Education practiceManagement of High-Grade Dysplasia and Intramucosal Adenocarcinoma in Barrett's Esophagus
Section snippets
Clinical Scenario
A 62-year-old Caucasian male with chronic long-standing gastroesophageal reflux disease and a history of nondysplastic Barrett's esophagus (BE) undergoes surveillance upper endoscopy with biopsies at an outside facility. Biopsies revealed high-grade dysplasia (HGD) and the patient is referred to a tertiary care referral center for endoscopic eradication therapy (EET). His symptoms are adequately controlled on twice daily proton pump inhibitor therapy, and he denies any alarm symptoms. His
Definition and Natural History
BE is defined by the displacement of the squamocolumnar junction proximal to the gastroesophageal junction with the presence of intestinal metaplasia. It is an established risk factor for the development of esophageal adenocarcinoma (EAC); a cancer with a rapidly rising incidence in the Western world and associated with a dismal 5-year survival rate of approximately 15%.1, 2 The progression of BE to EAC occurs as a multistep process in which patients progress from intestinal metaplasia to
Accurate Diagnosis and Staging
With the expanding endoscopic armamentarium for management of BE patients with HGD/IMC, accurate staging is critical.9 Patients with neoplasia limited to the mucosa have a minimal risk of lymph node metastasis (0%–3%) and hence are ideal candidates for EET. On the other hand, in patients with submucosal infiltration the risk of lymph node involvement increases significantly (20%) and hence should be referred for surgical resection.10, 11, 12
Areas of Uncertainty and Future Directions
Several challenges remain in the field of EET for Barrett's-related neoplasia. The role of advanced imaging techniques in making real-time decisions regarding EET needs to be elucidated. Long-term data on recurrence rates of dysplasia and EAC in patients undergoing EET are limited and should be evaluated in future large prospective studies. It is unclear what the surveillance intervals should be in patients who have been treated with EET for Barrett's-related neoplasia. The burning issue is
Published Guidelines
The most updated guidelines from the American Gastroenterological Association2 recommend against use of advanced imaging techniques for routine surveillance of BE patients at this time. Careful inspection of the columnar lined esophagus with high resolution white light endoscopy with biopsy sampling of any lesions or suspicious areas so identified followed by 4-quadrant biopsy sampling every 1 cm of the Barrett's segment in patients with known or suspected dysplasia should be performed; EMR for
Recommendations
An algorithm highlighting the suggested approach to a BE patient with HGD or IMC is provided (Figure 6). The patient presented earlier was discussed in a multidisciplinary setting in collaboration with the endoscopist, thoracic surgeon, oncologist, and pathologist. After a detailed discussion regarding the therapeutic options, a decision was made to proceed with EET. EUS and computed tomography (CT) scan performed revealed no lymphadenopathy or advanced disease. Performance of EUS in this
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Cited by (23)
Economic evaluation of Cytosponge®-trefoil factor 3 for Barrett esophagus: A cost-utility analysis of randomised controlled trial data
2021, EClinicalMedicineCitation Excerpt :There have been significant advances in cost-effective, outpatient-based endoscopic therapies which are now recommended for low- and high-grade dysplasia as well as intramucosal stage-1 cancer in BE with very low rates of recurrence [6–8]. These treatment advances substantially mitigate the risks and side effects from systemic therapy and esophagectomy required for more advanced disease [9,10]. The major challenge remains identifying individuals with BE, since using current clinical guidelines, it is estimated that only 20% of BE is diagnosed and hence the majority of EAC cases are diagnosed de novo without the opportunity to prevent progression [11,12].
Endoscopic eradication therapy for patients with Barrett's esophagus–associated dysplasia and intramucosal cancer
2018, Gastrointestinal EndoscopyCitation Excerpt :Discussion: Given the high tumor-free survival rates, esophagectomy was the standard treatment for BE patients with HGD and intramucosal EAC, and all other therapies were compared with this modality.23 Esophagectomy, especially in patients in whom the cancer had not yet penetrated the muscularis mucosa, is associated with a high 5-year survival rate.48 However, this treatment approach is associated with an operative mortality of 2% and a high morbidity rate seen even at high-volume centers.48,49
Challenges with Endoscopic Therapy for Barrett's Esophagus
2015, Gastroenterology Clinics of North AmericaCitation Excerpt :Similarly, a systematic review reported a T-stage concordance rate of 65% using EMR or surgical pathology as the gold standard.53 Peritumoral inflammation resulting in wall thickening, heterogeneous tissue architectures, anatomic factors in the gastric cardia and distal esophagus, and doubled muscularis mucosae contribute to the limited accuracy rates of EUS in this patient population.34 A recent meta-analysis that evaluated the use of EUS in patients with BE with HGD and early EAC (N = 656) showed that the overall proportion of patients with advanced disease (≥T1sm or ≥N1 disease) detected on EUS was 14% (95% CI, 8%–22%) and 4% (95% CI, 2%–6%) in the absence of nodules.54
Comparison of endoscopic therapies and surgical resection in patients with early esophageal cancer: A population-based study
2014, Gastrointestinal Endoscopy
Conflicts of interest The authors disclose the following: Steve Edmundowicz is a consultant for Olympus, BARRX, and has received a stipend for travel from Cellvizio; Prateek Sharma receives grant support from BARRX, Cook, Olympus, and Takeda. The remaining authors disclose no conflicts.