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Zeki SS, Miah I, Visaggi P, Wolak A, deSilva M, Dunn JM, Davies A, Gossage J, Botha A, Sui G, Jafari J, Wong T. Extended Wireless pH Monitoring Significantly Increases Gastroesophageal Reflux Disease Diagnoses in Patients With a Normal pH Impedance Study. J Neurogastroenterol Motil 2023; 29:335-342. [PMID: 37417260 PMCID: PMC10334198 DOI: 10.5056/jnm22130] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/31/2023] [Accepted: 04/02/2023] [Indexed: 07/08/2023] Open
Abstract
Background/Aims Extended wireless pH monitoring (WPM) is used to investigate gastroesophageal reflux disease (GERD) as subsequent or alternative investigation to 24-hour catheter-based studies. However, false negative catheter studies may occur in patients with intermittent reflux or due to catheter-induced discomfort or altered behavior. We aim to investigate the diagnostic yield of WPM after a negative 24-hour multichannel intraluminal impedance pH (MII-pH) monitoring study and to determine predictors of GERD on WPM given a negative MII-pH. Methods Consecutive adult patients (> 18 years) who underwent WPM for further investigation of suspected GERD following a negative 24-hour MII-pH and upper endoscopy between January 2010 and December 2019 were retrospectively included. Clinical data, endoscopy, MII-pH, and WPM results were retrieved. Fisher's exact test, Wilcoxon rank sum test, or Student's t test were used to compare data. Logistic regression analysis was used to investigate predictors of positive WMP. Results One hundred and eighty-one consecutive patients underwent WPM following a negative MII-pH study. On average and worst day analysis, 33.7% (61/181) and 34.2% (62/181) of the patients negative for GERD on MII-pH were given a diagnosis of GERD following WPM, respectively. On a stepwise multiple logistic regression analysis, the basal respiratory minimum pressure of the lower esophageal sphincter was a significant predictor of GERD with OR = 0.95 (0.90-1.00, P = 0.041). Conclusions WPM increases GERD diagnostic yield in patients with a negative MII-pH selected for further testing based on clinical suspicion. Further studies are needed to assess the role of WPM as a first line investigation in patients with GERD symptoms.
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Affiliation(s)
- Sebastian S Zeki
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
- King's College London, School of Cancer and Pharmaceutical Sciences, London, UK
| | - Ismail Miah
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
| | - Pierfrancesco Visaggi
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Anna Wolak
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
| | - Minerva deSilva
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
| | - Jason M Dunn
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
- King's College London, School of Cancer and Pharmaceutical Sciences, London, UK
| | - Andrew Davies
- King's College London, School of Cancer and Pharmaceutical Sciences, London, UK
- Guy's and St. Thomas' Esophago-gastric Center, London, UK
| | - James Gossage
- King's College London, School of Cancer and Pharmaceutical Sciences, London, UK
- Guy's and St. Thomas' Esophago-gastric Center, London, UK
| | - Abrie Botha
- Guy's and St. Thomas' Esophago-gastric Center, London, UK
| | - Guiping Sui
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
| | - Jafar Jafari
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
| | - Terry Wong
- Department of Gastroenterology, Center for Eosophageal Diseases, Guy's and St. Thomas' Hospital, London, UK
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Abujudeh S, Zeki SS, van Lanschot MCJ, Pusung M, Weaver JMJ, Li X, Noorani A, Metz AJ, Bornschein J, Bower L, Miremadi A, Fitzgerald RC, Morrissey ER, Lynch AG. Low-cost and clinically applicable copy number profiling using repeat DNA. BMC Genomics 2022; 23:599. [PMID: 35978291 PMCID: PMC9386984 DOI: 10.1186/s12864-022-08681-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Somatic copy number alterations (SCNAs) are an important class of genomic alteration in cancer. They are frequently observed in cancer samples, with studies showing that, on average, SCNAs affect 34% of a cancer cell's genome. Furthermore, SCNAs have been shown to be major drivers of tumour development and have been associated with response to therapy and prognosis. Large-scale cancer genome studies suggest that tumours are driven by somatic copy number alterations (SCNAs) or single-nucleotide variants (SNVs). Despite the frequency of SCNAs and their clinical relevance, the use of genomics assays in the clinic is biased towards targeted gene panels, which identify SNVs but provide limited scope to detect SCNAs throughout the genome. There is a need for a comparably low-cost and simple method for high-resolution SCNA profiling. RESULTS We present conliga, a fully probabilistic method that infers SCNA profiles from a low-cost, simple, and clinically-relevant assay (FAST-SeqS). When applied to 11 high-purity oesophageal adenocarcinoma samples, we obtain good agreement (Spearman's rank correlation coefficient, rs=0.94) between conliga's inferred SCNA profiles using FAST-SeqS data (approximately £14 per sample) and those inferred by ASCAT using high-coverage WGS (gold-standard). We find that conliga outperforms CNVkit (rs=0.89), also applied to FAST-SeqS data, and is comparable to QDNAseq (rs=0.96) applied to low-coverage WGS, which is approximately four-fold more expensive, more laborious and less clinically-relevant. By performing an in silico dilution series experiment, we find that conliga is particularly suited to detecting SCNAs in low tumour purity samples. At two million reads per sample, conliga is able to detect SCNAs in all nine samples at 3% tumour purity and as low as 0.5% purity in one sample. Crucially, we show that conliga's hidden state information can be used to decide when a sample is abnormal or normal, whereas CNVkit and QDNAseq cannot provide this critical information. CONCLUSIONS We show that conliga provides high-resolution SCNA profiles using a convenient, low-cost assay. We believe conliga makes FAST-SeqS a more clinically valuable assay as well as a useful research tool, enabling inexpensive and fast copy number profiling of pre-malignant and cancer samples.
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Affiliation(s)
- Sam Abujudeh
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK.
| | - Sebastian S Zeki
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK. .,Department of Gastroenterology, Guy's and St Thomas' NHS Trust, London, SE1 7EH, UK.
| | | | - Mark Pusung
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Jamie M J Weaver
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK.,Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4TX, UK
| | - Xiaodun Li
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Ayesha Noorani
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Andrew J Metz
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Jan Bornschein
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Lawrence Bower
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK
| | - Ahmad Miremadi
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK
| | - Rebecca C Fitzgerald
- Medical Research Council (MRC) Cancer Unit, University of Cambridge, Cambridge, UK.
| | - Edward R Morrissey
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK. .,Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK.
| | - Andy G Lynch
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK. .,School of Mathematics and Statistics/School of Medicine, University of St Andrews, St Andrews, UK.
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3
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Dunn JM, Reyhani A, Santaolalla A, Zylstra J, Gimson E, Pennington M, Baker C, Kelly M, Van Hemelrijck M, Lagergren J, Zeki SS, Gossage JA, Davies AR. Transition from esophagectomy to endoscopic therapy for early esophageal cancer. Dis Esophagus 2022; 35:6321381. [PMID: 34260693 DOI: 10.1093/dote/doab047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/24/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND To assess the outcomes of patients with early esophageal cancer and high-grade dysplasia comparing esophagectomy, the historical treatment of choice, to endoscopic eradication therapy (EET). METHODS Retrospective cohort study of consecutive patients with early esophageal cancer/high-grade dysplasia, treated between 2000 and 2018 at a tertiary center. Primary outcomes were all-cause and disease-specific mortality assessed by multivariable Cox regression and a propensity score matching sub analysis, providing hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, tumor grade (G1/2 vs. G3), tumor stage, and lymphovascular invasion. Secondary outcomes included complications, hospital stay, and overall costs. RESULTS Among 269 patients, 133 underwent esophagectomy and 136 received EET. Adjusted survival analysis showed no difference between groups regarding all-cause mortality (HR 1.85, 95% CI 0.73, 4.72) and disease-specific mortality (HR 1.10, 95% CI 0.26, 4.65). In-hospital and 30-day mortality was 0% in both groups. The surgical group had a significantly higher rate of complications (Clavien-Dindo ≥3 26.3% vs. endoscopic therapy 0.74%), longer in-patient stay (median 14 vs. 0 days endoscopic therapy) and higher hospital costs(£16 360 vs. £8786 per patient). CONCLUSION This series of patients treated during a transition period from surgery to EET, demonstrates a primary endoscopic approach does not compromise oncological outcomes with the benefit of fewer complications, shorter hospital stays, and lower costs compared to surgery. It should be available as the gold standard treatment for patients with early esophageal cancer. Those with adverse prognostic features may still benefit from esophagectomy.
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Affiliation(s)
- Jason M Dunn
- Gastroenterology, Guy's and St.Thomas' Esophago-Gastric Centre, London, UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Arasteh Reyhani
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Aida Santaolalla
- Gastroenterology Unit,Translational Oncology & Urology Research(TOUR). King's College London, London UK
| | - Janine Zylstra
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Eliza Gimson
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Mark Pennington
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Cara Baker
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Mark Kelly
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Mieke Van Hemelrijck
- Gastroenterology Unit,Translational Oncology & Urology Research(TOUR). King's College London, London UK
| | - Jesper Lagergren
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Sebastian S Zeki
- Gastroenterology, Guy's and St.Thomas' Esophago-Gastric Centre, London, UK
| | - James A Gossage
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Andrew R Davies
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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4
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Zeki SS, Bergman JJ, Dunn JM. Endoscopic management of dysplasia and early oesophageal cancer. Best Pract Res Clin Gastroenterol 2018; 36-37:27-36. [PMID: 30551853 DOI: 10.1016/j.bpg.2018.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/19/2018] [Indexed: 01/31/2023]
Abstract
In the past decade there have been technological advances in Endoscopic Eradication Therapy (EET) for the management of patients with oesophageal neoplasia and early cancer. Multiple endoscopic techniques now exist for both squamous and Barrett's oesophagus associated neoplasia or early cancer. A fundamental aspect of endotherapy is removal of the target lesion by endoscopic mucosal resection, or endosopic submucosal dissection. Residual tissue is subsequently ablated to remove the risk of recurrence. The most validated technique for Barrett's oesophagus is radiofrequency ablation, but other techniques such as hybrid-APC and cryotherapy also show good results. This chapter will discuss the evolution of EET, and which patients are most likely to benefit. It will also explore the evidence behind the success of different techniques and provide practical advice on how to carry out the endoscopic techniques with a focus on radiofrequency ablation and endoscopic mucosal resection in particular.
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Affiliation(s)
- S S Zeki
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom.
| | - J J Bergman
- Dep. of Gastroenterology, Academic Medical Center, Amsterdam, Netherlands
| | - J M Dunn
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom
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5
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Zeki SS, Ooi J, Wilson P, Walker G, Blaker P, DeMartino S, O'Donohue J, Reffitt D, Lanaspre E, Chang F, Meenan J, Dunn JM. Reply to Westerveld et al. and Schembri et al. Endoscopy 2017; 49:1115. [PMID: 29073698 DOI: 10.1055/s-0043-118217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Sebastian S Zeki
- Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Joanne Ooi
- Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Patrick Wilson
- Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Giles Walker
- Department of Gastroenterology, Lewisham University Hospital, London, United Kingdom
| | - Paul Blaker
- Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sabina DeMartino
- Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - John O'Donohue
- Department of Gastroenterology, Lewisham University Hospital, London, United Kingdom
| | - David Reffitt
- Department of Gastroenterology, Lewisham University Hospital, London, United Kingdom
| | - Effie Lanaspre
- Department of Histopathology, Lewisham University Hospital, London, United Kingdom
| | - Fuju Chang
- Department of Histopathology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - John Meenan
- Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jason M Dunn
- Department of Gastroenterology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom.,Institute of Medical Informatics, Oslo University Hospital, Norway
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6
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Lavery DL, Nicholson AM, Poulsom R, Jeffery R, Hussain A, Gay LJ, Jankowski JA, Zeki SS, Barr H, Harrison R, Going J, Kadirkamanathan S, Davis P, Underwood T, Novelli MR, Rodriguez-Justo M, Shepherd N, Jansen M, Wright NA, McDonald SAC. The stem cell organisation, and the proliferative and gene expression profile of Barrett's epithelium, replicates pyloric-type gastric glands. Gut 2014; 63:1854-63. [PMID: 24550372 PMCID: PMC4251192 DOI: 10.1136/gutjnl-2013-306508] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 01/20/2014] [Accepted: 01/21/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Barrett's oesophagus shows appearances described as 'intestinal metaplasia', in structures called 'crypts' but do not typically display crypt architecture. Here, we investigate their relationship to gastric glands. METHODS Cell proliferation and migration within Barrett's glands was assessed by Ki67 and iododeoxyuridine (IdU) labelling. Expression of mucin core proteins (MUC), trefoil family factor (TFF) peptides and LGR5 mRNA was determined by immunohistochemistry or by in situ hybridisation, and clonality was elucidated using mitochondrial DNA (mtDNA) mutations combined with mucin histochemistry. RESULTS Proliferation predominantly occurs in the middle of Barrett's glands, diminishing towards the surface and the base: IdU dynamics demonstrate bidirectional migration, similar to gastric glands. Distribution of MUC5AC, TFF1, MUC6 and TFF2 in Barrett's mirrors pyloric glands and is preserved in Barrett's dysplasia. MUC2-positive goblet cells are localised above the neck in Barrett's glands, and TFF3 is concentrated in the same region. LGR5 mRNA is detected in the middle of Barrett's glands suggesting a stem cell niche in this locale, similar to that in the gastric pylorus, and distinct from gastric intestinal metaplasia. Gastric and intestinal cell lineages within Barrett's glands are clonal, indicating derivation from a single stem cell. CONCLUSIONS Barrett's shows the proliferative and stem cell architecture, and pattern of gene expression of pyloric gastric glands, maintained by stem cells showing gastric and intestinal differentiation: neutral drift may suggest that intestinal differentiation advances with time, a concept critical for the understanding of the origin and development of Barrett's oesophagus.
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Affiliation(s)
- Danielle L Lavery
- Epithelial Stem Cell Group, Centre for Tumour Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anna M Nicholson
- Stem Cell Biology of the Intestine Laboratory, Cancer Research UK Cambridge Research Institute, Li Ka Shing Centre, Cambridge, UK
| | - Richard Poulsom
- Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rosemary Jeffery
- Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alia Hussain
- Epithelial Stem Cell Group, Centre for Tumour Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Laura J Gay
- Epithelial Stem Cell Group, Centre for Tumour Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Janusz A Jankowski
- Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sebastian S Zeki
- Epithelial Stem Cell Group, Centre for Tumour Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Hugh Barr
- Department of Surgery, Gloucestershire Royal Hospital, Gloucestershire Royal Hospital, Gloucester, UK
| | - Rebecca Harrison
- Department of Pathology, University Hospitals Leicester, Leicester, UK
| | - James Going
- University of Glasgow, Institute of Cancer Sciences, Glasgow, UK
| | | | - Peter Davis
- Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Chelmsford, UK
| | | | - Marco R Novelli
- Department of Histopathology, University College London, London, UK
| | | | - Neil Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Cheltenham, UK
| | - Marnix Jansen
- Department of Pathology, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Nicholas A Wright
- Epithelial Stem Cell Group, Centre for Tumour Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Stuart A C McDonald
- Epithelial Stem Cell Group, Centre for Tumour Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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7
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Zeki SS, Haidry R, Justo-Rodriguez M, Lovat LB, Wright NA, McDonald SA. Squamous cell carcinoma after radiofrequency ablation for Barrett's dysplasia. World J Gastroenterol 2014; 20:4453-6. [PMID: 24764687 PMCID: PMC3989985 DOI: 10.3748/wjg.v20.i15.4453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 08/23/2013] [Accepted: 09/04/2013] [Indexed: 02/06/2023] Open
Abstract
Barrett's oesophagus (BO) is a usually indolent condition that occasionally requires endoscopic therapy. Radiofrequency ablation (RFA) is an effective endoscopic treatment for high grade dysplasia (HGD) and intramucosal cancer in BO. It has a good efficacy, durability and safety profile although complications can occur. Here we describe a case of RFA in a patient with high grade dysplasia. Although the response to treatment was initially very good with the development of neosquamous epithelium, the patient very rapidly developed a squamous cell cancer of the oesophagus confirmed on radiology, histology and immunohistochemistry. Sanger sequencing confirmed that the original HGD and the squamous cell cancer (SCC) were derived from separate clonal origins. The report highlights the fact that SCC of the oesophagus has been noted after endoscopic ablation for BO previously and suggest that ablation of BO may encourage the clonal expansion of cells carrying carcinogenic mutations once a dominant clonal population has been eradicated.
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8
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Zeki SS, Haidry R, Graham TA, Rodriguez-Justo M, Novelli M, Hoare J, Dunn J, Wright NA, Lovat LB, McDonald SAC. Clonal selection and persistence in dysplastic Barrett's esophagus and intramucosal cancers after failed radiofrequency ablation. Am J Gastroenterol 2013; 108:1584-92. [PMID: 23939625 DOI: 10.1038/ajg.2013.238] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 07/08/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Radiofrequency ablation (RFA) is used to successfully eliminate Barrett's esophagus (BE)-related dysplasia or intramucosal carcinoma and aims to cause reversion to squamous epithelium. However, in 20% of cases RFA fails to return the epithelium to squamous phenotype. Follow-up studies show a similar dysplasia recurrence rate. We hypothesize that failed RFA is due to clonally mutated epithelial populations harbored in RFA-privileged sites and that RFA can select for the mutant clonal expansion. METHODS A longitudinal case series of 19 patients with BE and high-grade dysplasia or intramucosal carcinoma were studied. DNA was extracted from individual Barrett's glands, deep esophageal glands within mucosal resections and biopsy specimens before and after RFA. Mutations were identified by targeted sequencing of genes commonly mutated in Barrett's adenocarcinoma. RESULTS Five patients demonstrated persistent post-RFA pathology with persistent mutations, sometimes detected in deep esophageal glands or neighboring squamous epithelium after several rounds of RFA preceded by mucosal resection. Recurrence of pathology in three other patients was characterized by de novo mutations. CONCLUSIONS Protumorigenic mutations can be found in post-ablation squamous mucosa as well as in mutant deep esophageal glands; both are associated with dysplasia recurrence. Following RFA, non-dysplastic Barrett's epithelium can contain mutant clones that are found in a subsequent adenocarcinoma. Ablation may also drive the clonal expansion of pre-existing clones after a "bottleneck" created by the RFA. Overall, recurrence of dysplasia post RFA reflects the multicentric origins of Barrett's clones and highlights the role of clonal selection in carcinogenesis.
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Affiliation(s)
- Sebastian S Zeki
- Centre for Tumour Biology, Barts Cancer Institute, John Vane Science Centre, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
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9
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Zeki SS, McDonald SA, Graham TA. Field cancerization in Barrett's esophagus. Discov Med 2011; 12:371-379. [PMID: 22127108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Barrett's esophagus is a columnar metaplasia conferring an increased risk of adenocarcinoma development. Evidence suggests that this increased risk is due to field cancerization - the formation of histologically undistinguishable field of clonally derived, mutant cells within the Barrett's segment. Field cancerization can occur prior to both dysplasia and invasive neoplasia and potentially provides a mechanism for the development of multifocal and metachronous tumors. In the gastrointestinal tract, mutant clones spread predominately by crypt fission; the same is likely to be true in Barrett's lesions. Epithelial interactions in the form of cooperation or competition between epithelial clones, as well as with stromal cells, may further drive clone growth. Field cancerization is a clinically relevant phenomenon, knowledge of which could influence the size of resection margins to enhance prognosis after curative surgery, as well as provide a rationale for the development of effective biomarkers for neoplasia risk in Barrett's esophagus. This may provide a foundation for streamlined surveillance programs to prevent the development of invasive tumors.
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Affiliation(s)
- Sebastian S Zeki
- Division of Digestive Diseases, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London, E1 2AT, UK
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