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Rubenstein JH, Sawas T, Wani S, Eluri S, Singh S, Chandar AK, Perumpail RB, Inadomi JM, Thrift AP, Piscoya A, Sultan S, Singh S, Katzka D, Davitkov P. AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia. Gastroenterology 2024; 166:1020-1055. [PMID: 38763697 PMCID: PMC11345740 DOI: 10.1053/j.gastro.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia. METHODS The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics. CONCLUSIONS This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.
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Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Tarek Sawas
- Division of Digestive and Liver Disease, University of Texas Southwestern, Dallas, Texas
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida
| | - Shailendra Singh
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia; Advanced Center for Endoscopy, West Virginia University Medicine, Morgantown, West Virginia
| | - Apoorva K Chandar
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - John M Inadomi
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - David Katzka
- Division of Gastroenterology and Hepatology, Columbia University, New York, New York
| | - Perica Davitkov
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Division of Gastroenterology, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio
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High rate of missed Barrett's esophagus when screening with forceps biopsies. Esophagus 2023; 20:143-149. [PMID: 35864425 PMCID: PMC9813185 DOI: 10.1007/s10388-022-00943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Screening for Barrett's esophagus (BE) with endoscopy plus forceps biopsy (FB) has poor compliance with the recommended Seattle protocol and fails to sample large areas of mucosa. This statistical modeling study estimates, for the first time, the actual frequency of missed BE cases by FB. METHODS Published, calibrated models in the literature were combined to calculate the age-specific prevalence of BE in white males with gastroesophageal reflux disease (GERD). We started with estimates of the prevalence of BE and GERD, and applied the relative risk for BE in patients with GERD based on the literature. This created estimates of the true prevalence of BE in white males with GERD by decade of life. The proportion of BE missed was calculated as the difference between the prevalence and the proportion with a positive screen. RESULTS The prevalence of BE in white males with GERD was 8.9%, 12.1%, 15.3%, 18.7% and 22.0% for the third through eighth decades of life. Even after assuming no false positives, missed cases of BE were about 50% when estimated for patients of ages 50 or 60 years, and over 60% for ages of 30, 40 or 70 years. Sensitivity analysis was done for all variables in the model calculations. For ages 50 and 60 years, this resulted in values from 30.3 to 57.3% and 36.4 to 60.9%. CONCLUSION Screening for BE with endoscopy and FB misses approximately 50% of BE cases. More sensitive methods of BE detection or better adherence to the Seattle protocol are needed.
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Yang X, Shen Z, Tian M, Lin Y, Li L, Chai T, Zhang P, Kang M, Lin J. LncRNA C9orf139 can regulate the progression of esophageal squamous carcinoma by mediating the miR-661/HDAC11 axis. Transl Oncol 2022; 24:101487. [PMID: 35917643 PMCID: PMC9352544 DOI: 10.1016/j.tranon.2022.101487] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/04/2022] [Accepted: 07/09/2022] [Indexed: 12/03/2022] Open
Abstract
LncRNA C9orf139 was highly expressed in ESCC. LncRNA C9orf139 could negatively regulate miR-661 expression. HDAC11 expression was negatively regulated by miR-661. LncRNA C9orf139 regulates the progression of ESCC through the miR-661/HDAC11 axis.
Increasing evidence has indicated that long non-coding RNAs (LncRNAs) play multiple functions in the development of cancer and function as indicators of diagnosis and prognosis. This aim of this study was to investigate the roles LncRNA C9orF139 had in the progression of esophageal squamous carcinoma (ESCC). We found C9orf139 was highly expressed in ESCC and knock down the expression of C9orf139 significantly suppressed cell proliferation, promoted apoptosis, and inhibited migration and invasion. C9orf139 was able to negatively regulate miR-661 expression. At the same time, HDAC11 expression was negatively regulated by miR-661. The C9orf139/miR-661/HDAC11 axis was further involved in regulating the expression of the NF-κB signaling pathway. The association between the C9orf139 knockdown and the reduced tumor growth and size was observed during in vivo study. C9orf139 is highly expressed in ESCC, and is thus qualified to be used as a potential diagnostic and prognostic marker for ESCC. Its promotion of ESCC progression is achieved by mediating the miR-661/HDAC11 axis.
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Affiliation(s)
- Xiaojie Yang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Zhimin Shen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Mengyue Tian
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Yukang Lin
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Liming Li
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Tianci Chai
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China; Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Peipei Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Mingqiang Kang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China.
| | - Jiangbo Lin
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China.
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Rubenstein JH, Omidvari AH, Lauren BN, Hazelton WD, Lim F, Tan SX, Kong CY, Lee M, Ali A, Hur C, Inadomi JM, Luebeck G, Lansdorp-Vogelaar I. Endoscopic Screening Program for Control of Esophageal Adenocarcinoma in Varied Populations: A Comparative Cost-Effectiveness Analysis. Gastroenterology 2022; 163:163-173. [PMID: 35364064 DOI: 10.1053/j.gastro.2022.03.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/23/2022] [Accepted: 03/22/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Guidelines suggest endoscopic screening for esophageal adenocarcinoma (EAC) among individuals with symptoms of gastroesophageal reflux disease (GERD) and additional risk factors. We aimed to determine at what age to perform screening and whether sex and race should influence the decision. METHODS We conducted comparative cost-effectiveness analyses using 3 independent simulation models. For each combination of sex and race (White/Black, 100,000 individuals each), we considered 41 screening strategies, including one-time or repeated screening. The optimal strategy was that with the highest effectiveness and an incremental cost-effectiveness ratio <$100,000 per quality-adjusted life-year gained. RESULTS Among White men, 536 EAC deaths were projected without screening, and screening individuals with GERD twice at ages 45 and 60 years was optimal. Screening the entire White male population once at age 55 years was optimal in 26% of probabilistic sensitivity analysis runs. Black men had fewer EAC deaths without screening (n = 84), and screening those with GERD once at age 55 years was optimal. Although White women had slightly more EAC deaths (n = 103) than Black men, the optimal strategy was no screening, although screening those with GERD once at age 55 years was optimal in 29% of probabilistic sensitivity analysis runs. Black women had a very low burden of EAC deaths (n = 29), and no screening was optimal, as benefits were very small and some strategies caused net harm. CONCLUSIONS The optimal strategy for screening differs by race and sex. White men with GERD symptoms can potentially be screened more intensely than is recommended currently. Screening women is not cost-effective and may cause net harm for Black women.
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Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Epidemiology and Prevention Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Amir-Houshang Omidvari
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Brianna N Lauren
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - William D Hazelton
- Computational Biology Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Francesca Lim
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sarah Xinhui Tan
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chung Yin Kong
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Minyi Lee
- Gastrointestinal Unit, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts; The Graduate Program in Bioinformatics, Boston University, Boston, Massachusetts
| | - Ayman Ali
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - John M Inadomi
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Georg Luebeck
- Computational Biology Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Pilonis ND, Killcoyne S, Tan WK, O'Donovan M, Malhotra S, Tripathi M, Miremadi A, Debiram-Beecham I, Evans T, Phillips R, Morris DL, Vickery C, Harrison J, di Pietro M, Ortiz-Fernandez-Sordo J, Haidry R, Kerridge A, Sasieni PD, Fitzgerald RC. Use of a Cytosponge biomarker panel to prioritise endoscopic Barrett's oesophagus surveillance: a cross-sectional study followed by a real-world prospective pilot. Lancet Oncol 2022; 23:270-278. [PMID: 35030332 PMCID: PMC8803607 DOI: 10.1016/s1470-2045(21)00667-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Endoscopic surveillance is recommended for patients with Barrett's oesophagus because, although the progression risk is low, endoscopic intervention is highly effective for high-grade dysplasia and cancer. However, repeated endoscopy has associated harms and access has been limited during the COVID-19 pandemic. We aimed to evaluate the role of a non-endoscopic device (Cytosponge) coupled with laboratory biomarkers and clinical factors to prioritise endoscopy for Barrett's oesophagus. METHODS We first conducted a retrospective, multicentre, cross-sectional study in patients older than 18 years who were having endoscopic surveillance for Barrett's oesophagus (with intestinal metaplasia confirmed by TFF3 and a minimum Barrett's segment length of 1 cm [circumferential or tongues by the Prague C and M criteria]). All patients had received the Cytosponge and confirmatory endoscopy during the BEST2 (ISRCTN12730505) and BEST3 (ISRCTN68382401) clinical trials, from July 7, 2011, to April 1, 2019 (UK Clinical Research Network Study Portfolio 9461). Participants were divided into training (n=557) and validation (n=334) cohorts to identify optimal risk groups. The biomarkers evaluated were overexpression of p53, cellular atypia, and 17 clinical demographic variables. Endoscopic biopsy diagnosis of high-grade dysplasia or cancer was the primary endpoint. Clinical feasibility of a decision tree for Cytosponge triage was evaluated in a real-world prospective cohort from Aug 27, 2020 (DELTA; ISRCTN91655550; n=223), in response to COVID-19 and the need to provide an alternative to endoscopic surveillance. FINDINGS The prevalence of high-grade dysplasia or cancer determined by the current gold standard of endoscopic biopsy was 17% (92 of 557 patients) in the training cohort and 10% (35 of 344) in the validation cohort. From the new biomarker analysis, three risk groups were identified: high risk, defined as atypia or p53 overexpression or both on Cytosponge; moderate risk, defined by the presence of a clinical risk factor (age, sex, and segment length); and low risk, defined as Cytosponge-negative and no clinical risk factors. The risk of high-grade dysplasia or intramucosal cancer in the high-risk group was 52% (68 of 132 patients) in the training cohort and 41% (31 of 75) in the validation cohort, compared with 2% (five of 210) and 1% (two of 185) in the low-risk group, respectively. In the real-world setting, Cytosponge results prospectively identified 39 (17%) of 223 patients as high risk (atypia or p53 overexpression, or both) requiring endoscopy, among whom the positive predictive value was 31% (12 of 39 patients) for high-grade dysplasia or intramucosal cancer and 44% (17 of 39) for any grade of dysplasia. INTERPRETATION Cytosponge atypia, p53 overexpression, and clinical risk factors (age, sex, and segment length) could be used to prioritise patients for endoscopy. Further investigation could validate their use in clinical practice and lead to a substantial reduction in endoscopy procedures compared with current surveillance pathways. FUNDING Medical Research Council, Cancer Research UK, Innovate UK.
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Affiliation(s)
| | - Sarah Killcoyne
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK
| | - W Keith Tan
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK
| | - Maria O'Donovan
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK; Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - Shalini Malhotra
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK; Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - Monika Tripathi
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK; Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - Ahmad Miremadi
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK; Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - Irene Debiram-Beecham
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK
| | - Tara Evans
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK
| | - Rosemary Phillips
- Department of Gastroenterology, Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Danielle L Morris
- Department of Gastroenterology, East and North Herts NHS Trust, Stevenage, UK
| | - Craig Vickery
- Department of Surgery, West Suffolk Hospital, Bury St Edmunds, UK
| | - Jon Harrison
- Department of Gastroenterology, Harrogate District Hospital, Harrogate, UK
| | | | - Jacobo Ortiz-Fernandez-Sordo
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Rehan Haidry
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Abigail Kerridge
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK
| | - Peter D Sasieni
- Cancer Prevention Group in Clinical Trials Unit, King's Clinical Trials Unit, King's College London, London, UK
| | - Rebecca C Fitzgerald
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK.
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Maslyonkina KS, Konyukova AK, Alexeeva DY, Sinelnikov MY, Mikhaleva LM. Barrett's esophagus: The pathomorphological and molecular genetic keystones of neoplastic progression. Cancer Med 2022; 11:447-478. [PMID: 34870375 PMCID: PMC8729054 DOI: 10.1002/cam4.4447] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/07/2021] [Accepted: 11/09/2021] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus is a widespread chronically progressing disease of heterogeneous nature. A life threatening complication of this condition is neoplastic transformation, which is often overlooked due to lack of standardized approaches in diagnosis, preventative measures and treatment. In this essay, we aim to stratify existing data to show specific associations between neoplastic transformation and the underlying processes which predate cancerous transition. We discuss pathomorphological, genetic, epigenetic, molecular and immunohistochemical methods related to neoplasia detection on the basis of Barrett's esophagus. Our review sheds light on pathways of such neoplastic progression in the distal esophagus, providing valuable insight into progression assessment, preventative targets and treatment modalities. Our results suggest that molecular, genetic and epigenetic alterations in the esophagus arise earlier than cancerous transformation, meaning the discussed targets can help form preventative strategies in at-risk patient groups.
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Chen S, Ju G, Gu J, Shi M, Wang Y, Wu X, Wang Q, Zheng L, Xiao T, Fan Y. Competing endogenous RNA network for esophageal cancer progression. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1473. [PMID: 34734025 PMCID: PMC8506737 DOI: 10.21037/atm-21-4478] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/18/2021] [Indexed: 11/27/2022]
Abstract
Background Esophageal cancer (ESCA) constitutes one of the most common cancers worldwide. The identification of potential biomarkers is important to improving the diagnostic accuracy and treatment efficiency for patients with ESCA. In this study, we aimed to identify biomarkers related to ESCA progression through a comprehensive analysis of long non-coding RNAs (lncRNAs), microRNA (miRNAs), and mRNA expression profiles in ESCA. Methods Differentially expressed lncRNAs, miRNAs, and mRNAs (DElncRNAs, DEmiRNAs, and DEmRNAs, respectively) in ESCA samples compared with normal controls were obtained. A competing endogenous RNA (ceRNA) network consisting of interacting DElncRNAs, DEmiRNAs, and DEmRNAs was constructed using a combination of the miRCode and TargetScan databases. Relationships between RNAs in the ceRNA network and overall survival in patients with EC were explored through another independent ESCA dataset from The Cancer Genome Atlas. Results A total of 1,014 DElncRNAs, 3,677 DEmRNAs, and 35 DEmiRNAs were identified in ESCA samples compared with normal samples. Functional enrichment analysis indicated that the DEmRNAs were involved in cell activity, inflammatory response, and oxygen metabolism-related biological processes. A ceRNA network containing 5 DEmiRNAs, 582 DEmRNAs and 764 DElncRNAs was obtained. In the survival analysis, 39 genes were found to be significantly associated with overall survival in patients with EC, including GOLGA7, NFYB, TOP1, and TMTC3. Conclusions Our study constructed a ceRNA network for ESCA for the first time, which will be helpful for the disease’s diagnosis and treatment.
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Affiliation(s)
- Saihua Chen
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Guanjun Ju
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Jianmei Gu
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Minxin Shi
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Yilang Wang
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Xiaodan Wu
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Qing Wang
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Liyun Zheng
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Ting Xiao
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Yihui Fan
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Nantong University & Nantong Tumor Hospital, Nantong, China
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Norita K, Koike T, Saito M, Shinkai H, Ami R, Abe Y, Dairaku N, Inomata Y, Kayaba S, Ishiyama F, Oikawa T, Ohyauchi M, Ito H, Asonuma S, Hoshi T, Kato K, Ohara S, Shimodaira Y, Watanabe K, Shimosegawa T, Masamune A, Iijima K. Long-term endoscopic surveillance for Barrett's esophagus in Japan: Multicenter prospective cohort study. Dig Endosc 2021; 33:1085-1092. [PMID: 33277694 DOI: 10.1111/den.13910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023]
Abstract
OBJECTS Although a recent study showed the cancer incidence of Barrett's esophagus (BE) to be 1.2%/year in 251 patient-years in Japan, the long-term outcomes remain unclear. The present study estimated the cancer risk of BE in Japan using our original prospective multicenter cohort. METHODS A total of 98 patients with BE of maximum length of ≥2 cm were enrolled during the period of 2010-2012 and received at least one follow-up endoscopy over 5 years thereafter. Cancer incidence rates with 95% confidence interval for occurrence of esophageal adenocarcinoma (EAC) were calculated as the number of events divided by patient-years of follow-up and were expressed as %/year. RESULTS Overall, the median endoscopic follow-up period was 59.9 (first and third quartiles, 48.5-60.8) months, constituting a total of 427 patient-years of observation. Since two EAC cases developed, the cancer incidence was 0.47% (0.01%-1.81%)/year. The cancer incidence was 0.39% (-0.16% to 2.44%) in 232 patient-years and 0.31% (-0.13% to 1.95%)/year in 318 patient-years for 55 cases with specialized intestinal metaplasia and 70 with BE ≥3 cm (maximum), respectively. At the end of follow-up, 12 of 92 patients (13.0%) died, but none died from EAC. CONCLUSION This is the largest prospective follow-up study with endoscopy to investigate the incidence of EAC in unequivocal BE with the maximum length of ≥2 cm in Japan. Although a further large-scale study will be required to validate our results, the cancer risk of BE in Japan would be lower than previously reported (0.47% vs 1.2%/year).
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Affiliation(s)
- Kazuaki Norita
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Hirohiko Shinkai
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Reiko Ami
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yasuhiko Abe
- Department of Gastroenterology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Naohiro Dairaku
- Department of Gastroenterology, Iwaki Kyoritsu General Hospital, Fukushima, Japan
| | | | - Shoichi Kayaba
- Department of Gastroenterology, Iwate Prefectural Isawa Hospital, Iwate, Japan
| | - Fumitake Ishiyama
- Department of Gastroenterology, Iwate Prefectural Isawa Hospital, Iwate, Japan
| | - Tomoyuki Oikawa
- Department of Gastroenterology, Hachinohe City Hospital, Aomori, Japan
| | - Motoki Ohyauchi
- Department of Gastroenterology, Osaki Citizen Hospital, Miyagi, Japan
| | - Hirotaka Ito
- Department of Gastroenterology, Osaki Citizen Hospital, Miyagi, Japan
| | - Sho Asonuma
- Department of Gastroenterology, South Miyagi Medical Center, Miyagi, Japan
| | - Tatsuya Hoshi
- Department of Gastroenterology, Kesennuma City Hospital, Miyagi, Japan
| | - Katsuaki Kato
- Cancer Detection Center, Miyagi Cancer Society, Miyagi, Japan
| | - Shuichi Ohara
- Department of Gastroenterology, Tohoku Rosai Hospital, Miyagi, Japan
| | - Yosuke Shimodaira
- Department of Gastroenterology, Akita University School of Medicine, Akita, Japan
| | - Kenta Watanabe
- Department of Gastroenterology, Akita University School of Medicine, Akita, Japan
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan.,Department of Gastroenterology, South Miyagi Medical Center, Miyagi, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University School of Medicine, Akita, Japan
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9
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Salimian KJ, Birkness-Gartman J, Waters KM. The path(ology) from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. Pathology 2021; 54:147-156. [PMID: 34711413 DOI: 10.1016/j.pathol.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
This review seeks to summarise the steps in the path from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. The epidemiology, clinical presentation, definitions, pathological features, diagnostic pitfalls, and emerging concepts are reviewed for each entity. The histological features of reflux oesophagitis can be variable and are not specific. Cases of reflux oesophagitis with numerous eosinophils are difficult to distinguish from eosinophilic oesophagitis and other oesophagitides with eosinophils (Crohn's disease, medication effect, and connective tissue disorders). In reflux oesophagitis, the findings are often most pronounced in the distal oesophagus, the eosinophils are randomly distributed throughout the epithelium, and eosinophilic abscesses and degranulated eosinophils are rare. For reflux oesophagitis with prominent lymphocytes, clinical history and ancillary clinical studies are paramount to distinguish reflux oesophagitis from other causes of lymphocytic oesophagitis pattern. For Barrett oesophagus, the definition remains a hotly debated topic for which the requirement for intestinal metaplasia to make the diagnosis is not applied unanimously across the globe. Assessing for dysplasia is a challenging aspect of the histological interpretation that guides clinical management. We describe the histological features that we find useful in making this evaluation. Oesophageal adenocarcinoma has been steadily increasing in incidence and has a poor prognosis. The extent of invasion can be overdiagnosed due to a duplicated muscularis mucosae. We also describe the technical factors that can lead to challenges in distinguishing the mucosal and deep margins of endoscopic resections. Lastly, we give an overview of targeted therapies with emerging importance and the ancillary tests that can identify the cases best suited for each therapy.
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Affiliation(s)
- Kevan J Salimian
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Kevin M Waters
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA.
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10
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Guccione C, Yadlapati R, Shah S, Knight R, Curtius K. Challenges in Determining the Role of Microbiome Evolution in Barrett's Esophagus and Progression to Esophageal Adenocarcinoma. Microorganisms 2021; 9:2003. [PMID: 34683324 PMCID: PMC8541168 DOI: 10.3390/microorganisms9102003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 01/22/2023] Open
Abstract
Esophageal adenocarcinoma (EAC) claims the lives of half of patients within the first year of diagnosis, and its incidence has rapidly increased since the 1970s despite extensive research into etiological factors. The changes in the microbiome within the distal esophagus in modern populations may help explain the growth in cases that other common EAC risk factors together cannot fully explain. The precursor to EAC is Barrett's esophagus (BE), a metaplasia adapted to a reflux-mediated microenvironment that can be challenging to diagnose in patients who do not undergo endoscopic screening. Non-invasive procedures to detect microbial communities in saliva, oral swabs and brushings from the distal esophagus allow us to characterize taxonomic differences in bacterial population abundances within patients with BE versus controls, and may provide an alternative means of BE detection. Unique microbial communities have been identified across healthy esophagus, BE, and various stages of progression to EAC, but studies determining dynamic changes in these communities, including migration from proximal stomach and oral cavity niches, and their potential causal role in cancer formation are lacking. Helicobacter pylori is negatively associated with EAC, and the absence of this species has been implicated in the evolution of chromosomal instability, a main driver of EAC, but joint analyses of microbiome and host genomes are needed. Acknowledging technical challenges, future studies on the prediction of microbial dynamics and evolution within BE and the progression to EAC will require larger esophageal microbiome datasets, improved bioinformatics pipelines, and specialized mathematical models for analysis.
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Affiliation(s)
- Caitlin Guccione
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA;
- Bioinformatics and Systems Biology Program, University of California San Diego, La Jolla, CA 92093, USA;
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093, USA
| | - Rena Yadlapati
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA; (R.Y.); (S.S.)
| | - Shailja Shah
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA; (R.Y.); (S.S.)
- Veterans Affairs, San Diego Healthcare System, San Diego, CA 92161, USA
| | - Rob Knight
- Bioinformatics and Systems Biology Program, University of California San Diego, La Jolla, CA 92093, USA;
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093, USA
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Center for Microbiome Innovation, University of California San Diego, La Jolla, CA 92093, USA
- Department of Computer Science and Engineering, University of California San Diego, La Jolla, CA 92093, USA
| | - Kit Curtius
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA;
- Bioinformatics and Systems Biology Program, University of California San Diego, La Jolla, CA 92093, USA;
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11
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Zagari RM, Eusebi LH, Galloro G, Rabitti S, Neri M, Pasquale L, Bazzoli F. Attending Training Courses on Barrett's Esophagus Improves Adherence to Guidelines: A Survey from the Italian Society of Digestive Endoscopy. Dig Dis Sci 2021; 66:2888-2896. [PMID: 32984930 PMCID: PMC8379114 DOI: 10.1007/s10620-020-06615-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little is known on practice patterns of endoscopists for the management of Barrett's esophagus (BE) over the last decade. AIMS Our aim was to assess practice patterns of endoscopists for the diagnosis, surveillance and treatment of BE. METHODS All members of the Italian Society of Digestive Endoscopy (SIED) were invited to participate to a questionnaire-based survey. The questionnaire included questions on demographic and professional characteristics, and on diagnosis and management strategies for BE. RESULTS Of the 883 SIED members, 259 (31.1%) completed the questionnaire. Of these, 73% were males, 42.9% had > 50 years of age and 68.7% practiced in community hospitals. The majority (82.9%) of participants stated to use the Prague classification; however 34.5% did not use the top of gastric folds to identify the gastro-esophageal junction (GEJ); only 51.4% used advanced endoscopy imaging routinely. Almost all respondents practiced endoscopic surveillance for non-dysplastic BE, but 43.7% performed eradication in selected cases and 30% practiced surveillance every 1-2 years. The majority of endoscopists managed low-grade dysplasia with surveillance (79.1%) and high-grade dysplasia with ablation (77.1%). Attending a training course on BE in the previous 5 years was significantly associated with the use of the Prague classification (OR 4.8, 95% CI 1.9-12.1), the top of gastric folds as landmark for the GEJ (OR 2.45, 95% CI 1.27-4.74) and advanced imaging endoscopic techniques (OR 3.33, 95% CI 1.53-7.29). CONCLUSIONS Practice patterns for management of BE among endoscopists are variable. Attending training courses on BE improves adherence to guidelines.
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Affiliation(s)
- Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy.
| | - Leonardo Henry Eusebi
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy
| | - Giuseppe Galloro
- Surgical Digestive Endoscopy, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Stefano Rabitti
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy
| | - Matteo Neri
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Luigi Pasquale
- Gastroenterology Unit, San Giuseppe Moscati Hospital, Ariano Irpino, Avellino, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy
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12
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Omidvari AH, Hazelton WD, Lauren BN, Naber SK, Lee M, Ali A, Seguin C, Kong CY, Richmond E, Rubenstein JH, Luebeck GE, Inadomi JM, Hur C, Lansdorp-Vogelaar I. The Optimal Age to Stop Endoscopic Surveillance of Patients With Barrett's Esophagus Based on Sex and Comorbidity: A Comparative Cost-Effectiveness Analysis. Gastroenterology 2021; 161:487-494.e4. [PMID: 33974935 PMCID: PMC8495224 DOI: 10.1053/j.gastro.2021.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 04/15/2021] [Accepted: 05/01/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Current guidelines recommend surveillance for patients with nondysplastic Barrett's esophagus (NDBE) but do not include a recommended age for discontinuing surveillance. This study aimed to determine the optimal age for last surveillance of NDBE patients stratified by sex and level of comorbidity. METHODS We used 3 independently developed models to simulate patients diagnosed with NDBE, varying in age, sex, and comorbidity level (no, mild, moderate, and severe). All patients had received regular surveillance until their current age. We calculated incremental costs and quality-adjusted life-years (QALYs) gained from 1 additional endoscopic surveillance at the current age versus not performing surveillance at that age. We determined the optimal age to end surveillance as the age at which incremental cost-effectiveness ratio of 1 more surveillance was just less than the willingness-to-pay threshold of $100,000/QALY. RESULTS The benefit of having 1 more surveillance endoscopy strongly depended on age, sex, and comorbidity. For men with NDBE and severe comorbidity, 1 additional surveillance at age 80 years provided 4 more QALYs per 1000 patients with BE at an additional cost of $1.2 million, whereas for women with severe comorbidity the benefit at that age was 7 QALYs at a cost of $1.3 million. For men with no, mild, moderate, and severe comorbidity, the optimal ages of last surveillance were 81, 80, 77, and 73 years, respectively. For women, these ages were younger: 75, 73, 73, and 69 years, respectively. CONCLUSIONS Our comparative modeling analysis illustrates the importance of considering comorbidity status and sex when deciding on the age to discontinue surveillance in patients with NDBE.
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Affiliation(s)
- Amir-Houshang Omidvari
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands.
| | - William D. Hazelton
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Steffie K. Naber
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - Minyi Lee
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Ayman Ali
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Claudia Seguin
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chun Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Ellen Richmond
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
| | - Joel H. Rubenstein
- Barrett’s Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan,Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Georg E. Luebeck
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John M. Inadomi
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chin Hur
- Department of Medicine, Columbia University, New York, New York
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, The Netherlands
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13
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Vissapragada R, Bulamu NB, Brumfitt C, Karnon J, Yazbeck R, Watson DI. Improving cost-effectiveness of endoscopic surveillance for Barrett's esophagus by reducing low-value care: a review of economic evaluations. Surg Endosc 2021; 35:5905-5917. [PMID: 34312726 DOI: 10.1007/s00464-021-08646-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Individuals with Barrett's esophagus are believed to be at 30-120× risk of developing esophageal adenocarcinoma (EAC). Early detection and endoscopic treatment of dysplasia/early cancer confers a significant advantage to patients under surveillance; however, most do not progress past the non-dysplastic state of Barrett's esophagus (NDBE), which is potentially an inefficient distribution of health care resources. OBJECTIVES This article aimed to review the outcomes of cost-effectiveness studies reducing low-value care in the context of endoscopic surveillance for non-dysplastic Barrett's esophagus (NDBE). METHODS A systematic search was conducted by two reviewers in accordance with PRISMA guidelines. INCLUSION CRITERIA cost-utility analyses of endoscopic surveillance of NDBE patients with at least one treatment strategy focused on reduction of surveillance. A narrative synthesis of economic evaluations was undertaken, along with an in-depth analysis of input parameters contributing to stated Incremental cost-effectiveness ratios (ICER). Study appraisal was performed using the consolidated health economic evaluation reporting standards (CHEERS) tool. RESULTS 10 Studies met inclusion criteria. There was significant variation in cost-model structures, input parameters, ICER values, and willingness-to-pay thresholds between studies. All studies except one concluded guideline-specified endoscopic surveillance for NDBE patients was not cost-effective. Studies that explored a modified surveillance by deselection of low-risk NDBE patients found it to be a cost-effective strategy. CONCLUSION Guideline specified endoscopic surveillance for NDBE was not found to be cost-effective in the studies examined. A modified endoscopic surveillance strategy removing individuals with the lowest risk for progression from NDBE to adenocarcinoma is likely to be cost-effective but is dependent on risk profile of patients excluded from surveillance.
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Affiliation(s)
- Ravi Vissapragada
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia.,Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia.,Department of Surgery, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia
| | - Norma B Bulamu
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia.,Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia
| | - Christine Brumfitt
- Department of Surgery, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia
| | - Jonathan Karnon
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia
| | - Roger Yazbeck
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia.,Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia
| | - David I Watson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia. .,Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia. .,Department of Surgery, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia.
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14
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Omidvari AH, Lansdorp-Vogelaar I, de Koning HJ, Meester RGS. Impact of assumptions on future costs, disutility and mortality in cost-effectiveness analysis; a model exploration. PLoS One 2021; 16:e0253893. [PMID: 34252090 PMCID: PMC8274850 DOI: 10.1371/journal.pone.0253893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 06/16/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION In cost-effectiveness analyses, the future costs, disutility and mortality from alternative causes of morbidity are often not completely taken into account. We explored the impact of different assumed values for each of these factors on the cost-effectiveness of screening for colorectal cancer (CRC) and esophageal adenocarcinoma (EAC). METHODS Twenty different CRC screening strategies and two EAC screening strategies were evaluated using microsimulation. Average health-related expenses, disutility and mortality by age for the U.S. general population were estimated using surveys and lifetables. First, we evaluated strategies under default assumptions, with average mortality, and no accounting for health-related costs and disutility. Then, we varied costs, disutility and mortality between 100% and 150% of the estimated population averages, with 125% as the best estimate. Primary outcome was the incremental cost per quality-adjusted life-year (QALY) gained among efficient strategies. RESULTS The set of efficient strategies was robust to assumptions on future costs, disutility and mortality from other causes of morbidity. However, the incremental cost per QALY gained increased with higher assumed values. For example, for CRC, the ratio for the recommended strategy increased from $15,600 with default assumptions, to $32,600 with average assumption levels, $61,100 with 25% increased levels, and $111,100 with 50% increased levels. Similarly, for EAC, the incremental costs per QALY gained for the recommended EAC screening strategy increased from $106,300 with default assumptions to $198,300 with 50% increased assumptions. In sensitivity analyses without discounting or including only above-average expenses, the impact of assumptions was relatively smaller, but best estimates of the cost per QALY gained remained substantially higher than default estimates. CONCLUSIONS Assumptions on future costs, utility and mortality from other causes of morbidity substantially impact cost-effectiveness outcomes of cancer screening. More empiric evidence and consensus are needed to guide assumptions in future analyses.
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Affiliation(s)
- Amir-Houshang Omidvari
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry J. de Koning
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Reinier G. S. Meester
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- * E-mail:
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15
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Ekeke CN, Chan EG, Fabian T, Villa-Sanchez M, Luketich JD. Recommendations for Surveillance and Management of Recurrent Esophageal Cancer Following Endoscopic Therapies. Surg Clin North Am 2021; 101:415-426. [PMID: 34048762 DOI: 10.1016/j.suc.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
With advancing endoscopic technology and screening protocols for Barrett disease, more patients are being diagnosed with early-stage esophageal cancer. These early-stage patients may be amendable to endoscopic therapies, such as endomucosal resection and ablation. These therapies may minimize morbidity, but the elevated risk of recurrence cannot be overlooked. This article reports outcomes and recommendations for surveillance and management of recurrent esophageal cancer following endoscopic therapies.
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Affiliation(s)
- Chigozirim N Ekeke
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - Thomas Fabian
- Department of Surgery, Section of Thoracic Surgery, Albany Medical Center, 43 New Scotland Avenue, MC-50, R-113, Albany, NY 12208, USA
| | - Manuel Villa-Sanchez
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C816, Pittsburgh, PA 15213, USA.
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16
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Risk of Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus in Patients With Achalasia: A Long-Term Prospective Cohort Study in Italy. Am J Gastroenterol 2021; 116:289-295. [PMID: 33009050 DOI: 10.14309/ajg.0000000000000955] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/24/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Epidemiological studies assessing relative risk and incidence rate of esophageal cancer in patients with achalasia are scarce. We performed a long-term prospective cohort study to evaluate the risk of both squamous cell carcinoma and adenocarcinoma of the esophagus in these patients. METHODS Between 1973 and 2018, patients with primary achalasia were followed by the same protocol including upper endoscopy with esophageal biopsies. Standardized incidence ratios (SIRs) with 95% confidence interval (CI) were used to estimate the relative risk of esophageal cancer in patients with achalasia compared with the sex- and age-matched general population. RESULTS A cohort of 566 patients with achalasia (46% men, mean age at diagnosis: 48.1 years) was followed for a mean of 15.5 years since the diagnosis of achalasia. Overall, 20 patients (15 men) developed esophageal cancer: 15 squamous cell carcinoma and 5 adenocarcinoma. The risk of esophageal cancer was significantly greater than the general population (SIR 104.2, 95% CI 63.7-161), and this for both squamous cell carcinoma (SIR 126.9, 95% CI 71.0-209.3) and adenocarcinoma (SIR 110.2, 95% CI 35.8-257.2). The excess risk was higher in men than women. Annual incidence rate of esophageal cancer was only 0.24% and was higher for squamous cell carcinoma (0.18%) than adenocarcinoma (0.06%). DISCUSSION Patients with achalasia have an excess risk of developing both squamous cell carcinoma and adenocarcinoma of the esophagus; however, this prospective cohort study confirms that the annual incidence of esophageal cancer is rather low. These findings may have implications for endoscopic surveillance of patients with achalasia.
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17
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Andalib A, Bouchard P, Demyttenaere S, Ferri LE, Court O. Esophageal cancer after sleeve gastrectomy: a population-based comparative cohort study. Surg Obes Relat Dis 2020; 17:879-887. [PMID: 33547014 DOI: 10.1016/j.soard.2020.12.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most common bariatric surgery; however, this approach may induce gastroesophageal reflux disease (GERD). Both obesity and GERD are independent risk factors for esophageal cancer, however the impact of SG on risk of esophageal cancer remains unknown. OBJECTIVE To evaluate the risk of esophageal cancer after reflux-prone bariatric surgery. SETTING Population-level, provincial administrative healthcare database, Quebec, Canada. METHODS We identified a population-based cohort of all patients with obesity who underwent reflux-prone surgery (SG and duodenal switch [DS]) or reflux-protective Roux-en-Y gastric bypass (RYGB) during 01/2006-12/2012 in Quebec, Canada. For every surgical patient, 2-3 nonsurgical controls with obesity matched for age, sex, and geography were also identified. Crude incidence rate ratios (IRRs) for esophageal cancer were calculated using person-time analysis. Hazard ratios (HRs) were obtained using multivariate cox regression. RESULTS A total of 4121 patients had reflux-prone procedures and 852 underwent RYGB. At a mean follow-up of 7.6 years, 8 cases of esophageal cancer were identified after bariatric surgery. Compared with RYGB, IRR for esophageal cancer in reflux-prone group was 1.45 (95%CI: .19-65.5) and HR = .83 (95%CI: .10-7.27). The crude incidence rate of esophageal cancer in the reflux-prone group was higher than that of nonsurgical controls (n = 12,159; IRR = 3.46, 95%CI: 1.00-12.5), but after adjustment the difference disappeared (HR = 2.47, 95%CI: .82-7.45). CONCLUSIONS Long-term incidence of esophageal cancer after reflux-prone bariatric surgery is not greater than RYGB. While crude incidence of esophageal cancer after reflux-prone surgery is higher than in nonsurgical patients with obesity, such difference disappears after accounting for confounders. Given the low incidence of esophageal cancer and slow progression of dysplastic Barrett esophagus, studies with longer follow-up are needed.
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Affiliation(s)
- Amin Andalib
- Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, Canada.
| | - Philippe Bouchard
- Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, Canada
| | - Sebastian Demyttenaere
- Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, Canada
| | - Lorenzo E Ferri
- Division of Thoracic Surgery, Department of Surgery, McGill University, Montreal, Canada
| | - Olivier Court
- Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, Canada
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18
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Curtius K, Rubenstein JH, Chak A, Inadomi JM. Computational modelling suggests that Barrett's oesophagus may be the precursor of all oesophageal adenocarcinomas. Gut 2020; 70:gutjnl-2020-321598. [PMID: 33234525 PMCID: PMC8292551 DOI: 10.1136/gutjnl-2020-321598] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Barrett's oesophagus (BE) is a known precursor to oesophageal adenocarcinoma (OAC) but current clinical data have not been consolidated to address whether BE is the origin of all incident OAC, which would reinforce evidence for BE screening efforts. We aimed to answer whether all expected prevalent BE, diagnosed and undiagnosed, could account for all incident OACs in the US cancer registry data. DESIGN We used a multiscale computational model of OAC that includes the evolutionary process from normal oesophagus through BE in individuals from the US population. The model was previously calibrated to fit Surveillance, Epidemiology and End Results cancer incidence curves. Here, we also utilised age-specific and sex-specific US census data for numbers at-risk. The primary outcome for model validation was the expected number of OAC cases for a given calendar year. Secondary outcomes included the comparisons of resulting model-predicted prevalence of BE and BE-to-OAC progression to the observed prevalence and progression rates. RESULTS The model estimated the total number of OAC cases from BE in 2010 was 9970 (95% CI: 9140 to 11 980), which recapitulates nearly all OAC cases from population data. The model simultaneously predicted 8%-9% BE prevalence in high-risk males age 45-55, and 0.1%-0.2% non-dysplastic BE-to-OAC annual progression in males, consistent with clinical studies. CONCLUSION There are likely few additional OAC cases arising in the US population outside those expected from individuals with BE. Effective screening of high-risk patients could capture the majority of population destined for OAC progression and potentially decrease mortality through early detection and curative removal of small (pre)cancers during surveillance.
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Affiliation(s)
- Kit Curtius
- Centre for Genomics and Computational Biology, Barts Cancer Institute, School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Joel H Rubenstein
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - John M Inadomi
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Martinho MS, Nancarrow DJ, Lawrence TS, Beer DG, Ray D. Chaperones and Ubiquitin Ligases Balance Mutant p53 Protein Stability in Esophageal and Other Digestive Cancers. Cell Mol Gastroenterol Hepatol 2020; 11:449-464. [PMID: 33130332 PMCID: PMC7788241 DOI: 10.1016/j.jcmgh.2020.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/07/2020] [Accepted: 10/14/2020] [Indexed: 02/07/2023]
Abstract
The incidence of esophageal adenocarcinoma (EAC) and other gastrointestinal (GI) cancers have risen dramatically, thus defining the oncogenic drivers to develop effective therapies are necessary. Patients with Barrett's Esophagus (BE), have an elevated risk of developing EAC. Around 70%-80% of BE cases that progress to dysplasia and cancer have detectable TP53 mutations. Similarly, in other GI cancers higher rates of TP53 mutation are reported, which provide a significant survival advantage to dysplastic/cancer cells. Targeting molecular chaperones that mediate mutant p53 stability may effectively induce mutant p53 degradation and improve cancer outcomes. Statins can achieve this via disrupting the interaction between mutant p53 and the chaperone DNAJA1, promoting CHIP-mediated degradation of mutant p53, and statins are reported to significantly reduce the risk of BE progression to EAC. However, statins demonstrated sub-optimal efficacy depending on cancer types and TP53 mutation specificity. Besides the well-established role of MDM2 in p53 stability, we reported that individual isoforms of the E3 ubiquitin ligase GRAIL (RNF128) are critical, tissue-specific regulators of mutant p53 stability in BE progression to EAC, and targeting the interaction of mutant p53 with these isoforms may help mitigate EAC development. In this review, we discuss the critical ubiquitin-proteasome and chaperone regulation of mutant p53 stability in EAC and other GI cancers with future insights as to how to affect mutant p53 stability, further noting how the precise p53 mutation may influence the efficacy of treatment strategies and identifying necessary directions for further research in this field.
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Affiliation(s)
- May San Martinho
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Derek J Nancarrow
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - David G Beer
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Dipankar Ray
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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Amano Y, Ishimura N, Ishihara S. Is Malignant Potential of Barrett's Esophagus Predictable by Endoscopy Findings? Life (Basel) 2020; 10:E244. [PMID: 33081277 PMCID: PMC7602941 DOI: 10.3390/life10100244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/01/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
Given that endoscopic findings can be used to predict the potential of neoplastic progression in Barrett's esophagus (BE) cases, the detection rate of dysplastic Barrett's lesions may become higher even in laborious endoscopic surveillance because a special attention is consequently paid. However, endoscopic findings for effective detection of the risk of neoplastic progression to esophageal adenocarcinoma (EAC) have not been confirmed, though some typical appearances are suggestive. In the present review, endoscopic findings that can be used predict malignant potential to EAC in BE cases are discussed. Conventional results obtained with white light endoscopy, such as length of BE, presence of esophagitis, ulceration, hiatal hernia, and nodularity, are used as indicators of a higher risk of neoplastic progression. However, there are controversies in some of those findings. Absence of palisade vessels may be also a new candidate predictor, as that reveals degree of intense inflammation and of cyclooxygenase-2 protein expression with accelerated cellular proliferation. Furthermore, an open type of mucosal pattern and enriched stromal blood vessels, which can be observed by image-enhanced endoscopy, including narrow band imaging, have been confirmed as factors useful for prediction of neoplastic progression of BE because they indicate more frequent cyclooxygenase-2 protein expression along with accelerated cellular proliferation. Should the malignant potential of BE be shown predictable by these endoscopic findings, that would simplify methods used for an effective surveillance, because patients requiring careful monitoring would be more easily identified. Development in the near future of a comprehensive scoring system for BE based on clinical factors, biomarkers and endoscopic predictors is required.
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Affiliation(s)
- Yuji Amano
- Department of Endoscopy, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan
| | - Norihisa Ishimura
- Department of Internal Medicine II, Faculty of Medicine, Shimane University, Shimane 693-8501, Japan; (N.I.); (S.I.)
| | - Shunji Ishihara
- Department of Internal Medicine II, Faculty of Medicine, Shimane University, Shimane 693-8501, Japan; (N.I.); (S.I.)
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Chronic High-Fat Diet Induces Early Barrett's Esophagus in Mice through Lipidome Remodeling. Biomolecules 2020; 10:biom10050776. [PMID: 32429496 PMCID: PMC7277507 DOI: 10.3390/biom10050776] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/07/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022] Open
Abstract
Esophageal adenocarcinoma (EAC) incidence has been rapidly increasing, potentially associated with the prevalence of the risk factors gastroesophageal reflux disease (GERD), obesity, high-fat diet (HFD), and the precursor condition Barrett’s esophagus (BE). EAC development occurs over several years, with stepwise changes of the squamous esophageal epithelium, through cardiac metaplasia, to BE, and then EAC. To establish the roles of GERD and HFD in initiating BE, we developed a dietary intervention model in C57/BL6 mice using experimental HFD and GERD (0.2% deoxycholic acid, DCA, in drinking water), and then analyzed the gastroesophageal junction tissue lipidome and microbiome to reveal potential mechanisms. Chronic (9 months) HFD alone induced esophageal inflammation and metaplasia, the first steps in BE/EAC pathogenesis. While 0.2% deoxycholic acid (DCA) alone had no effect on esophageal morphology, it synergized with HFD to increase inflammation severity and metaplasia length, potentially via increased microbiome diversity. Furthermore, we identify a tissue lipid signature for inflammation and metaplasia, which is characterized by elevated very-long-chain ceramides and reduced lysophospholipids. In summary, we report a non-transgenic mouse model, and a tissue lipid signature for early BE. Validation of the lipid signature in human patient cohorts could pave the way for specific dietary strategies to reduce the risk of BE in high-risk individuals.
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Amano Y, Nakahara R, Yuki T, Murakami D, Ujihara T, Tomoyuki I, Sagami R, Suehiro S, Katsuyama Y, Hayasaka K, Harada H, Tada Y, Miyaoka Y, Fujishiro H. Relationship between Barrett's esophagus and colonic diseases: a role for colonoscopy in Barrett's surveillance. J Gastroenterol 2019; 54:984-993. [PMID: 31240437 DOI: 10.1007/s00535-019-01600-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/18/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Given that risk factors for Barrett's carcinogenesis are predictive, appropriate management and surveillance of Barrett's esophagus (BE) may be provided. The presence of colorectal neoplasms (CRNs) is a possible predictor of the development of BE and the progression to esophageal adenocarcinoma (EAC). We evaluated the relationship between BE or EAC and colonic diseases, including neoplasms and diverticulosis. METHODS Patients (N = 5606) who underwent both colonoscopy and esophagogastroduodenoscopy between January 2016 and December 2017 at three institutions were enrolled. The relationships between the presence of colonic diseases and BE or EAC and other clinical or endoscopic predictors of the presence of BE were investigated retrospectively. RESULTS The prevalence of BE ≥ 1 cm and ≥ 3 cm in length was 13.0% and 0.52%, respectively. BE was closely related with the presence of colorectal adenoma (48.4% vs. 37.2% in non-BE; P < 0.001), adenocarcinoma (16.6% vs. 8.4%, P < 0.001) and colonic diverticulosis (CD) (34.1% vs. 29.3%, P < 0.001). In patients with long-segment BE, CRNs (79.3%, P < 0.001) and CD (48.2%, P = 0.038) were more common. EAC patients also had a statistically significantly higher incidence of CRNs than non-BE patients (87.5% vs. 45.6%, P = 0.027). Diverticulosis at the distal colon correlated significantly with EAC and BE (50.0%, P = 0.010 and 15.4%, P = 0.024, vs. 12.0% in non-BE). Multivariate analysis showed that CRNs (t = 8.55, P < 0.001), reflux esophagitis (t = 5.26, P < 0.001) and hiatal hernia (t = 11.68, P < 0.001) were predictors of BE. CONCLUSIONS The presence of CRNs was strongly associated with BE and EAC. Therefore, colonoscopy may be useful for establishing a strategy for the surveillance of BE.
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Affiliation(s)
- Yuji Amano
- Department of Endoscopy, New Tokyo Hospital, 1271 Wanagaya, Matsudo, 270-2232, Chiba, Japan.
| | - Ryotaro Nakahara
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Takafumi Yuki
- Department of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan
| | - Daisuke Murakami
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Tetsuro Ujihara
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Iwaki Tomoyuki
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Ryota Sagami
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Satoshi Suehiro
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Yasushi Katsuyama
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Kenji Hayasaka
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Hideaki Harada
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Yasumasa Tada
- Department of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan
| | - Youichi Miyaoka
- Department of Endoscopy, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Hirofumi Fujishiro
- Department of Gastroenterology, Shimane Prefectural Central Hospital, Izumo, Japan
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Mukaisho KI, Kanai S, Kushima R, Nakayama T, Hattori T, Sugihara H. Barretts's carcinogenesis. Pathol Int 2019; 69:319-330. [PMID: 31290583 PMCID: PMC6851828 DOI: 10.1111/pin.12804] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 03/22/2019] [Indexed: 12/14/2022]
Abstract
Barrett's esophagus is considered a precancerous lesion of esophageal adenocarcinoma (EAC). Long‐segment Barrett's esophagus, which is generally associated with intestinal metaplasia, has a higher rate of carcinogenesis than short‐segment Barrett's esophagus, which is mainly composed of cardiac‐type mucosa. However, a large number of cases reportedly develop EAC from the cardiac‐type mucosa which has the potential to involve intestinal phenotypes. There is no consensus regarding whether the definition of Barrett's epithelium should include intestinal metaplasia. Basic researches using rodent models have provided information regarding the origins of Barrett's epithelium. Nevertheless, it remains unclear whether differentiated gastric columnar epithelium or stratified esophageal squamous epithelium undergo transdifferentiation into the intestinal‐type columnar epithelium, transcommittment into the columnar epithelium, or whether the other pathways exist. Reflux of duodenal fluid including bile acids into the stomach may occur when an individual lies down after eating, which could cause the digestive juices to collect in the fornix of the stomach. N‐nitroso‐bile acids are produced with nitrites that are secreted from the salivary glands, and bile acids can drive expression of pro‐inflammatory cytokines via EGFR or the NF‐κB pathway. These steps may contribute significantly to carcinogenesis.
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Affiliation(s)
- Ken-Ichi Mukaisho
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
| | - Shunpei Kanai
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
| | - Ryoji Kushima
- Division of Diagnostic Pathology, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Takahisa Nakayama
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
| | - Takanori Hattori
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
| | - Hiroyuki Sugihara
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
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24
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Vaughan TL, Onstad L, Dai JY. Interactive decision support for esophageal adenocarcinoma screening and surveillance. BMC Gastroenterol 2019; 19:109. [PMID: 31248371 PMCID: PMC6598240 DOI: 10.1186/s12876-019-1022-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A key barrier to controlling esophageal adenocarcinoma (EAC) is identifying those most likely to benefit from screening and surveillance. We aimed to develop an online educational tool, termed IC-RISC™, for providers and patients to estimate more precisely their absolute risk of developing EAC, interpret this estimate in the context of risk of dying from other causes, and aid in decision-making. RESULTS U.S. incidence and mortality data and published relative risk estimates from observational studies and clinical trials were used to calculate absolute risk of EAC over 10 years adjusting for competing risks. These input parameters varied depending on presence of the key precursor, Barrett's esophagus. The open source application works across common devices to gather risk factor data and graphically illustrate estimated risk on a single page. Changes to input data are immediately reflected in the colored graphs. We used the calculator to compare the risk distribution between EAC cases and controls from six population-based studies to gain insight into the discrimination metrics of current practice guidelines for screening, observing that current guidelines sacrifice a significant amount of specificity to identify 78-86% of eventual cases in the US population. CONCLUSIONS This educational tool provides a simple and rapid means to graphically communicate risk of EAC in the context of other health risks, facilitates "what-if" scenarios regarding potential preventative actions, and can inform discussions regarding screening, surveillance and treatment options. Its generic architecture lends itself to being easily extended to other cancers with distinct pathways and/or intermediate stages, such as hepatocellular cancer. IC-RISC™ extends current qualitative clinical practice guidelines into a quantitative assessment, which brings the possibility of preventative actions being offered to persons not currently targeted for screening and, conversely, reducing unnecessary procedures in those at low risk. Prospective validation and application to existing well-characterized cohort studies are needed.
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Affiliation(s)
- Thomas L. Vaughan
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 98109 USA
- Program in Cancer Epidemiology, M4-B874, 1100 Fairview Ave N, Seattle, WA 98109 USA
| | - Lynn Onstad
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 98109 USA
| | - James Y. Dai
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 98109 USA
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25
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Definition of Barrett Esophagus in the United States: Support for Retention of a Requirement for Goblet Cells. Am J Surg Pathol 2019; 42:264-268. [PMID: 29016405 DOI: 10.1097/pas.0000000000000971] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Barrett esophagus (BE) predisposes patients to the development of esophageal adenocarcinoma (EAC). However, the global definition of BE is controversial. Pathologists in Europe and the United States require intestinal metaplasia (IM) within columnar-lined mucosa (CLM) in the tubular esophagus to diagnose BE, whereas in the UK and Japan only the presence of CLM is required. To aid in establishing an appropriate definition for BE, we evaluated whether IM accompanies EAC in a US patient cohort. We examined a series of 139 consecutive patients who underwent endoscopic mucosal resections or esophagectomies for EAC performed at a US tertiary care center. The resection specimens were evaluated for the presence (IM+) or absence (IM-) of IM within CLM. Ninety-seven (70%) patients were IM+. Tumors found in IM- patients tended to be advanced at the time of resection (57% pT3 or greater, IM-; 31% pT3 or greater, IM+; P=0.02) such that the tumor may have "overgrown" zones of IM. We hypothesized that changes as a result of neoadjuvant chemotherapy or radiation might mask preexisting IM. When evaluating this hypothesis, we found that 34 of 39 of treatment-naive patients were IM+. Two of the 5 IM- patients had prior IM+ biopsies resulting in 92% of treatment-naive patients who were IM+. In our US hospital population, CLM with IM in the tubular esophagus is found in association with EAC in 70% to 92% of patients. We believe that based on these data the United States definition of BE should continue to require the presence of IM.
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26
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Refined Criteria for Separating Low-grade Dysplasia and Nondysplastic Barrett Esophagus Reduce Equivocal Diagnoses and Improve Prediction of Patient Outcome. Am J Surg Pathol 2018; 42:1723-1729. [DOI: 10.1097/pas.0000000000001162] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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27
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Cook MB, Coburn SB, Lam JR, Taylor PR, Schneider JL, Corley DA. Cancer incidence and mortality risks in a large US Barrett's oesophagus cohort. Gut 2018; 67:418-529. [PMID: 28053055 PMCID: PMC5827961 DOI: 10.1136/gutjnl-2016-312223] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 12/01/2016] [Accepted: 12/04/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Barrett's oesophagus (BE) increases the risk of oesophageal adenocarcinoma by 10-55 times that of the general population, but no community-based cancer-specific incidence and cause-specific mortality risk estimates exist for large cohorts in the USA. DESIGN Within Kaiser Permanente Northern California (KPNC), we identified patients with BE diagnosed during 1995-2012. KPNC cancer registry and mortality files were used to estimate standardised incidence ratios (SIR), standardised mortality ratios (SMR) and excess absolute risks. RESULTS There were 8929 patients with BE providing 50 147 person-years of follow-up. Compared with the greater KPNC population, patients with BE had increased risks of any cancer (SIR=1.40, 95% CI 1.31 to 1.49), which slightly decreased after excluding oesophageal cancer. Oesophageal adenocarcinoma risk was increased 24 times, which translated into an excess absolute risk of 24 cases per 10 000 person-years. Although oesophageal adenocarcinoma risk decreased with time since BE diagnosis, oesophageal cancer mortality did not, indicating that the true risk is stable and persistent with time. Relative risks of cardia and stomach cancers were increased, but excess absolute risks were modest. Risks of colorectal, lung and prostate cancers were unaltered. All-cause mortality was slightly increased after excluding oesophageal cancer (SMR=1.24, 95% CI 1.18 to 1.31), but time-stratified analyses indicated that this was likely attributable to diagnostic bias. Cause-specific SMRs were elevated for ischaemic heart disease (SMR=1.39, 95% CI 1.18 to 1.63), respiratory system diseases (SMR=1.51, 95% CI 1.29 to 1.75) and digestive system diseases (SMR=2.20 95% CI 1.75 to 2.75). CONCLUSIONS Patients with BE had a persistent excess risk of oesophageal adenocarcinoma over time, although their absolute excess risks for this cancer, any cancer and overall mortality were modest.
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Affiliation(s)
- Michael B Cook
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Sally B Coburn
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Jameson R Lam
- Division of Research, Oakland Medical Center, Kaiser Permanente, Oakland, California, USA
| | - Philip R Taylor
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Jennifer L Schneider
- Division of Research, Oakland Medical Center, Kaiser Permanente, Oakland, California, USA
| | - Douglas A Corley
- Division of Research, Oakland Medical Center, Kaiser Permanente, Oakland, California, USA
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28
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McLaren PJ, Dolan JP. Surgical Treatment of High-Grade Dysplasia and Early Esophageal Cancer. World J Surg 2018; 41:1712-1718. [PMID: 28258451 DOI: 10.1007/s00268-017-3958-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar survival outcomes without the associated morbidity of a major operation. However, a number of these cases may still require surgical intervention as the best treatment option. METHODS The current scientific literature, national and international guidelines were reviewed for recommendations regarding optimal treatment of early esophageal malignancy. RESULTS The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy. In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal lesions, tumors within a long segment of Barrett's esophagus, tumors adjacent to a hiatal hernia, tumors that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy. CONCLUSIONS When performed at high-volume centers in experienced hands, esophagectomy can have consistently good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a treatment option.
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Affiliation(s)
- Patrick J McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA
| | - James P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA.
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Voltaggio L, Montgomery EA. Diagnosis and Management of Barrett-Related Neoplasia in the Modern Era. Surg Pathol Clin 2017; 10:781-800. [PMID: 29103533 DOI: 10.1016/j.path.2017.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Whereas in the past, pathologists were hesitant to diagnose high-grade dysplasia in patients with Barrett esophagus, because this diagnosis prompted esophagectomy, current international consensus is that endoscopic treatment is the management for high-grade dysplasia and intramucosal carcinoma. Furthermore, many centers advocate endoscopic ablation for low-grade dysplasia. As such, establishing a diagnosis of dysplasia has become the key step; separation between the grades of dysplasia is less critical. This article offers some criteria for separating dysplasia from reactive changes, discusses pitfalls in interpreting endoscopic mucosal resection specimens, and outlines management strategies.
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Affiliation(s)
- Lysandra Voltaggio
- Department of Pathology, Johns Hopkins Medical Institutions, 401 North Broadway, Baltimore, MD 21231, USA
| | - Elizabeth A Montgomery
- Department of Pathology, Johns Hopkins Medical Institutions, 401 North Broadway, Baltimore, MD 21231, USA.
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30
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Voltaggio L, Cimino-Mathews A, Bishop JA, Argani P, Cuda JD, Epstein JI, Hruban RH, Netto GJ, Stoler MH, Taube JM, Vang R, Westra WH, Montgomery EA. Current concepts in the diagnosis and pathobiology of intraepithelial neoplasia: A review by organ system. CA Cancer J Clin 2016; 66:408-36. [PMID: 27270763 DOI: 10.3322/caac.21350] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Answer questions and earn CME/CNE In this report, a team of surgical pathologists has provided a review of intraepithelial neoplasia in a host of (but not all) anatomic sites of interest to colleagues in various medical specialties, namely, uterine cervix, ovary, breast, lung, head and neck, skin, prostate, bladder, pancreas, and esophagus. There is more experience with more readily accessible sites (such as the uterine cervix and skin) than with other anatomic sites, and the lack of uniform terminology, together with divergent biology in various sites, makes it difficult to paint a unifying, relevant portrait. The authors' aim was to provide a framework from which to move forward as we care for patients with such precancerous lesions. CA Cancer J Clin 2016;66:408-436. © 2016 American Cancer Society.
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Affiliation(s)
- Lysandra Voltaggio
- Assistant Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Ashley Cimino-Mathews
- Assistant Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Justin A Bishop
- Associate Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Pedram Argani
- Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Jonathan D Cuda
- Assistant Professor of Dermatology, Department of Dermatology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Jonathan I Epstein
- Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
- Professor of Urology, Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
| | - Ralph H Hruban
- Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - George J Netto
- Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Mark H Stoler
- Professor of Pathology, Department of Pathology, University of Virginia Health System, Charlottesville, VA
| | - Janis M Taube
- Associate Professor of Dermatology and Pathology, Department of Dermatology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Russell Vang
- Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - William H Westra
- Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Elizabeth A Montgomery
- Professor of Pathology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
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Abstract
Esophageal cancer carries a poor prognosis among gastrointestinal malignancies. Although esophageal squamous cell carcinoma predominates worldwide, Western nations have seen a marked rise in the incidence of esophageal adenocarcinoma that parallels the obesity epidemic. Efforts directed toward early detection have been difficult, given that dysplasia and early cancer are generally asymptomatic. However, significant advances have been made in the past 10 to 15 years that allow for endoscopic management and often cure in early stage esophageal malignancy. New diagnostic imaging technologies may provide a means by which cost-effective, early diagnosis of dysplasia allows for definitive therapy and ultimately improves the overall survival among patients.
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Affiliation(s)
- Benjamin R Alsop
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, USA; Department of Gastroenterology and Hepatology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1023, Kansas City, KS 66160, USA.
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, USA; Department of Gastroenterology and Hepatology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1023, Kansas City, KS 66160, USA
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32
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Abstract
PURPOSE OF REVIEW The incidence of esophageal adenocarcinoma and its precursor, Barrett's esophagus, have increased greatly over the past 40 years and continue to rise. This report summarizes the most recent data on the risk factors for Barrett's esophagus and esophageal adenocarcinoma. RECENT FINDINGS Other factors, highly correlated with increasing trends for obesity, are the dominant driver of the increase in incidence of esophageal adenocarcinoma, interacting with gastroesophageal reflux disease symptoms. Abdominal obesity, independently of gastroesophageal reflux disease symptoms, is associated with increased risk of Barrett's esophagus and this association is likely mediated by high levels of leptin and insulin. Use of aspirin, nonsteroidal anti-inflammatory drugs, statins, and proton pump inhibitors are associated with a reduced risk of Barrett's esophagus as well as lower risk of neoplastic progression in patients with Barrett's esophagus. An increasing number of genetic loci have been associated with risk of Barrett's esophagus and esophageal adenocarcinoma. SUMMARY Recent advances in identifying risk factors and reporting of more precise estimates of effect for the main risk factors will positively impact clinical risk stratification efforts for Barrett's esophagus and esophageal adenocarcinoma. Large pooling studies are underway to derive and validate reliable clinical risk models.
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