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Turker-Burhan M, Ellidokuz EB, Bagriyanik HA, Tozburun S. An endoscopic approach providing near-infrared laser-induced coagulation with accurate depth limits. JOURNAL OF BIOPHOTONICS 2024; 17:e202300377. [PMID: 38247032 DOI: 10.1002/jbio.202300377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024]
Abstract
This article investigates an endoscopic approach that utilizes negative pressure to achieve laser-induced thermal coagulation limited to the esophageal wall's mucosal and superficial submucosal layers. The study was built upon a series of studies combining numerical simulation based on the Monte-Carlo technique and ex vivo porcine tissue experiments, including apparatus design and histology analysis. An endoscopy apparatus was developed using 3D printing to validate the tissue stretching-based approach. A fiber-pigtailed diode was used as the near-infrared source, emitting 208.8 W/cm2 laser irradiance at 1.5 μm. Simulation results suggested that the approach successfully created a local heat well to prevent residual thermal effects (>65°C) from penetrating the deeper submucosal layer. Histology analysis of ex vivo tissues showed that at a fluence of 5.22 kJ/cm2, the depth of thermal coagulation was reduced by half compared to the control. With further preclinical studies, including endoscopy apparatus design, the approach can be applied to the larger esophageal surface.
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Affiliation(s)
- Merve Turker-Burhan
- Izmir Biomedicine and Genome Center, Izmir, Turkey
- Izmir International Biomedicine and Genome Institute, Dokuz Eylul University, Izmir, Türkiye
| | - Ender Berat Ellidokuz
- Izmir Biomedicine and Genome Center, Izmir, Turkey
- Department of Internal Medicine Gastroenterology, Faculty of Medicine, Dokuz Eylul University, Izmir, Türkiye
| | - Husnu Alper Bagriyanik
- Izmir Biomedicine and Genome Center, Izmir, Turkey
- Department of Histology and Embryology, Faculty of Medicine, Dokuz Eylul University, Izmir, Türkiye
| | - Serhat Tozburun
- Izmir Biomedicine and Genome Center, Izmir, Turkey
- Izmir International Biomedicine and Genome Institute, Dokuz Eylul University, Izmir, Türkiye
- Department of Biophysics, Faculty of Medicine, Dokuz Eylul University, Izmir, Türkiye
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Čunderlíková B, Kalafutová A, Babál P, Mlkvý P, Teplický T. Suppression of resistance to aminolevulinic acid-based photodynamic therapy in esophageal cell lines by administration of iron chelators in collagen type I matrices. Int J Radiat Biol 2022; 99:474-487. [PMID: 35930496 DOI: 10.1080/09553002.2022.2110310] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
PURPOSE Photodynamic therapy (PDT) utilizes visible light to activate the cytotoxic effects of photosensitizing drugs. PDT protocols require optimization to overcome treatment resistance and induce a beneficial anti-tumor immune response. The aim of this study was to examine the possibility to suppress the resistance of esophageal cell lines to aminolevulinic acid (ALA)-PDT by administration of iron chelators to induce sufficient cell cytotoxicity under pathophysiologically relevant conditions, mimicking the advanced stages of cancer. MATERIALS AND METHODS Effects of ALA-PDT in combination with iron chelators were compared in three esophageal cell lines in conventional monolayers and in 3 D cultures based on collagen type I. Modified colony assay and fluorescence-based live cell imaging, respectively were applied. The latter was used also to test the capability of pre-polarized macrophages to interact with cancer cells subjected to ALA-PDT with or without iron chelators. RESULTS Iron chelators were effective in the enhancement of ALA-PDT in all cell lines under both culture conditions. Fluorescence evaluation of cell viability in 3 D cultures indicated the contribution of apoptotic cell death after ALA-PDT, both with and without iron chelators. Engulfment of remnants of dead cancer cells by macrophages in 2 D cultures was indicated, however, the interaction between macrophages and cancer cells in 3 D cultures subjected to ALA-PDT with or without iron chelators was not present. CONCLUSIONS The potential of iron chelators to enhance ALA-PDT was maintained in 3 D collagen matrices. Although PDT dose (ALA concentration, light exposure time) required modification in a cell line-dependent manner to achieve a comparable effect of PDT alone in conventional monolayers and in collagen matrices, the potential of iron chelators to suppress the resistance of esophageal cells to ALA-PDT was not influenced by a fibrillar collagen matrix.
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Affiliation(s)
- Beata Čunderlíková
- Institute of Medical Physics, Biophysics, Informatics and Telemedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia.,International Laser Centre-CVTI, Bratislava, Slovakia
| | - Adriana Kalafutová
- Faculty of Natural Sciences, University of SS. Cyril and Methodius, Trnava, Slovakia
| | - Pavel Babál
- Institute of Pathological Anatomy, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Peter Mlkvý
- International Laser Centre-CVTI, Bratislava, Slovakia.,St. Elisabeth Cancer Institute Hospital, Bratislava, Slovakia
| | - Tibor Teplický
- Institute of Medical Physics, Biophysics, Informatics and Telemedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
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Endoscopic management of Barrett's dysplasia and early neoplasia: efficacy, safety and long-term outcomes in a UK tertiary centre. Eur J Gastroenterol Hepatol 2021; 33:e413-e422. [PMID: 33731587 DOI: 10.1097/meg.0000000000002121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are effective treatments for dysplastic Barrett's esophagus (BE). This study evaluates efficacy, durability and safety in a single high-volume UK tertiary centre with 15-years' experience. METHODS Prospective data were collected from Nottingham University Hospitals 2004-2019 for endotherapy of dysplastic BE or intramucosal adenocarcinoma. Procedural outcome measures include complete resection, complications and surgery rates. Efficacy outcomes include complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM), recurrence, treatment failure rates, durability of RFA, median follow up and tumor-associated mortality. RESULTS A total of 319 lesions were resected; 671 RFAs were performed on 239 patients. Median age was 67 (±9.5) years, male:female ratio was 5:1 and median BE length was C3 [interquartile range (IQR): 6] M6 (IQR: 5). The most common lesion was Paris IIa (64%) with a median size of 10 mm (3-70). Final histology was adenocarcinoma in 50%. Complete resection rates were 96%. The multiband mucosectomy technique (91%) was most commonly used. The median number of RFA sessions was 3 (IQR: 2). The rates of CR-D and CR-IM were 90.4%% and 89.8% achieved after a median of 20.1 (IQR: 14) months. The most common complications: EMR was bleeding 2.2% and RFA was stricture (5.4%) requiring a median of 2 (range 1-7) dilatations. Median follow up post CR-IM/CR-D was 38 months (14-60). Metachronous lesions developed in 4.7% after CR-D and tumor-related mortality was 0.8%. Dysplasia and intestinal metaplasia-free survival at 5 years was 95 and 90%, respectively. CONCLUSION BE endotherapy is minimally invasive, effective, safe and deliverable in a day-case setting.
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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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Bennett C, Green S, DeCaestecker J, Almond M, Barr H, Bhandari P, Ragunath K, Singh R, Jankowski J. Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus. Cochrane Database Syst Rev 2020; 5:CD007334. [PMID: 32442322 PMCID: PMC7390331 DOI: 10.1002/14651858.cd007334.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). OBJECTIVES We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). SEARCH METHODS We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. SELECTION CRITERIA Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. TYPES OF PARTICIPANTS patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. DATA COLLECTION AND ANALYSIS Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. MAIN RESULTS We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. AUTHORS' CONCLUSIONS This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.
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Affiliation(s)
- Cathy Bennett
- Centre for Innovative Research Across the Life Course (CIRAL), Coventry University, Coventry, UK
| | - Susi Green
- Gastroenterology, Portsmouth Hospitals Trust, Cosham, UK
| | | | - Max Almond
- Department of Oesphogastric Surgery, Gloucestershire Royal Hospital, Gloucester, UK
| | - Hugh Barr
- Surgery, Gloucester Royal Hospital, Gloucester, UK
| | - Pradeep Bhandari
- Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Krish Ragunath
- Wolfson Digestive Diseases Centre, Queens Medical Centre, Nottingham University NHS Trust, Nottingham, UK
| | - Rajvinder Singh
- Gastroenterology, The Lyell McEwin Hospital, Elizabeth Vale, Australia
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Franklin J, Jankowski J. Recent advances in understanding and preventing oesophageal cancer. F1000Res 2020; 9. [PMID: 32399195 PMCID: PMC7194479 DOI: 10.12688/f1000research.21971.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 12/24/2022] Open
Abstract
Oesophageal cancer is a common cancer that continues to have a poor survival. This is largely in part due to its late diagnosis and early metastatic spread. Currently, screening is limited to patients with multiple risk factors via a relatively invasive technique. However, there is a large proportion of patients diagnosed with oesophageal cancer who have not been screened. This has warranted the development of new screening techniques that could be implemented more widely and lead to earlier identification and subsequently improvements in survival rates. This article also explores progress in the surveillance of Barrett’s oesophagus, a pre-malignant condition for the development of oesophageal adenocarcinoma. In recent years, advances in early endoscopic intervention have meant that more patients are considered at an earlier stage for potentially curative treatment.
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Affiliation(s)
- James Franklin
- Gastroenterology and Endoscopy Department, Kings Mill Hospital NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
| | - Janusz Jankowski
- Gastroenterology and Endoscopy Department, Kings Mill Hospital NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
- University of Liverpool, Liverpool, UK
- University of Roehampton, London, UK
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Endoscopic Eradication Therapy in Barrett's Esophagus. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017; 19:137-142. [PMID: 29269998 DOI: 10.1016/j.tgie.2017.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic eradication therapy (EET), the standard of care for treatment of Barrett's esophagus with dysplasia and early neoplasia, consists of a combination of endoscopic resection and ablative modalities. Resection techniques primarily include endoscopic mucosal resection or endoscopic submucosal dissection. Resection of nodular disease is generally followed by one of multiple ablative therapies among which radiofrequency ablation has the best evidence supporting safety and efficacy. These advanced endoscopic procedures require both experience and expertise in the cognitive and procedural aspects of EET. However, very few formal programs exist that teach endoscopists the necessary skills to perform EET in a safe, standardized, and efficacious manner. Case volume at both the endoscopist and center level has been shown to impact clinical outcomes based on limited data. As a result, some recent guidelines endorse case volume as a measure of competency. Quality indicators, which can be used as benchmarks for training and as part of pay for quality initiatives, have recently been derived for EET. However, quality metrics in EET have not been widely accepted, nor are they broadly used currently. While the efficacy of EET for BE is established, there is a need for application of quality metrics to both assure adequate training in these procedures, as well as to assess treatment outcomes. A standardized EET training curriculum during endoscopic training, with competency assessment of both new clinicians and endoscopists in practice has potential to improve care in EET.
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8
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Bustamante FAC, Hourneaux DE Moura EG, Bernardo W, Sallum RAA, Ide E, Baba E. SURGERY VERSUS ENDOSCOPIC THERAPIES FOR EARLY CANCER AND HIGH-GRADE DYSPLASIA IN THE ESOPHAGUS: a systematic review. ARQUIVOS DE GASTROENTEROLOGIA 2017; 53:10-9. [PMID: 27281499 DOI: 10.1590/s0004-28032016000100004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/19/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Esophageal cancer occurs as a local disease in 22% of cases, and a minority of this disease is limited to the mucosa or submucosa (early lesions). Endoscopic mucosal resection, endoscopic submucosal dissection, photodynamic therapy, laser therapy, and argon plasma coagulation have emerged as alternatives to surgical resection for early lesions. OBJECTIVE The aim of this systematic review is to identify studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in the endoscopic versus surgical therapies. DATA SOURCES A systematic review using MEDLINE, COCHRANE, EMBASE, EBSCO, LILACS, Library University of Sao Paulo, BVS, and SCOPE. STUDY SELECTION Randomized controlled trial, controlled clinical trial, clinical trial, and cohort study. CRITERIA - Studies that statistically compare survival, disease-free survival, morbidity and mortality associated with the procedure, and mortality associated with cancer in patients who underwent endoscopic and surgical therapy for early lesions of esophageal cancer. DATA EXTRACTION Independent extraction of the articles by two authors using predefined data fields, including study quality indicators. LIMITATION Only retrosprospective cohort studies comparing the endoscopic and surgical therapies were recovered. RESULTS The survival rates after 3 and 5 years were different and exhibited superiority with the surgical therapies over time. Endoscopy is superior in the control of mortality related to cancer with a high rate of disease recurrence. With regard to the comorbidity and the mortality associated with the procedure, endoscopy is superior. CONCLUSION There is no evidence from clinical trials. In this systematic review, surgical therapies showed superiority for survival, and endoscopic therapies showed superiority in the control of mortality related to cancer with a high rate of disease recurrence; also, for the comorbidity and the mortality associated with the procedure, endoscopy is superior. Prospective, controlled trials with large sample sizes are necessary to confirm the results of the current analysis.
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Affiliation(s)
- Fabio Alberto Castillo Bustamante
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Eduardo Guimarães Hourneaux DE Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Wanderley Bernardo
- Projeto Diretrizes, Associação Médica Brasileira, São Paulo, SP, Brasil, Associação Médica Brasileira, São Paulo SP , Brasil
| | - Rubens Antonio Aissar Sallum
- Divisão de Cirurgia Esofágica, Departamento de Gastroenterologia, Hospital das Clinicas Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Departamento de Gastroenterologia, Hospital das Clinicas, Universidade de São Paulo, São Paulo SP , Brazil
| | - Edson Ide
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
| | - Elisa Baba
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina Universidade de São Paulo, São Paulo, SP, Brasil, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo SP , Brazil
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9
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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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10
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Kohoutova D, Haidry R, Banks M, Bown S, Sehgal V, Butt MA, Graham D, Thorpe S, Novelli M, Rodriguez-Justo M, Lovat L. Esophageal neoplasia arising from subsquamous buried glands after an apparently successful photodynamic therapy or radiofrequency ablation for Barrett's associated neoplasia. Scand J Gastroenterol 2016; 50:1315-21. [PMID: 25956748 DOI: 10.3109/00365521.2015.1043578] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Photodynamic therapy (PDT) and radiofrequency ablation (RFA) are effective non-surgical options for the treatment of Barrett's esophagus (BE) associated neoplasia. Development of subsquamous intestinal metaplasia after successful PDT and/or RFA is a recognized phenomenon; however, the occurrence of neoplasia arising from buried glands is a rare complication. METHODS This is a prospective case series of patients treated with PDT and/or RFA from 1999 to 2014 at University College London Hospital for neoplasia associated with BE, whose outcomes were analyzed retrospectively. Prior to any ablative therapy any visible nodularity was removed with endoscopic mucosal resection (EMR). After successful PDT and/or HALO RFA treatment, defined as a complete reversal of dysplasia and metaplasia, patients underwent endoscopic follow up using the Seattle protocol. RESULTS A total of 288 patients were treated, 91 with PDT between 1999 and 2010, 173 with RFA between 2007 and 2014, and 24 with both PDT and RFA for neoplasia associated with BE. Subsquamous neoplasia occurred in seven patients (7/288, 2%). The first patient developed subsquamous invasive adenocarcinoma and underwent curative surgery. Another five patients with subsquamous neoplasia (either high-grade dysplasia or intramucosal cancer) were treated successfully with EMR. The final patient developed subsquamous invasive esophagogastric junctional adenocarcinoma with liver metastases. CONCLUSION Development of subsquamous neoplasia after an apparently successful PDT and/or RFA is a rare but recognized complication. Clinicians should be aware of this phenomenon and have a low threshold for performing an EMR. Thorough surveillance following successful PDT and/or RFA ensuring high-quality endoscopy is required.
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Affiliation(s)
- Darina Kohoutova
- Research Department of Tissue & Energy, National Medical Laser Centre, Devision of Surgery and Interventional Science, University College London , London , UK
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11
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Neoplastic Barrett’s oesophagus and long-term follow-up after endoscopic therapy: complete histological eradication of Barrett associated with high-grade dysplasia significantly decreases neoplasia relapse. Surg Endosc 2016; 30:5410-5418. [DOI: 10.1007/s00464-016-4898-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/26/2016] [Indexed: 01/28/2023]
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12
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Kastelein F, van Olphen SH, Steyerberg EW, Spaander MCW, Bruno MJ. Impact of surveillance for Barrett's oesophagus on tumour stage and survival of patients with neoplastic progression. Gut 2016; 65:548-54. [PMID: 25903690 DOI: 10.1136/gutjnl-2014-308802] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 04/01/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Endoscopic surveillance for Barrett's oesophagus (BO) is under discussion given the overall low incidence of neoplastic progression and lack of evidence that it prevents advanced oesophageal adenocarcinoma (OAC). The aim of this study was to evaluate the impact of endoscopic BO surveillance on tumour stage and survival of patients with neoplastic progression. DESIGN 783 patients with BO of at least 2 cm were included in a multicentre prospective cohort and followed during surveillance according to the American College of Gastroenterology guidelines. Cases of high-grade dysplasia and OAC were identified during follow-up. OAC staging was performed according to the 7th UICC-AJCC classification. Survival data were collected and crosschecked using death and municipal registries. Data from patients with OAC in the general population were obtained from the Dutch cancer registry. We compared survival of patients with BO with neoplastic progression during surveillance with those of patients without neoplastic progression and patients with OAC in the general population. RESULTS 53 patients with BO developed high-grade dysplasia or OAC during surveillance. Thirty-five (66%) were classified as stage 0, 14 (26%) as stage 1 and 4 (8%) as stage 2. OAC was diagnosed at an earlier stage during BO surveillance than in the general population (p<0.001). Survival of patients with BO with neoplastic progression was not significantly worse than those of patients without neoplastic progression and similar to survival of patients with stage 0 or stage 1 OAC in the general population. CONCLUSIONS OAC is detected at an earlier stage during BO surveillance than in the general population with good survival rates.
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Affiliation(s)
- F Kastelein
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S H van Olphen
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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13
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Management of Barrett's esophagus: Screening to newer treatments. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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14
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Thoguluva Chandrasekar V, Vennalaganti P, Sharma P. Management of Barrett's esophagus: From screening to newer treatments. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:91-102. [PMID: 26964773 DOI: 10.1016/j.rgmx.2015.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/15/2015] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus is a premalignant condition of the esophagus in which the squamous epithelium of the lower end of the esophagus is replaced with columnar epithelium. Since the incidence of esophageal adenocarcinoma is on the rise, the major gastroenterology societies have come up with their recommendations for screening and surveillance. Specific factors like obesity, white race, age over 50 years, early age of onset of GERD, smoking and hiatal hernia have been identified as increasing the risk of Barrett's esophagus and adenocarcinoma. The diagnosis requires both endoscopic identification of columnar-lined mucosa and histological confirmation with biopsy. Most medical societies recommend screening people with GERD and other risk factors with endoscopy, but other alternatives employing less invasive methods are currently being studied. Surveillance strategies vary depending on the endoscopic findings and the Seattle biopsy protocol with random 4-quadrant sampling is recommended. Biomarkers have shown promising results, but more studies are needed in the future. White light endoscopy is the standard practice, but other advanced imaging modalities have shown variable results and hence more studies are awaited for further validation. Endoscopic eradication techniques, including both resection and ablation, have shown good but variable results for treating dysplastic lesions confined to the mucosa. Resection procedures to remove visible lesions followed by ablation of the dysplastic mucosa have shown the best results with higher eradication rates and lower recurrence rates. Surgical management is reserved for lesions with sub-mucosal invasion and lymph node spread with increased risk of metastasis.
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Affiliation(s)
| | - P Vennalaganti
- Department of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas city, Missouri, EE. UU
| | - P Sharma
- Department of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas city, Missouri, EE. UU..
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15
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Abstract
Although there are many unanswered questions with Barrett esophagus, we can safely say that the incidence is increasing, chemoprevention strategies for the prevention of Barrett metaplasia and its progression to adenocarcinoma may be in the offing, surveillance should be considered for all patients who are discovered to have Barrett esophagus, RFA is the treatment of choice for those with HGD and strongly considered in those with LGD, EMR should be the treatment of choice for patients with nodular high-grade Barrett esophagus, and, finally, vagal-sparing esophagectomy reserved for patients with persistent HGD or a strong suspicion of carcinoma, with consideration of a concomitant fundoplication.
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Affiliation(s)
- Mark Splittgerber
- Division of General Surgery, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, FL, USA.
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16
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Whiteman DC, Appleyard M, Bahin FF, Bobryshev YV, Bourke MJ, Brown I, Chung A, Clouston A, Dickins E, Emery J, Eslick GD, Gordon LG, Grimpen F, Hebbard G, Holliday L, Hourigan LF, Kendall BJ, Lee EY, Levert-Mignon A, Lord RV, Lord SJ, Maule D, Moss A, Norton I, Olver I, Pavey D, Raftopoulos S, Rajendra S, Schoeman M, Singh R, Sitas F, Smithers BM, Taylor AC, Thomas ML, Thomson I, To H, von Dincklage J, Vuletich C, Watson DI, Yusoff IF. Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma. J Gastroenterol Hepatol 2015; 30:804-20. [PMID: 25612140 DOI: 10.1111/jgh.12913] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.
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Affiliation(s)
- David C Whiteman
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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17
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Abstract
In the last 5-10 years, endoscopic ablative therapies have been gaining ground as treatment for Barrett's esophagus associated with high-grade dysplasia and early cancer, and they are becoming the most preferred technique over surgery as the standard of care. These therapies are associated with a lower rate of complications and mortality than surgery; studies have found them to be safe, effective and tolerable. Endoscopic ablative therapies are not, however, without their drawbacks. There is a paucity of data on long-term efficacy, and direct comparisons of the different modalities are lacking. Unlike surgery, current data suggest that endoscopic ablation treatments may not be curative in all patients, so patients require ongoing surveillance and acid suppression. Questions remain regarding durability as well as factors promoting recurrence after endoscopic therapy. The authors conducted a systematic review of the literature on ablative therapies in Barrett's esophagus to describe the modalities currently available and to provide an understanding of their limitations.
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Affiliation(s)
- Avyakta Kallam
- Department of Internal Medicine, Creighton University Medical Center, 601 N 30th Street, Omaha, NE 68131, USA
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18
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Le Page PA, Velu PP, Penman ID, Couper GW, Paterson-Brown S, Lamb PJ. Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma. Surgeon 2015; 14:315-321. [PMID: 25744636 DOI: 10.1016/j.surge.2015.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 11/26/2014] [Accepted: 01/27/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The introduction of endoscopic techniques has led to debate about optimal management of early oesophageal adenocarcinoma. The aim was to evaluate patient selection and outcomes for endoscopic or surgical treatment at a tertiary referral centre. METHODS A prospectively collected database of consecutive patients staged with high-grade dysplasia (HGD) or T1 oesophageal adenocarcinoma treated with curative intent between 2005 and 2013 was undertaken. All patients were discussed at the multidisciplinary team meeting. Surgical treatment was by thoracoscopic assisted or standard/laparoscopic assisted Ivor Lewis oesophagectomy. Endoscopic treatment was a structured programme of endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA). Outcomes included treatment variables, recurrence and complications. RESULTS 83 patients treated; 50 with endoscopic therapy (EMR only-4, EMR then RFA-22, RFA only-24) and 38 by surgery (33 straight to surgery and 5 following EMR). Median age (67) and mean follow-up (21 months) were similar. HGD was more common in the endoscopic group (32/50, 64%, vs.3/33, 9%, p = 0.0001). Significant complications were more common following surgery (13/38, 34%, vs. 1/50, 2%, p = 0.0001). There were two in-hospital deaths following oesophagectomy (1 open, 1 thoracoscopic). Endoscopic treatment beyond 12 months for persisting HGD/intramucosal disease was required in 2 patients. Recurrence of HGD/invasive cancer was diagnosed in 2/36 (5.6%, T1a recurrence) of endoscopic and 1/38 (2.6%, T2N0 - subsequent hepatic metastases) surgical patients. CONCLUSION A management algorithm including both endoscopic treatment and oesophagectomy provides optimal outcome for these patients. Due to additional morbidity of surgery, endoscopic treatment is appropriate first-line treatment.
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Affiliation(s)
- Philip A Le Page
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.
| | - Pras P Velu
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Ian D Penman
- Department of Gastroenterology, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Graeme W Couper
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Simon Paterson-Brown
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Peter J Lamb
- Department of Oesophago-Gastric Surgery, Royal Infirmary Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
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19
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Lam YH, Bright T, Leong M, Thompson SK, Mayne G, Watson DI. Oesophagectomy is a safe option for early adenocarcinoma arising from Barrett's oesophagus. ANZ J Surg 2015; 86:905-909. [DOI: 10.1111/ans.13023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Yick Ho Lam
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| | - Tim Bright
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| | - Matthew Leong
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| | - Sarah K. Thompson
- Department of Surgery; University of Adelaide; Adelaide South Australia Australia
| | - George Mayne
- Department of Surgery; Flinders University; Adelaide South Australia Australia
| | - David I Watson
- Department of Surgery; Flinders University; Adelaide South Australia Australia
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20
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Anders M, Bähr C, El-Masry MA, Marx AH, Koch M, Seewald S, Schachschal G, Adler A, Soehendra N, Izbicki J, Neuhaus P, Pohl H, Rösch T. Long-term recurrence of neoplasia and Barrett's epithelium after complete endoscopic resection. Gut 2014; 63:1535-43. [PMID: 24389236 DOI: 10.1136/gutjnl-2013-305538] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current endoscopic therapy for neoplastic Barrett's oesophagus (BO) consists of complete resection/ablation of all Barrett's tissue including neoplastic lesions. Recurrence seems to be frequent after thermal therapy, such as radiofrequency ablation. OBJECTIVE To analyse long-term recurrence of neoplasia and BO after successful widespread endoscopic mucosal resection (EMR). DESIGN In a retrospective analysis, all patients undergoing widespread EMR of neoplastic BO between 2002 and 2007 at two referral centres were followed for at least 3 years after completion of endotherapy. Recurrence was diagnosed if neoplasia and/or BO were detected following previous successful complete removal, defined as at least two negative endoscopies and biopsies. RESULTS Ninety patients undergoing widespread EMR were included (mean age 63 years; 82 male), 58% of whom underwent additional thermal ablation for minor residual disease. Complete eradication of neoplasia and Barrett's tissue was achieved in 90% of patients. On further follow-up (mean 64.8 months), recurrence of neoplastic and non-neoplastic BO was found in 6.2% and 39.5%, respectively. Recurring neoplasia (3 adenocarcinomas, 1 low-grade and 1 high-grade dysplasia) were found after a median of 44 months (range 38-85) and could be retreated endoscopically. In a multivariate analysis, Barrett's length was the only factor significantly associated with recurrence (OR 2.73). CONCLUSIONS Even after seemingly complete endoscopic resection, recurrence of BO is frequent and independent of additional thermal therapy. Due to the possibility of neoplasia recurrence even after long disease-free intervals, follow-up should be extended beyond 5 years.
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Affiliation(s)
- Mario Anders
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Bähr
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Muhammad Abbas El-Masry
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany Division of Gastroenterology, Department of Internal Medicine, Assiut University, Assiut, Egypt
| | - Andreas H Marx
- Department of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Koch
- Department of Pathology, Charité University Hospital, Berlin, Germany
| | - Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany Gastrozentrum, Hirslanden Clinic, Zürich, Switzerland
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Adler
- Department of Gastroenterology, Charité University Hospital, Berlin, Germany
| | - Nib Soehendra
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Izbicki
- Department of Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Neuhaus
- Department of Surgery, Charité University Hospital, Berlin, Germany
| | - Heiko Pohl
- VA Medical Center, White River Junction, Vermont, USA
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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21
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Ablative therapy for esophageal dysplasia and early malignancy: focus on RFA. BIOMED RESEARCH INTERNATIONAL 2014; 2014:642063. [PMID: 25140320 PMCID: PMC4129136 DOI: 10.1155/2014/642063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/07/2014] [Indexed: 02/07/2023]
Abstract
Ablative therapies have been utilized with increasing frequency for the treatment of Barrett's esophagus with and without dysplasia. Multiple modalities are available for topical ablation of the esophagus, but radiofrequency ablation (RFA) remains the most commonly used. There have been significant advances in technique since the introduction of RFA. The aim of this paper is to review the indications, techniques, outcomes, and most common complications following esophageal ablation with RFA.
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22
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Incidence and predictors of adenocarcinoma following endoscopic ablation of Barrett's esophagus. Dig Dis Sci 2014; 59:1560-6. [PMID: 24395382 PMCID: PMC4071117 DOI: 10.1007/s10620-013-3002-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 12/14/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND The rate and risk factors of recurrent or metachronous adenocarcinoma following endoscopic ablation therapy in patients with Barrett's esophagus (BE) have not been specifically reported. AIM The aim of this study was to determine the incidence and predictors of adenocarcinoma after ablation therapy for BE high-grade dysplasia (HGD) or intramucosal carcinoma (IMC). METHODS This is a single center, retrospective review of prospectively collected data on consecutive cases of endoscopic ablation for BE. A total of 223 patients with BE (HGD or IMC) were treated by ablation between 1996 and 2011. Primary outcome measures were recurrence and new development of adenocarcinoma after ablation. Recurrence was defined as the presence of adenocarcinoma following the absence of adenocarcinoma in biopsy samples from two consecutive surveillance endoscopies. Logistic regression analysis was performed to assess predictors of adenocarcinoma after ablation. RESULTS One hundred and eighty-three patients were included in the final analysis, and 40 patients were excluded: 22 for palliative ablation, eight lost to follow-up, five for residual carcinoma and five for postoperative state. Median follow-up was 39 months. Recurrence or new development of adenocarcinoma was found in 20 patients (11 %) and the median time to recurrence/development of adenocarcinoma was 11.5 months. Independent predictors of recurrent or metachronous adenocarcinoma were hiatal hernia size ≥ 4 cm (odds ratio 3.649, P = 0.0233) and histology (HGD/adenocarcinoma) after first ablation (odds ratio 4.141, P = 0.0065). CONCLUSIONS Adenocarcinoma after endoscopic therapy for HGD or IMC in BE is associated with large hiatal hernia and histology status after initial ablation therapy.
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23
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Zaninotto G, Bennett C. Surveillance for low-grade dysplastic Barrett's oesophagus: one size fits all? World J Surg 2014; 39:578-85. [PMID: 24919861 DOI: 10.1007/s00268-014-2661-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This paper reviews the role of low-grade dysplasia (LGD) as a marker of progression in Barrett's oesophagus (BO). Albeit with its limits due to the difficulty of its diagnosis and the low agreement among pathologists, LGD remains the most relevant single prognostic factor of progression, and, when the diagnosis is confirmed by two or three pathologists, the chances of progression to high-grade dysplasia or invasive adenocarcinoma are as high as 40%. On the other hand, BO patients who remain dysplasia free at several follow-up examinations seem to have a very low likelihood of progression. The diagnosis of LGD should be confirmed by two pathologists, and surveillance programs should be tailored depending on the presence or persistent absence of LGD. Ablative therapy should be also considered for cases where LGD persists in a series of follow-ups.
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Affiliation(s)
- Giovanni Zaninotto
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK,
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24
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Aranda-Hernandez J, Cirocco M, Marcon N. Treatment of dysplasia in barrett esophagus. Clin Endosc 2014; 47:55-64. [PMID: 24570884 PMCID: PMC3928493 DOI: 10.5946/ce.2014.47.1.55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 12/27/2013] [Accepted: 12/28/2013] [Indexed: 12/20/2022] Open
Abstract
Barrett esophagus is recognized as a risk factor for the development of dysplasia and adenocarcinoma of the esophagus. Cancer is usually diagnosed at an advanced stage with a 5-year survival rate of 15%. Most of these patients present de novo and are not part of a surveillance program. Endoscopic screening with improvement in recognition of early lesions may change this pattern. In the past, patients diagnosed with dysplasia and mucosal cancer were best managed by esophagectomy. Endoscopic techniques such as endoscopic mucosal resection and radiofrequency ablation have resulted in high curative rates and a shift away from esophagectomy. This pathway is supported by the literature review of esophagectomies performed for mucosal disease, as well as pathologists' interpretation of endoscopic mucosal specimens, which document the low risk of lymph node metastasis. The role of endoscopic therapy for superficial submucosal disease continues to be a challenge.
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Affiliation(s)
- Javier Aranda-Hernandez
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Maria Cirocco
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Norman Marcon
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, ON, Canada
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25
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Fitzgerald RC, di Pietro M, Ragunath K, Ang Y, Kang JY, Watson P, Trudgill N, Patel P, Kaye PV, Sanders S, O'Donovan M, Bird-Lieberman E, Bhandari P, Jankowski JA, Attwood S, Parsons SL, Loft D, Lagergren J, Moayyedi P, Lyratzopoulos G, de Caestecker J. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut 2014; 63:7-42. [PMID: 24165758 DOI: 10.1136/gutjnl-2013-305372] [Citation(s) in RCA: 828] [Impact Index Per Article: 82.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.
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26
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Bornschein J, Fitzgerald RC. Barrett's oesophagus: diagnosis, surveillance and treatment. Br J Hosp Med (Lond) 2013; 74:444-50. [PMID: 23958982 DOI: 10.12968/hmed.2013.74.8.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jan Bornschein
- Clinical Research Fellow in the MRC Cancer Cell Unit, Hutchison Research Centre, Cambridge
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27
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Estores D, Velanovich V. Barrett esophagus: epidemiology, pathogenesis, diagnosis, and management. Curr Probl Surg 2013; 50:192-226. [PMID: 23601575 DOI: 10.1067/j.cpsurg.2013.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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28
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Parasa S, Sharma P. Complications of gastro-oesophageal reflux disease. Best Pract Res Clin Gastroenterol 2013; 27:433-42. [PMID: 23998980 DOI: 10.1016/j.bpg.2013.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/05/2013] [Indexed: 01/31/2023]
Abstract
Gastro-oesophageal reflux disease (GORD) is on the rise with more than 20% of the western population reporting symptoms and is the most common gastrointestinal disorder in the United States. This increase in GORD is not exactly clear but has been attributed to the increasing prevalence of obesity, changing diet, and perhaps the decreasing prevalence of H. pylori infection. Complications of GORD could be either benign or malignant. Benign complications include erosive oesophagitis, bleeding and peptic strictures. Premalignant and malignant lesions include Barrett's metaplasia, and oesophageal cancer. Management of both the benign and malignant complications can be challenging. With the use of proton-pump inhibitors, peptic strictures (i.e., strictures related to reflux) have significantly declined. Several aspects of Barrett's management remain controversial including the stage in the disease process which needs to be intervened, type of the intervention and surveillance of these lesions to prevent development of high grade dysplasia and oesophageal adenocarcinoma.
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Affiliation(s)
- S Parasa
- Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, KS, USA.
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29
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Evolving changes in the management of early oesophageal adenocarcinoma in a tertiary centre. Ir J Med Sci 2012; 182:363-9. [PMID: 23242575 DOI: 10.1007/s11845-012-0890-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 11/28/2012] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Series from high volume oesophageal centres highlight an increasing prevalence of early malignant (EM) lesions. The advent of endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) offer alternatives to traditional surgery. The evolution of this pattern of care in a high volume centre is analysed. METHODS Data were collected from a prospectively maintained database. 96 patients were treated with an EM lesion from 2000 to 2011. Surgery was the standard approach during the initial period (2000-2006). In 2007, with the introduction of EMR±RFA to our Centre, a rising trend toward definitive endoscopic treatment was seen. This study details the selection of cases into treatment groups and their outcomes. RESULTS From 2000 to 2006, 23 patients were treated with EM lesions, 96% by surgery. Seventy-three were treated from 2007 to 2011, 55% surgically and 45% by EMR±RFA. In the entire experience, there was one death from surgery and morbidity was higher in the surgery group compared with EMR±RFA (p<0.001). Three surgical patients (4.8%) relapsed with HGD or cancer, and one patient with T1N1 disease died of disease recurrence. At a median of 13 months, EMR±RFA offered 100% disease control, 72% had no endoscopic or histological evidence of Barrett's oesophagus and one patient represented with low grade dysplasia. CONCLUSIONS This study highlights the changing pattern of care in the management of early oesophageal cancer. EMR±RFA appears an acceptable alternative to surgery in carefully selected cases. However, long-term outcome analysis using these methods is required and close interdisciplinary collaboration of specialists in gastroenterology, surgery, pathology and radiology is mandatory to achieve optimum outcomes.
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30
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Bennett C, Green S, Decaestecker J, Almond M, Barr H, Bhandari P, Ragunath K, Singh R, Jankowski J. Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus. Cochrane Database Syst Rev 2012; 11:CD007334. [PMID: 23152243 DOI: 10.1002/14651858.cd007334.pub4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). OBJECTIVES We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). SEARCH METHODS We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. SELECTION CRITERIA Types of studies: RCTs comparing endotherapies with surgery in the treatment of or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. TYPES OF PARTICIPANTS patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus.Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. DATA COLLECTION AND ANALYSIS Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. MAIN RESULTS We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. AUTHORS' CONCLUSIONS This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.
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Affiliation(s)
- Cathy Bennett
- Centre for Digestive Diseases, Blizard Institute, Queen Mary, University of London, London, UK
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31
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Abstract
Barrett's esophagus is a pathologic change of the normal squamous epithelium of the esophagus to specialized columnar metaplasia. Barrett's esophagus is a result of prolonged exposure of the esophagus to gastroduodenal refluxate. Although Barrett's itself is not symptomatic, and, in fact, patients with Barrett's esophagus may be completely asymptomatic, it does identify patients at higher risk of developing esophageal adenocarcinoma. Traditionally, antireflux surgery was reserved for patients with symptoms, because it was believed that antireflux surgery did not eliminate Barrett's esophagus and reduce cancer risk. Rationale for the treatment of Barrett's esophagus beyond treating symptoms of gastroesophageal reflux disease stems from the hope to decrease, if not eliminate, the risk of adenocarcinoma. Treatment options ranged from medical acid suppression without surveillance to resection. Ablation, particularly endoscopic radio-frequency ablation, has become the standard of care for Barrett's esophagus with high-grade dysplasia. It role in nondysplastic or low-grade dysplastic Barrett's is less clear. Combined endoscopic mucosal resection with ablation is effective in nodular high-grade Barrett's esophagus. Resection should be reserved for patients with persistent high-grade dysplasia despite multiple attempts at endoscopic ablation or resection or for patients with evidence of carcinoma.
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Affiliation(s)
- Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
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Tahara K, Tanabe S, Ishido K, Higuchi K, Sasaki T, Katada C, Azuma M, Nakatani K, Naruke A, Kim M, Koizumi W. Argon plasma coagulation for superficial esophageal squamous-cell carcinoma in high-risk patients. World J Gastroenterol 2012; 18:5412-7. [PMID: 23082058 PMCID: PMC3471110 DOI: 10.3748/wjg.v18.i38.5412] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 06/07/2012] [Accepted: 06/15/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the usefulness and safety of argon plasma coagulation (APC) for superficial esophageal squamous-cell carcinoma (SESC) in high-risk patients.
METHODS: We studied 17 patients (15 men and 2 women, 21 lesions) with SESC in whom endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and open surgery were contraindicated from March 1999 through February 2009. None of the patients could tolerate prolonged EMR/ESD or open surgery because of severe concomitant disease (e.g., liver cirrhosis, cerebral infarction, or ischemic heart disease) or scar formation after EMR/ESD and chemoradiotherapy. After conventional endoscopy, an iodine stain was sprayed on the esophageal mucosa to determine the lesion margins. The lesion was then ablated by APC. We retrospectively studied the treatment time, number of APC sessions per site, complications, presence or absence of recurrence, and time to recurrence.
RESULTS: The median duration of follow-up was 36 mo (range: 6-120 mo). All of the tumors were macroscopically classified as superficial and slightly depressed type (0-IIc). The preoperative depth of invasion was clinical T1a (mucosal cancer) for 19 lesions and clinical T1b (submucosal cancer) for 2. The median treatment time was 15 min (range: 10-36 min). The median number of treatment sessions per site was 2 (range: 1-4). The median hospital stay was 14 d (range: 5-68 d). Among the 17 patients (21 lesions), 2 (9.5%) had recurrence and underwent additional APC with no subsequent evidence of recurrence. There were no treatment-related complications, such as bleeding or perforation.
CONCLUSION: APC is considered to be safe and effective for the management of SESC that cannot be resected endoscopically because of underlying disease, as well as for the control of recurrence after EMR and local recurrence after chemoradiotherapy.
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Gordon LG, Hirst NG, Mayne GC, Watson DI, Bright T, Cai W, Barbour AP, Smithers BM, Whiteman DC, Eckermann S. Modeling the cost-effectiveness of strategies for treating esophageal adenocarcinoma and high-grade dysplasia. J Gastrointest Surg 2012; 16:1451-61. [PMID: 22644445 DOI: 10.1007/s11605-012-1911-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/07/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study aims to synthesize cost and health outcomes for current treatment pathways for esophageal adenocarcinoma and high-grade dysplasia (HGD) and to model comparative net clinical and economic benefits of alternative management scenarios. METHODS A decision-analytic model of real-world practices for esophageal adenocarcinoma treatment by tumor stage was constructed and validated. The model synthesized treatment probabilities, survival, quality of life, and resource use extracted from epidemiological datasets, published literature, and expert opinion. Comparative analyses between current practice and five hypothetical scenarios for modified treatment were undertaken. RESULTS Over 5 years, outcomes across T stage ranged from 4.06 quality-adjusted life-years and costs of $3,179 for HGD to 1.62 quality-adjusted life-years and costs of $50,226 for stage T4. Greater use of endoscopic mucosal resection for stage T1 and measures to reduce esophagectomy mortality to 0-3 % produced modest gains, whereas a 20 % reduction in the proportion of patients presenting at stage T3 produced large incremental net benefits of $4,971 (95 % interval, $1,560-8,368). CONCLUSION These findings support measures that promote earlier diagnosis, such as developing risk assessment processes or endoscopic surveillance of Barrett's esophagus. Incremental net monetary benefits for other strategies are relatively small in comparison to predicted gains from early detection strategies.
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Affiliation(s)
- Louisa G Gordon
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131, Australia.
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BENNETT CATHY, VAKIL NIMISH, BERGMAN JACQUES, HARRISON REBECCA, ODZE ROBERT, VIETH MICHAEL, SANDERS SCOTT, GAY LAURA, PECH OLIVER, LONGCROFT–WHEATON GAIUS, ROMERO YVONNE, INADOMI JOHN, TACK JAN, CORLEY DOUGLASA, MANNER HENDRIK, GREEN SUSI, DULAIMI DAVIDAL, ALI HAYTHEM, ALLUM BILL, ANDERSON MARK, CURTIS HOWARD, FALK GARY, FENNERTY MBRIAN, FULLARTON GRANT, KRISHNADATH KAUSILIA, MELTZER STEPHENJ, ARMSTRONG DAVID, GANZ ROBERT, CENGIA GIANPAOLO, GOING JAMESJ, GOLDBLUM JOHN, GORDON CHARLES, GRABSCH HEIKE, HAIGH CHRIS, HONGO MICHIO, JOHNSTON DAVID, FORBES–YOUNG RICKY, KAY ELAINE, KAYE PHILIP, LERUT TONI, LOVAT LAURENCEB, LUNDELL LARS, MAIRS PHILIP, SHIMODA TADAKUZA, SPECHLER STUART, SONTAG STEPHEN, MALFERTHEINER PETER, MURRAY IAIN, NANJI MANOJ, POLLER DAVID, RAGUNATH KRISH, REGULA JAROSLAW, CESTARI RENZO, SHEPHERD NEIL, SINGH RAJVINDER, STEIN HUBERTJ, TALLEY NICHOLASJ, GALMICHE JEAN, THAM TONYCK, WATSON PETER, YERIAN LISA, RUGGE MASSIMO, RICE THOMASW, HART JOHN, GITTENS STUART, HEWIN DAVID, HOCHBERGER JUERGEN, KAHRILAS PETER, PRESTON SEAN, SAMPLINER RICHARD, SHARMA PRATEEK, STUART ROBERT, WANG KENNETH, WAXMAN IRVING, ABLEY CHRIS, LOFT DUNCAN, PENMAN IAN, SHAHEEN NICHOLASJ, CHAK AMITABH, DAVIES GARETH, DUNN LORNA, FALCK–YTTER YNGVE, DECAESTECKER JOHN, BHANDARI PRADEEP, ELL CHRISTIAN, GRIFFIN SMICHAEL, ATTWOOD STEPHEN, BARR HUGH, ALLEN JOHN, FERGUSON MARKK, MOAYYEDI PAUL, JANKOWSKI JANUSZAZ. Consensus statements for management of Barrett's dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process. Gastroenterology 2012; 143:336-46. [PMID: 22537613 PMCID: PMC5538857 DOI: 10.1053/j.gastro.2012.04.032] [Citation(s) in RCA: 271] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/26/2012] [Accepted: 04/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal adenocarcinoma (EA) is increasingly common among patients with Barrett's esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA. METHODS We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement. RESULTS Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated. CONCLUSIONS We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.
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Affiliation(s)
| | - NIMISH VAKIL
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - ROBERT ODZE
- Harvard Medical School, Boston, Massachusetts
| | | | | | - LAURA GAY
- Queen Mary University London, London, UK
| | | | | | | | | | - JAN TACK
- Leuven University, Leuven, Belgium
| | | | | | - SUSI GREEN
- Queen Alexandra Hospital, Portsmouth, UK
| | | | - HAYTHEM ALI
- Maidstone and Tunbridge Wells NHS trust, Maidstone, UK
| | | | - MARK ANDERSON
- City Hospital, Birmingham, UK and Sandwell Hospital, West Midlands, UK
| | | | - GARY FALK
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | - ROBERT GANZ
- Bloomington Medical Centre, Bloomington, Minnesota
| | | | | | - JOHN GOLDBLUM
- Anatomic Pathology, The Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | | | | | | | - PHILIP KAYE
- Digestive Diseases Centre, Nottingham University Hospital, Nottingham, UK
| | | | | | - LARS LUNDELL
- Karolinska Institutet, CLINTEC, Stockholm, Sweden
| | | | | | | | | | | | | | | | | | - KRISH RAGUNATH
- Digestive Diseases Centre, Nottingham University Hospital, Nottingham, UK
| | | | | | - NEIL SHEPHERD
- Gloucestershire Royal Hospitals, Gloucestershire, UK
| | - RAJVINDER SINGH
- Lyell McEwin Hosptial, University of Adelaide, Adelaide, Australia
| | | | | | - JEAN–PAUL GALMICHE
- Department of Gastroenterology, CHU and University of Nantes, Nantes, France
| | | | | | - LISA YERIAN
- Anatomic Pathology, The Cleveland Clinic, Cleveland, Ohio
| | | | - THOMAS W. RICE
- Anatomic Pathology, The Cleveland Clinic, Cleveland, Ohio
| | - JOHN HART
- University of Chicago, Chicago, Illinois
| | - STUART GITTENS
- ECD Solutions, PO Box 862, Bridgetown, St. Michael, Barbados
| | - DAVID HEWIN
- Gloucestershire Royal Hospitals, Gloucestershire, UK
| | | | | | | | | | - PRATEEK SHARMA
- Veterans Affairs Medical Center and University of Kansas
| | | | | | | | - CHRIS ABLEY
- University Hospitals of Leicester, Leicester, UK
| | | | | | - NICHOLAS J. SHAHEEN
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - AMITABH CHAK
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - LORNA DUNN
- Northern Oesophagogastric Cancer Unit Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | | | | | | | - S. MICHAEL GRIFFIN
- Northern Oesophagogastric Cancer Unit Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - HUGH BARR
- Gloucestershire Royal Hospitals, Gloucestershire, UK
| | - JOHN ALLEN
- University of Minnesota School of Medicine, Minneapolis, Minnesota
| | | | | | - JANUSZ A. Z. JANKOWSKI
- University Hospitals of Leicester, Leicester, UK,Queen Mary University London, London, UK,University of Oxford, Oxford, UK
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Anand S, Ortel BJ, Pereira SP, Hasan T, Maytin EV. Biomodulatory approaches to photodynamic therapy for solid tumors. Cancer Lett 2012; 326:8-16. [PMID: 22842096 DOI: 10.1016/j.canlet.2012.07.026] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 07/19/2012] [Accepted: 07/19/2012] [Indexed: 12/12/2022]
Abstract
Photodynamic Therapy (PDT) uses a photosensitizing drug in combination with visible light to kill cancer cells. PDT has an advantage over surgery or ionizing radiation because PDT can eliminate tumors without causing fibrosis or scarring. Disadvantages include the dual need for drug and light, and a generally lower efficacy for PDT vs. surgery. This minireview describes basic principles of PDT, photosensitizers available, and aspects of tumor biology that may provide further opportunities for treatment optimization. An emerging biomodulatory approach, using methotrexate or Vitamin D in combination with aminolevulinate-based PDT, is described. Finally, current clinical uses of PDT for solid malignancies are reviewed.
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Affiliation(s)
- Sanjay Anand
- Department of Dermatology, Cleveland Clinic, Cleveland, OH 44195, USA
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Komanduri S. Endoscopic therapies for Barrett's-associated dysplasia: a new paradigm for a new decade. Expert Rev Gastroenterol Hepatol 2012; 6:291-300. [PMID: 22646252 DOI: 10.1586/egh.12.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The emergence of endoscopic therapies for Barrett's esophagus (BE)-associated dysplasia has significantly altered the management of this complex disease. Over the past decade, there has been a paradigm shift from that of pure surveillance to a more therapeutic approach in eradicating dysplastic BE. This strategy includes less invasive options than esophagectomy for high-grade dysplasia and early eradication of confirmed low-grade dysplasia. Although multiple modalities exist for endoscopic therapy, endoscopic mucosal resection coupled with radiofrequency ablation appears to be the most effective therapy, with minimal complications. Recent advances in endoscopic eradication therapies for dysplastic BE have fueled excitement for a significant weapon against the rising incidence of esophageal cancer.
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Affiliation(s)
- Sri Komanduri
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Surveillance and follow-up strategies in patients with high-grade dysplasia in Barrett's esophagus: a Dutch population-based study. Am J Gastroenterol 2012; 107:534-42. [PMID: 22270082 DOI: 10.1038/ajg.2011.459] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In patients with high-grade dysplasia (HGD) in Barrett's esophagus (BE), it is incompletely known which factors are associated with developing esophageal adenocarcinoma (EAC). We analyzed prior biopsy and follow-up strategies in a large nationwide population-based cohort of patients with HGD in BE, and identified predictors of EAC progression. METHODS Prior biopsy records and follow-up evaluations were studied in patients with HGD in BE diagnosed between 1999 and 2008, using PALGA, a nationwide network and registry of histopathology and cytopathology in the Netherlands. Multivariate Cox proportional hazards regression analysis was performed to identify predictors for prevalent (≤ 6 months) and incident (> 6 months) EAC. RESULTS In total, 827 patients with HGD in BE were included. Follow-up data after HGD diagnosis were available in 699 (85%) patients. In 249 (36%) of these patients, an EAC was detected (14.1 EACs per 100 person-years). The risk of prevalent EAC (n=177) was lower with previous surveillance (hazards ratio 0.7; 95% confidence interval 0.5-0.9), unifocal HGD (0.3;0.2-0.6), diagnosis in a university hospital (0.5;0.3-0.9), endoscopic resection (0.5;0.3-0.7), or ablation (0.0;0.0-0.3); and higher when patients were 65-75 years (1.5;1.04-2.04). After exclusion of prevalent EACs, the progression rate was 4.2 EACs per 100 person-years. The risk of progression to incident EAC (n = 72) was lower with previous surveillance (0.6;0.3-0.9) and ablation (0.2;0.0-0.8), and higher when > 75 years (3.8;2.0-7.2) or with an interval > 6 months between HGD diagnosis and first follow-up (e.g., 7-12 months 2.9;1.3-6.3). CONCLUSIONS In this cohort of patients with HGD in BE, the EAC detection rate was 14.1 per 100 person-years and 4.2 per 100 person-years after excluding prevalent cases. The risk of both prevalent and incident EAC was reduced with previous surveillance and endoscopic treatment, while it was increased with older age.
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Nava HR, Allamaneni SS, Dougherty TJ, Cooper MT, Tan W, Wilding G, Henderson BW. Photodynamic therapy (PDT) using HPPH for the treatment of precancerous lesions associated with Barrett's esophagus. Lasers Surg Med 2011; 43:705-12. [PMID: 22057498 PMCID: PMC3218433 DOI: 10.1002/lsm.21112] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Photodynamic therapy (PDT) with porfimer sodium, FDA approved to treat premalignant lesions in Barrett's esophagus, causes photosensitivity for 6-8 weeks. HPPH (2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a) shows minimal photosensitization of short duration and promising efficacy in preclinical studies. Here we explore toxicity and optimal drug and light dose with endoscopic HPPH-PDT. We also want to know the efficacy of one time treatment with HPPH-PDT. STUDY DESIGN/MATERIALS AND METHODS Two nonrandomized dose escalation studies were performed (18 patients each) with biopsy-proven high grade dysplasia or early intramucosal adenocarcinoma of esophagus. HPPH doses ranged from 3 to 6 mg/m2 . At 24 or 48 hours after HPPH administration the lesions received one endoscopic exposure to 150, 175, or 200 J/cm of 665 nm light. RESULTS Most patients experienced mild to moderate chest pain requiring symptomatic treatment only. Six patients experienced grade 3 and 4 adverse events (16.6%). Three esophageal strictures were treated with dilatation. No clear pattern of dose dependence of toxicities emerged. In the drug dose ranging study (light dose of 150 J/cm at 48 hours), 3 and 4 mg/m2 of HPPH emerged as most effective. In the light dose ranging study (3 or 4 mg/m2 HPPH, light at 24 hours), complete response rates (disappearance of high grade dysplasia and early carcinoma) of 72% were achieved at 1 year, with all patients treated with 3 mg/m2 HPPH plus 175 J/cm and 4 mg/m2 HPPH plus 150 J/cm showing complete responses at 1 year. CONCLUSIONS HPPH-PDT for precancerous lesions in Barrett's esophagus appears to be safe and showing promising efficacy. Further clinical studies are required to establish the use of HPPH-PDT.
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Affiliation(s)
- Hector R Nava
- Roswell Park Cancer Institute, Buffalo, New York 14263, USA
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