Barrett's esophagus: review of diagnosis and treatment

Anterior Cutaneous Nerve Entrapment Syndrome: Two Case Reports of the Forgotten Diagnosis After Bariatric Surgery

Unexplained abdominal pain is an increasing phenomenon after laparoscopic bariatric surgery, with an occurrence of 7.4%. The pain could be explained by the anterior cutaneous nerve entrapment syndrome (ACNES). However, the incidence of ACNES after laparoscopic bariatric surgery is unclear. We report the cases of two patients with unexplained abdominal pain after laparoscopic bariatric surgery and a significant delay in the diagnosis of ACNES. In both cases, clinical signs of ACNES were demonstrated by a centralized trigger point in the abdominal wall and specific neuropathic aspects during examination. Both patients were temporary pain-free after a diagnostic local lidocaine injection. A neurectomy was performed in both cases, after which they remained pain-free. There was a significant delay (six months and three years, respectively) in the diagnosis of ACNES, and many additional imaging procedures including a diagnostic laparoscopy were performed. ACNES is difficult to diagnose due to its relatively unknown entity.

This case report confirms that the diagnosis of ACNES is still frequently overlooked as a cause of chronic abdominal pain. Earlier diagnosis recognition can probably prevent unnecessary investigations and may improve the quality of life in bariatric patients with unexplained abdominal pain.

Endoscopic submucosal dissection is associated with less pathologic uncertainty than endoscopic mucosal resection in diagnosing and staging Barrett's-related neoplasia

BACKGROUND & AIMS

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have demonstrated similar efficacy in removal of neoplastic esophageal lesions. However, significant controversy exists over the preferred resection technique. Our primary aim was to compare the pathologic specimens produced via EMR and ESD and secondarily gauge their effect on clinical decision making and patient outcomes.

METHODS

Using a retrospective cohort study design, all esophageal Barrett's-associated neoplastic lesions resected by a single provider from 2012 to 2017 were reviewed. The pathology was re-reviewed by two blinded authors for diagnosis, margins, and adverse outcomes and recurrence rates were also collected.

RESULTS

Thirty-one EMR and 20 ESD cases were identified. Baseline demographics and lesion characteristics were similar. ESD produced more R0 resections and more en bloc resections compared to EMR. EMR produced more equivocal lateral (13/31, 41.9% vs 1/20, 5.0%) and vertical margins (13/31, 41.9% vs. 0/20, 0%, both P < 0.05). This led to an inability to reach a definitive diagnosis in 13/31 EMR vs 0/20 ESD pathology specimens (P = 0.003). Of the 13 EMR specimens with equivocal pathology, 11 were noted to have 'at least intramucosal adenocarcinoma'. Four of the 11 patients chose to undergo elective esophagectomy with final surgical pathology demonstrating ≤T1a disease in 2, and ≥T1b disease in two.

CONCLUSION

Compared to ESD, EMR was associated with greater pathologic uncertainty in Barrett's-associated neoplasia.

Proton Pump Inhibitors and Radiofrequency Ablation for Treatment of Barrett's Esophagus

Gastroesophageal Reflux Disease (GERD) is characterized by acid and bile reflux in the distal oesophagus, and this may cause the development of reflux esophagitis and Barrett's oesophagus (BE). The natural histological course of untreated BE is non-dysplastic or benign BE (ND), then lowgrade (LGD) and High-Grade Dysplastic (HGD) BE, with the expected increase in malignancy transfer to oesophagal adenocarcinoma (EAC). The gold standard for BE diagnostics involves high-resolution white-light endoscopy, followed by uniform endoscopy findings description (Prague classification) with biopsy performance according to Seattle protocol. The medical treatment of GERD and BE includes the use of proton pump inhibitors (PPIs) regarding symptoms control. It is noteworthy that long-term use of PPIs increases gastrin level, which can contribute to transfer from BE to EAC, as a result of its effects on the proliferation of BE epithelium. Endoscopy treatment includes a wide range of resection and ablative techniques, such as radio-frequency ablation (RFA), often concomitantly used in everyday endoscopy practice (multimodal therapy). RFA promotes mucosal necrosis of treated oesophagal region via high-frequency energy. Laparoscopic surgery, partial or total fundoplication, is reserved for PPIs and endoscopy indolent patients or in those with progressive disease. This review aims to explain distinct effects of PPIs and RFA modalities, illuminate certain aspects of molecular mechanisms involved, as well as the effects of their concomitant use regarding the treatment of BE and prevention of its transfer to EAC.

Worldwide incidence, mortality and time trends for cancer of the oesophagus

The incidence and mortality trends of oesophageal cancer are changing significantly across the world with considerable heterogeneity between sex, histological types, ethnic patterns and geographical distribution. Recent oesophageal cancer incidence and mortality trends have been analysed using data available from the WHO mortality database, the GLOBOCAN 2012 database and the Cancer Incidence in Five Continents database managed by the International Agency for Research on Cancer. Huge geographical variation is an epidemiological characteristic of oesophageal cancer, with the highest incidence rates observed in Eastern Asia and in Eastern and Southern Africa and the lowest rates observed in Western Africa. The variation is to the order of more than 21 times between the lowest-incidence and the highest-incidence countries. Although the incidence of squamous cell carcinoma is increasing globally, its incidence rates are decreasing in the USA and a few European countries. However, the decrease in the incidence of squamous cell carcinomas in these countries has been accompanied by a marked increase in adenocarcinoma incidence rates. There is a significant sex variation as well, with men being affected three to four times more commonly than women worldwide. The observed trends reflect significant global variations in the incidence and mortality of oesophageal cancers on the basis of sex, geographical distribution, ethnicity and histology. These epidemiological factors related to oesophageal cancers point out a possibly significant role of molecular epidemiological factors (genetic susceptibility and response to treatment) with major differences likely between the characteristics of Asian and Western populations.

Long Noncoding RNAs in the Pathogenesis of Barrett's Esophagus and Esophageal Carcinoma

For many years, only a small fraction of the human genome was believed to regulate cell function and development. This protein-coding portion composed only 1% to 2% of 3 billion human DNA base pairs-the remaining sequence was classified as junk DNA. Subsequent research has revealed that most of the genome is transcribed into a broad array of noncoding RNAs, ranging in size from microRNA (20-23 nucleotides) to long noncoding RNA (lncRNA, more than 200 nucleotides). These noncoding RNA classes have been shown to use diverse molecular mechanisms to control gene expression and organ system development. As anticipated, alterations in this large control system can contribute to disease pathogenesis and carcinogenesis. We review the involvement of noncoding RNAs, lncRNAs in particular, in development of Barrett's esophagus and esophageal carcinoma.

Association Between Germline Mutation in VSIG10L and Familial Barrett Neoplasia

Importance

Esophageal adenocarcinoma and its precursor lesion Barrett esophagus have seen a dramatic increase in incidence over the past 4 decades yet marked genetic heterogeneity of this disease has precluded advances in understanding its pathogenesis and improving treatment.

Objective

To identify novel disease susceptibility variants in a familial syndrome of esophageal adenocarcinoma and Barrett esophagus, termed familial Barrett esophagus, by using high-throughput sequencing in affected individuals from a large, multigenerational family.

Design, Setting, and Participants

We performed whole exome sequencing (WES) from peripheral lymphocyte DNA on 4 distant relatives from our multiplex, multigenerational familial Barrett esophagus family to identify candidate disease susceptibility variants. Gene variants were filtered, verified, and segregation analysis performed to identify a single candidate variant. Gene expression analysis was done with both quantitative real-time polymerase chain reaction and in situ RNA hybridization. A 3-dimensional organotypic cell culture model of esophageal maturation was utilized to determine the phenotypic effects of our gene variant. We used electron microscopy on esophageal mucosa from an affected family member carrying the gene variant to assess ultrastructural changes.

Main Outcomes and Measures

Identification of a novel, germline disease susceptibility variant in a previously uncharacterized gene.

Results

A multiplex, multigenerational family with 14 members affected (3 members with esophageal adenocarcinoma and 11 with Barrett esophagus) was identified, and whole-exome sequencing identified a germline mutation (S631G) at a highly conserved serine residue in the uncharacterized gene VSIG10L that segregated in affected members. Transfection of S631G variant into a 3-dimensional organotypic culture model of normal esophageal squamous cells dramatically inhibited epithelial maturation compared with the wild-type. VSIG10L exhibited high expression in normal squamous esophagus with marked loss of expression in Barrett-associated lesions. Electron microscopy of squamous esophageal mucosa harboring the S631G variant revealed dilated intercellular spaces and reduced desmosomes.

Conclusions and Relevance

This study presents VSIG10L as a candidate familial Barrett esophagus susceptibility gene, with a putative role in maintaining normal esophageal homeostasis. Further research assessing VSIG10L function may reveal pathways important for esophageal maturation and the pathogenesis of Barrett esophagus and esophageal adenocarcinoma.

LINE-1 expression and retrotransposition in Barrett's esophagus and esophageal carcinoma

Barrett's esophagus (BE) is a common disease in which the lining of the esophagus transitions from stratified squamous epithelium to metaplastic columnar epithelium that predisposes individuals to developing esophageal adenocarcinoma (EAC). We hypothesized that BE provides a unique environment for increased long-interspersed element 1 (LINE-1 or L1) retrotransposition. To this end, we evaluated 5 patients with benign BE, 5 patients with BE and concomitant EAC, and 10 additional patients with EAC to determine L1 activity in this progressive disease. After L1-seq, we confirmed 118 somatic insertions by PCR in 10 of 20 individuals. We observed clonal amplification of several insertions which appeared to originate in normal esophagus (NE) or BE and were later clonally expanded in BE or in EAC. Additionally, we observed evidence of clonality within the EAC cases; specifically, 22 of 25 EAC-only insertions were present identically in distinct regions available from the same tumor, suggesting that these insertions occurred in the founding tumor cell of these lesions. L1 proteins must be expressed for retrotransposition to occur; therefore, we evaluated the expression of open reading frame 1 protein (ORF1p), a protein encoded by L1, in eight of the EAC cases for which formalin-fixed paraffin embedded tissue was available. With immunohistochemistry, we detected ORF1p in all tumors evaluated. Interestingly, we also observed dim ORF1p immunoreactivity in histologically NE of all patients. In summary, our data show that somatic retrotransposition occurs early in many patients with BE and EAC and indicate that early events occurring even in histologically NE cells may be clonally expanded in esophageal adenocarcinogenesis.