Endoscopic Diagnosis and Management of Barrett's Esophagus with Low-Grade Dysplasia

Outcomes of patients with Barrett's oesophagus with low-grade dysplasia undergoing endoscopic surveillance in a tertiary centre: a retrospective cohort study

BACKGROUND AND AIM

Barrett's oesophagus predisposes individuals to oesophageal adenocarcinoma (OAC), with the risk of progression to malignancy increasing with the degree of dysplasia, categorized as either low-grade dysplasia (LGD) or high-grade dysplasia (HGD). The reported incidence of progression to OAC in LGD ranges from 0.02% to 11.43% per annum. In patients with LGD, Australian guidelines recommend 6-monthly endoscopic surveillance. We aimed to describe the surveillance practices within a tertiary centre, and to determine the predictive value of surveillance as well as other risk factors for progression.

METHODS

Endoscopy and pathology databases were searched over a 10-year period to collate all cases of Barrett's oesophagus with LGD. Medical records were reviewed to document patient factors and endoscopic and histologic details. Because follow-up times varied greatly, survival analysis techniques were employed.

RESULTS

Fifty-nine patients were found to have LGD. Thirteen patients (22.0%) progressed to either HGD or OAC (10 (16.9%) and three (5.1%) respectively); the annual incidence rates of progression to HGD/OAC and OAC were 5.5% and 1.1% respectively. All patients who developed OAC had non-guideline-adherent surveillance. A Cox model found only two predictors of progression: (i) guideline-adherent surveillance, performed in 16 (27.1%), detected progression to HGD/OAC four times earlier than non-guideline-adherent surveillance (95% confidence interval (CI) = 1.3-12.3; P = 0.016). (ii) The detection of visible lesions at exit endoscopy independently predicted progression (hazard ratio = 6.5; 95% CI = 1.9-22.8; P = 0.003).

CONCLUSION

Barrett's oesophagus with LGD poses a significant risk of progression to HGD/OAC. Guideline-recommended surveillance is effective, but is difficult to adhere to. Clinical predictors for those who are more likely to progress are yet to be defined.

Microenvironment and Biomarkers in Esophageal Cancers: An Approach for Early Detection and Identification

Background Esophageal cancer is a prevalent and highly lethal malignancy worldwide, comprising two main subtypes: esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC). While both subtypes are frequently encountered, ESCC has historically been more common globally. However, in recent decades, EAC has emerged as the predominant type in industrialized nations, often developing from Barrett's esophagus, a condition driven by chronic gastroesophageal reflux disease (GERD). ESCC typically occurs in the upper esophagus, whereas EAC arises near the lower gastroesophageal junction. The etiology of esophageal cancer is multifactorial, with diverse causes and clinical management strategies. Notably, diagnosing tumors located in the lower esophagus presents significant challenges. EAC is particularly prone to diagnostic errors, as it can be mistaken for ESCC. This study aims to investigate potential histological biomarkers for EAC to facilitate early and accurate identification of histological changes, especially in patients with GERD. Methods This cross-sectional study examined archival histological samples from patients with lower esophageal abnormalities. Immunohistochemistry was used to investigate the P63 marker, while Masson's trichrome stain was employed to evaluate cancer progression and associated microenvironmental changes. Results A total of 104 cases were analyzed, including 13 with known P63-positive staining and five P63-negative controls. The remaining cases consisted of both precancerous and cancerous tissues diagnosed as EAC. Among these, 86 cases showed negative P63 staining, confirming their origin from non-squamous cells and supporting their classification as true Barrett's-related epithelium. In contrast, five of the 13 SCC control cases exhibited P63 positivity, demonstrating a highly significant association (p < 0.00001). Additionally, Masson's trichrome staining revealed stromal collagen fibers infiltrating the malignant tissue areas. Conclusions This study highlights the significance of the P63 marker in distinguishing between ESCC and EAC. It also suggests a potential role for Masson's trichrome stain in identifying early microenvironmental changes associated with EAC progression.

Endoscopic Management of Dysplastic Barrett's Oesophagus and Early Oesophageal Adenocarcinoma

Barrett's oesophagus is a pathological condition whereby the normal oesophageal squamous mucosa is replaced by specialised, intestinal-type metaplasia, which is strongly linked to chronic gastro-oesophageal reflux. A correct endoscopic and histological diagnosis is pivotal in the management of Barrett's oesophagus to identify patients who are at high risk of progression to neoplasia. The presence and grade of dysplasia and the characteristics of visible lesions within the mucosa of Barrett's oesophagus are both important to guide the most appropriate endoscopic therapy. In this review, we provide an overview on the management of Barrett's oesophagus, with a particular focus on recent advances in the diagnosis and recommendations for endoscopic therapy to reduce the risk of developing oesophageal adenocarcinoma.

Role of Confocal Laser Endomicroscopy in Early Detection of Upper Gastrointestinal Malignancy in High Risk Patients

BACKGROUND

Upper gastrointestinal malignancies are a major global health burden. Early diagnosis of upper gastrointestinal premalignant and malignant lesions is crucial for improving prognosis and reducing morbidity and mortality. The purpose of this study was to investigate the diagnostic accuracy of confocal laser endomicroscopy (CLE) in detecting upper gastrointestinal premalignant and early malignant lesions in high-risk patients, as well as diagnosing patients with inconclusive white light endoscopy (WLE) and histopathology results.

METHODS

It was a cross-sectional study that included ninety (n = 90) high-risk patients with inconclusive diagnoses of upper gastrointestinal lesions on WLE and WLE-based biopsy histopathology. These patients underwent CLE, and the definitive diagnosis was confirmed using CLE and CLE-target biopsy histopathology. Diagnostic accuracy was determined by comparing the sensitivity, specificity, predictive values, and accuracy between the procedures.

RESULT

The mean patient age was 47.43 ± 11.18 years. CLE and target biopsy confirmed that 30 (33.3%) patients had normal histology, while 60 (66.7%) patients were diagnosed with gastritis, gastric intestinal metaplasia, high-grade dysplasia, adenocarcinoma, Barrett's esophagus, and squamous cell carcinoma of the esophagus. The results of CLE were superior to those of WLE in terms of diagnostic parameters. Additionally, CLE demonstrated nearly similar results in sensitivity (98.33%), specificity (100%), positive predictive value (100%), negative predictive value (96.77%), and accuracy (98.89%) when compared to CLE-target biopsy.

CONCLUSION

CLE showed higher diagnostic accuracy in differentiating normal, premalignant and malignant lesions. It effectively diagnosed patients who initially had inconclusive WLE and/or biopsy results. Furthermore, early detection of upper gastrointestinal premalignant or malignant lesions may improve prognosis and reduce morbidity and mortality.

Construction of the Interaction Network of Hub Genes in the Progression of Barrett's Esophagus to Esophageal Adenocarcinoma

Introduction

Esophageal adenocarcinoma (EAC) is one of the histologic types of esophageal cancer with a poor prognosis. The majority of EAC originate from Barrett's esophagus (BE). There are few studies focusing on the dynamic progression of BE to EAC.

Methods

R software was used to analyze differentially expressed genes (DEGs) based on RNA-seq data of 94 normal esophageal squamous epithelial (NE) tissues, 113 BE tissues and 147 EAC tissues. The overlapping genes of DEGs between BE and EAC were analyzed by Venn diagram tool. The hub genes were selected by Cytoscape software based on the protein-protein interaction network of the overlapping genes using STRING database. The functional analysis of hub genes was performed by R software and the protein expression was identified by immunohistochemistry.

Results

In the present study, we found a large degree of genetic similarity between BE and EAC, and further identified seven hub genes (including COL1A1, TGFBI, MMP1, COL4A1, NID2, MMP12, CXCL1) which were all progressively upregulated in the progression of NE-BE-EAC. We have preliminarily uncovered the probable molecular mechanisms of these hub genes in disease development and constructed the ceRNA regulatory network of hub genes. More importantly, we explored the possibility of hub genes as biomarkers in the disease progression of NE-BE-EAC. For example, TGFBI can be used as biomarkers to predict the prognosis of EAC patients. COL1A1, NID2 and COL4A1 can be used as biomarkers to predict the response to immune checkpoint blockade (ICB) therapy. We also constructed a disease progression risk model for NE-BE-EAC based on CXCL1, MMP1 and TGFBI. Finally, the results of drug sensitivity analysis based on hub genes showed that drugs such as PI3K inhibitor TGX221, bleomycin, PKC inhibitor Midostaurin, Bcr-Abl inhibitor Dasatinib, HSP90 inhibitor 17-AAG, and Docetaxel may be potential candidates to inhibit the progression of BE to EAC.

Conclusion

This study is based on a large number of clinical samples with high credibility, which is useful for revealing the probable carcinogenic mechanism of BE to EAC and developing new clinical treatment strategies.