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Pettis J, Paruch J. Endoscopic Assessment of Colorectal Polyps. Clin Colon Rectal Surg 2024; 37:271-276. [PMID: 39132200 PMCID: PMC11309797 DOI: 10.1055/s-0043-1770940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Colorectal cancer is the third most common cancer among men and the second among women. In the United States alone, there are 150,000 cases diagnosed each year. Colonoscopy remains the best method for identifying, evaluating, and intervening on patients with precancerous lesions. Multiple guidelines and techniques are available to assist the endoscopist with accurate diagnosis of these lesions. These include the Paris, Narrow-Band Imaging (NBI) International Colorectal Endoscopic (NICE), Japan NBI Expert Team (JNET), Kudo, Hiroshima, and Shudo classifications which utilize techniques such as chromoendoscopy, narrow-band imaging, and endocytoscopy to evaluate pit pattern and surface morphology. Utilization of these tools can help the endoscopist predict the cytology of a colonic lesion and select the most appropriate method for resection while maximizing organ preservation.
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Affiliation(s)
- Jaron Pettis
- Ochsner Clinic Foundation, Department of Colon and Rectal Surgery, New Orleans, Louisiana
| | - Jennifer Paruch
- Ochsner Clinic Foundation, Department of Colon and Rectal Surgery, New Orleans, Louisiana
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Nagula S, Parasa S, Laine L, Shah SC. AGA Clinical Practice Update on High-Quality Upper Endoscopy: Expert Review. Clin Gastroenterol Hepatol 2024; 22:933-943. [PMID: 38385942 DOI: 10.1016/j.cgh.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 02/23/2024]
Abstract
DESCRIPTION The purpose of this Clinical Practice Update (CPU) Expert Review is to provide clinicians with guidance on best practices for performing a high-quality upper endoscopic exam. METHODS The best practice advice statements presented herein were developed from a combination of available evidence from published literature, guidelines, and consensus-based expert opinion. No formal rating of the strength or quality of the evidence was carried out, which aligns with standard processes for American Gastroenterological Association (AGA) Institute CPUs. These statements are meant to provide practical, timely advice to clinicians practicing in the United States. This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates (CPU) Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology & Hepatology. BEST PRACTICE ADVICE 1: Endoscopists should ensure that upper endoscopy is being performed for an appropriate indication and that informed consent clearly explaining the risks, benefits, alternatives, sedation plan, and potential diagnostic and therapeutic interventions is obtained. These elements should be documented by the endoscopist before the procedure. BEST PRACTICE ADVICE 2: Endoscopists should ensure that adequate visualization of the upper gastrointestinal mucosa, using mucosal cleansing and insufflation as necessary, is achieved and documented. BEST PRACTICE ADVICE 3: A high-definition white-light endoscopy system should be used for upper endoscopy instead of a standard-definition white-light endoscopy system whenever possible. The endoscope used for the procedure should be documented in the procedure note. BEST PRACTICE ADVICE 4: Image enhancement technologies should be used during the upper endoscopic examination to improve the diagnostic yield for preneoplasia and neoplasia. Suspicious areas should be clearly described, photodocumented, and biopsied separately. BEST PRACTICE ADVICE 5: Endoscopists should spend sufficient time carefully inspecting the foregut mucosa in an anterograde and retroflexed view to improve the detection and characterization of abnormalities. BEST PRACTICE ADVICE 6: Endoscopists should document any abnormalities noted on upper endoscopy using established classifications and standard terminology whenever possible. BEST PRACTICE ADVICE 7: Endoscopists should perform biopsies for the evaluation and management of foregut conditions using standardized biopsy protocols. BEST PRACTICE ADVICE 8: Endoscopists should provide patients with management recommendations based on the specific endoscopic findings (eg, peptic ulcer disease, erosive esophagitis), and this should be documented in the medical record. If recommendations are contingent upon histopathology results (eg, H pylori infection, Barrett's esophagus), then endoscopists should document that appropriate guidance will be provided after results are available. BEST PRACTICE ADVICE 9: Endoscopists should document whether subsequent surveillance endoscopy is indicated and, if so, provide appropriate surveillance intervals. If the determination of surveillance is contingent on histopathology results, then endoscopists should document that surveillance intervals will be suggested after results are available.
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Affiliation(s)
- Satish Nagula
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Shailja C Shah
- Gastroenterology Section, Jennifer Moreno Department of Veterans Affairs Medical Center, San Diego, California; Division of Gastroenterology, University of California, San Diego, San Diego, California.
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Weusten BLAM, Bisschops R, Dinis-Ribeiro M, di Pietro M, Pech O, Spaander MCW, Baldaque-Silva F, Barret M, Coron E, Fernández-Esparrach G, Fitzgerald RC, Jansen M, Jovani M, Marques-de-Sa I, Rattan A, Tan WK, Verheij EPD, Zellenrath PA, Triantafyllou K, Pouw RE. Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2023; 55:1124-1146. [PMID: 37813356 DOI: 10.1055/a-2176-2440] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.
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Affiliation(s)
- Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Massimiliano di Pietro
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Francisco Baldaque-Silva
- Advanced Endoscopy Center Carlos Moreira da Silva, Department of Gastroenterology, Pedro Hispano Hospital, Matosinhos, Portugal
- Division of Medicine, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital and University of Paris, Paris, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, Centre hospitalier universitaire Hôtel-Dieu, Nantes, Nantes, France
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biomedical Research Network on Hepatic and Digestive Diseases (CIBEREHD), Barcelona, Spain
| | - Rebecca C Fitzgerald
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospital NHS Trust, London, UK
| | - Manol Jovani
- Division of Gastroenterology, Maimonides Medical Center, New York, New York, USA
| | - Ines Marques-de-Sa
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Arti Rattan
- Department of Gastroenterology, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - W Keith Tan
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Pauline A Zellenrath
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Acharya R, Mahapatra A, Verma HK, Bhaskar LVKS. Unveiling Therapeutic Targets for Esophageal Cancer: A Comprehensive Review. Curr Oncol 2023; 30:9542-9568. [PMID: 37999111 PMCID: PMC10670555 DOI: 10.3390/curroncol30110691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/25/2023] Open
Abstract
Esophageal cancer is a highly aggressive and deadly disease, ranking as the sixth leading cause of cancer-related deaths worldwide. Despite advances in treatment, the prognosis remains poor. A multidisciplinary approach is crucial for achieving complete remission, with treatment options varying based on disease stage. Surgical intervention and endoscopic treatment are used for localized cancer, while systemic treatments like chemoradiotherapy and targeted drug therapy play a crucial role. Molecular markers such as HER2 and EGFR can be targeted with drugs like trastuzumab and cetuximab, and immunotherapy drugs like pembrolizumab and nivolumab show promise by targeting immune checkpoint proteins. Epigenetic modifications offer new avenues for targeted therapy. Treatment selection depends on factors like stage, tumor location, and patient health, with post-operative and rehabilitation care being essential. Early diagnosis, appropriate treatment, and supportive care are key to improving outcomes. Continued research is needed to develop effective targeted drugs with minimal side effects. This review serves as a valuable resource for clinicians and researchers dedicated to enhancing esophageal cancer treatment outcomes.
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Affiliation(s)
- Rakesh Acharya
- Department of Zoology, Guru Ghasidas Vishwavidyalaya, Bilaspur 495009, India; (R.A.); (A.M.)
| | - Ananya Mahapatra
- Department of Zoology, Guru Ghasidas Vishwavidyalaya, Bilaspur 495009, India; (R.A.); (A.M.)
| | - Henu Kumar Verma
- Department of Immunopathology, Institute of lungs Health and Immunity, Comprehensive Pneumology Center, Helmholtz Zentrum, Neuherberg, 85764 Munich, Germany;
| | - L. V. K. S. Bhaskar
- Department of Zoology, Guru Ghasidas Vishwavidyalaya, Bilaspur 495009, India; (R.A.); (A.M.)
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Beveridge CA, Mittal C, Muthusamy VR, Rastogi A, Kushnir V, Wood M, Wani S, Komanduri S. Identification of visible lesions during surveillance endoscopy for Barrett's esophagus: a video-based survey study. Gastrointest Endosc 2023; 97:241-247.e2. [PMID: 36007583 DOI: 10.1016/j.gie.2022.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/17/2022] [Accepted: 08/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Visible lesion (VL) detection is essential in patients with Barrett's esophagus (BE). We sought to assess the rate of VL detection by academic and community endoscopists using high-definition white-light endoscopy (HD-WLE) and narrow-band imaging (NBI) during surveillance endoscopy. METHODS Fifty endoscopists were invited to participate in a prospective video survey study. Participants viewed 25 standardized clips of patients referred for endoscopic therapy. Participants noted identification of anatomic landmarks and VLs using HD-WLE and NBI and reported practice-level data. The criterion standard of VL identification was established by consensus of 5 BE experts. Our primary outcome was the rate of VL identification using HD-WLE and NBI. RESULTS Forty-four of 50 participants completed the study (22 academic and 22 community). Compared with the criterion standard, participants did not identify 28% (HD-WLE) and 31% (NBI) of VLs. Community endoscopists had more experience (>5 years in practice: community 85% vs academic 54.5%, P = .041; >5 surveillance endoscopies a month: community 85% vs academic 31.8%, P = .046). Across all participants, VL detection using NBI improved significantly with a minimum of 5 surveillance endoscopies per month (area under the curve = .72; 95% confidence interval, .56-.85; P = .006). CONCLUSIONS Despite improved endoscope resolution and availability of virtual chromoendoscopy, the overall rate of VL detection remains low. Identification of VLs using NBI may be volume dependent. Further education and training efforts focused on VL detection during BE surveillance endoscopy are needed.
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Affiliation(s)
- Claire A Beveridge
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Chetan Mittal
- Interventional Oncology and Surgical Endoscopy, Parkview Cancer Institute, Parkview Health System, Fort Wayne, Indiana, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Amit Rastogi
- Department of Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas University School of Medicine, Kansas City, Kansas, USA
| | - Vladimir Kushnir
- Department of Medicine, Division of Gastroenterology, Washington University, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Mariah Wood
- Department of Medicine, Division of Gastroenterology, Northwestern Medical Center, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sachin Wani
- Department of Medicine, Division of Gastroenterology, University of Colorado Anschutz Medical Campus, University of Colorado School of Medicine, Boulder, Colorado, USA
| | - Srinadh Komanduri
- Department of Medicine, Division of Gastroenterology, Northwestern Medical Center, Feinberg School of Medicine, Chicago, Illinois, USA
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Gubbiotti A, Spadaccini M, Badalamenti M, Hassan C, Repici A. Key factors for improving adenoma detection rate. Expert Rev Gastroenterol Hepatol 2022; 16:819-833. [PMID: 36151898 DOI: 10.1080/17474124.2022.2128761] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Colonoscopy is a fundamental tool in colorectal cancer (CRC) prevention. Nevertheless, one-fourth of colorectal neoplasms are still missed during colonoscopy, potentially being the main reason for post-colonoscopy colorectal cancer (PCCRC). Adenoma detection rate (ADR) is currently known as the best quality indicator correlating with PCCRC incidence. AREAS COVERED We performed a literature review in order to summarize evidences investigating key factors affecting ADR: endoscopists education and training, patient management, endoscopic techniques, improved navigation (exposition defect), and enhanced lesions recognition (vision defect) were considered. EXPERT OPINION 'Traditional' factors, such as split dose bowel preparation, adequate withdrawal time, and right colon second view, held a significant impact on ADR. Several devices and technologies have been developed to promote high-quality colonoscopy, however artificial intelligence may be considered the most promising tool for ADR improvement, provided that endoscopists education and recording are guaranteed.
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Affiliation(s)
- Alessandro Gubbiotti
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Marco Spadaccini
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Matteo Badalamenti
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Cesare Hassan
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Alessandro Repici
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
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Paiji C, Sedarat A. Endoscopic Management of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14153583. [PMID: 35892840 PMCID: PMC9329770 DOI: 10.3390/cancers14153583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.
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Emura F, Chandrasekar VT, Hassan C, Armstrong D, Messmann H, Arantes V, Araya R, Barrera-Leon O, Bergman JJGHM, Bandhari P, Bourke MJ, Cerisoli C, Chiu PWY, Desai M, Dinis-Ribeiro M, Falk GW, Fujishiro M, Gaddam S, Goda K, Gross S, Haidry R, Ho L, Iyer PG, Kashin S, Kothari S, Lee YY, Matsuda K, Neuhaus H, Oyama T, Ragunath K, Repici A, Shaheen N, Singh R, Sobrino-Cossio S, Wang KK, Waxman I, Sharma P. Rio de Janeiro Global Consensus on Landmarks, Definitions, and Classifications in Barrett's Esophagus: World Endoscopy Organization Delphi Study. Gastroenterology 2022; 163:84-96.e2. [PMID: 35339464 DOI: 10.1053/j.gastro.2022.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND & AIMS Despite the significant advances made in the diagnosis and treatment of Barrett's esophagus (BE), there is still a need for standardized definitions, appropriate recognition of endoscopic landmarks, and consistent use of classification systems. Current controversies in basic definitions of BE and the relative lack of anatomic knowledge are significant barriers to uniform documentation. We aimed to provide consensus-driven recommendations for uniform reporting and global application. METHODS The World Endoscopy Organization Barrett's Esophagus Committee appointed leaders to develop an evidence-based Delphi study. A working group of 6 members identified and formulated 23 statements, and 30 internationally recognized experts from 18 countries participated in 3 rounds of voting. We defined consensus as agreement by ≥80% of experts for each statement and used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to assess the quality of evidence and the strength of recommendations. RESULTS After 3 rounds of voting, experts achieved consensus on 6 endoscopic landmarks (palisade vessels, gastroesophageal junction, squamocolumnar junction, lesion location, extraluminal compressions, and quadrant orientation), 13 definitions (BE, hiatus hernia, squamous islands, columnar islands, Barrett's endoscopic therapy, endoscopic resection, endoscopic ablation, systematic inspection, complete eradication of intestinal metaplasia, complete eradication of dysplasia, residual disease, recurrent disease, and failure of endoscopic therapy), and 4 classification systems (Prague, Los Angeles, Paris, and Barrett's International NBI Group). In round 1, 18 statements (78%) reached consensus, with 12 (67%) receiving strong agreement from more than half of the experts. In round 2, 4 of the remaining statements (80%) reached consensus, with 1 statement receiving strong agreement from 50% of the experts. In the third round, a consensus was reached on the remaining statement. CONCLUSIONS We developed evidence-based, consensus-driven statements on endoscopic landmarks, definitions, and classifications of BE. These recommendations may facilitate global uniform reporting in BE.
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Affiliation(s)
- Fabian Emura
- Gastroenterology Division, Universidad de La Sabana, Chía, Colombia; Advanced GI Endoscopy, EmuraCenter LatinoAmerica, Bogotá DC, Colombia.
| | | | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy; Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - David Armstrong
- Division of Gastroenterology & Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Vitor Arantes
- Endoscopy Division, Hospital das Clınicas e Mater Dei Contorno, Belo Horizonte, Brazil; Alfa Institute of Gastroenterology, Medical School, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Raul Araya
- Clinic Los Andes University, Division of Gastroenterology and Endoscopy, Army Hospital of Santiago, Santiago, Chile
| | - Oscar Barrera-Leon
- Gastroenterology Division, Universidad de La Sabana, Chía, Colombia; Advanced GI Endoscopy, EmuraCenter LatinoAmerica, Bogotá DC, Colombia
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Pradeep Bandhari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Cecilio Cerisoli
- Gastroenterology and Diagnostic and Therapeutic Endoscopy (GEDYT), Buenos Aires, Argentina
| | | | - Madhav Desai
- Division of Gastroenterology, VA Medical Center and University of Kansas School of Medicine, Kansas City, Missouri
| | - Mário Dinis-Ribeiro
- MEDCIDS-Department of Community Medicine, Information and Decision in Health, Faculty of Porto, University of Medicine, Porto, Portugal
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Srinivas Gaddam
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kenichi Goda
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Seth Gross
- Division of Gastroenterology, NYU Langone Medical Center, New York, New York
| | - Rehan Haidry
- Department of Gastrointestinal and Endoscopy, University College London Hospital, London, UK
| | - Lawrence Ho
- Division of Gastroenterology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Sergey Kashin
- Department of Gastroenterology, Yaroslavl Oncology Hospital, Yaroslavl, Russian Federation
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center and Strong Memorial Hospital, Rochester, New York; Developmental Endoscopy, Lab at University of Rochester (DELUR), University of Rochester Medical, Rochester, New York
| | - Yeong Yeh Lee
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Koji Matsuda
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, Kawasaki, Japan
| | - Horst Neuhaus
- Department of Internal Medicine, Gastroenterology and Interventional Endoscopy, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan
| | - Krish Ragunath
- Department of Gastroenterology, Curtin University Medical School, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy; Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Nicholas Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rajvinder Singh
- Department of Gastroenterology, The Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Sergio Sobrino-Cossio
- Unidad de Endoscopia y Fisiología Digestiva, Hospital Ángeles del Pedregal, México DF, México
| | - Kenneth K Wang
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Irving Waxman
- Division of Gastroenterology, University of Chicago Medical Center, Chicago, Illinois
| | - Prateek Sharma
- Division of Gastroenterology, VA Medical Center and University of Kansas School of Medicine, Kansas City, Missouri
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9
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Martínez-Domínguez SJ, Lanas Á, Domper-Arnal MJ. Esófago de Barrett, hacia la mejora de la práctica clínica. Med Clin (Barc) 2022; 159:92-100. [DOI: 10.1016/j.medcli.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
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10
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Ishimura N, Okimoto E, Shibagaki K, Ishihara S. Endoscopic diagnosis and screening of Barrett's esophagus: Inconsistency of diagnostic criteria between Japan and Western countries. DEN OPEN 2022; 2:e73. [PMID: 35310704 PMCID: PMC8828243 DOI: 10.1002/deo2.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/10/2021] [Accepted: 10/16/2021] [Indexed: 11/11/2022]
Abstract
Barrett's esophagus (BE) is an endoscopically identifiable premalignant condition for esophageal adenocarcinoma (EAC). To diagnose BE precisely, careful inspection of the anatomic landmarks, including the esophagogastric junction and the squamocolumnar junction is important. The distal end of the palisade vessels and the proximal end of the gastric folds are used as the landmark of the esophagogastric junction in endoscopic diagnosis, with the latter solely used internationally, except in some Asian countries, including Japan. In addition, the diagnostic criteria adopted internationally for BE are inconsistent, particularly between Japan and Western countries. Recently updated guidelines in Western countries have included length criteria, with a 1‐cm threshold of columnar epithelium by endoscopic observation and/or histologic confirmation of the presence of specialized intestinal metaplasia. Since BE is endoscopically diagnosed at any length without histologic assessment in Japan, the reported prevalence of short‐segment BE is very high in Japan compared with that in Western countries. Although guidelines on screening exist for BE, the current strategies based on the presence of chronic gastroesophageal reflux disease with multiple risk factors may miss the opportunity for early detection of EAC. Indeed, up to 40% of patients with EAC have no history of chronic gastroesophageal reflux disease. To discuss BE on the same footing worldwide, standardization of diagnostic criteria, screening indication, and establishment of effective techniques for detecting dysplastic lesions are eagerly awaited. Japanese guidelines for BE should be revised regarding the length criteria, including the minimum length and long‐segment BE, in line with the recently updated Western guidelines.
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Affiliation(s)
- Norihisa Ishimura
- Second Department of Internal Medicine Shimane University Faculty of Medicine Shimane Japan
| | - Eiko Okimoto
- Second Department of Internal Medicine Shimane University Faculty of Medicine Shimane Japan
| | - Kotaro Shibagaki
- Division of Gastrointestinal Endoscopy Shimane University Hospital Shimane Japan
| | - Shunji Ishihara
- Second Department of Internal Medicine Shimane University Faculty of Medicine Shimane Japan
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11
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Marabotto E, Pellegatta G, Sheijani AD, Ziola S, Zentilin P, De Marzo MG, Giannini EG, Ghisa M, Barberio B, Scarpa M, Angriman I, Fassan M, Savarino V, Savarino E. Prevention Strategies for Esophageal Cancer-An Expert Review. Cancers (Basel) 2021; 13:cancers13092183. [PMID: 34062788 PMCID: PMC8125297 DOI: 10.3390/cancers13092183] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary In the last decades, there has been a rapid increase in the incidence and prevalence of esophageal cancer in many countries around the world. Although several important risk factors have been identified, strong evidence-based preventive strategies are still lacking, and the prognosis of patients diagnosed with esophageal cancer remains poor, with an average survival rate of 5 years for only 20%. This review is an attempt to summarize the epidemiology and risk factors of EC and to highlight the unresolved aspects of current prevention strategies in order to plan more fruitful future initiatives aimed at ameliorating the disappointing prognosis of this kind of digestive tumor. Abstract In the last 30 years, we have witnessed a rapid increase in the incidence and prevalence of esophageal cancer in many countries around the word. However, despite advancements in diagnostic technologies, the early detection of this cancer is rare, and its prognosis remains poor, with only about 20% of these patients surviving for 5 years. The two major forms are the esophageal squamous cell carcinoma (ESCC), which is particularly frequent in the so-called Asian belt, and the esophageal adenocarcinoma (EAC), which prevails in Western populations. This review provides a summary of the epidemiological features and risk factors associated with these tumors. Moreover, a major focus is posed on reporting and highlighting the various preventing strategies proposed by the most important international scientific societies, particularly in high-risk populations, with the final aim of detecting these lesions as early as possible and therefore favoring their definite cure. Indeed, we have conducted analysis with attention to the current primary, secondary and tertiary prevention guidelines in both ESCC and EAC, attempting to emphasize unresolved research and clinical problems related to these topics in order to improve our diagnostic strategies and management.
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Affiliation(s)
- Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (P.Z.); (M.G.D.M.); (E.G.G.); (V.S.)
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy;
| | - Afscin Djahandideh Sheijani
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (P.Z.); (M.G.D.M.); (E.G.G.); (V.S.)
| | - Sebastiano Ziola
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (P.Z.); (M.G.D.M.); (E.G.G.); (V.S.)
| | - Patrizia Zentilin
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (P.Z.); (M.G.D.M.); (E.G.G.); (V.S.)
| | - Maria Giulia De Marzo
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (P.Z.); (M.G.D.M.); (E.G.G.); (V.S.)
| | - Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (P.Z.); (M.G.D.M.); (E.G.G.); (V.S.)
| | - Matteo Ghisa
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (M.G.); (B.B.)
| | - Brigida Barberio
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (M.G.); (B.B.)
| | - Marco Scarpa
- Clinica Chirurgica 1, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (M.S.); (I.A.)
| | - Imerio Angriman
- Clinica Chirurgica 1, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (M.S.); (I.A.)
| | - Matteo Fassan
- Department of Medicine (DIMED), Surgical Pathology & Cytopathology Unit, University of Padua, 35121 Padua, Italy;
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (E.M.); (A.D.S.); (S.Z.); (P.Z.); (M.G.D.M.); (E.G.G.); (V.S.)
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (M.G.); (B.B.)
- Correspondence:
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12
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Kolb JM, Wani S. Barrett's esophagus: current standards in advanced imaging. Transl Gastroenterol Hepatol 2021; 6:14. [PMID: 33409408 DOI: 10.21037/tgh.2020.02.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/21/2020] [Indexed: 12/13/2022] Open
Abstract
Esophageal adenocarcinoma (EAC) continues to be one of the fastest rising incident cancers in the Western population with the majority of patients presenting with late stage disease and associated with a dismal 5-year survival rate. Barrett's esophagus (BE) is the only identifiable precursor lesion to EAC. Strategies to screen for and survey BE are critical to detect earlier cancers and reduce morbidity and mortality related to EAC. A high-quality endoscopic examination with careful inspection of the Barrett's segment and adherence to the Seattle protocol for tissue sampling are critical. Advanced imaging modalities offer the potential to improve dysplasia detection, predict histopathology in real time and guide endoscopic eradication therapy (EET). Several technologies have been studied and although most are not yet recommended for routine clinical practice, high definition white light endoscopy (HD-WLE) as well as chromoendoscopy (including virtual chromoendoscopy) improved dysplasia detection in numerous studies supporting their use. Future studies should evaluate the role of artificial intelligence in optimizing detection of dysplasia in BE patients.
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Affiliation(s)
- Jennifer M Kolb
- Division of Gastroenterology & Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology & Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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13
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Abstract
Barrett's esophagus is the precursor lesion for esophageal adenocarcinoma. The goals of endoscopic surveillance are to detect dysplasia and early esophageal adenocarcinoma in order to improve patient outcomes. Despite the ongoing debate regarding the efficacy of surveillance, all current gastrointestinal societies recommend surveillance at this time. Optimal surveillance technique includes adequate inspection time, evaluation using high-definition white light and chromoendoscopy, appropriate documentation of the metaplastic segment using the Prague C & M criteria as well as the Paris classification should lesions be found, utilization of the Seattle biopsy protocol, and endoscopic resection of visible lesions.
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Affiliation(s)
- Joseph R. Triggs
- Clinical Instructor, Division of Gastroenterology. Hospital of the University of Pennsylvania. University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gary W. Falk
- Professor of Medicine, Division of Gastroenterology, Hospital of the University of Pennsylvania. University of Pennsylvania Perelman School of Medicine Pennsylvania, Philadelphia, PA, USA
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14
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Sehgal V, Ragunath K, Haidry R. Measuring Quality in Barrett's Esophagus: Time to Embrace Quality Indicators. Gastrointest Endosc Clin N Am 2021; 31:219-236. [PMID: 33213797 DOI: 10.1016/j.giec.2020.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic eradication therapy is a safe and effective therapy that has revolutionized the management of patients with Barrett's esophagus (BE)-related neoplasia. Despite this, there remains significant heterogeneity in clinical practice with consequent variation in patient outcomes. The aim of this article was to align consensus statements based on the best available evidence and expert opinion from the United States and United Kingdom to develop robust and measurable quality indicators that help to ensure patients with BE-related neoplasia receive the highest possible quality of care uniformly.
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Affiliation(s)
- Vinay Sehgal
- Department of Gastroenterology and Endoscopy, University College London Hospitals NHS Foundation Trust, Ground Floor West, 250 Euston Road, London NW1 2PG, UK.
| | - Krish Ragunath
- Department of Gastroenterology, Curtin University Medical School, Royal Perth Hospital, Victoria Square, Perth, Western Australia 6000, Australia
| | - Rehan Haidry
- Department of Gastroenterology and Endoscopy, University College London Hospitals NHS Foundation Trust, Ground Floor West, 250 Euston Road, London NW1 2PG, UK
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15
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Badgery H, Read M, Winter NN, Taylor ACF, Hii MW. The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia. Ann N Y Acad Sci 2020; 1481:72-89. [PMID: 32812261 DOI: 10.1111/nyas.14439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/12/2020] [Accepted: 06/24/2020] [Indexed: 12/19/2022]
Abstract
Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.
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Affiliation(s)
- Henry Badgery
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Matthew Read
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Nicole N Winter
- Department of Upper Gastrointestinal Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Andrew C F Taylor
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, the University of Melbourne, Melbourne, Victoria, Australia
| | - Michael W Hii
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
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16
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Abstract
Because of the rising incidence and lethality of esophageal adenocarcinoma, Barrett's esophagus (BE) is an increasingly important premalignant target for cancer prevention. BE-associated neoplasia can be safely and effectively treated with endoscopic eradication therapy (EET), incorporating tissue resection and ablation. Because EET has proliferated, managing patients after complete eradication of intestinal metaplasia has taken on increasing importance. Recurrence after complete eradication of intestinal metaplasia occurs in 8%-10% of the patients yearly, and the incidence may remain constant over time. Most recurrences occur at the gastroesophageal junction, whereas those in the tubular esophagus are endoscopically visible and distally located. A simplified biopsy protocol limited to the distal aspect of the BE segment, in addition to gastroesophageal junction sampling, may enhance efficiency and cost without significantly reducing recurrence detection. Similarly, research suggests that current surveillance intervals may be excessively frequent, failing to reflect the cancer risk reduction of EET. If validated, longer surveillance intervals could reduce the burden of resource-intensive endoscopic surveillance. Several important questions in post-EET management remain unanswered, including surveillance duration, the significance of gastric cardia intestinal metaplasia, and the role of advanced imaging and nonendoscopic sampling techniques in detecting recurrence. These merit further research to enhance quality of care and promote a more evidence-based approach.
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17
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Houston T, Sharma P. Volumetric laser endomicroscopy in Barrett's esophagus: ready for primetime. Transl Gastroenterol Hepatol 2020; 5:27. [PMID: 32258531 DOI: 10.21037/tgh.2019.11.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/14/2019] [Indexed: 12/20/2022] Open
Abstract
Barrett's esophagus (BE) is the condition where intestinal metaplastic changes are found in the normal stratified squamous epithelium of the esophagus predisposing an individual to dysplasia and esophageal adenocarcinoma (EAC). It tends to affect males and is often the result of chronic gastroesophageal reflux disease (GERD). The current standard of therapy for diagnosing Barrett's is white light endoscopy (WLE) with biopsies obtained using the Seattle protocol. Multiple newer advanced modalities have been developed to improve diagnostic abilities, including volumetric laser endomicroscopy (VLE). This technique utilizes second generation optical coherence tomography (OCT) to provide an enhanced circumferential image to a depth of 3 mm with the potential for improved diagnostic yield for dysplasia, particularly submucosal lesions or lesions not seen by WLE. It has also been evaluated in guiding mapping of endotherapy as well as post therapy surveillance for recurrence. Although the results have been promising when used with current diagnostic standards, overall data are limited to support the routine use of VLE.
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Affiliation(s)
- Trevor Houston
- Department of Internal Medicine, University of Nevada, Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Prateek Sharma
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, KS, USA
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18
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Nachiappan A, Ragunath K, Card T, Kaye P. Diagnosing dysplasia in Barrett's oesophagus still requires Seattle protocol biopsy in the era of modern video endoscopy: results from a tertiary centre Barrett's dysplasia database. Scand J Gastroenterol 2020; 55:9-13. [PMID: 31880176 DOI: 10.1080/00365521.2019.1706762] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: The role of random, four-quadrant biopsy (i.e. systematic biopsy) in Barrett's oesophagus surveillance has been questioned given its drawbacks and the emergence of high-resolution endoscopy and advanced imaging modalities. Our study aims to assess whether neoplastic pathology is typically diagnosed in routine clinical practice by random, four-quadrant or targeted biopsy whilst using high-resolution endoscopy.Methods: The Nottingham University Hospital Barrett's oesophagus dysplasia database was retrospectively analysed. Endoscopic and histopathologic data pertaining to the initial endoscopy in which pathology was diagnosed was extracted from the medical records. The most advanced histopathologic abnormality at initial diagnosis and within twelve months were noted. The corresponding endoscopic impression at initial diagnosis was used to group cases per type of biopsy - random, four-quadrant or targeted. Pearson's χ2 test of independence was used to analyse the relationship between the type of biopsy and diagnosis, indication for endoscopy, endoscopist level and advanced techniques used.Results: Of the 222 patients involved in the study - a higher proportion were diagnosed through random, four-quadrant biopsy (72.97%) than targeted biopsy (27.03%). 90.91% of low-grade dysplasia, 71.43% of high-grade dysplasia and 50% of intramucosal adenocarcinoma cases were diagnosed by random, four-quadrant biopsy. Across all grades of clinicians, patients were typically diagnosed through random, four-quadrant biopsy. However, amongst specialist consultant endoscopists (n = 10) the proportion was equal.Conclusions: Our findings strongly emphasize the importance of random, four-quadrant biopsy in the detection of not only low-grade dysplasia, but also high-grade dysplasia and early invasive carcinoma as part of Barrett's oesophagus surveillance.
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Affiliation(s)
- Arun Nachiappan
- Department of Gastroenterology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Krish Ragunath
- Department of Gastroenterology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,NIHR Nottingham Digestive Diseases and Biomedical Research Centre, Nottingham, UK
| | - Timothy Card
- Department of Gastroenterology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,NIHR Nottingham Digestive Diseases and Biomedical Research Centre, Nottingham, UK
| | - Philip Kaye
- NIHR Nottingham Digestive Diseases and Biomedical Research Centre, Nottingham, UK.,Department of Histopathology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
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19
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Ahmed O, Ajani JA, Lee JH. Endoscopic management of esophageal cancer. World J Gastrointest Oncol 2019; 11:830-841. [PMID: 31662822 PMCID: PMC6815921 DOI: 10.4251/wjgo.v11.i10.830] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/29/2019] [Accepted: 08/28/2019] [Indexed: 02/05/2023] Open
Abstract
Esophageal cancer (EC) generally consists of squamous cell carcinoma (which arise from squamous epithelium) and adenocarcinoma (which arise from columnar epithelium). Due to the increased recognition of risk factors associated with EC and the development of screening programs, there has been an increase in the diagnosis of early EC. Early EC is amenable to curative therapy by endoscopy, which can be performed by either endoscopic resection or endoscopic ablation. Endoscopic resection consists of either endoscopic mucosal resection (preferred in cases of adenocarcinoma) or endoscopic submucosal dissection (preferred in cases of squamous cell carcinoma). Endoscopic ablation can be performed by either radiofrequency ablation, cryotherapy, argon plasma coagulation or photodynamic therapy, amongst others. Endoscopy can also assist in the management of complications post-esophageal surgery, such as anastomotic leaks and perforations. Finally, there is a growing role for endoscopy to manage end-of-life palliative symptoms, especially dysphagia. The growing use of esophageal stents, debulking therapy and dilation can assist in improving a patient’s quality of life. In this review, we examine the multiple roles of endoscopy in the management of patients with EC.
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Affiliation(s)
- Osman Ahmed
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Jaffer A Ajani
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
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20
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Cholapranee A, Trindade AJ. Challenges in Endoscopic Therapy of Dysplastic Barrett's Esophagus. ACTA ACUST UNITED AC 2019; 17:32-47. [PMID: 30663018 DOI: 10.1007/s11938-019-00215-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Barrett's esophagus (BE) is the only known measurable factor associated with esophageal adenocarcinoma. The development of endoscopic eradication therapy (EET) has transformed the way BE is managed. Given the fairly recent development of EET, its role in BE is still evolving. RECENT FINDINGS This paper discusses the challenges that endoscopists face at the preprocedural, intraprocedural, and postprocedural stages of BE management. These include challenges in risk stratification, dysplasia detection, ablation methods and dosimetry, choice of resection technique, and management of refractory disease. Despite the advances in EET in BE, there remain challenges that this review focuses on. Future research into these challenges will optimize ablation techniques and strategies in the future.
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Affiliation(s)
- Aurada Cholapranee
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA.
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21
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Braden B, Jones-Morris E. How to get the most out of costly Barrett's oesophagus surveillance. Dig Liver Dis 2018; 50:871-877. [PMID: 29730158 DOI: 10.1016/j.dld.2018.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 12/11/2022]
Abstract
Current endoscopic surveillance protocols for Barrett's oesophagus have several limitations, mainly the poor cost-effectiveness and high miss rate. However, there is sufficient evidence that patients enrolled in a surveillance program have better survival chances of oesophageal cancer due to earlier tumor stages at diagnosis compared to patients with de novo diagnosed oesophagus cancer. Risk stratifications aim to identify patients at highest risk of developing adenocarcinoma of the oesophagus; most of them base on the length of the Barrett's segment and the presence of dysplasia. This review discusses prognostic factors and provides practical guidance on how to improve the efficacy and outcome in Barrett's surveillance programs.
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Affiliation(s)
- Barbara Braden
- Translation Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Evonne Jones-Morris
- Translation Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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22
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Machine Learning Creates a Simple Endoscopic Classification System that Improves Dysplasia Detection in Barrett's Oesophagus amongst Non-expert Endoscopists. Gastroenterol Res Pract 2018; 2018:1872437. [PMID: 30245711 PMCID: PMC6136585 DOI: 10.1155/2018/1872437] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/23/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction Barrett's oesophagus (BE) is a precursor to oesophageal adenocarcinoma (OAC). Endoscopic surveillance is performed to detect dysplasia arising in BE as it is likely to be amenable to curative treatment. At present, there are no guidelines on who should perform surveillance endoscopy in BE. Machine learning (ML) is a branch of artificial intelligence (AI) that generates simple rules, known as decision trees (DTs). We hypothesised that a DT generated from recognised expert endoscopists could be used to improve dysplasia detection in non-expert endoscopists. To our knowledge, ML has never been applied in this manner. Methods Video recordings were collected from patients with non-dysplastic (ND-BE) and dysplastic Barrett's oesophagus (D-BE) undergoing high-definition endoscopy with i-Scan enhancement (PENTAX®). A strict protocol was used to record areas of interest after which a corresponding biopsy was taken to confirm the histological diagnosis. In a blinded manner, videos were shown to 3 experts who were asked to interpret them based on their mucosal and microvasculature patterns and presence of nodularity and ulceration as well as overall suspected diagnosis. Data generated were entered into the WEKA package to construct a DT for dysplasia prediction. Non-expert endoscopists (gastroenterology specialist registrars in training with variable experience and undergraduate medical students with no experience) were asked to score these same videos both before and after web-based training using the DT constructed from the expert opinion. Accuracy, sensitivity, and specificity values were calculated before and after training where p < 0.05 was statistically significant. Results Videos from 40 patients were collected including 12 both before and after acetic acid (ACA) application. Experts' average accuracy for dysplasia prediction was 88%. When experts' answers were entered into a DT, the resultant decision model had a 92% accuracy with a mean sensitivity and specificity of 97% and 88%, respectively. Addition of ACA did not improve dysplasia detection. Untrained medical students tended to have a high sensitivity but poor specificity as they "overcalled" normal areas. Gastroenterology trainees did the opposite with overall low sensitivity but high specificity. Detection improved significantly and accuracy rose in both groups after formal web-based training although it did it reach the accuracy generated by experts. For trainees, sensitivity rose significantly from 71% to 83% with minimal loss of specificity. Specificity rose sharply in students from 31% to 49% with no loss of sensitivity. Conclusion ML is able to define rules learnt from expert opinion. These generate a simple algorithm to accurately predict dysplasia. Once taught to non-experts, the algorithm significantly improves their rate of dysplasia detection. This opens the door to standardised training and assessment of competence for those who perform endoscopy in BE. It may shorten the learning curve and might also be used to compare competence of trainees with recognised experts as part of their accreditation process.
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23
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Komanduri S, Muthusamy VR, Wani S. Controversies in Endoscopic Eradication Therapy for Barrett's Esophagus. Gastroenterology 2018; 154:1861-1875.e1. [PMID: 29458152 DOI: 10.1053/j.gastro.2017.12.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/05/2017] [Accepted: 12/20/2017] [Indexed: 02/07/2023]
Abstract
Advances in endoscopic eradication therapy for Barrett's Esophagus-associated neoplasia have resulted in a significant paradigm shift in the diagnosis and management of this complex disease. A robust body of literature critically evaluating outcomes of resection and ablative strategies has allowed gastroenterologists to make quality, evidence-based decisions for their patients. Despite this progress, there are still many unanswered questions and challenges that remain. Ultimately, identification of a cost-effective screening modality, biomarkers for risk stratification, and strides to eliminate post surveillance endoscopy after endoscopic eradication therapy are essential to reach our long-term goal for eradication of esophageal adenocarcinoma.
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Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois.
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Qiu L, Chuttani R, Pleskow DK, Turzhitsky V, Khan U, Zakharov YN, Zhang L, Berzin TM, Yee EU, Sawhney MS, Li Y, Vitkin E, Goldsmith JD, Itzkan I, Perelman LT. Multispectral light scattering endoscopic imaging of esophageal precancer. LIGHT, SCIENCE & APPLICATIONS 2018; 7:17174. [PMID: 30839534 PMCID: PMC6060057 DOI: 10.1038/lsa.2017.174] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 05/14/2023]
Abstract
Esophageal adenocarcinoma is the most rapidly growing cancer in America. Although the prognosis after diagnosis is unfavorable, the chance of a successful outcome increases tremendously if detected early while the lesion is still dysplastic. Unfortunately, the present standard-of-care, endoscopic surveillance, has major limitations, since dysplasia is invisible, often focal, and systematic biopsies typically sample less than one percent of the esophageal lining and therefore easily miss malignancies. To solve this problem we developed a multispectral light scattering endoscopic imaging system. It surveys the entire esophageal lining and accurately detects subcellular dysplastic changes. The system combines light scattering spectroscopy, which detects and identifies invisible dysplastic sites by analyzing light scattered from epithelial cells, with rapid scanning of the entire esophageal lining using a collimated broadband light beam delivered by an endoscopically compatible fiber optic probe. Here we report the results of the first comprehensive multispectral imaging study, conducted as part of routine endoscopic procedures performed on patients with suspected dysplasia. In a double-blind study that characterized the system's ability to serve as a screening tool, 55 out of 57 patients were diagnosed correctly. In addition, a smaller double-blind comparison of the multispectral data in 24 patients with subsequent pathology at locations where 411 biopsies were collected yielded an accuracy of 90% in detecting individual locations of dysplasia, demonstrating the capability of this method to serve as a guide for biopsy.
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Affiliation(s)
- Le Qiu
- Center for Advanced Biomedical Imaging and Photonics, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Ram Chuttani
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Douglas K Pleskow
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Vladimir Turzhitsky
- Center for Advanced Biomedical Imaging and Photonics, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Umar Khan
- Center for Advanced Biomedical Imaging and Photonics, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Yuri N Zakharov
- Center for Advanced Biomedical Imaging and Photonics, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Lei Zhang
- Center for Advanced Biomedical Imaging and Photonics, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Tyler M Berzin
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Eric U Yee
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Yunping Li
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Edward Vitkin
- Center for Advanced Biomedical Imaging and Photonics, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Jeffrey D Goldsmith
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Irving Itzkan
- Center for Advanced Biomedical Imaging and Photonics, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
| | - Lev T Perelman
- Center for Advanced Biomedical Imaging and Photonics, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA
- Biological and Biomedical Sciences Program, Harvard University, Boston, MA 02215, USA
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Wani S, Muthusamy VR, Shaheen NJ, Yadlapati R, Wilson R, Abrams JA, Bergman J, Chak A, Chang K, Das A, Dumot J, Edmundowicz SA, Eisen G, Falk GW, Fennerty MB, Gerson L, Ginsberg GG, Grande D, Hall M, Harnke B, Inadomi J, Jankowski J, Lightdale CJ, Makker J, Odze RD, Pech O, Sampliner RE, Spechler S, Triadafilopoulos G, Wallace MB, Wang K, Waxman I, Komanduri S. Development of Quality Indicators for Endoscopic Eradication Therapies in Barrett's Esophagus: The TREAT-BE (Treatment With Resection and Endoscopic Ablation Techniques for Barrett's Esophagus) Consortium. Am J Gastroenterol 2017; 112:1032-1048. [PMID: 28570552 DOI: 10.1038/ajg.2017.166] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - V Raman Muthusamy
- University of California in Los Angeles, Los Angeles, California, USA
| | | | | | - Robert Wilson
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | | | | | | | - Kenneth Chang
- University of California in Irvine, Irvine, California, USA
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona, USA
| | - John Dumot
- University Hospitals, Cleveland, Ohio, USA
| | | | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Lauren Gerson
- California Pacific Medical Center, San Francisco, California, USA
| | - Gregory G Ginsberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Matt Hall
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Ben Harnke
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John Inadomi
- University of Washington, Seattle, Washington, USA
| | | | | | - Jitin Makker
- University of California in Los Angeles, Los Angeles, California, USA
| | - Robert D Odze
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Oliver Pech
- St. John of God Hospital, Regensburg, Germany
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Development of quality indicators for endoscopic eradication therapies in Barrett's esophagus: the TREAT-BE (Treatment with Resection and Endoscopic Ablation Techniques for Barrett's Esophagus) Consortium. Gastrointest Endosc 2017; 86:1-17.e3. [PMID: 28576294 DOI: 10.1016/j.gie.2017.03.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
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Pant C, Olyaee MS, Rastogi A. Advanced imaging and therapeutic endoscopy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Han S, Wani S. Quality Indicators in Endoscopic Ablation for Barrett's Esophagus. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2017; 15:241-255. [PMID: 28421454 DOI: 10.1007/s11938-017-0136-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT Barrett's esophagus (BE) is a well-established premalignant condition for esophageal adenocarcinoma (EAC); a cancer that is associated with a poor 5-year survival rate. Several strategies have been explored in the context of reducing the burden of EAC. Endoscopic eradication therapy (EET) is considered the standard of care for the management of patients with BE with dysplasia and early neoplasia; a practice that has been endorsed by all gastroenterology societal guidelines. The effectiveness of EET has been demonstrated in multiple studies and contemporary management includes a combination of endoscopic mucosal resection (EMR) of all visible lesions followed by eradication of the remaining BE using ablative techniques of which radiofrequency ablation (RFA) has the best evidence supporting effectiveness and safety. These techniques are being used increasingly at academic tertiary care centers and community practices. In this era of value-based health care, there is increased focus on the establishment, documentation, and reporting of quality indicators; indicators that are important to physicians, patients, and payers. The purpose of this review is to highlight the current status of quality indicators in EET for the management of patients with BE-related neoplasia and discuss the future steps required to ensure that these quality indicators are uniformly incorporated into practice.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Rm 2.031, Aurora, CO, 80045, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Rm 2.031, Aurora, CO, 80045, USA.
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Muñoz-Largacha JA, Fernando HC, Litle VR. Optimizing the diagnosis and therapy of Barrett's esophagus. J Thorac Dis 2017; 9:S146-S153. [PMID: 28446978 DOI: 10.21037/jtd.2017.01.58] [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: 12/13/2022]
Abstract
The incidence of Barrett's esophagus (BE) in the Western world has increased over the last decades. BE is considered a premalignant lesion that can progress to esophageal adenocarcinoma (EAC), a highly aggressive malignancy with poor survival rates. The close association between BE and EAC highlights the need for an early diagnosis in order to improve survival and outcomes in this group of patients. Although the evidence for BE screening with conventional endoscopy is controversial and limited by cost-effectiveness studies, screening can be suggested in patients with chronic gastroesophageal reflux disease (GERD) and two or more risk factors for EAC. Less invasive techniques with lower costs and higher acceptability by the patients may be useful for screening in the general population. Several novel techniques have been described to aid in the early diagnosis and management of BE and dysplasia. However, these techniques have shown variable results with higher costs, the need of specific training, and variable inter-observer imaging interpretation, making its widespread implementation problematic. High-definition/high-resolution white-light endoscopy (WLE) continues to be a well-accepted technique for the evaluation and surveillance of patients with BE. Further studies are required in order to establish the efficacy of less invasive methods that can be performed in an outpatient setting for BE screening in higher risk individuals.
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Affiliation(s)
- Juan A Muñoz-Largacha
- Division of Thoracic Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Hiran C Fernando
- Division of Thoracic Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Virginia R Litle
- Division of Thoracic Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA, USA
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Triadafilopoulos G, Akiyama J. Emerging endoscopic techniques for the identification of esophageal disease. Expert Rev Gastroenterol Hepatol 2017; 10:605-13. [PMID: 26753504 DOI: 10.1586/17474124.2016.1140037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Esophageal diseases, both benign and malignant, impose an increasing burden to global health. In the West, gastroesophageal reflux disease (GERD) and Barrett's esophagus are increasing in prevalence and impact. In the East, squamous esophageal cancer remains a large burden, but increasingly, precancerous lesions related to GERD are recognized. We review the various advanced endoscopic techniques that have been developed to improve the accuracy of endoscopic identification of esophageal disease. These techniques are designed to increase the sensitivity of detecting disease and high-risk lesions, enable targeted biopsies, decrease total number of biopsies and costs for surveillance, but also guide therapy in real-time. After proper clinical validation, the widespread use of these technologies will lead to improved outcomes, mostly in cancer prevention.
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Affiliation(s)
- George Triadafilopoulos
- a School of Medicine, Division of Gastroenterology & Hepatology , Stanford University , Stanford , CA , USA
| | - Junichi Akiyama
- b Division of Gastroenterology , National Center for Global Health and Medicine , Tokyo , Japan
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Abstract
Barrett esophagus (BE) is the only identifiable premalignant condition for esophageal adenocarcinoma (EAC), a cancer associated with a poor 5-year survival rate. The stepwise pathologic progression of BE to invasive cancer provides an opportunity to halt progression and potentially decrease incidence and ultimately the morbidity and mortality related to this lethal cancer. Endoscopic eradication therapy (EET) in patients at increased risk of progression to invasive EAC (intramucosal EAC, high-grade dysplasia, and low-grade dysplasia) is a practice that is endorsed by multiple societies and has replaced esophagectomy as the standard of care for these patients. Although the effectiveness, safety, and durability of EET have been demonstrated in several studies, this review addresses the several challenges with EET that need to be considered to optimize patient outcomes. Finally, the critical role of training, competence, and quality indicators in EET are emphasized in this era of value-based health care practice.
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Evans RPT, Mourad MM, Fisher SG, Bramhall SR. Evolving management of metaplasia and dysplasia in Barrett's epithelium. World J Gastroenterol 2016; 22:10316-10324. [PMID: 28058012 PMCID: PMC5175244 DOI: 10.3748/wjg.v22.i47.10316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/30/2016] [Accepted: 12/02/2016] [Indexed: 02/06/2023] Open
Abstract
Oesophageal cancer affects more than 450000 people worldwide and despite continued medical advancements the incidence of oesophageal cancer is increasing. Oesophageal cancer has a 5 year survival of 15%-25% and now globally attempts are made to more aggressively diagnose and treat Barrett's oesophagus the known precursor to invasive disease. Currently diagnosis the of Barrett's oesophagus is predominantly made after endoscopic visualisation and histopathological confirmation. Minimally invasive techniques are being developed to improve the viability of screening programs. The management of Barrett's oesophagus can vary greatly dependent on the presence and severity of dysplasia. There is no consensus between the major international medical societies to determine and agreed surveillance and intervention pathway. In this review we analysed the current literature to demonstrate the evolving management of metaplasia and dysplasia in Barrett's epithelium.
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Abstract
Incidence of oesophageal adenocarcinoma has increased exponentially in the West over the past few decades. Following detection of advanced cancers, 5-year survival rates remain bleak, making identification of early neoplasia, which has a better outcome, important. Detection of subtle oesophageal lesions during endoscopy can be challenging, and advanced imaging techniques might improve their detection. High-definition endoscopy has become a standard in most endoscopy centres, and this technology probably provides better delineation of mucosal features than standard-definition endoscopy. Various image enhancement techniques are now available with the development of new electronics and software systems. Image enhancement with chromoendoscopy using dyes has been a cost-effective option for many years, yet these techniques have been replaced in some contexts by electronic chromoendoscopy, which can be used with the press of a button. However, Lugol's chromoendoscopy remains the gold standard to identify squamous dysplasia. Identification and characterization of subtle neoplastic lesions could help to target biopsies and perform endoscopic resection for better local staging and definitive therapy. In vivo histology with techniques such as confocal endomicroscopy could make endotherapy feasible within a shorter timescale than when relying on histology on tissue samples. Once early neoplasia is identified, treatments include endoscopic resection, endoscopic submucosal dissection or various ablative techniques. Endotherapy has the advantage of being a less invasive technique than oesophagectomy, and is associated with lower mortality and morbidity. Endoscopic ablation therapies have evolved over the past few years, with radiofrequency ablation showing the best results in terms of success rates and complications in Barrett dysplasia.
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Naveed M, Dunbar KB. Endoscopic imaging of Barrett’s esophagus. World J Gastrointest Endosc 2016; 8:259-266. [PMID: 26981177 PMCID: PMC4781906 DOI: 10.4253/wjge.v8.i5.259] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 09/14/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
The incidence of esophageal adenocarcinoma (EAC) has dramatically increased in the United States as well as Western European countries. The majority of esophageal adenocarcinomas arise from a backdrop of Barrett’s esophagus (BE), a premalignant lesion that can lead to dysplasia and cancer. Because of the increased risk of EAC, GI society guidelines recommend endoscopic surveillance of patients with BE. The emphasis on early detection of dysplasia in BE through surveillance endoscopy has led to the development of advanced endoscopic imaging technologies. These techniques have the potential to both improve mucosal visualization and characterization and to detect small mucosal abnormalities which are difficult to identify with standard endoscopy. This review summarizes the advanced imaging technologies used in evaluation of BE.
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Coletta M, Sami SS, Nachiappan A, Fraquelli M, Casazza G, Ragunath K. Acetic acid chromoendoscopy for the diagnosis of early neoplasia and specialized intestinal metaplasia in Barrett's esophagus: a meta-analysis. Gastrointest Endosc 2016; 83:57-67.e1. [PMID: 26371851 DOI: 10.1016/j.gie.2015.07.023] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 07/12/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Barrett's esophagus (BE) surveillance with random biopsies is time-consuming, invasive, and can lead to sampling error. Acetic acid chromoendoscopy (AAC) with targeted biopsies has been proposed as an effective alternative. The aim of this study was to assess the diagnostic accuracy of AAC for the detection of early neoplasia (high-grade dysplasia [HGD] or early cancer [EC]) and specialized intestinal metaplasia (SIM) in patients with BE. METHODS We performed a meta-analysis of all primary studies that compared AAC-based diagnoses (index test) with histopathology as the reference standard. The data were extracted on a per-patient, per-area, and per-procedure basis whenever available. RESULTS Thirteen prospective studies met the inclusion criteria. For the diagnosis of HGD/EC, the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for all included studies (9 studies, 1379 patients) were 0.92 (95% confidence interval [CI], 0.83-0.97), 0.96 (95% CI, 0.85-0.99), 25.0 (95% CI, 5.9-105.3), and 0.08 (95% CI, 0.04-0.18), respectively. Results were not significantly different when considering only studies with a per-patient analysis. For the characterization of SIM, the pooled sensitivity, specificity, LR+, and LR- for all the included studies (8 studies, 516 patients) were 0.96 (95% CI, 0.83-0.99), 0.69 (95% CI, 0.54-0.81), 3.0 (95% CI, 2.0-4.7), and 0.06 (95% CI, 0.01-0.26), respectively. No significant sources of heterogeneity were identified on subgroup analysis. CONCLUSION AAC has an overall high diagnostic accuracy for detecting HGD/EC in patients with BE. For SIM characterization, AAC sensitivity is very high but has poor specificity, suggesting that histological confirmation is necessary when AAC is positive.
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Affiliation(s)
- Marina Coletta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Sarmed S Sami
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Arun Nachiappan
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
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Greening GJ, Powless AJ, Hutcheson JA, Prieto SP, Majid AA, Muldoon TJ. Design and validation of a diffuse reflectance and spectroscopic microendoscope with poly(dimethylsioxane)-based phantoms. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2015; 9332:93320R. [PMID: 25983372 DOI: 10.1117/12.2076300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Many cases of epithelial cancer originate in basal layers of tissue and are initially undetected by conventional microendoscopy techniques. We present a bench-top, fiber-bundle microendoscope capable of providing high resolution images of surface cell morphology. Additionally, the microendoscope has the capability to interrogate deeper into material by using diffuse reflectance and broadband diffuse reflectance spectroscopy. The purpose of this multimodal technique was to overcome the limitation of microendoscopy techniques that are limited to only visualizing morphology at the tissue or cellular level. Using a custom fiber optic probe, high resolution surface images were acquired using topical proflavine to fluorescently stain non-keratinized epithelia. A 635 nm laser coupled to a 200 μm multimode fiber delivers light to the sample and the diffuse reflectance signal was captured by a 1 mm image guide fiber. Finally, a tungsten-halogen lamp coupled to a 200 μm multimode fiber delivers broadband light to the sample to acquire spectra at source-detector separations of 374, 729, and 1051 μm. To test the instrumentation, a high resolution proflavine-induced fluorescent image of resected healthy mouse colon was acquired. Additionally, five monolayer poly(dimethylsiloxane)-based optical phantoms with varying absorption and scattering properties were created to acquire diffuse reflectance profiles and broadband spectra.
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Affiliation(s)
- Gage J Greening
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, USA 72701
| | - Amy J Powless
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, USA 72701
| | - Joshua A Hutcheson
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, USA 72701
| | - Sandra P Prieto
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, USA 72701
| | - Aneeka A Majid
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, USA 72701
| | - Timothy J Muldoon
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, USA 72701
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