cancer. Non-RCTs showed a high incidence and the reported better survival after screening could be caused by selection bias, lead-time and length-time biases. RCTs are needed to determine the efficacy of screening for oesophageal cancer.
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Affiliation(s)
- Shujuan Yang
- West China School of Public Health, Sichuan University, Chengdu, China.
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Abstract
Esophageal cancer most commonly presents with upper digestive symptoms such as dysphagia. Lymph nodes are among the most common metastatic sites of this type of cancer. We report the case of a 53-year-old man presenting with unusual sole presenting features of esophageal cancer. The patient sought medical attention for abdominal pain without dysphagia, which was first investigated with an abdominal computed tomography scan. A large abdominal mass was discovered on imaging. Biopsies of this mass were in keeping with esophageal squamous cell cancer. With this finding, gastroscopy was performed, confirming the presence of primary esophageal cancer. This is a rare presentation of esophageal cancer without upper gastrointestinal symptoms. This case reinforces the value of biopsy for any neoplastic mass, especially in a context of unusual symptoms.
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Affiliation(s)
- Katarzyna Orlicka
- Department of Gastroenterology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
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Didden P, Spaander MCW, Wijnhoven BPL, Kuipers EJ, Bruno MJ. Improving the quality of pretreatment staging in patients with esophageal carcinoma - a fast track study. Acta Oncol 2012; 51:362-7. [PMID: 22023087 DOI: 10.3109/0284186x.2011.626449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Current guidelines for esophageal cancer recommend series of diagnostic investigations to determine pretreatment TNM stage. When investigations are done sequentially, diagnostic work-up time may be prolonged considerably. Aim of the study was to determine the feasibility and efficacy of a fast track staging strategy within five days after the first consultation. MATERIAL AND METHODS Between 2007 and 2010 all patients presenting with esophageal cancer at the Department of Gastroenterology in a tertiary referral center were prospectively analyzed. At Day 1 all patients underwent computed tomography (CT), endoscopic ultrasound (EUS) and ultrasonography of the neck (US). Results and treatment implications were discussed within a multidisciplinary meeting. This fast track strategy was considered completed successfully if pre-treatment TNM classification was achieved and therapy was proposed to the patient at the outpatient clinic at Day five. In those cases where staging period time was prolonged, the number and type of additional tests were documented including the ensuing time delay. RESULTS In 111 patients CT, EUS and US were performed in 100%, 88.3% and 97.3% respectively. A final TNM stage and treatment proposal was reached at Day 5 in 60% of the patients. Additional tests were diverse and mainly used to prove local irresectabilty or presence of distant metastasis. Multivariate analysis identified presence of lymphadenopathy (HR 0.25 p = 0.03) and metastasis (HR 0.27 p = 0.03) as significant predictors of not completing the staging period within five days. In 18% of patients overuse of at least one test occurred, most commonly because CT already revealed distant metastasis. CONCLUSION Employment of a fast track five day staging strategy in patients with esophageal carcinoma is feasible. Definite TNM stage and treatment proposal can be achieved in 60% of cases, but comes at the expense of test overuse in about one fifth of patients.
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Affiliation(s)
- Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Fang D, Das KM, Cao W, Malhotra U, Triadafilopoulos G, Najarian RM, Hardie LJ, Lightdale CJ, Beales ILP, Felix VN, Schneider PM, Bellizzi AM. Barrett's esophagus: progression to adenocarcinoma and markers. Ann N Y Acad Sci 2011; 1232:210-29. [PMID: 21950815 DOI: 10.1111/j.1749-6632.2011.06053.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The following on progression to adenocarcinoma and markers of Barrett's esophagus includes commentariess on the expression of claudin 4 in Barrett's adenocarcinoma; the role of acid and bile salts; the role of insulin-like growth factor; the value of reactive oxygen species; the importance of abnormal methylation; genetic alterations in stromal cells and genomic changes in the epithelial cells; the value of confocal laser endomicroscopy for the subsurface analysis of the mucosa; indications for statins as adjuvant chemotherapeutic agent; the sequence of molecular events in malignant progression in Barrett's mucosa; and the value of the macroscopic markers and of p53 mutations.
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Affiliation(s)
- Dianchun Fang
- South West Hospital, Third Military Medical University, Chongqing, China
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Endoscopy for upper GI cancer screening in the general population: a cost-utility analysis. Gastrointest Endosc 2011; 74:610-624.e2. [PMID: 21741639 DOI: 10.1016/j.gie.2011.05.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 05/02/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Colon cancer screening with colonoscopy is an accepted strategy; however, there are limited data regarding the cost-effectiveness of screening for upper GI cancers (esophageal adenocarcinoma with its premalignant precursor Barrett's esophagus, esophageal squamous cell cancer, gastric adenocarcinoma) in the United States. OBJECTIVE To evaluate the cost-effectiveness of screening the general population for upper GI cancers by performing an upper endoscopy at the time of screening colonoscopy. DESIGN Decision analysis. SETTING Third-party-payer perspective with a time horizon of 30 years or until death. PATIENTS This study involved 50-year-old patients already undergoing screening colonoscopy. INTERVENTION Comparison of two strategies: performing and not performing a screening upper endoscopy at the time of screening colonoscopy. MAIN OUTCOME MEASUREMENTS Incremental cost-effectiveness ratio (ICER). RESULTS One-time screening for the general population at the age of 50 for upper GI cancers required $115,664 per quality-adjusted life year (QALY) compared with no screening or surveillance. A strategy of screening and surveillance for Barrett's esophagus required only $95,559 per QALY saved. In 1-way sensitivity analyses, the prevalence rates of esophageal adenocarcinoma, esophageal squamous cell cancer, or gastric adenocarcinoma would have to increase by 654%, 1948%, and 337%, respectively, to generate an ICER of less than $50,000 per QALY. LIMITATIONS Omission of premalignant conditions for squamous cell cancer and gastric adenocarcinoma. CONCLUSION The ICER for screening the general population for upper GI cancers with endoscopy remains high, despite accounting for reduced endoscopy costs and the combined benefits of detecting early esophageal adenocarcinoma, esophageal squamous cell cancer, and gastric adenocarcinoma. However, the ICER compares favorably with commonly performed screening strategies for other cancers.
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Long-term remission of nondysplastic Barrett's esophagus after multipolar electrocoagulation ablation: report of 139 patients with 10 years of follow-up. Gastrointest Endosc 2011; 73:651-8. [PMID: 21111417 DOI: 10.1016/j.gie.2010.09.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 09/21/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ablation of Barrett's esophagus (BE) has been advocated as a method to eliminate the risk of malignant transformation of BE. OBJECTIVE To provide longer follow-up and determine safety and efficacy of multipolar ablation for nondysplastic BE. DESIGN Prospective cohort study. SETTING Gastroenterology Unit at the Policlinica Metropolitana, a tertiary care center in Caracas, Venezuela. PATIENTS One hundred sixty-six patients with nondysplastic BE and histologic evidence of intestinal metaplasia. INTERVENTIONS Patients underwent multipolar electrocoagulation ablation therapy to areas of BE identified with magnification chromoendoscopy. The identified areas were treated with a 50-W energy source and a 7F "gold" probe. After complete ablation, patients were followed on an annual basis with magnification chromoendoscopy. At annual visits, biopsy specimens were taken in areas identified at baseline as BE. Targeted biopsy specimens were taken in areas of recurrent BE identified by using magnification chromoendoscopy. MAIN OUTCOME MEASUREMENTS Mortality, incidence of recurrent BE, incidence of adenocarcinoma in ablated BE, and morbidity associated with multipolar electrocoagulation. RESULTS One hundred sixty-six patients were recruited for the study; 139 completed at least 10 years of follow-up. Complications developed in less than 5% of patients, all of which were minor. Recurrent BE occurred in less than 5% of patients. No adenocarcinoma or high-grade dysplasia of the esophagus developed in any of the patients. LIMITATION Uncontrolled clinical trial. CONCLUSIONS Long-term follow-up of ablation of BE with multipolar electrocoagulation ablation therapy indicates that this is a safe, effective method to ablate BE over the long term.
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Treatment of GERD and proton pump inhibitor use in the elderly: practical approaches and frequently asked questions. Am J Gastroenterol 2011; 106:386-92. [PMID: 21378759 DOI: 10.1038/ajg.2010.409] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Katona BW, Falk GW. Barrett's esophagus surveillance: When, how often, does it work? Gastrointest Endosc Clin N Am 2011; 21:9-24. [PMID: 21112494 DOI: 10.1016/j.giec.2010.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus is a well-known risk factor for the development of esophageal adenocarcinoma. Current practice guidelines recommend endoscopic surveillance of patients with Barrett's esophagus in an attempt to detect cancer at an early and potentially curable stage. This review addresses the rationale behind surveillance and criteria for inclusion of patients in surveillance programs as well as the appropriate technique and intervals that should be used. This work addresses other key topics in Barrett's esophagus surveillance, including the efficacy of surveillance programs, physician compliance with surveillance guidelines, cost-effectiveness of surveillance programs, and areas for future research.
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Affiliation(s)
- Bryson W Katona
- Department of Internal Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 100 Centrex, Philadelphia, PA 19104, USA
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Chennat J, Ferguson MK. Endoscopic interventions in Barrett's esophagus: Do the dollars make sense? Gastrointest Endosc Clin N Am 2011; 21:145-53. [PMID: 21112504 DOI: 10.1016/j.giec.2010.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Advances in the development of endoscopic therapies for Barrett's esophagus have resulted in the emergence of an important paradigm shift for management of early neoplasia and represent an opportunity to alter the natural history of the disease. Clinical incorporation of these endoscopic modalities may have significant implications for disease management and health care delivery from a cost perspective. This article reviews the current literature on the cost analyses of commonly used Barrett endoscopic interventions and summarizes the overall cost-effectiveness of these treatments as compared with surveillance or surgery.
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Affiliation(s)
- Jennifer Chennat
- Section of Gastroenterology, Department of Medicine, Center for Endoscopic Research and Therapeutics, The University of Chicago Medical Center, 5758 South Maryland Avenue, MC 9028, Chicago, IL 60637, USA.
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Kamal A, Vaezi MF. Diagnosis and initial management of gastroesophageal complications. Best Pract Res Clin Gastroenterol 2010; 24:799-820. [PMID: 21126695 DOI: 10.1016/j.bpg.2010.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 09/21/2010] [Accepted: 09/23/2010] [Indexed: 01/31/2023]
Abstract
Chronic esophageal exposure to reflux of gastroduodenal contents can result in complications of GERD including esophageal stricture, Barrett's oesophagus or extraesophageal symptoms such as laryngitis, chronic cough or asthma. Endoscopy is the main diagnostic tool for patients with chronic reflux presenting with dysphagia to visualise esophageal mucosa and identify the underlying pathology. Barrett's oesophagus should be suspected in those with chronic reflux disease. Patients with Barrett's oesophagus should undergo surveillance endoscopy in order to risk stratify to dysplasia or adenocarcinoma. New endoscopic ablative therapies in patients with Barrett's oesophagus and high grade dysplasia are promising new treatment modality for those who may not be candidates for definitive intervention. Given poor sensitivity of diagnostic tests in extraesophageal reflux, empiric therapy with proton pump patients is the initial recommended approach. Diagnostic testing with esophagogastroduodenoscopy and ambulatory pH and impedance monitoring is usually reserved for those unresponsive to acid suppressive therapy. Many uncertainties remain in this group of patients including which patient subgroups might benefit from acid suppressive therapy. Future outcome studies are needed to assess the role of impedance/pH monitoring in this group of patients and to determine who might symptomatically benefit from medical or surgical intervention.
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Affiliation(s)
- Afrin Kamal
- Vanderbilt University Medical Center, Nashville, TN 37232, United States
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Rubenstein JH, Taylor JB. Meta-analysis: the association of oesophageal adenocarcinoma with symptoms of gastro-oesophageal reflux. Aliment Pharmacol Ther 2010; 32:1222-7. [PMID: 20955441 PMCID: PMC3481544 DOI: 10.1111/j.1365-2036.2010.04471.x] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic screening has been proposed for patients with symptoms of gastro-oesophageal reflux disease (GERD) in the hope of reducing mortality from oesophageal adenocarcinoma. Assessing the net benefits of such a strategy requires a precise understanding of the cancer risk in the screened population. AIM To estimate precisely the association between symptoms of GERD and oesophageal adenocarcinoma. METHODS Systematic review and meta-analysis of population-based studies with strict ascertainment of exposure and outcomes. RESULTS Five eligible studies were identified. At least weekly symptoms of GERD increased the odds of oesophageal adenocarcinoma fivefold (odds ratio = 4.92; 95% confidence interval = 3.90, 6.22), and daily symptoms increased the odds sevenfold (random effects summary odds ratio = 7.40, 95% confidence interval = 4.94, 11.1), each compared with individuals without symptoms or less frequent symptoms. Duration of symptoms was also associated with oesophageal adenocarcinoma, but with very heterogeneous results, and unclear thresholds. CONCLUSIONS Frequent GERD symptoms are strongly associated with oesophageal adenocarcinoma. These results should be useful in developing epidemiological models of the development of oesophageal adenocarcinoma, and in models of interventions aimed at reducing mortality from this cancer.
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Affiliation(s)
- J. H. Rubenstein
- Veterans Affairs Center of Excellence, for Clinical Management Research, Ann Arbor, MI, USA,Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - J. B. Taylor
- Multidisciplinary Clinical Research in Training Program, University of Michigan Medical School, Ann Arbor, MI, USA
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Gonzalez S, Yu WM, Smith MS, Slack KN, Rotterdam H, Abrams JA, Lightdale CJ. Randomized comparison of 3 different-sized biopsy forceps for quality of sampling in Barrett's esophagus. Gastrointest Endosc 2010; 72:935-40. [PMID: 21034895 PMCID: PMC3144471 DOI: 10.1016/j.gie.2010.07.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 07/24/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Several types of forceps are available for use in sampling Barrett's esophagus (BE). Few data exist with regard to biopsy quality for histologic assessment. OBJECTIVE To evaluate sampling quality of 3 different forceps in patients with BE. DESIGN Single-center, randomized clinical trial. PATIENTS Consecutive patients with BE undergoing upper endoscopy. INTERVENTIONS Patients randomized to have biopsy specimens taken with 1 of 3 types of forceps: standard, large capacity, or jumbo. MAIN OUTCOME MEASUREMENTS Specimen adequacy was defined a priori as a well-oriented biopsy sample 2 mm or greater in diameter and with at least muscularis mucosa present. RESULTS A total of 65 patients were enrolled and analyzed (standard forceps, n = 21; large-capacity forceps, n = 21; jumbo forceps, n = 23). Compared with jumbo forceps, a significantly higher proportion of biopsy samples with large-capacity forceps were adequate (37.8% vs 25.2%, P = .002). Of the standard forceps biopsy samples, 31.9% were adequate, which was not significantly different from specimens taken with large-capacity (P = .20) or jumbo (P = .09) forceps. Biopsy specimens taken with jumbo forceps had the largest diameter (median, 3.0 mm vs 2.5 mm [standard] vs 2.8 mm [large capacity]; P = .0001). However, jumbo forceps had the lowest proportion of specimens that were well oriented (overall P = .001). LIMITATIONS Heterogeneous patient population precluded dysplasia detection analyses. CONCLUSIONS Our results challenge the requirement of jumbo forceps and therapeutic endoscopes to properly perform the Seattle protocol. We found that standard and large-capacity forceps used with standard upper endoscopes produced biopsy samples at least as adequate as those obtained with jumbo forceps and therapeutic endoscopes in patients with BE.
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Barrett's surveillance identifies patients with early esophageal adenocarcinoma. Am J Med 2010; 123:462-7. [PMID: 20399324 DOI: 10.1016/j.amjmed.2009.10.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 09/24/2009] [Accepted: 10/13/2009] [Indexed: 12/20/2022]
Abstract
BACKGROUND Barrett's surveillance for dysplasia is recommended, but few studies have documented the benefit of endoscopic surveillance for dysplasia or cancer. OBJECTIVES Using a retrospective study design, we aim to demonstrate the impact of a Barrett's surveillance program on the stage of esophageal adenocarcinoma and identify factors for progression of metaplasia to cancer. SUBJECTS The Institutional Review Board at Veterans Affairs Connecticut Healthcare approved the study. We report a retrospective review of a prospectively followed Barrett's cohort in a surveillance program and compared their outcome with patients with a new diagnosis of esophageal adenocarcinoma, identified at the same center between 1999 and 2005. RESULTS There were 248 patients with Barrett's esophagus entered into a surveillance program from 1999 to 2005. During the surveillance period of 987 patient-years, 5 (0.5% patient-year) patients developed esophageal adenocarcinoma. During the same period, 46 patients were diagnosed with new-onset esophageal adenocarcinoma outside of our surveillance program. Only 5% of these patients had a history of gastroesophageal reflux disease. There were 248 patients who underwent a mean number of 2.7+/-1.7 upper endoscopic procedures, with 26 (10%) patients developing dysplasia. Compared with nonsurveillance, more patients had early stage of cancer in the surveillance group (P <.001). All 5 patients with cancer diagnosed from Barrett's esophagus surveillance endoscopy were alive, compared with 20 of 46 (43%) patients with cancer diagnosed outside of the surveillance program. The length of Barrett's segment >3 cm was found to be associated with development of dysplasia, P=.004 (odds ratio 1.2; 95% confidence interval, 1.07-1.34). CONCLUSION Patients with Barrett's esophagus undergoing endoscopic surveillance benefit from early-stage cancer diagnosis. Progression to adenocarcinoma is low, but long-segment and high-grade dysplasias have an increased risk of cancer. A significant number of patients with newly diagnosed esophageal adenocarcinoma do not complain of gastroesophageal reflux disease and are therefore not investigated for Barrett's esophagus nor entered into surveillance. Patients and physicians can use this information in making a decision about surveillance.
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Schmitt F, Oliveira MH. Oesophagus and gastrointestinal tract. Diagn Cytopathol 2010. [DOI: 10.1016/b978-0-7020-3154-0.00007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Dumot JA, Vargo JJ, Falk GW, Frey L, Lopez R, Rice TW. An open-label, prospective trial of cryospray ablation for Barrett's esophagus high-grade dysplasia and early esophageal cancer in high-risk patients. Gastrointest Endosc 2009; 70:635-44. [PMID: 19559428 DOI: 10.1016/j.gie.2009.02.006] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 02/01/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic ablation of Barrett's esophagus (BE) is a treatment option for patients with high-grade dysplasia (HGD) and intramucosal carcinoma (IMCA). OBJECTIVE To assess the safety and efficacy of a unique noncontact method of liquid nitrogen cryoablation as measured by histologic response rate and cancer-free survival. DESIGN Single-center, nonrandomized cohort study. SETTING Referral center, conducted between September 2005 and September 2008. PATIENTS Patients with BE and HGD or IMCA who were deemed inoperable or who refused esophagectomy. Age, length of BE, and previous ablation were not exclusion criteria. INTERVENTION Cryoablation every 6 weeks until endoscopic resolution. EMR was used for pathologic staging of nodular areas before cryoablation and focal residual areas during the follow-up period. MAIN OUTCOME MEASUREMENTS Histologic response was defined by the worst pathology obtained at any level of the esophagus or gastric cardia in 1 of 3 categories: (1) incremental = absence of HGD and IMCA in all biopsy specimens, (2) partial = residual IMCA with absence of any dysplasia, and (3) complete = absence of any intestinal metaplasia or dysplasia. RESULTS Thirty patients underwent ablation; 9 had undergone previous ablation or mucosectomy. Twenty-seven of 30 patients (90%) had downgrading of pathology stage after treatment. Elimination of cancer or downgrading of HGD at last follow-up was 68% for HGD and 80.0% for IMCA, with a median follow-up period of 12 months (25th percentile, 6; 75th percentile, 24). Minor adverse events included mild pain (n = 7), a low incidence of mild strictures (n = 3), and lip ulcer (n = 1). One major adverse event (perforation) in a patient with Marfan syndrome occurred with the prototype system. During follow-up, 3 of 6 patients with complete response had recurrence of dysplasia or cancer in the gastric cardia. LIMITATIONS A nonrandomized, single-center study with a heterogeneous cohort of patients. CONCLUSIONS Patients with BE and HGD or IMCA have a positive response to endoscopic cryotherapy at 1-year follow-up.
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Affiliation(s)
- John A Dumot
- Departments of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA.
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Bujanda L, Gil I, Sarasqueta C, Hijona E, Cosme A, Elorza JL, Asensio JI, Larburu S, Lacasta A, Arévalo S, Mínguez J. [Clinicopathological characteristics and survival outcome of esophageal cancer. Results from a series of 200 patients]. Med Clin (Barc) 2009; 133:689-93. [PMID: 19767034 DOI: 10.1016/j.medcli.2009.04.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 05/06/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The esophageal cancer (EC) is a slightly frequent but serious disease. Our aim is to describe the characteristics of the patients with EC in our Hospital. PATIENTS AND METHOD We included 200 patients consecutively diagnosed and/or treated for CE between between January, 2003 and December, 2007. The location of the tumor was analyzed, the histological type, the proofs realized for to establish the classification, the treatments, the survival and the morbi-mortality of the surgery. RESULTS The endoscopic ultrasonography (EUS) modified the therapeutic strategy in 12% of the patients. The survival to the year, 3 years and 5 years was 48%, 25% and 21%, respectively. 74 (32%) patients were operated, 48 (65%) of them was treated with neoadjuvant chemoradiotherapy. The postsurgical mortality was 8% (6 patients) and the morbidity was 57% (114 patients). In multivariate analysis, after adjustment for traditional risk factors, were the location in the average third ( [HR, hazard ratio]=2.3; confidence interval [IC] of 95%, 1.3-4.1) and not accomplishment of surgery after the chemotherapy and radiotherapy (HR=1.9; IC to 95%, 1.15-3). CONCLUSIONS The diagnosis is realized very later. The EUS has contributed a better therapeutic strategy to our patients. The mortality continues being high.
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Affiliation(s)
- Luis Bujanda
- Servicio de Digestivo, Hospital Donostia, Universidad del País Vasco, CIBEREHD, San Sebastián, Guipúzcoa, España.
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Abstract
The incidence of esophageal adenocarcinoma (EAC) has risen dramatically over the past three decades in western countries. The importance of Barrett's esophagus (BE) derives from its potential to transform to adenocarcinoma. BE is characterized by endoscopically recognized displacement of the squamocolumnar junction proximal to the gastroesophageal junction, with replacement of squamous mucosa with columnar lined mucosa. Adenocarcinomas of the esophagus appear to arise from Barrett's mucosa through progressive degrees of dysplasia, but the pathogenesis and natural history of this process are still unclear. Much of our knowledge regarding BE and the risk of EAC is based on observational and cross-sectional analyses, and recommendations regarding management have traditionally represented "expert opinion." The past few years have seen an explosion in new information and the initiation of longitudinal studies to define the risk of adenocarcinoma in BE, the identification of predictive and prognostic markers of cancer risk, sensitive and cost-effective methods of surveillance, and methods of management of dysplasia and early neoplasia including disease prevention.
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Affiliation(s)
- Robert S Bresalier
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030-4009, USA.
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Abstract
BACKGROUND It is recommended that patients in whom Barrett's esophagus is diagnosed undergo surveillance endoscopy. However, multiple issues regarding the efficacy and feasibility of surveillance remain. METHODS Quantitative techniques were used to examine surveillance in patients with Barrett's esophagus. A retrospective case-control study was performed to determine whether surveillance endoscopy prolonged survival in a cohort of U.S. veterans diagnosed with esophageal adenocarcinoma. Cost-effectiveness analysis was employed to compare competing strategies of management for patients with Barrett's esophagus to determine whether surveillance strategies using alternative biomarkers could out-perform dysplasia based surveillance, and whether new techniques for eradicating Barrett's metaplasia would constitute cost-effective strategies. RESULTS Surveillance did not improve long-term survival among veterans diagnosed with esophageal adenocarcinoma. Lead-time bias has confounded previous reports claiming the efficacy of endoscopic surveillance. Cost-effectiveness analysis revealed that while screening 50-year old Caucasian males with heartburn may be cost-effective, surveillance even at 5 year intervals among patients with Barrett's esophagus without dysplasia exceeded the threshold of cost-effective care. If a biomarker were developed whose sensitivity and specificity to predict cancer development exceeded 80%, this could represent a more viable strategy than dysplasia-based surveillance and overcome the inherent inter- and intra-observer variations in dysplasia diagnosis that currently limit the effectiveness of surveillance programs. Finally, techniques that reduce cancer incidence such as endoscopic mucosal resection or ablation will likely be more cost-effective than current surveillance strategies that rely on early detection of cancer. CONCLUSIONS Current recommendations for the management of patients with Barrett's esophagus are flawed. Future guidelines should include alternative markers of cancer risk and focus on strategies that reduce cancer incidence instead of cancer detection.
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Shaheen NJ, Palmer LB. Improving Screening Practices for Barrett's Esophagus. Surg Oncol Clin N Am 2009; 18:423-37. [DOI: 10.1016/j.soc.2009.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Inadomi JM, Somsouk M, Madanick RD, Thomas JP, Shaheen NJ. A cost-utility analysis of ablative therapy for Barrett's esophagus. Gastroenterology 2009; 136:2101-2114.e1-6. [PMID: 19272389 PMCID: PMC2693449 DOI: 10.1053/j.gastro.2009.02.062] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 02/17/2009] [Accepted: 02/20/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Recommendations for patients with Barrett's esophagus (BE) include endoscopic surveillance with esophagectomy for early-stage cancer, although new technologies to ablate dysplasia and metaplasia are available. This study compares the cost utility of ablation with that of endoscopic surveillance strategies. METHODS A decision analysis model was created to examine a population of patients with BE (mean age 50), with separate analyses for patients with no dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). Strategies compared were no endoscopic surveillance; endoscopic surveillance with ablation for incident dysplasia; immediate ablation followed by endoscopic surveillance in all patients or limited to patients in whom metaplasia persisted; and esophagectomy. Ablation modalities modeled included radiofrequency, argon plasma coagulation, multipolar electrocoagulation, and photodynamic therapy. RESULTS Endoscopic ablation for patients with HGD could increase life expectancy by 3 quality-adjusted years at an incremental cost of <$6,000 compared with no intervention. Patients with LGD or no dysplasia can also be optimally managed with ablation, but continued surveillance after eradication of metaplasia is expensive. If ablation permanently eradicates >or=28% of LGD or 40% of nondysplastic metaplasia, ablation would be preferred to surveillance. CONCLUSIONS Endoscopic ablation could be the preferred strategy for managing patients with BE with HGD. Ablation might also be preferred in subjects with LGD or no dysplasia, but the cost effectiveness depends on the long-term effectiveness of ablation and whether surveillance endoscopy can be discontinued after successful ablation. As further postablation data become available, the optimal management strategy will be clarified.
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Affiliation(s)
- John M. Inadomi
- Division of Gastroenterology, San Francisco General Hospital, San Francisco, CA, GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Ma Somsouk
- Division of Gastroenterology, San Francisco General Hospital, San Francisco, CA, GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Ryan D. Madanick
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jennifer P. Thomas
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC
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Effect of Tumor Characteristics and Duplication of the Muscularis Mucosae on the Endoscopic Staging of Superficial Barrett Esophagus-related Neoplasia. Am J Surg Pathol 2009; 33:620-5. [DOI: 10.1097/pas.0b013e31818d632f] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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The Italian validation of the Montreal Global definition and classification of gastroesophageal reflux disease. Eur J Gastroenterol Hepatol 2009; 21:394-408. [PMID: 19262401 DOI: 10.1097/meg.0b013e32830a70e2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Recently, a Global definition and a classification of gastroesophageal reflux disease (GERD) were developed by Montreal Consensus Group, composed of international expert gastroenterologists. Guidelines and consensus documents are, however, infrequently accepted and adopted at a local level. The aim of this study was to measure the acceptance of Montreal Global definition of GERD consensus document by specialists in a single country (Italy) and to measure the linguistic, scientific, and practical differences between the international consensus document and the Italian version. METHODS A 2-day meeting was held in June 2007 in Rome, Italy, attended by 147 Italian physicians who were experts in gastroenterology. They reviewed the individual original statements in their Italian translation and then voted on the statement using the scoring system used by the Montreal Consensus Group (6-point Likert scale). Voting was performed at baseline and after an analytical discussion on each statement, led by six internationally renowned experts. Consensus was defined as an agreement with a statement by at least two-thirds of the group. Results were compared with the Montreal statements. RESULTS AND DISCUSSION The level of consensus was already extremely high at the first vote (>90% with the two-thirds threshold). The level of agreement at the second vote increased slightly. The maximum variation between two votes was 33% (of increase from first to second round, 59-92%). The high level of agreement could be because of both the general acceptance of Montreal Consensus by scientific community, and the new scientific evidences published after the Montreal report, which fit with the original statements. CONCLUSION This study is the first national linguistic validation of the Montreal Global definition of GERD and is also proof of its scientific validity, based on the same methodology used to create the Montreal statements. It also suggests that evidence-based International disease classification systems can be applied to local settings after validation by local experts.
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Tomizawa Y, Wang KK. Screening, surveillance, and prevention for esophageal cancer. Gastroenterol Clin North Am 2009; 38:59-73, viii. [PMID: 19327567 PMCID: PMC3815691 DOI: 10.1016/j.gtc.2009.01.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The incidence of esophageal cancer, especially esophageal adenocarcinoma, is increasing and its high mortality rate is a notable fact. Improving survival rates of this disease depend on earlier detection through screening and surveillance; however, standard diagnostic modalities, such as endoscopy with biopsy, have several limitations as screening tools, including low negative predictive value and relatively high cost. Recently developed biomarkers such as FISH and improved imaging techniques, may help overcome current problems and provide improved screening and surveillance for esophageal cancer.
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Affiliation(s)
- Yutaka Tomizawa
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Kenneth K. Wang
- Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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Prospective comparison of the perceived preoperative computed tomographic, endosonographic and histopathological stage of oesophageal cancer related to body mass indices. Eur Radiol 2008; 19:935-40. [DOI: 10.1007/s00330-008-1208-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 07/29/2008] [Accepted: 08/24/2008] [Indexed: 01/01/2023]
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Armstrong D. Should patients with Barrett's oesophagus be kept under surveillance? The case for. Best Pract Res Clin Gastroenterol 2008; 22:721-39. [PMID: 18656826 DOI: 10.1016/j.bpg.2008.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Oesophageal adenocarcinoma is associated with high mortality rates and its incidence is increasing more rapidly than any other gastrointestinal cancer in the Western world. Several factors, including gastro-oesophageal reflux disease, smoking, alcohol and male gender, are associated with oesophageal adenocarcinoma but none can be used to identify accurately those individuals who will develop adenocarcinoma. It is generally accepted that oesophageal adenocarcinoma arises predominantly in Barrett's oesophagus and it is arguable that Barrett's oesophagus is currently the only clinically useful predictor of oesophageal adenocarcinoma. Surveillance - periodic testing to detect adenocarcinoma or its precursor, high grade dysplasia - is widely recommended for patients with Barrett's oesophagus with the aim of reducing mortality from oesophageal adenocarcinoma. The annual incidence of oesophageal adenocarcinoma in patients with Barrett's oesophagus is 0.5%-1.0% although there is marked variation between studies, attributable variously to publication bias, concurrent acid suppression therapy and differences in patient characteristics. There is limited evidence that surveillance reduces the incidence of oesophageal adenocarcinoma or consequent mortality and the cause of death for patients undergoing surveillance is often unrelated to oesophageal disease. There are, nonetheless, observational studies which suggest that surveillance is associated with earlier detection of malignancy and a reduction in mortality; in addition, data from modelling studies suggest that surveillance can be cost-effective. Furthermore, the advent of new, non-surgical treatments (endoscopic mucosal resection, photodynamic therapy, argon plasma coagulation) for high grade dysplasia and early cancer has reduced the risks associated with therapy for disease detected during surveillance. Surveillance programs have high drop out rates and, for patients who continue surveillance, adherence to standard, published protocols is highly variable. The establishment of specialist Barrett's oesophagus surveillance programs, with coordinator support, has considerable potential to improve adherence to current guidelines, pending the acquisition and publication of data from ongoing studies of chemoprophylaxis and surveillance in the management of Barrett's oesophagus. In consequence, although there is a paucity of data providing unequivocal demonstration of benefit, there is no proof that surveillance is ineffective. It is, therefore, appropriate to offer surveillance for Barrett's oesophagus in accordance with locally-applicable published guidelines after a full informed discussion of the risks and benefits of surveillance and therapy; continued participation should be reviewed regularly to accommodate changes in the patient's health and expectations.
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Affiliation(s)
- David Armstrong
- HSC-2F55, Division of Gastroenterology, McMaster University Medical Centre, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
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Seibel EJ, Carroll RE, Dominitz JA, Johnston RS, Melville CD, Lee CM, Seitz SM, Kimmey MB. Tethered capsule endoscopy, a low-cost and high-performance alternative technology for the screening of esophageal cancer and Barrett's esophagus. IEEE Trans Biomed Eng 2008; 55:1032-42. [PMID: 18334395 DOI: 10.1109/tbme.2008.915680] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Esophageal cancer is currently the fastest growing cancer in the United States. To help combat the recent rise in morbidity, our laboratory has developed a low-cost tethered capsule endoscope system (TCE) aimed at improving early detection of esophageal cancer. The TCE contains a resonant fiberoptic laser scanner (1.6 mm O.D.) which fits into 6.4-mm easy-to-swallow capsule at the distal tip. The tethered portion contains a single mode optical fiber multiplexed to three laser diodes at the proximal end. This design offers two main advantages over current endoscope technology. First, because of its small size, the TCE can be swallowed with minimal patient discomfort, thereby obviating sedation. Second, by imaging via directed laser light, the TCE is strategically positioned to employ several burgeoning laser-based diagnostic technologies, such as narrow-band, hyperspectral, and fluorescence imaging. It is believed that the combination of such imaging techniques with novel biomarkers of dysplasia will greatly assist in identifying precancerous conditions such as Barrett's esophagus (BE). As the probe is swallowed, the fiber scanner captures high resolution, wide-field color images of the gastroesophageal junction (500 lines at 0.05-mm resolution) currently at 15-Hz frame rate. Video images are recorded as the capsule is slowly retracted by its tether. Accompanying software generates panoramic images from the video output by mosaicing individual frames to aid in pattern recognition. This initial report describes the rationale for the unique TCE system design, results from preliminary testing in vitro and in vivo, and discussion on the merits of this new platform technology as a basis for developing a low-cost screening program for esophageal cancer.
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Affiliation(s)
- Eric J Seibel
- Department of Mechanical Engineering, University of Washington, Human Photonics Lab, Box 352600, Seattle, WA 98195, USA.
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Ogunwobi OO, Beales ILP. Statins inhibit proliferation and induce apoptosis in Barrett's esophageal adenocarcinoma cells. Am J Gastroenterol 2008; 103:825-37. [PMID: 18371146 DOI: 10.1111/j.1572-0241.2007.01773.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The incidence and mortality rates from esophageal adenocarcinoma (EAC) are rapidly increasing in the western world. Chemoprevention is being advocated to reduce the burden of disease. Statins are used clinically to treat hypercholesterolemia, and have an excellent safety profile. Statins reduce the intracellular availability of several biosynthetic intermediates important in intracellular signaling. We hypothesized that statins may effect EAC proliferation or apoptosis. METHODS The OE33 and BIC-1 EAC cell lines and simvastatin, lovastatin, and pravastatin were studied. Proliferation was quantified by thiazoyl blue colormetric and bromodeoxyuridine incorporation assays. Apoptosis was determined using assays for intracellular nucleosomes and caspase-3 activity. Detection of phosphorylated kinases, affinity precipitation, immunoblotting, and reverse transcriptase-polymerase chain reaction (RT-PCR) were used to determine the effects on intracellular signaling. RESULTS All three statins reduced viable cell number and inhibited proliferation in a similar dose-dependent manner. Statins induced apoptosis and enhanced the antiproliferative effect of NS-398, a selective cyclooxygenase (COX)-2 inhibitor. The effects were dependent on farnesylation, but not geranylgeranylation, of intracellular targets, and statins reduced serum-stimulated Ras activity . Simvastatin inhibited activation of extracellular signal-regulated kinase (ERK) and protein kinase B (Akt) but not c-Jun NH(2)-terminal kinase or p38 mitogen-activated protein (MAP) kinase. Statin treatment increased messenger RNA (mRNA) and protein expression of the proapoptotic proteins Bax and Bad, but protein levels of the antiapoptotic proteins B-cell lymphoma (Bcl)-2 and Bcl-X(L) were unchanged. CONCLUSIONS Statins inhibit proliferation and induce apoptosis in EAC cells via inhibition of Ras farnesylation and inhibition of the ERK and Akt signaling pathways. Statins may have some potential as chemopreventative and adjuvant chemotherapeutic agents in EAC.
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Affiliation(s)
- Olorunseun O Ogunwobi
- Biomedical Research Centre, School of Medicine, Health Policy and Practive, University of East Anglia, Norwich, United Kingdom
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Abstract
OBJECTIVE The incidence rates of oesophageal cancer vary more than those of any other cancer, world-wide. The aim of this study was to examine the epidemiological features of oesophageal cancer in the Nordic countries. MATERIAL AND METHODS Epidemiological data from the Nordic Cancer Registry (NORDCAN Database, http://www.ancr.nu/nordcan.asp) were used for the study analysis. RESULTS From 1971 to 2000 in the Nordic countries, 18,034 oesophageal cancers were detected in males and 8216 in females. In males, the incidence rates (world age standardized incidence per 100,000) of oesophageal cancer in 1971-75 and 1996-2000 were 2.7 and 6.0 in Denmark, 4.2 and 3.2 in Finland, 3.4 and 5.6 in Iceland, 2.6 and 3.3 in Norway, and 2.9 and 3.3 in Sweden, respectively. In females, the corresponding figures were: Denmark 1.1 and 1.8, Finland 3.1 and 1.3, Iceland 2.5 and 1.3, Norway 0.7 and 0.9, and Sweden 1.1 and 1.0. Each Nordic country showed a significant geographical variation in the incidence of oesophageal cancer. In both males and females the incidence curves began rising after 40 years of age, but significantly more steeply in males than in females. Over the study period, oesophageal cancer mortality increased from 2.97 to 3.68 per 100,000 in males but decreased from 1.30 to 1.08 in females. The incidence rates of oesophageal adenocarcinoma increased in males in all Nordic countries, and the increase was most marked in Denmark. The incidence of oesophageal adenocarcinoma also increased among Danish females, but compared with males, the incidence rate remained significantly lower. CONCLUSIONS The time trends in incidence of oesophageal cancer differ between the Nordic countries, and there has also been geographical variation within them. On a global comparison, the incidence rates of oesophageal cancer are low in the Nordic region. Oesophageal cancer is a male-predominant disease in all Nordic countries, and the incidence rates of oesophageal adenocarcinoma have increased in males and Danish females.
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Affiliation(s)
- Markku Voutilainen
- Department of Internal Medicine, Jyväskylä Central Hospital, Keskussairaalantie 19, FIN-40620 Jyväskylä, Finland.
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Lee TY, Lien HC, Chang CS, Wen MC. Barrett's esophagus and severe reflux esophagitis share common pathophysiological characteristics among Chinese in Taiwan. Intern Med 2008; 47:1767-73. [PMID: 18854627 DOI: 10.2169/internalmedicine.47.1381] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The pathophysiological data on Barrett's esophagus are scant in Asia, so the purpose of this study was to compare and analyze the pathophysiological characteristics of Barrett's esophagus and reflux esophagitis among Chinese in Taiwan. PATIENTS AND METHODS From November 2001 to January 2003, fifteen patients with Barrett's esophagus were consecutively enrolled as the Barrett's esophagus group. Fourteen patients with Los Angeles grade A/B esophagitis (mild esophagitis group) and fourteen patients with LA grade C/D esophagitis (severe esophagitis group) who were matched in age and gender with the Barrett's esophagus group were enrolled. The data of esophageal manometry and ambulatory 24-hour pH monitoring were collected. RESULTS We found that the Barrett's esophagus group had significantly weaker lower esophageal sphincter (LES) pressure and distal esophageal body contractions (p<0.05) than the mild esophagitis group. Both the Barrett's esophagus group and severe esophagitis group had significantly higher esophageal acid reflux scores and frequency (p<0.05-0.01) compared to the mild esophagitis group. However, data on esophageal manometry and 24-hour pH monitoring in the Barrett's esophagus and severe esophagitis groups did not significantly differ. CONCLUSION We concluded that Barrett's esophagus had significantly stronger acid reflux, lower LES pressure, and weaker distal esophageal peristalsis compared to mild esophagitis. Barrett's esophagus and severe reflux esophagitis share common pathophysiological characteristics among Chinese in Taiwan.
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Affiliation(s)
- Teng-Yu Lee
- Department of Internal Medicine, Division of Gastroenterology, Taichung Veterans General Hospital, Taichung, Taiwan
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Ponce M, Garrigues V, Ortiz V, Ponce J. Trastornos de la deglución: un reto para el gastroenterólogo. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:487-97. [DOI: 10.1157/13110504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Mino-Kenudson M, Hull MJ, Brown I, Muzikansky A, Srivastava A, Glickman J, Park DY, Zuckerberg L, Misdraji J, Odze RD, Lauwers GY. EMR for Barrett's esophagus-related superficial neoplasms offers better diagnostic reproducibility than mucosal biopsy. Gastrointest Endosc 2007; 66:660-6; quiz 767, 769. [PMID: 17905005 DOI: 10.1016/j.gie.2007.02.063] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Accepted: 02/19/2007] [Indexed: 12/25/2022]
Abstract
BACKGROUND EMR of Barrett's esophagus (BE)-related superficial neoplasms represents an efficacious staging modality. It also allows for better pathologic grading compared with mucosal biopsy specimens. However, the interobserver variation in the interpretation of EMR specimens has not been tested. OBJECTIVE To evaluate consistency in the diagnosis of BE-related neoplasia on EMR specimens. DESIGN Nine pathologists reviewed 25 esophageal EMR specimens and corresponding biopsy specimens independently. Each pathologist classified the cases as either non-neoplastic BE, low-grade dysplasia, high-grade dysplasia, intramucosal adenocarcinoma, or invasive adenocarcinoma. Interobserver concordance for both specimens from EMRs and biopsies was measured by intraclass correlation and Kendall's coefficient of concordance. The proportion of agreement was also calculated for each specimen and compared for EMR and biopsy by using the Wilcoxon signed rank test. SETTING Teaching hospitals. PATIENTS Twenty-five patients who underwent EMR for BE-related neoplasia. RESULTS The intraclass correlation and the Kendall's coefficient for the 25 biopsy specimens was 0.938 (95% CI 0.880-0.965) and 0.677, respectively; for the 25 EMRs, these were significantly improved, at 0.977 (95% CI 0.957-0.987) and 0.831, respectively. In addition, the proportion of agreement for EMR specimens was significantly better compared with biopsy specimens (P = .015). CONCLUSIONS Interobserver agreement of BE-related neoplasia on EMR specimens is significantly higher compared with biopsy specimens. The results may relate to the larger tissue sampling compared with biopsy specimens and the ability to evaluate mucosal landmarks, such as double muscularis mucosae. Thus, we suggest that EMRs, in addition to being a staging and therapeutic procedure, improve diagnostic consistency.
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Affiliation(s)
- Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
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Beales ILP, Ogunwobi O, Cameron E, El-Amin K, Mutungi G, Wilkinson M. Activation of Akt is increased in the dysplasia-carcinoma sequence in Barrett's oesophagus and contributes to increased proliferation and inhibition of apoptosis: a histopathological and functional study. BMC Cancer 2007; 7:97. [PMID: 17559672 PMCID: PMC1899509 DOI: 10.1186/1471-2407-7-97] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 06/08/2007] [Indexed: 01/01/2023] Open
Abstract
Background The incidence of oesophageal adenocarcinoma is increasing rapidly in the developed world. The serine-threonine protein kinase and proto-oncogene Akt has been reported to regulate proliferation and apoptosis in several tissues but there are no data on the involvement of Akt in oesophageal carcinogenesis. Therefore we have examined the activation of Akt in Barrett's oesophagus and oesophageal adenocarcinoma and the functional effects of Akt activation in vitro. Methods Expression of total and active (phosphorylated) Akt were determined in endoscopic biopsies and surgical resection specimens using immunohistochemistry. The functional effects of Akt were examined using Barrett's adenocarcinoma cells in culture. Results In normal squamous oesophagus, erosive oesophagitis and non-dysplastic Barrett's oesophagus, phospho-Akt was limited to the basal 1/3 of the mucosa. Image analysis confirmed that Akt activation was significantly increased in non-dysplastic Barrett's oesophagus compared to squamous epithelium and further significantly increased in high-grade dysplasia and adenocarcinoma. In all cases of high grade dysplasia and adenocarcinoma Akt was activated in the luminal 1/3 of the epithelium. Transient acid exposure and the obesity hormone leptin activated Akt, stimulated proliferation and inhibited apoptosis: the combination of acid and leptin was synergistic. Inhibition of Akt phosphorylation with LY294002 increased apoptosis and blocked the effects of acid and leptin both alone and in combination. Activation of Akt was associated with downstream phosphorylation and deactivation of the pro-apoptotic protein Bad and phosphorylation of the Forkhead family transcription factor FOXO1. Conclusion Akt is abnormally activated in Barrett's oesophagus, high grade dysplasia and adenocarcinoma. Akt activation promotes proliferation and inhibits apoptosis in Barrett's adenocarcinoma cells and both transient acid exposure and leptin stimulate Akt phosphorylation. Downstream targets of Akt include Bad and Forkhead transcription factors. Activation of Akt in obesity and by reflux of gastric acid may be important in the pathogenesis of Barrett's adenocarcinoma
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Affiliation(s)
- Ian LP Beales
- Gastroenterology Unit, Norfolk and Norwich University Hospital, Norwich, NR4 7UZ, UK
- Department of Cell Biology and Physiology, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Olorunseun Ogunwobi
- Department of Cell Biology and Physiology, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Ewen Cameron
- Gastroenterology Unit, Norfolk and Norwich University Hospital, Norwich, NR4 7UZ, UK
| | - Khalid El-Amin
- Gastroenterology Unit, Norfolk and Norwich University Hospital, Norwich, NR4 7UZ, UK
| | - Gabriel Mutungi
- Department of Cell Biology and Physiology, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Mark Wilkinson
- Department of Histopathology, Norfolk and Norwich University Hospital, Norwich, NR4 7UZ, UK
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Lu F, Chen H, Zhou C, Liu S, Guo M, Chen P, Zhuang H, Xie D, Wu S. T-type Ca2+ channel expression in human esophageal carcinomas: a functional role in proliferation. Cell Calcium 2007; 43:49-58. [PMID: 17532042 PMCID: PMC2692709 DOI: 10.1016/j.ceca.2007.03.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 03/19/2007] [Accepted: 03/28/2007] [Indexed: 11/29/2022]
Abstract
In the present study the role of T-type Ca(2+) channels in cancer cell proliferation was examined. Seventeen human esophageal cancer cell lines were screened for T-type channels using RT-PCR and voltage-clamp recordings. mRNAs for all three T-type channel alpha(1)-subunits (alpha(1G), alpha(1H), and alpha(1I)) were detected in all 17 cell lines: either alpha(1H) alone, alpha(1H) and alpha(1G), or all three T-type alpha(1)-subunits. Eleven cell lines were further subjected to voltage-clamp recordings: one, i.e. the TE8 cell line, was found to exhibit a typical T-type current while others exhibited a minimal or no T-type current. Cell proliferation assays were performed in the presence or absence of T-type channel blocker mibefradil in KYSE150, KYSE180 and TE1 cells expressing mRNA for T-type channel alpha(1)-subunits but lacking T-type current, and TE8 cells exhibiting T-type current. Only TE8 cell proliferation was reduced by mibefradil. Silencing the alpha(1G)-gene that encodes functional T-type Ca(2+) channels in TE8 cells with type-specific shRNA transduction also significantly decreased TE8 cell proliferation. The reduction of cell proliferation in TE8 cells was found to be associated with an up-regulation of p21(CIP1). Moreover, p53 silencing nearly abolished the up-regulation of p21(CIP1) resulting from mibefradil T-type channel blockade. Together, these findings suggest a functional role of T-type channels in certain esophageal carcinomas, and that inhibition of T-type channels reduces cell proliferation via a p53-dependent p21(CIP1) pathway.
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Affiliation(s)
- Fengmin Lu
- Department of Microbiology, Peking University Health Science Center, Beijing 100083, China
| | - Hairu Chen
- Center for Lung Biology and Department of Pharmacology, The University of South Alabama College of Medicine, Mobile, Alabama 36688, U.S.A
| | - Chun Zhou
- Center for Lung Biology and Department of Pharmacology, The University of South Alabama College of Medicine, Mobile, Alabama 36688, U.S.A
| | - Shuang Liu
- Otsuka Beijing Research Institute, Beijing 100738, China
| | - Mingzhou Guo
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland 21231, U.S.A
| | | | - Hui Zhuang
- Department of Microbiology, Peking University Health Science Center, Beijing 100083, China
| | | | - Songwei Wu
- Center for Lung Biology and Department of Pharmacology, The University of South Alabama College of Medicine, Mobile, Alabama 36688, U.S.A
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Abstract
The key clinical management points in this article are that (i) endoscopic ultrasound is the most accurate imaging method for local staging of oesophageal, gastric and pancreatic neoplasms; (ii) addition of fine-needle aspiration biopsy to the technique is safe and well tolerated and increases diagnostic accuracy for nodal staging purposes; and (iii) endoscopic ultrasound +/- fine-needle aspiration has the capacity to influence significantly, the management of patients with malignancies of the upper gastrointestinal tract, particularly with respect to selection for surgery. The learning objectives were that at the end of this paper the reader should be able to (i) understand the usefulness and limitations of various imaging methods in the staging of upper gastrointestinal cancers; and (ii) incorporate the various imaging methods, particularly endoscopic ultrasound, into management algorithms for oesophageal cancer, gastric cancer, mucosa-associated lymphoid tissue lymphomas, gastrointestinal stromal tumours, pancreatic cystic lesions and pancreatic cancer.
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Affiliation(s)
- D Brian Jones
- Department of Gastroenterology, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia.
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Carneiro F, Chaves P. Pathologic Risk Factors of Adenocarcinoma of the Gastric Cardia and Gastroesophageal Junction. Surg Oncol Clin N Am 2006; 15:697-714. [PMID: 17030268 DOI: 10.1016/j.soc.2006.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Available evidence supports the existence of two major pathways of neoplastic development in the gastroesophageal region: the Barrett pathway, related to gastroesophageal reflux disease, and the gastric pathway, related to Helicobacter pylori infection. The existence of an independent junctional pathway is questionable, and gastroesophageal junction adenocarcinomas share features of esophageal and gastric adenocarcinomas. It has been impossible to accommodate all data that are provided by different levels and tools of observation in tumors that develop in the gastroesophageal region in a single, coherent classification. That is why the stratification of pathologic risk in such tumors, and their respective precursors, incorporates features from topography, histology, immunohistochemistry, and molecular pathology.
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Affiliation(s)
- Fátima Carneiro
- Medical Faculty of the University of Porto and Hospital S.João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.
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Brankley SM, Wang KK, Harwood AR, Miller DV, Legator MS, Lutzke LS, Kipp BR, Morrison LE, Halling KC. The development of a fluorescence in situ hybridization assay for the detection of dysplasia and adenocarcinoma in Barrett's esophagus. J Mol Diagn 2006; 8:260-7. [PMID: 16645214 PMCID: PMC1867582 DOI: 10.2353/jmoldx.2006.050118] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The goal of this study was to identify a set of fluorescence in situ hybridization probes for the detection of dysplasia and adenocarcinoma in patients with Barrett's esophagus. We examined 170 brushing specimens from 138 patients with Barrett's esophagus or a history of Barrett's esophagus using fluorescence in situ hybridization with probes to 5p15, 5q21-22, centromere 7, 7p12, 8q24.12-13, centromere 9, 9p21, centromere 17, 17p13.1, 17q11.2-12, 20q13.2, and centromere Y. Receiver-operator curves were used to determine the sensitivity and specificity of various four-probe combinations for detecting low-grade dysplasia, high-grade dysplasia, and esophageal adenocarcinoma. Endoscopic biopsy results were used as the gold standard. Numerous four-probe combinations provided a similarly high sensitivity and specificity. Of these, a set consisting of probes to 8q24, 9p21, 17q11.2, and 20q13.2 was found to have a sensitivity and specificity, respectively, of 70% and 89% for low-grade dysplasia, 84% and 93% for high-grade dysplasia, and 94% and 93% for esophageal adenocarcinoma. This probe set was chosen for future prospective clinical evaluations based on its high sensitivity and specificity, its ability to distinguish adenocarcinoma and high-grade or low-grade dysplasia from lesser diagnostic categories, and the favorable signal quality for each of the probes.
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Affiliation(s)
- Shannon M Brankley
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Foundation, Rochester, MN 55902, USA
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Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101:1900-20; quiz 1943. [PMID: 16928254 DOI: 10.1111/j.1572-0241.2006.00630.x] [Citation(s) in RCA: 2252] [Impact Index Per Article: 125.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES A globally acceptable definition and classification of gastroesophageal reflux disease (GERD) is desirable for research and clinical practice. The aim of this initiative was to develop a consensus definition and classification that would be useful for patients, physicians, and regulatory agencies. METHODS A modified Delphi process was employed to reach consensus using repeated iterative voting. A series of statements was developed by a working group of five experts after a systematic review of the literature in three databases (Embase, Cochrane trials register, Medline). Over a period of 2 yr, the statements were developed, modified, and approved through four rounds of voting. The voting group consisted of 44 experts from 18 countries. The final vote was conducted on a 6-point scale and consensus was defined a priori as agreement by two-thirds of the participants. RESULTS The level of agreement strengthened throughout the process with two-thirds of the participants agreeing with 86%, 88%, 94%, and 100% of statements at each vote, respectively. At the final vote, 94% of the final 51 statements were approved by 90% of the Consensus Group, and 90% of statements were accepted with strong agreement or minor reservation. GERD was defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The disease was subclassified into esophageal and extraesophageal syndromes. Novel aspects of the new definition include a patient-centered approach that is independent of endoscopic findings, subclassification of the disease into discrete syndromes, and the recognition of laryngitis, cough, asthma, and dental erosions as possible GERD syndromes. It also proposes a new definition for suspected and proven Barrett's esophagus. CONCLUSIONS Evidence-based global consensus definitions are possible despite differences in terminology and language, prevalence, and manifestations of the disease in different countries. A global consensus definition for GERD may simplify disease management, allow collaborative research, and make studies more generalizable, assisting patients, physicians, and regulatory agencies.
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Affiliation(s)
- Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53233, USA
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