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Stachler MD, Bass AJ. Can Genomic Sequencing Identify High-Risk Barrett's Esophagus Earlier Than Pathologists? Cancer Cell 2020; 38:626-628. [PMID: 33171128 DOI: 10.1016/j.ccell.2020.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Barrett's esophagus (BE) is a precursor to esophageal adenocarinoma, and screening for cancer risk focuses upon histologic assessment of dysplasia within endoscopic biopsies. A recent study in Nature Medicine contributes to growing evidence that genomic assessment of non-dysplastic BE samples can identify patients at greatest risk of progressing to cancer.
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Affiliation(s)
- Matthew D Stachler
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Adam J Bass
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA; Eli and Edythe L. Broad Institute, Cambridge, MA, USA.
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Liu YJ, Rogers J, Liu YZ, Gui X, Jalikis F, Koch L, Swanson PE, Truong CD, Yeh MM. Interobserver agreement in pathologic evaluation of bile duct biopsies. Hum Pathol 2020; 107:29-38. [PMID: 33129823 DOI: 10.1016/j.humpath.2020.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/20/2022]
Abstract
Intraductal biopsy is commonly used for preoperative evaluation of the etiology of biliary strictures. Interpretation of intraductal biopsies is frequently challenging. The diagnosis often suffers from interobserver disagreement, which has not been studied in the literature. We sought to assess interobserver concordance in the interpretation of intraductal biopsies. Eighty-five biopsies were retrieved, falling into five diagnostic categories: negative for dysplasia (NED), indefinite for dysplasia (IND), low-grade dysplasia (LGD), high-grade dysplasia (HGD), and carcinoma (CA). Eight gastrointestinal pathologists blindly reviewed all the slides. Agreement among pathologists was analyzed using Fleiss κ and weighted concordance coefficient S∗. A face-to-face consensus/training session was held to discuss the classification criteria, followed by a second round review. The overall interobserver agreement was fair in the first round review (κ = 0.39; S∗ = 0.56) and improved to moderate in the second round review (κ = 0.48; S∗ = 0.69). The agreement before and after consensus meeting was substantial to nearly perfect for CA (κ = 0.65, S∗ = 0.83; and κ = 0.80, S∗ = 0.91), fair for HGD (κ = 0.28, S∗ = 0.69; and κ = 0.40, S∗ = 0.63), and moderate for NED (κ = 0.47, S∗ = 0.50; and κ = 0.47, S∗ = 0.53). Agreement improved from fair to moderate for LGD (κ = 0.36, S∗ = 0.61; and κ = 0.49, S∗ = 0.71) and slight to fair for IND (κ = 0.16, S∗ = 0.51; and κ = 0.33, S∗ = 0.50). Compared with Hollande's fixed specimens, the agreement was higher in almost all diagnostic categories in formalin-fixed biopsies. Overall, interobserver concordance was improved after a consensus/training session. Interobserver reproducibility was high at the end of the diagnostic spectrum (CA) but fair to moderate for other diagnostic categories.
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Affiliation(s)
- Yong-Jun Liu
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA; Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, WI, 53705, USA
| | - Jessica Rogers
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Yao-Zhong Liu
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, LA, 70112, USA
| | - Xianyong Gui
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Florencia Jalikis
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Lisa Koch
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Paul E Swanson
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Camtu D Truong
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Matthew M Yeh
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA; Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98195, USA.
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Saracco M, Savarino V, Bodini G, Saracco GM, Pellicano R. Gastroesophageal reflux disease: key messages for clinicians. Minerva Gastroenterol (Torino) 2020; 67:390-403. [PMID: 33103406 DOI: 10.23736/s2724-5985.20.02783-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a chronic common disorder for which patients often refer to specialists. In the last decades, numerous studies helped to clarify the pathophysiology and the natural history of this disease. Currently, in the clinical setting, GERD is defined by the presence of symptoms that, when endoscopic investigation is required, permit to distinguish between cases with or without associated esophageal mucosal injuries. These conditions are called erosive reflux disease and non-erosive reflux disease (NERD), respectively. The latter is the most common manifestation of GERD. Symptoms are defined typical, as heartburn and regurgitation, and atypical (also called extra-esophageal), as coughing and/or wheezing, hoarseness, sore throat, otitis media, and dental manifestations. In this context, it is crucial for clinicians to investigate the presence of features of suspected malignancy, as unexplained weight loss, anemia, dysphagia, persistent vomiting, familiar history of cancer, long history of GERD, and beginning of GERD symptoms after the age of 50 years. The presence of these risk factors should induce to perform an endoscopic examination. Particular attention should be given to functional conditions that can mimic GERD, such as functional heartburn and hypersensitive esophagus as well as, more rarely, eosinophilic esophagitis. The former ones have different pathophysiology and this explains the frequent non-response to proton pump inhibitor drugs. This narrative review provides to clinicians a useful and practical overview of the state-of-the-art on advancements in the knowledge of GERD.
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Affiliation(s)
| | | | - Giorgia Bodini
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Giorgio M Saracco
- Department of Medical Sciences, University of Turin, Turin, Italy.,Unit of Gastroenterology, Molinette Hospital, Turin, Italy
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Maitra I, Date RS, Martin FL. Towards screening Barrett's oesophagus: current guidelines, imaging modalities and future developments. Clin J Gastroenterol 2020; 13:635-649. [PMID: 32495144 PMCID: PMC7519897 DOI: 10.1007/s12328-020-01135-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma (OAC). Although guidelines on the screening and surveillance exist in Barrett's oesophagus, the current strategies are inadequate. Oesophagogastroduodenoscopy (OGD) is the gold standard method in screening for Barrett's oesophagus. This invasive method is expensive with associated risks negating its use as a current screening tool for Barrett's oesophagus. This review explores current definitions, epidemiology, biomarkers, surveillance, and screening in Barrett's oesophagus. Imaging modalities applicable to this condition are discussed, in addition to future developments. There is an urgent need for an alternative non-invasive method of screening and/or surveillance which could be highly beneficial towards reducing waiting times, alleviating patient fears and reducing future costs in current healthcare services. Vibrational spectroscopy has been shown to be promising in categorising Barrett's oesophagus through to high-grade dysplasia (HGD) and OAC. These techniques need further validation through multicentre trials.
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Affiliation(s)
- Ishaan Maitra
- School of Pharmacy and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE UK
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Lipman G, Markar S, Gupta A, Haidry RJ, Lovat LB, Banks M, Sehgal V, Graham D, Sweis R, Morris D, Miah H, Dunn JM, Smart HL, Bhandari P, Smith L, Willert R, Fullarton G, Morris J, Di Pietro M, Gordon C, Penman I, Barr H, Patel P, Boger P, Kapoor N, Hoare J, Direkze N, Ang Y, Veitch A, Ragunath K, Cheong E, Dhar A, Nylander D, Mahon B, Narayanasamy R, O’Toole D. Learning curves and the influence of procedural volume for the treatment of dysplastic Barrett's esophagus. Gastrointest Endosc 2020; 92:543-550.e1. [PMID: 32145288 DOI: 10.1016/j.gie.2020.02.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resections and radiofrequency ablation (RFA) are the established treatments for Barrett's-associated dysplasia and early esophageal neoplasia. The UK RFA Registry collects patient outcomes from 24 centers treating patients in the United Kingdom and Ireland. Learning curves for treatment of Barrett's dysplasia and the impact of center caseload on patient outcomes is still unknown. METHODS We examined outcomes of 678 patients treated with RFA in the UK Registry using risk-adjusted cumulative sum control chart (RA-CUSUM) analysis to identify change points in complete resolution of intestinal metaplasia (CR-IM) and complete resolution of dysplasia (CR-D) outcomes. We compared outcomes between those treated at high-volume (>100 enrolled patients), medium-volume (51-100), and low-volume (<50) centers. RESULTS There was no association between center volume and CR-IM and CR-D rates, but recurrence rates were lower in high-volume versus low-volume centers (log rank P = .001). There was a significant change point for outcomes at 12 cases for CR-D (reduction from 24.5% to 10.4%; P < .001) and at 18 cases for CR-IM (30.7% to 18.6%; P < .001) from RA-CUSUM curve analysis. CONCLUSION Our data suggest that 18 supervised cases of endoscopic ablation may be required before competency in endoscopic treatment of Barrett's dysplasia can be achieved. The difference in outcomes between a high-volume and low-volume center does not support further centralization of services to only high-volume centers.
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Affiliation(s)
- Gideon Lipman
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, United Kingdom; Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
| | - Sheraz Markar
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Abhinav Gupta
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Rehan J Haidry
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Laurence B Lovat
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom
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Chueca E, Valero A, Hördnler C, Puertas A, Carrera P, García-González MA, Strunk M, Lanas A, Piazuelo E. Quantitative analysis of p16 methylation in Barrett's carcinogenesis. Ann Diagn Pathol 2020; 47:151554. [PMID: 32570024 DOI: 10.1016/j.anndiagpath.2020.151554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 05/12/2020] [Accepted: 06/15/2020] [Indexed: 11/19/2022]
Abstract
p16 hypermethylation in Barrett's carcinogenesis has been evaluated in studies which did not take into account sample heterogeneity and yielded qualitative (methylated/unmethylated) instead of accurate quantitative (percentage of CpG methylation) data. We aimed to measure the degree of p16 methylation in pure samples representing all the steps of Barrett's tumorogenesis and to evaluate the influence of sample heterogeneity in methylation analysis. METHODS 77 paraffin-embedded human esophageal samples were analyzed. Histological grading was established by two pathologists in: negative for dysplasia, indefinite for dysplasia, low-grade dysplasia, high-grade dysplasia and adenocarcinoma. Areas of interest were selected by laser-capture microdissection. p16 methylation was quantified by pyrosequencing. An adjacent section of the whole sample was also analyzed to compare methylation data. RESULTS After microdissection, we obtained 15 samples of squamous epithelium, 36 non-dysplastic Barrett's esophagus, 3 indefinite for dysplasia, 24 low-grade dysplasia, 4 high-grade dysplasia and 12 adenocarcinoma. Squamous epithelium showed the lowest methylation rates: 6% (IQR 5-11) vs. 11%(7-39.50) in negative/indefinite for dysplasia, p<0.01; 10.60%(6-24) in low-grade dysplasia, p<0.05; and 44.50%(9-66.75) in high-grade dysplasia/adenocarcinoma, p<0.01. This latter group also exhibited higher methylation rates than Barrett's epithelium with and without low-grade dysplasia (p<0.05). p16 methylation rates of microdissected and non-microdissected samples did not correlate unless the considered histological alteration comprised >71% of the sample. CONCLUSIONS p16 methylation is an early event in Barrett's carcinogenesis which increases with the severity of histological alteration. p16 methylation rates are profoundly influenced by sample heterogeneity, so selection of samples is crucial in order to detect differences.
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Affiliation(s)
- E Chueca
- CIBERehd, Instituto de Salud Carlos III, Calle Monforte de Lemos 3-5, 28029 Madrid, Spain; IIS Aragón, Instituto de Investigación Sanitaria Aragón, Avenida San Juan Bosco 13, 50009 Zaragoza, Spain
| | - A Valero
- Service of Pathology, University Hospital Miguel Servet, Paseo Isabel la Católica 1-3, 50009 Zaragoza, Spain
| | - C Hördnler
- Service of Pathology, University Hospital Miguel Servet, Paseo Isabel la Católica 1-3, 50009 Zaragoza, Spain
| | - A Puertas
- Service of Pathology, University Hospital Miguel Servet, Paseo Isabel la Católica 1-3, 50009 Zaragoza, Spain
| | - P Carrera
- CIBERehd, Instituto de Salud Carlos III, Calle Monforte de Lemos 3-5, 28029 Madrid, Spain
| | - M A García-González
- CIBERehd, Instituto de Salud Carlos III, Calle Monforte de Lemos 3-5, 28029 Madrid, Spain; IIS Aragón, Instituto de Investigación Sanitaria Aragón, Avenida San Juan Bosco 13, 50009 Zaragoza, Spain; IACS Aragón, Instituto Aragonés de Ciencias de la Salud, Avenida San Juan Bosco 13, 50009 Zaragoza, Spain
| | - M Strunk
- IACS Aragón, Instituto Aragonés de Ciencias de la Salud, Avenida San Juan Bosco 13, 50009 Zaragoza, Spain
| | - A Lanas
- CIBERehd, Instituto de Salud Carlos III, Calle Monforte de Lemos 3-5, 28029 Madrid, Spain; IIS Aragón, Instituto de Investigación Sanitaria Aragón, Avenida San Juan Bosco 13, 50009 Zaragoza, Spain; University of Zaragoza, Calle de Pedro Cerbuna 12, 50009, Zaragoza, Spain
| | - E Piazuelo
- CIBERehd, Instituto de Salud Carlos III, Calle Monforte de Lemos 3-5, 28029 Madrid, Spain; IIS Aragón, Instituto de Investigación Sanitaria Aragón, Avenida San Juan Bosco 13, 50009 Zaragoza, Spain; IACS Aragón, Instituto Aragonés de Ciencias de la Salud, Avenida San Juan Bosco 13, 50009 Zaragoza, Spain.
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Independent Blinded Validation of a Tissue Systems Pathology Test to Predict Progression in Patients With Barrett's Esophagus. Am J Gastroenterol 2020; 115:843-852. [PMID: 32079863 PMCID: PMC7274882 DOI: 10.14309/ajg.0000000000000556] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION A risk prediction test was previously validated to predict progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus (BE). The aim of our study was to independently validate this test to predict the risk of progression to HGD/EAC in BE patients with nondysplastic (ND), indefinite for dysplasia and low-grade dysplasia (LGD). METHODS A single-blinded, case-control study was conducted to stratify patients with BE as low, intermediate, or high risk for progression to HGD/EAC within 5 years using a previously described risk prediction test. Patients with BE who progressed to HGD/EAC after at least 1 year (n = 58) were matched to patients undergoing surveillance without progression (n = 210, median surveillance 7 years). Baseline biopsies with subspecialist diagnoses of ND, indefinite for dysplasia, or LGD were tested in a blinded manner, and the predictive performance of the test was assessed. RESULTS This risk prediction test stratified patients with BE based on progression risk with the high-risk group at 4.7-fold increased risk for HGD/EAC compared with the low-risk group (95% confidence interval 2.5-8.8, P < 0.0001). Prevalence-adjusted positive predictive value at 5 years was 23%. The high-risk class and male sex provided predictive power that was independent of pathologic diagnosis, age, segment length, and hiatal hernia. Patients with ND BE who scored high risk progressed at a higher rate (26%) than patients with subspecialist-confirmed LGD (21.8%) at 5 years. DISCUSSION A risk prediction test identifies patients with ND BE who are at high risk for progression to HGD/EAC and may benefit from early endoscopic therapy or increased surveillance.
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van der Wel MJ, Coleman HG, Bergman JJGHM, Jansen M, Meijer SL. Histopathologist features predictive of diagnostic concordance at expert level among a large international sample of pathologists diagnosing Barrett's dysplasia using digital pathology. Gut 2020; 69:811-822. [PMID: 31852770 DOI: 10.1136/gutjnl-2019-318985] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Guidelines mandate expert pathology review of Barrett's oesophagus (BO) biopsies that reveal dysplasia, but there are no evidence-based standards to corroborate expert reviewer status. We investigated BO concordance rates and pathologist features predictive of diagnostic discordance. DESIGN Pathologists (n=51) from over 20 countries assessed 55 digitised BO biopsies from across the diagnostic spectrum, before and after viewing matched p53 labelling. Extensive demographic and clinical experience data were obtained via online questionnaire. Reference diagnoses were obtained from a review panel (n=4) of experienced Barrett's pathologists. RESULTS We recorded over 6000 case diagnoses with matched demographic data. Of 2805 H&E diagnoses, we found excellent concordance (>70%) for non-dysplastic BO and high-grade dysplasia, and intermediate concordance for low-grade dysplasia (42%) and indefinite for dysplasia (23%). Major diagnostic errors were found in 248 diagnoses (8.8%), which reduced to 232 (8.3%) after viewing p53 labelled slides. Demographic variables correlating with diagnostic proficiency were analysed in multivariate analysis, which revealed that at least 5 years of professional experience was protective against major diagnostic error for H&E slide review (OR 0.48, 95% CI 0.31 to 0.74). Working in a non-teaching hospital was associated with increased odds of major diagnostic error (OR 1.76, 95% CI 1.15 to 2.69); however, this was neutralised when pathologists viewed p53 labelled slides. Notably, neither case volume nor self-identifying as an expert predicted diagnostic proficiency. Extrapolating our data to real-world case prevalence suggests that 92.3% of major diagnostic errors are due to overinterpreting non-dysplastic BO. CONCLUSION Our data provide evidence-based criteria for diagnostic proficiency in Barrett's histopathology.
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Affiliation(s)
| | - Helen G Coleman
- Centre for Public Health, Queens University Belfast, Belfast, UK
| | | | | | - Sybren L Meijer
- Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Establishing spectrochemical changes in the natural history of oesophageal adenocarcinoma from tissue Raman mapping analysis. Anal Bioanal Chem 2020; 412:4077-4087. [PMID: 32333079 PMCID: PMC7320044 DOI: 10.1007/s00216-020-02637-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/26/2020] [Accepted: 04/02/2020] [Indexed: 12/17/2022]
Abstract
Raman spectroscopy is a fast and sensitive technique able to identify molecular changes in biological specimens. Herein, we report on three cases where Raman microspectroscopy was used to distinguish normal vs. oesophageal adenocarcinoma (OAC) (case 1) and Barrett’s oesophagus vs. OAC (cases 2 and 3) in a non-destructive and highly accurate fashion. Normal and OAC tissues were discriminated using principal component analysis plus linear discriminant analysis (PCA-LDA) with 97% accuracy (94% sensitivity and 100% specificity) (case 1); Barrett’s oesophagus vs. OAC tissues were discriminated with accuracies ranging from 98 to 100% (97–100% sensitivity and 100% specificity). Spectral markers responsible for class differentiation were obtained through the difference-between-mean spectrum for each group and the PCA loadings, where C–O–C skeletal mode in β-glucose (900 cm−1), lipids (967 cm−1), phosphodioxy (1296 cm−1), deoxyribose (1456 cm−1) and collagen (1445, 1665 cm−1) were associated with normal and OAC tissue differences. Phenylalanine (1003 cm−1), proline/collagen (1066, 1445 cm−1), phospholipids (1130 cm−1), CH2 angular deformation (1295 cm−1), disaccharides (1462 cm−1) and proteins (amide I, 1672/5 cm−1) were associated with Barrett’s oesophagus and OAC tissue differences. These findings show the potential of using Raman microspectroscopy imaging for fast and accurate diagnoses of oesophageal pathologies and establishing subtle molecular changes predisposing to adenocarcinoma in a clinical setting. Graphical abstract demonstrating how oesophageal tissue is processed through Raman mapping analysis in order to detect spectral differences between stages of oesophageal transformation to adenocarcinoma ![]()
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Yousaf H, Hayat U, Manivel J, Iwamoto C, Peltola J, Hanson B, Larson W, Dachel S, Gravely A, Mesa H. Surface Ki-67 Expression Improves Reproducibility of Dysplasia Diagnosis in Barrett's Esophagus. Am J Clin Pathol 2020; 153:695-704. [PMID: 32076708 DOI: 10.1093/ajcp/aqaa004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Many studies have shown poor reproducibility among pathologists for diagnosing dysplasia in Barrett's esophagus (BE). Immunohistochemical stains (IHC) are not widely used due to overlapping expression patterns in reactive and dysplastic processes. We hypothesized that markers involved in cell-cycle (cyclin D1, Ki-67, P16), differentiation/cell-cell interaction (β-catenin, SATB2 CD44, OCT4) and senescence (γH2AX) would produce different results in reactive and dysplastic processes. METHODS A micrograph album of 40 H&E and matching IHCs depicting optimally oriented lesions were evaluated independently by 3 pathologists. Expression was scored separately in the surface, isthmus, and base regions of the glands. RESULTS Statistical analysis showed that surface Ki-67 expression showed the largest difference in expression and smallest P value (P < .001) for identifying dysplasia. At a cutoff level of 5% or less, negative predictive value (NPV) was 100%. κ correlation between pathologists improved from substantial to almost perfect (0.70-0.95) using ancillary surface Ki-67. CONCLUSION A case-control study with glass slides including all diagnostic categories using this parameter confirmed improved κ correlation among pathologists (0.29 vs 0.60), better correlation with outcomes (76% vs 69%), increased odd risks (15.3) for progression in positive cases, and an improvement in sensitivity (88% vs 64%) and NPV (88% vs 73%) compared to histology alone.
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Affiliation(s)
- Hira Yousaf
- Departments of Pathology, University of Minnesota, Minneapolis
| | - Umar Hayat
- Departments of Gastroenterology, University of Minnesota, Minneapolis
| | - Juan Manivel
- Departments of Pathology, University of Minnesota, Minneapolis
- Veterans Administration Health Care System, Minneapolis, MN
| | - Carlos Iwamoto
- Departments of Pathology, University of Minnesota, Minneapolis
- Veterans Administration Health Care System, Minneapolis, MN
| | - Justin Peltola
- Departments of Pathology, University of Minnesota, Minneapolis
- Veterans Administration Health Care System, Minneapolis, MN
| | - Brian Hanson
- Departments of Gastroenterology, University of Minnesota, Minneapolis
- Veterans Administration Health Care System, Minneapolis, MN
| | - Wendy Larson
- Departments of Pathology, University of Minnesota, Minneapolis
- Veterans Administration Health Care System, Minneapolis, MN
| | - Susan Dachel
- Departments of Pathology, University of Minnesota, Minneapolis
- Veterans Administration Health Care System, Minneapolis, MN
| | - Amy Gravely
- Research Service, University of Minnesota, Minneapolis
- Veterans Administration Health Care System, Minneapolis, MN
| | - Hector Mesa
- Departments of Pathology, University of Minnesota, Minneapolis
- Veterans Administration Health Care System, Minneapolis, MN
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Bonavina L, Fisichella PM, Gavini S, Lee YY, Tatum RP. Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients. Ann N Y Acad Sci 2020; 1481:117-126. [PMID: 32266986 DOI: 10.1111/nyas.14350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/14/2022]
Abstract
In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.
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Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milano, Italy
| | - P Marco Fisichella
- Department of Surgery, Northwestern University, Feinberge School of Medicine, Chicago, Illinois
| | - Sravanya Gavini
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Gut Research Group, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,St George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Roger P Tatum
- Department of Surgery, University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, Washington
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Neutrophil-Lymphocyte Ratio as a Marker of Progression from Non-Dysplastic Barrett's Esophagus to Esophageal Adenocarcinoma: a Cross-Sectional Retrospective Study. J Gastrointest Surg 2020; 24:8-18. [PMID: 31745889 DOI: 10.1007/s11605-019-04456-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Immune imbalance and inflammation have been suggested as key factors of Barrett's esophagus (BE) pathway towards adenocarcinoma. The neutrophil-lymphocyte ratio (NLR) indirectly reflects the relation between innate and adaptive immune systems and has been studied in premalignant conditions as a biomarker for cancer diagnosis. Our aim was to investigate if increasing values of NLR correlated with advancing stages of BE progression to dysplasia and neoplasia. METHODS We retrospectively analyzed data of patients with biopsies reporting BE between 2013 and 2017 and with a complete blood count within 6 months from the endoscopy, as well as patients with esophageal adenocarcinoma (EAC). NLR was calculated as neutrophil count/lymphocyte count. Cases (n = 113) were classified as non-dysplastic BE (NDBE, n = 72), dysplastic BE (DBE, n = 11) and EAC (n = 30). RESULTS NLR progressively increased across groups (NDBE, 1.92 ± 0.7; DBE, 2.92 ± 1.1; EAC 4.54 ± 2.9), with a significant correlation between its increasing value and the presence of dysplasia or neoplasia (r = 0.53, p < 0.001). NLR > 2.27 was able to diagnose EAC with 80% sensitivity and 71% specificity (area under the curve = 0.8). CONCLUSION NLR correlates with advancing stages of BE progression, a finding that reinforces the role of immune imbalance in EAC carcinogenesis and suggests a possible use of this marker for risk stratification on surveillance strategies.
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Duits LC, Klaver E, Bureo Gonzalez A, Boerwinkel DF, Ten Kate FJW, Offerhaus GJA, Meijer SL, Visser M, Seldenrijk CA, Krishnadath KK, Schoon EJ, Weusten BLAM, Mallant-Hent RC, Pouw RE, Bergman JJGHM. The Amsterdam ReBus progressor cohort: identification of 165 Barrett's surveillance patients who progressed to early neoplasia and 723 nonprogressor patients. Dis Esophagus 2019; 32:5032889. [PMID: 29873685 DOI: 10.1093/dote/doy037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 12/11/2022]
Abstract
Patient selection is suboptimal in most studies focused on identifying biological markers for neoplastic progression in Barrett's esophagus (BE). This study aims to describe a stringently selected community-based case-control cohort of non-dysplastic BE (NDBE) patients who progressed to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) and BE patients who never progressed to be used for future biomarker studies. We identified all patients referred for endoscopic work-up of BE neoplasia at three tertiary referral centers for treatment of BE neoplasia between 2000 and 2013. We performed a detailed registration of any endoscopic surveillance history before neoplastic progression. Controls were selected from a retrospective BE surveillance registration in 10 community hospitals. A total of 887 patients were referred for endoscopic work-up of BE neoplasia. Based on predefined selection criteria, we identified 165 progressor patients (82% men; mean age 55 years ± 10.4) with a baseline endoscopy demonstrating NDBE > 2 years before neoplastic progression. Using the same predefined selection criteria, 723 nonprogressor patients (67% men; mean age 57 years ± 11.3) with >2 years of endoscopic surveillance were identified. Median length of the BE segment was 5 cm (IQR 4-7) in progressors and 4 cm (IQR 2-6) in controls. Median duration of surveillance was 89 months (IQR 54-139) in progressors and 76 months (IQR 47-116) in nonprogressors. Paraffin embedded biopsies are available for biomarker research in all patients. Ethical approval was obtained and material transfer agreements were signed with all 58 contributing pathology labs. This is the largest community-based case-control cohort of BE patients with and without progression to early neoplasia. The stringent selection criteria and the availability of paraffin embedded biopsy specimens make this a unique cohort for biomarker studies.
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Affiliation(s)
- L C Duits
- Departments of Gastroenterology and Hepatology
| | - E Klaver
- Departments of Gastroenterology and Hepatology
| | | | | | - F J W Ten Kate
- Pathology, Academic Medical Center, Amsterdam.,Department of Pathology, University Medical Center, Utrecht
| | - G J A Offerhaus
- Pathology, Academic Medical Center, Amsterdam.,Department of Pathology, University Medical Center, Utrecht
| | - S L Meijer
- Pathology, Academic Medical Center, Amsterdam
| | - M Visser
- Pathology, Academic Medical Center, Amsterdam
| | | | | | - E J Schoon
- Gastroenterology, St Antonius Ziekenhuis, Nieuwegein
| | | | | | - Roos E Pouw
- Departments of Gastroenterology and Hepatology
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64
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Hiremath G, Locke A, Sivakumar A, Thomas G, Mahadevan-Jansen A. Clinical translational application of Raman spectroscopy to advance Benchside biochemical characterization to bedside diagnosis of esophageal diseases. J Gastroenterol Hepatol 2019; 34:1911-1921. [PMID: 31124184 DOI: 10.1111/jgh.14738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022]
Abstract
Esophageal diseases result in significant mortality, morbidity, and health care costs worldwide. Current approaches to detect and monitor esophageal diseases have severe limitations. Advanced imaging technologies are being developed to complement current approaches to improve diagnostic, therapeutic and surveillance protocols in order to advance the field. Raman spectroscopy-based technologies hold promise to increase the sensitivity for detection of diseased and high-risk lesions in vitro and in vivo in real time. This technique allows for the investigation of microstructural changes and also facilitates the discovery of disease-specific biochemical alterations with the potential to provide novel insights into the pathobiology of these conditions. Raman spectroscopy has been increasingly applied in precancerous and cancerous esophageal conditions. However, its application in benign esophageal diseases is still in the early stages. Continuing its application in cancerous and precancerous conditions and expanding its use to benign esophageal disorders could lay a foundation for integration of this technology in clinical practice and diagnostic paradigms and development of an accurate and cost-effective tool for use in a clinical setting. Furthermore, Raman spectroscopy can also be used as an innovative technique to advance our understanding of the biochemical transformations associated with esophageal diseases and answer a myriad of fundamental questions in the field. In this review, we described the principles of Raman spectroscopy and instrumentation while providing an overview of current applications, challenges, and future directions in the context of esophageal diseases with an emphasis on its clinical translational application.
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Affiliation(s)
- Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrea Locke
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Adithya Sivakumar
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
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65
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Bhatia SJ, Makharia GK, Abraham P, Bhat N, Kumar A, Reddy DN, Ghoshal UC, Ahuja V, Rao GV, Devadas K, Dutta AK, Jain A, Kedia S, Dama R, Kalapala R, Alvares JF, Dadhich S, Dixit VK, Goenka MK, Goswami BD, Issar SK, Leelakrishnan V, Mallath MK, Mathew P, Mathew P, Nandwani S, Pai CG, Peter L, Prasad AVS, Singh D, Sodhi JS, Sud R, Venkataraman J, Midha V, Bapaye A, Dutta U, Jain AK, Kochhar R, Puri AS, Singh SP, Shimpi L, Sood A, Wadhwa RT. Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology. Indian J Gastroenterol 2019; 38:411-440. [PMID: 31802441 DOI: 10.1007/s12664-019-00979-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.
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Affiliation(s)
- Shobna J Bhatia
- Seth GS Medical College and KEM Hospital, Mumbai, 400 012, India.
| | | | - Philip Abraham
- P D Hinduja Hospital and MRC, and Hinduja Heathcare Surgical, Mumbai, 400 016, India
| | - Naresh Bhat
- Aster CMI Hospital, Bengaluru, 560 092, India
| | - Ajay Kumar
- Fortis Escorts Liver and Digestive Diseases Institute, Delhi, 110 025, India
| | | | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Vineet Ahuja
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - G Venkat Rao
- Asian Institute of Gastroenterology, Hyderabad, 500 082, India
| | | | - Amit K Dutta
- Christian Medical College, Vellore, 632 004, India
| | - Abhinav Jain
- Seth GS Medical College and KEM Hospital, Mumbai, 400 012, India
| | - Saurabh Kedia
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Rohit Dama
- Asian Institute of Gastroenterology, Hyderabad, 500 082, India
| | - Rakesh Kalapala
- Asian Institute of Gastroenterology, Hyderabad, 500 082, India
| | | | | | - Vinod Kumar Dixit
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221 005, India
| | | | - B D Goswami
- Gauhati Medical College, Dispur Hospitals, Guwahati, 781 032, India
| | - Sanjeev K Issar
- JLN Hospital and Research Center, Bhilai Steel Plant, Bhilai, 490 009, India
| | | | | | | | - Praveen Mathew
- Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, 560 066, India
| | | | - Cannanore Ganesh Pai
- Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576 104, India
| | | | - A V Siva Prasad
- Institute of Gastroenterology, Visakhapatnam, 530 002, India
| | | | | | - Randhir Sud
- Medanta - The Medicity, Gurugram, 122 001, India
| | | | - Vandana Midha
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Amol Bapaye
- Deenanath Mangeshkar Hospital and Research Center, Pune, 411 004, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ajay K Jain
- Choithram Hospital and Research Centre, Indore, 452 014, India
| | - Rakesh Kochhar
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | | | | | | | - Ajit Sood
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
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Abstract
Barrett esophagus is a metaplastic change in the lining of the distal esophageal epithelium, characterized by replacement of the normal squamous epithelium by specialized intestinal metaplasia. The presence of Barrett esophagus increases the risk of esophageal adenocarcinoma several-fold. Esophageal adenocarcinoma is a malignancy with rapidly rising incidence and persistently poor outcomes when diagnosed after the onset of symptoms. Risk factors for Barrett esophagus include chronic gastroesophageal reflux, central obesity, white race, male gender, older age, smoking, and a family history of Barrett esophagus or esophageal adenocarcinoma. Screening for Barrett esophagus in those with several risk factors followed by endoscopic surveillance to detect dysplasia or adenocarcinoma is currently recommended by society guidelines. Minimally invasive nonendoscopic tools for the early detection of Barrett esophagus are currently being developed. Multimodality endoscopic therapy-using a combination of endoscopic resection and ablation techniques-for the treatment of dysplasia and early adenocarcinoma is successful in eliminating intestinal metaplasia and preventing progression to adenocarcinoma, with outcomes comparable to those after esophagectomy. Risk stratification of those diagnosed with Barrett esophagus is a challenge at present, with active research focused on identifying clinical and biomarker panels to identify those with low and high risk of progression. This narrative review highlights some of the challenges and recent progress in this field.
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Affiliation(s)
- Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY.
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67
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Karamchandani DM, Zhang Q, Liao XY, Xu JH, Liu XL. Inflammatory bowel disease- and Barrett's esophagus-associated neoplasia: the old, the new, and the persistent struggles. Gastroenterol Rep (Oxf) 2019; 7:379-395. [PMID: 31857901 PMCID: PMC6911999 DOI: 10.1093/gastro/goz032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/30/2019] [Accepted: 06/04/2019] [Indexed: 12/30/2022] Open
Abstract
Early diagnosis of and adequate therapy for premalignant lesions in patients with inflammatory bowel disease (IBD) and Barrett's esophagus (BE) has been shown to decrease mortality. Endoscopic examination with histologic evaluation of random and targeted biopsies remains the gold standard for early detection and adequate treatment of neoplasia in both these diseases. Although eventual patient management (including surveillance and treatment) depends upon a precise histologic assessment of the initial biopsy, accurately diagnosing and grading IBD- and BE-associated dysplasia is still considered challenging by many general as well as subspecialized pathologists. Additionally, there are continuing updates in the literature regarding the diagnosis, surveillance, and treatment of these disease entities. This comprehensive review discusses the cancer risk, detailed histopathological features, diagnostic challenges, and updates as well as the latest surveillance and treatment recommendations in IBD- and BE-associated dysplasia.
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Affiliation(s)
- Dipti M Karamchandani
- Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Qin Zhang
- Department of Pathology, The Third Central Hospital of Tianjin, Tianjin, China
| | - Xiao-Yan Liao
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Jing-Hong Xu
- Department of Pathology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiu-Li Liu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, USA
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68
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Intraobserver and Interobserver Variability in the Assessment of Dysplasia in Ampullary Mucosal Biopsies. Am J Surg Pathol 2019; 42:1095-1100. [PMID: 29738360 DOI: 10.1097/pas.0000000000001079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Endoscopic mucosal biopsies of the ampulla of Vater (AmpBx) are obtained to histologically assess for dysplasia or carcinoma. However, biopsy material is often scant and a host of factors can induce histologic changes that pose diagnostic challenges. We sought to investigate observer variability in interpretation of AmpBx and the impact clinical data may have on diagnostic interpretation. Thirty-one cases from institutional archives were selected, including 12 cases of reactive atypia (RA), 8 indefinite for dysplasia (ID), and 11 showing low-grade dysplasia (LGD). Slides were independently reviewed at 3 time points with and without clinical information by 6 pathologists who categorized the biopsies RA, ID, or LGD. Following the reviews, intraobserver and interobserver agreement was assessed. Review of AmpBx without clinical data showed fair (κ, 0.27), poor (κ, 0.07), and good (κ, 0.42) interobserver agreement for diagnoses of RA, ID, and LGD, respectively. Interobserver agreement improved for LGD (κ, 0.66 and 0.73) when clinical information was provided; however, agreement remained fair for RA (κ, 0.4 and 0.42) and poor-to-fair for ID (κ, 0.17 and 0.25). When follow-up data were reviewed, all cases that reached unanimous agreement had that diagnosis substantiated by subsequent endoscopic or histologic findings. The same was true of 13 of 19 cases that reached majority consensus. Given the potential clinical consequences of these diagnoses combined with the significant intraobserver and interobserver variability found in this study, we conclude that better-defined diagnostic criteria and consensus reads on difficult cases would assist in the histologic assessment of these challenging cases.
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69
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Peters Y, Al-Kaabi A, Shaheen NJ, Chak A, Blum A, Souza RF, Di Pietro M, Iyer PG, Pech O, Fitzgerald RC, Siersema PD. Barrett oesophagus. Nat Rev Dis Primers 2019; 5:35. [PMID: 31123267 DOI: 10.1038/s41572-019-0086-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Barrett oesophagus (BE), the only known histological precursor of oesophageal adenocarcinoma (EAC), is a condition in which the squamous epithelium of the oesophagus is replaced by columnar epithelium as an adaptive response to gastro-oesophageal reflux. EAC has one of the fastest rising incidences of cancers in Western countries and has a dismal prognosis. BE is usually detected during endoscopic examination, and diagnosis is confirmed by the histological presence of intestinal metaplasia. Advances in genomics and transcriptomics have improved our understanding of the pathogenesis and malignant progression of intestinal metaplasia. As the majority of EAC cases are diagnosed in individuals without a known history of BE, screening for BE could potentially decrease disease-related mortality. Owing to the pre-malignant nature of BE, endoscopic surveillance of patients with BE is imperative for early detection and treatment of dysplasia to prevent further progression to invasive EAC. Developments in endoscopic therapy have resulted in a major shift in the treatment of patients with BE who have dysplasia or early EAC, from surgical resection to endoscopic resection and ablation. In addition to symptom control by optimization of lifestyle and pharmacological therapy with proton pump inhibitors, chemopreventive strategies based on NSAIDs and statins are currently being investigated for BE management.
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Affiliation(s)
- Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ali Al-Kaabi
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, OH, USA
| | - Andrew Blum
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, OH, USA
| | - Rhonda F Souza
- Department of Medicine and the Center for Esophageal Diseases, Baylor University Medical Center at Dallas and the Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, TX, USA
| | | | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Oliver Pech
- Department of Gastroenterology, St John of God Hospital, Regensburg, Germany
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands.
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70
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van der Wel MJ, Klaver E, Duits LC, Pouw RE, Seldenrijk CA, Offerhaus G, Visser M, Ten Kate F, Biermann K, Brosens L, Doukas M, Huysentruyt C, Karrenbeld A, Kats-Ugurlu G, van der Laan JS, van Lijnschoten G, Moll F, Ooms A, Tijssen JG, Bergman J, Meijer SL. Adherence to pre-set benchmark quality criteria to qualify as expert assessor of dysplasia in Barrett's esophagus biopsies - towards digital review of Barrett's esophagus. United European Gastroenterol J 2019; 7:889-896. [PMID: 31428413 PMCID: PMC6683647 DOI: 10.1177/2050640619853441] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/07/2019] [Indexed: 12/20/2022] Open
Abstract
Background Dysplasia assessment of Barrett’s esophagus biopsies is associated with low
observer agreement; guidelines advise expert review. We have developed a
web-based review panel for dysplastic Barrett’s esophagus biopsies. Objective The purpose of this study was to test if 10 gastrointestinal pathologists
working at Dutch Barrett’s esophagus expert centres met pre-set benchmark
scores for quality criteria. Methods Ten gastrointestinal pathologists twice assessed 60 digitalized Barrett’s
esophagus cases, enriched for dysplasia; then randomised (7520 assessments).
We tested predefined benchmark quality criteria: (a) percentage of
‘indefinite for dysplasia’ diagnoses, benchmark score ≤14% for all cases,
≤16% for dysplastic subset, (b) intra-observer agreement; benchmark score
≥0.66/≥0.39, (c) percentage agreement with ‘gold standard diagnosis’;
benchmark score ≥82%/≥73%, (d) proportion of cases with high-grade dysplasia
underdiagnosed as non-dysplastic Barrett’s esophagus; benchmark score ≤1/78
(≤1.28%) assessments for dysplastic subset. Results Gastrointestinal pathologists had seven years’ Barrett’s
esophagus-experience, handling seven Barrett’s esophagus-cases weekly. Three
met stringent benchmark scores; all cases and dysplastic subset, three met
extended benchmark scores. Four pathologists lacked one quality criterion to
meet benchmark scores. Conclusion Predefined benchmark scores for expert assessment of Barrett’s esophagus
dysplasia biopsies are stringent and met by some gastrointestinal
pathologists. The majority of assessors however, only showed limited
deviation from benchmark scores. We expect further training with group
discussions will lead to adherence of all participating gastrointestinal
pathologists to quality criteria, and therefore eligible to join the review
panel.
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Affiliation(s)
- M J van der Wel
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - E Klaver
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - L C Duits
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - C A Seldenrijk
- Department of Pathology, Pathology-DNA BV, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Gja Offerhaus
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - M Visser
- Department of Pathology, Symbiant BV, Zaans Medical Center, Zaandam, the Netherlands
| | - Fjw Ten Kate
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - K Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laa Brosens
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - M Doukas
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Huysentruyt
- Department of Pathology, Stichting PAMM, Eindhoven, The Netherlands
| | - A Karrenbeld
- Department of Pathology, Academic Medical Center Groningen, Groningen, The Netherlands
| | - G Kats-Ugurlu
- Department of Pathology, Academic Medical Center Groningen, Groningen, The Netherlands
| | - J S van der Laan
- Department of Pathology, Haga Hospital, The Hague, The Netherlands
| | | | - Fcp Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Ahag Ooms
- Department of Pathology, Pathan BV, St. Fransiscus Vlietland Hospital, Rotterdam, the Netherlands
| | - J G Tijssen
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jjghm Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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71
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Dzinic SH, Mahdi Z, Bernardo MM, Vranic S, Beydoun H, Nahra N, Alijagic A, Harajli D, Pang A, Saliganan DM, Rahman AM, Skenderi F, Hasanbegovic B, Dyson G, Beydoun R, Sheng S. Maspin differential expression patterns as a potential marker for targeted screening of esophageal adenocarcinoma/gastroesophageal junction adenocarcinoma. PLoS One 2019; 14:e0215089. [PMID: 31002675 PMCID: PMC6474598 DOI: 10.1371/journal.pone.0215089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/26/2019] [Indexed: 12/20/2022] Open
Abstract
AIM Barrett's esophagus (BE) is a predisposing factor of esophageal adenocarcinoma/gastroesophageal junction adenocarcinoma (ECA/GEJ Aca). BE patients are stratified and subsequently monitored according to the risk of malignant progression by the combination of endoscopy and biopsy. This study is to evaluate the maspin expression patterns as early diagnostic markers of malignancy in BE patients. MATERIALS AND METHODS Immunohistochemistry (IHC) staining was performed on 62 archival core biopsies from 35 patients, including BE without dysplasia (intestinal metaplasia, IM), BE with low grade dysplasia, BE with high grade dysplasia, carcinoma in situ, and well to poorly differentiated ECA/GEJ Aca (PD-ECA/GEJ Aca). The intensity and the subcellular distribution of immunoreactivity were evaluated microscopically. Statistical analysis was performed using the χ2 and Fisher exact tests. RESULTS The level of epithelial-specific tumor suppressor maspin protein inversely correlated with the progression from IM to PD-ECA/GEJ Aca. Lesions of each pathological grade could be divided into subtypes that exhibited distinct maspin subcellular distribution patterns, including nuclear only (Nuc), combined nuclear and cytoplasmic (Nuc+Cyt), cytoplasmic only (Cyt) and overall negligible (Neg). The Cyt subtype, which was minor in both IM and dysplasia (approximately 10%), was predominant in ECA/GEJ Aca as early as well-differentiated lesions (more than 50%: p = 0.0092). In comparison, nuclear staining of the tumor suppressor TP53 was heterogeneous in dysplasia, and did not correlate with the differentiation grades of ECA/GEJ Aca. CONCLUSION The Cyt subtype of maspin expression pattern in core biopsies of BE patients may serve as a molecular marker for early diagnosis of ECA/GEJ Aca.
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Affiliation(s)
- Sijana H. Dzinic
- Department of Oncology, Wayne State University School of Medicine, Detroit, United States of America
- Department of Pathology, Wayne State University School of Medicine, Detroit, United States of America
| | - Zaid Mahdi
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - M. Margarida Bernardo
- Department of Pathology, Wayne State University School of Medicine, Detroit, United States of America
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Semir Vranic
- College of Medicine, Qatar University, Doha, Qatar
| | - Haya Beydoun
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Nadine Nahra
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Amra Alijagic
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Deanna Harajli
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Aaron Pang
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Dan M. Saliganan
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Abid M. Rahman
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Faruk Skenderi
- Department of Pathology, University Clinical Center, Sarajevo, Bosnia and Herzegovina
| | - Berisa Hasanbegovic
- Department of Oncology, University Clinical Center, Sarajevo, Bosnia and Herzegovina
| | - Gregory Dyson
- Department of Oncology, Wayne State University School of Medicine, Detroit, United States of America
- Department of Pathology, Wayne State University School of Medicine, Detroit, United States of America
| | - Rafic Beydoun
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
| | - Shijie Sheng
- Department of Oncology, Wayne State University School of Medicine, Detroit, United States of America
- Department of Pathology, Wayne State University School of Medicine, Detroit, United States of America
- Tumor Biology and Microenvironment Program of the Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, United States of America
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72
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Hamade N, Vennelaganti S, Parasa S, Vennalaganti P, Gaddam S, Spaander MCW, van Olphen SH, Thota PN, Kennedy KF, Bruno MJ, Vargo JJ, Mathur S, Cash BD, Sampliner R, Gupta N, Falk GW, Bansal A, Young PE, Lieberman DA, Sharma P. Lower Annual Rate of Progression of Short-Segment vs Long-Segment Barrett's Esophagus to Esophageal Adenocarcinoma. Clin Gastroenterol Hepatol 2019; 17:864-868. [PMID: 30012433 PMCID: PMC7050470 DOI: 10.1016/j.cgh.2018.07.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/01/2018] [Accepted: 07/04/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS European guidelines recommend different surveillance intervals of non-dysplastic Barrett's esophagus (NDBE) based on segment length, as opposed to guidelines in the United States, which do recommend surveillance intervals based on BE length. We studied rates of progression of NDBE to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in patients with short-segment BE using the definition of BE in the latest guidelines (length ≥1 cm). METHODS We collected demographic, clinical, endoscopy, and histopathology data from 1883 patients with endoscopic evidence of NDBE (mean age, 57.3 years; 83.5% male; 88.1% Caucasians) seen at 7 tertiary referral centers. Patients were followed for a median 6.4 years. Cases of dysplasia or EAC detected within 1 year of index endoscopy were considered prevalent and were excluded. Unadjusted rates of progression to HGD or EAC were compared between patients with short (≥1 and <3) and long (≥3) BE lengths using log-rank tests. A subgroup analysis was performed on patients with a documented Prague C&M classification. We used a multivariable proportional hazards model to evaluate the association between BE length and progression. Adjusted hazards ratios were calculated after adjusting for variables associated with progression. RESULTS We found 822 patients to have a short-segment BE (SSBE) and 1061 to have long segment BE (LSBE). We found patients with SSBE to have a significantly lower annual rate of progression to EAC (0.07%) than of patients with LSBE (0.25%) (P = .001). For the combined endpoint of HGD or EAC, annual progression rates were significantly lower among patients with SSBE (0.29%) compared to compared to LSBE (0.91%) (P < .001). This effect persisted in multivariable analysis (hazard ratio, 0.32; 95% CI, 0.18-0.57; P < .001). CONCLUSION We analyzed progression of BE (length ≥1 cm) to HGD or EAC in a large cohort of patients seen at multiple centers and followed for a median 6.4 years. We found a lower annual rate of progression of SSBE to EAC (0.07%/year) than of LSBE (0.25%/year). We propose lengthening current surveillance intervals for patients with SSBE.
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Affiliation(s)
- Nour Hamade
- Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas,Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Sreekar Vennelaganti
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Sravanthi Parasa
- Division of Gastroenterology, Swedish Medical Group, Seattle, Washington
| | - Prashanth Vennalaganti
- Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas,Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Srinivas Gaddam
- Division of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California
| | - Manon C. W. Spaander
- Department of Gastroenterology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sophie H. van Olphen
- Department of Gastroenterology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Prashanthi N. Thota
- Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kevin F. Kennedy
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Marco J. Bruno
- Department of Gastroenterology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - John J. Vargo
- Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sharad Mathur
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Brooks D. Cash
- Division of Gastroenterology, Hepatology, and Nutrition, University of South Alabama, Mobile, Alabama
| | - Richard Sampliner
- Department of Gastroenterology and Hepatology, University of Arizona, Tucson, Arizona
| | - Neil Gupta
- Division of Gastroenterology, Loyola University Medical Center, Maywood, Illinois
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ajay Bansal
- Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Patrick E. Young
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David A. Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Prateek Sharma
- Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas; Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri.
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73
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Substantial Interobserver Agreement in the Diagnosis of Dysplasia in Barrett Esophagus Upon Review of a Patient's Entire Set of Biopsies. Am J Surg Pathol 2019; 42:376-381. [PMID: 29135518 DOI: 10.1097/pas.0000000000000988] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The pathologic diagnosis of dysplasia in Barrett esophagus (BE) suffers from interobserver disagreement. Many of the studies demonstrating disagreement in the diagnosis of dysplasia have pathologists review individual biopsy slides in isolation. To more closely mimic daily practice, 3 pathologists reviewed hematoxylin and eosin slides made from 549 individual biopsy jars obtained from 129 unique patients with a diagnosis of BE. Each pathologist reviewed the entirety of a given patient's biopsy material. The grade of dysplasia present in each biopsy jar was given as well as an overall highest grade of dysplasia from the patient's entire set of biopsies. The interobserver agreement in the diagnosis of dysplasia per biopsy jar and per patient's set of biopsies was measured by Fleiss κ statistic for multiple raters. The κ values for each diagnosis was higher in the per patient analysis compared with the per biopsy jar analysis indicating that pathologists are more likely to agree on the overall grade of dysplasia compared with the grade in an individual biopsy jar. In the per patient analysis, the interobserver agreement in the diagnosis of nondysplastic BE and high-grade dysplasia were substantial (κ=0.66; 95% confidence interval [CI], 0.56-0.76 and κ=0.76; 95% CI, 0.66-0.86, respectively). The interobserver agreement in the diagnosis of low-grade dysplasia (LGD) was fair (κ=0.31; 95% CI, 0.21-0.42). When LGD and high-grade dysplasia were collapsed into 1 category of positive for dysplasia, the interobserver agreement in the per patient analysis remained substantial (κ=0.70; 95% CI, 0.60-0.80), suggesting that much of the disagreement in LGD is not due to lack of recognition of dysplastic Barrett's mucosa, but rather the degree of dysplasia. These results indicate that pathologists can reliably distinguish between nondysplastic BE and dysplastic BE when a patient's entire set of biopsies is reviewed as a group. When second opinions are obtained, all available slides from that endoscopic procedure should be sent for review.
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74
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Trindade AJ, McKinley MJ, Alshelleh M, Levi G, Stewart M, Quinn KJ, Thomas RM. Mutational load may predict risk of progression in patients with Barrett's oesophagus and indefinite for dysplasia: a pilot study. BMJ Open Gastroenterol 2019; 6:e000268. [PMID: 30815274 PMCID: PMC6361327 DOI: 10.1136/bmjgast-2018-000268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/03/2019] [Accepted: 01/12/2019] [Indexed: 12/20/2022] Open
Abstract
Background and aims Mutational load (ML) has been shown to help risk-stratify those that may progress from non-dysplastic Barrett’s oesophagus (BE) to dysplastic disease. Management of patients with BE and indefinite for dysplasia (BE-IND) is challenging and risk stratification tools are lacking. The aim of this pilot study is to evaluate the utility of ML for risk stratification in patients with BE-IND. Methods This is a single-centre, retrospective pilot study evaluating ML quantification in patients with BE-IND. Histology at follow-up endoscopy at least 1 year after the baseline endoscopy was used to determine if a patient progressed to low or high dysplasia. The ML levels were then compared among patients who progressed to dysplasia versus those who did not. Results Thirty-five patients who met the inclusion criteria were identified, and seven met the exclusion criteria. Twenty-eight patients were analysed, of whom eight progressed to low-grade dysplasia (6) and high-grade dysplasia (2). Seven of these eight patients had some level of genomic instability detected in their IND biopsy (ML ≥0.5). Ten of the 20 (50%) who did not progress had no ML level. At an ML cut-off above 1.5, the risk of progression to high-grade dysplasia was 33% vs 0% (p=0.005), with a sensitivity of 100% and a specificity of 85%. Conclusion These results indicate that ML may be able to risk-stratify progression to high-grade dysplasia in BE-IND. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Matthew J McKinley
- Division of Gastroenterology, ProHEALTH Care Associates, Lake Success, New York, USA
| | - Mohammad Alshelleh
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Gabriel Levi
- Division of Pathology, ProHEALTH Care Associates, Lake Success, New York, USA
| | - Molly Stewart
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Kathy J Quinn
- Division of Pathology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Rebecca M Thomas
- Division of Pathology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
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75
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Cholapranee A, Trindade AJ. Challenges in Endoscopic Therapy of Dysplastic Barrett's Esophagus. ACTA ACUST UNITED AC 2019; 17:32-47. [PMID: 30663018 DOI: 10.1007/s11938-019-00215-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Barrett's esophagus (BE) is the only known measurable factor associated with esophageal adenocarcinoma. The development of endoscopic eradication therapy (EET) has transformed the way BE is managed. Given the fairly recent development of EET, its role in BE is still evolving. RECENT FINDINGS This paper discusses the challenges that endoscopists face at the preprocedural, intraprocedural, and postprocedural stages of BE management. These include challenges in risk stratification, dysplasia detection, ablation methods and dosimetry, choice of resection technique, and management of refractory disease. Despite the advances in EET in BE, there remain challenges that this review focuses on. Future research into these challenges will optimize ablation techniques and strategies in the future.
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Affiliation(s)
- Aurada Cholapranee
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA.
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76
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Duits LC, Lao-Sirieix P, Wolf WA, O’Donovan M, Galeano-Dalmau N, Meijer SL, Offerhaus GJA, Redman J, Crawte J, Zeki S, Pouw RE, Chak A, Shaheen NJ, Bergman JJGHM, Fitzgerald RC. A biomarker panel predicts progression of Barrett's esophagus to esophageal adenocarcinoma. Dis Esophagus 2019; 32:5212855. [PMID: 30496496 PMCID: PMC6303732 DOI: 10.1093/dote/doy102] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Progression from Barrett's esophagus (BE) to esophageal adenocarcinoma (EAC) is uncommon but the consequences are serious. Predictors of progression are essential to optimize resource utilization. This study assessed the utility of a promising panel of biomarkers applicable to routine paraffin embedded biopsies (FFPE) to predict progression of BE to EAC in a large population-based, nested case-control study.We utilized the Amsterdam-based ReBus nested case-control cohort. BE patients who progressed to high-grade dysplasia (HGD)/EAC (n = 130) and BE patients who never progressed (n = 130) were matched on age, sex, length of the BE segment, and duration of endoscopic surveillance. All progressors had minimum 2 years of endoscopic surveillance without HGD/EAC to exclude prevalent neoplasia. We assessed abnormal DNA content, p53, Cyclin A, and Aspergillus oryzae lectin (AOL) in FFPE sections. We performed conditional logistic regression analysis to estimate odds ratio (OR) of progression based on biomarker status.Expert LGD (OR, 8.3; 95% CI, 1.7-41.0), AOL (3 vs. 0 epithelial compartments abnormal; OR, 3.6; 95% CI, 1.2-10.6) and p53 (OR, 2.3; 95% CI, 1.2-4.6) were independently associated with neoplastic progression. Cyclin A did not predict progression and DNA ploidy analysis by image cytometry was unsuccessful in the majority of cases, both were excluded from the multivariate analysis. The multivariable biomarker model had an area under the receiver operating characteristic curve of 0.73.Expert LGD, AOL, and p53 independently predict neoplastic progression in BE patients and are applicable to routine practice. These biomarkers can aid in selecting patients for endoscopic ablation or more intensive surveillance.
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Affiliation(s)
- L C Duits
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands
| | - P Lao-Sirieix
- Medical Research Council Cancer Unit, Hutchison-MRC Research Center, University of Cambridge,Cambridge,United Kingdom
| | - W A Wolf
- Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - M O’Donovan
- Department of Pathology, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - N Galeano-Dalmau
- Medical Research Council Cancer Unit, Hutchison-MRC Research Center, University of Cambridge,Cambridge,United Kingdom
| | - S L Meijer
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - G J A Offerhaus
- Department of Pathology, University Medical Center, Utrecht, the Netherlands
| | - J Redman
- Medical Research Council Cancer Unit, Hutchison-MRC Research Center, University of Cambridge,Cambridge,United Kingdom
| | - J Crawte
- Medical Research Council Cancer Unit, Hutchison-MRC Research Center, University of Cambridge,Cambridge,United Kingdom
| | - S Zeki
- Medical Research Council Cancer Unit, Hutchison-MRC Research Center, University of Cambridge,Cambridge,United Kingdom
| | - R E Pouw
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands
| | - A Chak
- Division of Gastroenterology and Liver Disease, Case Western Reserve University, Cleveland, Ohio, USA
| | - N J Shaheen
- Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - J J G H M Bergman
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands
| | - R C Fitzgerald
- Medical Research Council Cancer Unit, Hutchison-MRC Research Center, University of Cambridge,Cambridge,United Kingdom
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77
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Davison JM, Shah MB, Deitrick C, Chennat J, Fasanella KE, McGrath K. Low-grade dysplasia diagnosis ratio and progression metrics identify variable Barrett's esophagus risk stratification proficiency in independent pathology practices. Gastrointest Endosc 2018; 88:807-815.e2. [PMID: 29944863 DOI: 10.1016/j.gie.2018.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 06/05/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The diagnosis of low-grade dysplasia (LGD) in Barrett's esophagus (BE) is subject to substantial interobserver variation. Our central aim in this study is to compare independent pathology practices using objective measures of BE risk stratification proficiency, including frequency of diagnosis and rate of progression, with high-grade dysplasia (HGD) or adenocarcinoma (EAC) after the first diagnosis of LGD. METHODS We retrospectively evaluated over 29,000 endoscopic biopsy cases to identify 4734 patients under endoscopic biopsy surveillance for BE in a healthcare system with multiple independent pathology practices: a subspecialized GI pathology group (SSGI; 162 BE cases per pathologist annually), 3 high BE volume general surgical pathology practices (GSPs; >50 BE cases per pathologist annually), and multiple low BE volume GSPs (10.6 BE cases per pathologist annually). We measured LGD diagnosis frequencies and rates of diagnostic progression to HGD or EAC in patients diagnosed with LGD. RESULTS The proportion of all BE cases diagnosed as LGD (LGD/BE diagnosis ratio) ranged from 1.1% to 6.8% in the different hospital settings (P < .001). The cumulative proportion of patients with HGD or EAC within 2 years of the first diagnosis of LGD was 35.3% in the SSGI and ranged from 1.4% to 14.3% in the GSPs (P < .001). LGD diagnosed by the GSP with the lowest LGD/BE diagnosis ratio had an adjusted risk of progression similar to LGD diagnosed by subspecialists (hazard ratio, .42; 95% CI, .06-3.03). However, when LGD was diagnosed by other generalists, the adjusted risk of progression was 79% to 91% lower than subspecialists (P < .001). When LGD was diagnosed in a low-volume GSP practice, the risk of progression was not significantly increased relative to patients with nondysplastic BE (hazard ratio, 1.3; 95% CI, .4-3.9). CONCLUSIONS General surgical pathologists and subspecialists show highly significant differences with respect to LGD/BE ratio, risk of progression relative to nondysplastic BE, crude annual progression rates, and the cumulative 2-year progression rate after LGD. These metrics can be used to assess proficiency in BE risk stratification in historical cases. Some general practitioners were able to achieve results similar to subspecialists. General surgical pathologists with little annual experience evaluating BE biopsy specimens did not successfully risk stratify patients with BE.
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Affiliation(s)
- Jon M Davison
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Maulin B Shah
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christopher Deitrick
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer Chennat
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ken E Fasanella
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin McGrath
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Jiang K, Lauwers GY. The dawn of a new era: performance measurement for the pathologic diagnosis of Barrett's esophagus-associated dysplasia. Gastrointest Endosc 2018; 88:816-817. [PMID: 30309491 DOI: 10.1016/j.gie.2018.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/17/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Kun Jiang
- Anatomic Pathology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Gregory Y Lauwers
- Anatomic Pathology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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Montgomery E, Arnold CA, Lam-Himlin D, Salimian K, Waters K. Some observations on Barrett esophagus and associated dysplasia. Ann Diagn Pathol 2018; 37:75-82. [PMID: 30312881 DOI: 10.1016/j.anndiagpath.2018.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 09/26/2018] [Indexed: 02/08/2023]
Abstract
Biopsy samples from esophageal columnar metaplasia and dysplasia are commonly encountered in Western pathology practice and knowing a few pitfalls can save both pathologists and patients a great deal of anxiety. Herein we discuss criteria for Barrett esophagus, evaluation of dysplasia, and some pitfalls in reviewing endoscopic mucosal resections. Also included is a summary of suggested follow-up for patients with Barrett esophagus.
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Affiliation(s)
| | - Christina A Arnold
- Department of Pathology, Ohio State University, United States of America
| | - Dora Lam-Himlin
- Department of Pathology, Mayo Clinic Scottsdale, United States of America
| | - Kevan Salimian
- Department of Pathology, Johns Hopkins University, United States of America
| | - Kevin Waters
- Department of Pathology, Cedars Sinai Health System, United States of America
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80
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Triadafilopoulos G, Friedland S. Precision care for Barrett's esophagus. Transl Gastroenterol Hepatol 2018; 3:67. [PMID: 30363757 DOI: 10.21037/tgh.2018.09.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/04/2018] [Indexed: 12/18/2022] Open
Abstract
Modern recognition and management of Barrett's esophagus, a precursor to esophageal adenocarcinoma depends on diagnostic accuracy, risk assessment, technical expertise and consideration of many options to best tailor therapy for every patient. Concomitant management of acid reflux is essential, frequently with proton pump inhibitors. Ablation and resection favorably affect the evolution towards cancer. Using precision medicine tools, such as imaging, molecular diagnostics and analytics may lead to cost- and comparatively-effective therapies ultimately aiming at cancer prevention. Knowledge of the risk factors for Barrett's esophagus and progression to dysplasia and cancer can help tailor a precision medicine approach with more aggressive screening and surveillance targeted at patients that are most likely to benefit.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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81
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Abstract
The cost-effectiveness of screening and surveillance for Barrett's esophagus continues to evolve as the incidence of esophageal adenocarcinoma increases, biomarkers enhance the identification of individuals at highest risk for developing cancer, and endoscopic eradication of Barrett's esophagus improves. Screening to detect Barrett's esophagus may be cost-effective in selected high-risk groups based on age, race, sex and other factors such as symptoms of heartburn. Currently, endoscopic eradication therapy for Barrett's esophagus and high-grade dysplasia is a cost-effective intervention, while endoscopic therapy for non-dysplastic Barrett's esophagus is not a cost-effective strategy. As diagnosis of low-grade dysplasia improves, endoscopic eradication therapy may also prove to be a cost-effective intervention.
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Affiliation(s)
- John M Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356424, Seattle, WA, 98195, USA.
| | - Nina Saxena
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356424, Seattle, WA, 98195, USA
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82
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Abstract
The currently recommended approach to managing cancer risk for patients with Barrett's esophagus is endoscopic surveillance including a biopsy protocol to sample the esophageal tissue randomly to detect dysplasia. However, there are numerous limitations in this practice that rely on the histopathological grading of dysplasia alone to make clinical decisions. The availability of in silico models demonstrating the potential cost-effectiveness of biomarker-based stratification has increased interest in finding a clinically relevant "Barrett's biomarker." The success of endoscopic eradication therapy in preventing neoplastic progression of dysplastic Barrett's esophagus has promoted the desire to stratify non-dysplastic Barrett's esophagus to those with "high risk" that may benefit from endotherapy. Furthermore, on the other end of the spectrum, there is interest in searching for a "low risk" marker that may identify those that would not likely benefit from endoscopy screening or surveillance. This review highlights recent data from the genomics (r)evolution revealing new genetic biomarkers of susceptibility to the development of Barrett's esophagus and novel pathways for its neoplastic progression, addresses the development of new modes of tissue sampling and imaging to detect early neoplasia in Barrett's esophagus, and discusses current progress in moving biomarkers from the laboratory into clinical practice in the era of precision medicine.
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83
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Abstract
Histopathology plays a central role in diagnosis of many diseases including solid cancers. Efforts are underway to transform this subjective art to an objective and quantitative science. Coherent Raman imaging (CRI), a label-free imaging modality with sub-cellular spatial resolution and molecule-specific contrast possesses characteristics which could support the qualitative-to-quantitative transition of histopathology. In this work we briefly survey major themes related to modernization of histopathology, review applications of CRI to histopathology and, finally, discuss potential roles for CRI in the transformation of histopathology that is already underway.
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84
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Choi WT, Tsai JH, Rabinovitch PS, Small T, Huang D, Mattis AN, Kakar S. Diagnosis and risk stratification of Barrett's dysplasia by flow cytometric DNA analysis of paraffin-embedded tissue. Gut 2018. [PMID: 28642331 DOI: 10.1136/gutjnl-2017-313815] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The diagnosis of dysplasia in Barrett's oesophagus (BO) can be challenging, and reliable ancillary techniques are not available. This study examines if DNA content abnormality detected by flow cytometry can serve as a diagnostic marker of dysplasia and facilitate risk stratification of low-grade dysplasia (LGD) and indefinite for dysplasia (IND) patients using formalin-fixed paraffin-embedded (FFPE) BO samples with varying degrees of dysplasia. DESIGN DNA flow cytometry was performed on 80 FFPE BO samples with high-grade dysplasia (HGD), 38 LGD, 21 IND and 14 negative for dysplasia (ND). Three to four 60-micron thick sections were cut from each tissue block, and the area of interest was manually dissected. RESULTS DNA content abnormality was identified in 76 HGD (95%), 8 LGD (21.1%), 2 IND (9.5%) and 0 ND samples. As a diagnostic marker of HGD, the estimated sensitivity and specificity of DNA content abnormality were 95% and 85%, respectively. For patients with DNA content abnormality detected at baseline LGD or IND, the univariate HRs for subsequent detection of HGD or oesophageal adenocarcinoma (OAC) were 7.0 and 20.0, respectively (p =<0.001). CONCLUSIONS This study demonstrates the promise of DNA flow cytometry using FFPE tissue in the diagnosis and risk stratification of dysplasia in BO. The presence of DNA content abnormality correlates with increasing levels of dysplasia, as 95% of HGD samples showed DNA content abnormality. DNA flow cytometry also identifies a subset of patients with LGD and IND who are at higher risk for subsequent detection of HGD or OAC.
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Affiliation(s)
- Won-Tak Choi
- Department of Pathology, University of California at San Francisco, San Francisco, California, USA
| | - Jia-Huei Tsai
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Thomas Small
- Department of Pathology, University of Washington, Seattle, Washington, USA
| | - Danning Huang
- Department of Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Aras N Mattis
- Department of Pathology, University of California at San Francisco, San Francisco, California, USA
| | - Sanjay Kakar
- Department of Pathology, University of California at San Francisco, San Francisco, California, USA
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85
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Goldblum JR, Shaheen NJ, Vennalaganti PR, Sharma P, Lightdale CJ. WATS for Barrett's surveillance. Gastrointest Endosc 2018; 88:201-202. [PMID: 29935618 DOI: 10.1016/j.gie.2018.01.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/11/2022]
Affiliation(s)
- John R Goldblum
- Anatomical Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicholas J Shaheen
- Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Prashanth R Vennalaganti
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA; Gastroenterology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Prateek Sharma
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA; Gastroenterology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Charles J Lightdale
- Gastroenterology, Columbia University School of Medicine, New York, New York, USA
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86
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Markoš P, Brčić I, Brčić L, Jakić-Razumović J, Pulanić R. Microsatellite instability in metaplasia-dysplasia-adenocarcinoma sequence of Barrett esophagus: a retrospective study. Croat Med J 2018; 59:100-107. [PMID: 29972732 PMCID: PMC6045894 DOI: 10.3325/cmj.2018.59.100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Aim To analyze the loss of mismatch repair (MMR) system protein expression in metaplasia-dysplasia-adenocarcinoma sequence of Barrett esophagus (BE). Methods This study retrospectively analyzed the data from 70 patients with pathohistological diagnosis of BE or esophageal adenocarcinoma (EAC) treated at the Clinical Department of Pathology and Cytology, University Hospital Center Zagreb, from January 2009 to January 2011. Patients were divided into three groups: BE without dysplasia (22 patients), BE with dysplasia (37 patients), and EAC (11 patients). Immunohistochemical expression of MutL homologue 1 (MLH1), MutS homologue 2 (MSH2), postmeiotic segregation increased 2 (PMS2), and MutS homologue 6 (MSH6) of DNA MMR system was measured and compared with tumor protein p53 expression. Results A total of 81.8% and 81.8% patients with EAC, 32.4% and 35.1% patients with dysplasia, and 50% and 54.5% patients without dysplasia had loss of MLH1 and PMS2 expression, respectively. Patients with EAC and patients with dysplasia did not have loss of MSH2 and MSH6 expression, and 18.2% patients without dysplasia had loss of MSH2 and MSH6 expression. There was a strong positive correlation between MLH1 and PMS2 expression (Spearman ρ 0.97; P < 0.001) and between MSH2 and MSH6 expression (Spearman ρ 0.90, P < 0.001) in the entire sample and in all BE groups. No significant correlations of MLH1 and PMS2 with p53 expression were found, except in dysplasia group (φ 0.402, P = 0.030 for MSH1; φ 0.371, P = 0.042 for PMS2). Conclusion Although we demonstrated considerable loss of MLH1 and PMS2 expression in BE-associated carcinoma sequence, due to the retrospective study design and low number of patients we cannot conclude that MLH1 and PMS2 can be used as biomarkers for patient surveillance and therapy-making decisions. Oxford Centre for Evidence-based Medicine level of evidence: 3
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Affiliation(s)
- Pave Markoš
- Pave Markoš, Division of Gastroenterology and Hepatology, University Hospital Center Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia,
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87
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Abdo J, Wichman CS, Dietz NE, Ciborowski P, Fleegel J, Mittal SK, Agrawal DK. Discovery of Novel and Clinically Relevant Markers in Formalin-Fixed Paraffin-Embedded Esophageal Cancer Specimen. Front Oncol 2018; 8:157. [PMID: 29868478 PMCID: PMC5954028 DOI: 10.3389/fonc.2018.00157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/25/2018] [Indexed: 12/26/2022] Open
Abstract
Due to the ineffectiveness of chemoradiation and targeted therapy in esophageal anticancer care and the subsequent low survival rates, we constructed a high throughput method to discover and investigate new markers with prognostic, diagnostic, and therapeutic clinical utility. This was accomplished by developing a quick, inexpensive, and dependable platform to simultaneously quantify thousands of proteins which subsequently revealed novel markers involved in the pathogenesis of esophageal adenocarcinoma (EAC) via discovery mass spectrometry paired with conservative biostatistics. Our method uncovered a perfect storm of tumor suppressors being downregulated, proliferation markers ramped up, and chemoresistance markers overexpressed—many of which could serve as new therapy targets for EAC. The 12 markers discovered by this method are novel regarding their involvement in the pathogenesis of EAC. The molecular oncology arena now has a dozen new proteomic targets suitable for validation and elucidation of their clinical utility via gene knockdown in cellular and animal models. This new method can be replicated and applied to other cancers or disease states for research and development and discovery-based investigations. Our findings, which serve as a proof of concept, will hopefully motivate research groups to further expound on the molecular processes involved in the aggressiveness of EAC and other solid tumor diseases, ultimately leading to improved patient management strategies.
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Affiliation(s)
- Joe Abdo
- Department of Clinical and Translational Science, Creighton University School of Medicine, Omaha, NE, United States
| | - Christopher S Wichman
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, United States
| | - Nicholas E Dietz
- Department of Clinical and Translational Science, Creighton University School of Medicine, Omaha, NE, United States.,Department of Pathology, CHI Health Creighton University Medical Center, College of Medicine, Omaha, NE, United States
| | - Pawel Ciborowski
- Department of Pharmacology, University of Nebraska Medical Center, Omaha, NE, United States
| | - John Fleegel
- Department of Clinical and Translational Science, Creighton University School of Medicine, Omaha, NE, United States
| | - Sumeet K Mittal
- Department of Clinical and Translational Science, Creighton University School of Medicine, Omaha, NE, United States.,Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Dignity Health, Phoenix, AZ, United States
| | - Devendra K Agrawal
- Department of Clinical and Translational Science, Creighton University School of Medicine, Omaha, NE, United States
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88
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Kinra P, Gahlot GPS, Yadav R, Baloda V, Makharia GK, Gupta SD, Das P. Histological assessment & use of immunohistochemical markers for detection of dysplasia in Barrett's esophageal mucosa. Pathol Res Pract 2018; 214:993-999. [PMID: 29764708 DOI: 10.1016/j.prp.2018.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/16/2018] [Accepted: 05/05/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Histological assessment of dysplasia in Barrett's esophagus (BE) has high inter-observer variability. Hence, use of ancillary markers for early detection of dysplasia in BE is an important clinical question. METHODS In this retrospective study consecutive cases of BE (n = 59), over a period of 4 years were included. Hematoxylin and eosin stained sections were reviewed independently by 3 senior qualified pathologists, who graded the dysplasia according to the Vienna Classification system and inter-observer agreement was analysed using the Kappa statistics. Subsequently Alpha-Methyl Acyl-CoA Racemase (AMACR), p53, CyclinD1, β-catenin, H2AX and M30 immunohistochemical (IHC) stains were examined on the following disease categories: BE with no dysplasia [NFD] (45), BE with indefinite for dysplasia (IFD) (4), low grade dysplasia (LGD) (3), high grade dysplasia (HGD) (2) and in adenocarcinomas (5). H score was calculated by adding up products of different grades of stain distribution and stain intensities (range of scores 0-300). RESULTS Among the 3 pathologists, overall agreement was poor (k 0.06; 95% CI -0.089 to 0.145), with highest disagreement noted for differentiating the LGD and IFDs (k = 0.21). After revising the histological criteria, the kappa improved to 0.53. Among the IHC stains performed, p53, β-catenin, H2AX and M30 stains were significantly useful to differentiate between IFD and LGD (P values: 0.04, 0.004, 0.05 & 0.04, respectively). AMACR and β-catenin stains though were up-regulated in HGD/adenocarcinomas than in other categories, their expression were not statistically different between the IFD and LGDs. CONCLUSIONS A detail histological scoring system may bring uniformity in histological interpretation of dysplasia in BE. Using a combined panel of IHC stains seems helpful in detection of dysplasia in BE, especially to differentiate the IFD and LGD changes in BE.
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Affiliation(s)
- Prateek Kinra
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Gaurav P S Gahlot
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Rajni Yadav
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vandana Baloda
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Govind K Makharia
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Siddhartha Datta Gupta
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Departments of Pathology and Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
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IMP3 Immunoreactivity is More Sensitive Than AMACR in Detecting Dysplastic Epithelium and Early Adenocarcinoma in Barrett Esophagus. Appl Immunohistochem Mol Morphol 2018; 25:386-391. [PMID: 26766126 DOI: 10.1097/pai.0000000000000319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT α-methylacyl coenzyme A racemase (AMACR) and insulin-like growth factor-II mRNA-binding protein 3 (IMP3) are 2 markers helpful in detecting difficult cases of dysplasia in Barrett esophagus (BE). However, no comparison studies have been performed to assess their performance in the same patient population. OBJECTIVES The aim of our study was to compare the immunohistochemical expression of IMP3 and AMACR in dysplastic lesions and early adenocarcinoma (EAC) arising in BE and evaluate their sensitivity and specificity. DESIGN A total of 98 cases [BE negative for dysplasia, n=24; indefinite for dysplasia (BE-IND), n=18; low-grade dysplasia (LGD), n=24; high-grade dysplasia (HGD), n=16; and EAC, n=16] were immunostained for AMACR and IMP3 and evaluated for the degree, the extent, and the intensity of staining. RESULTS No immunoreactivity for AMACR or IMP3 was observed in all 24 cases of BE negative for dyplasia. One of 18 (5.5%) cases of BE-IND was positive for IMP3, but all were negative for AMACR. AMACR and IMP3 were positive in 16.7% versus 41.7 % of the cases with BE-LGD, 25% versus 62.5% of BE-HGD, and 62.5% versus 93.7% of EAC, respectively. The sensitivity of AMACR and IMP3 for the detection of dysplasia in BE is 16.7% and 41.7% for LGD, 25% and 62.5% for HGD, and 62.5% and 93.7% in EAC, respectively. The specificity is 100% for both markers. In addition, a comparison of the intensity of reactivity shows a better result with IMP3 (36/98, 36.7%) than with AMACR (18/98, 18.4%) (P<0.001). CONCLUSIONS IMP3 has a similar specificity, but a better sensitivity, intensity, and extent of reactivity in comparison with AMACR, and may be used as an alternative to AMACR, in support of the diagnosis of BE-dysplasia and EAC.
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Management of low-grade dysplasia in Barrett’s esophagus: Ablate or survey? TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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91
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Chapter 2: Role of pathologic confirmation for Barrett′s esophagus and dysplasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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92
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Harrison M, Allen JE, Gorrepati VS, López-Jamar JME, Sharma P. Management of Barrett's esophagus with low-grade dysplasia. Dis Esophagus 2018; 31:4915944. [PMID: 29506235 DOI: 10.1093/dote/doy004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus progresses to esophageal adenocarcinoma in a stepwise histological fashion of no dysplasia, low grade dysplasia, high grade dysplasia and cancer. Hence the progression to cancer from various histological stages is different. Progression to cancer from low grade dysplasia is highly variable in the literature due to high inter-observer variability between pathologists in diagnosing it. Studies have shown the utility of having confirmation of low grade dysplasia by expert pathologists or documenting its persistence on two subsequent endoscopies in order to unify the diagnosis. The treatment of low grade dysplasia is variable. In this article we summarize the diagnosis, evaluation and management of low grade dysplasia in Barrett's Esophagus.
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Affiliation(s)
- M Harrison
- Department of Internal Medicine, University of Kansas School of Medicine and Veterans Affairs Medical Center
| | - J E Allen
- Department of Internal Medicine, University of Kansas School of Medicine and Veterans Affairs Medical Center
| | - V S Gorrepati
- Department of Gastroenterology, Department of Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | | | - P Sharma
- Department of Gastroenterology, Department of Veterans Affairs Medical Center, Kansas City, Missouri, USA
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Wani S, Qumseya B, Sultan S, Agrawal D, Chandrasekhara V, Harnke B, Kothari S, McCarter M, Shaukat A, Wang A, Yang J, Dewitt J. Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer. Gastrointest Endosc 2018; 87:907-931.e9. [PMID: 29397943 DOI: 10.1016/j.gie.2017.10.011] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 02/07/2023]
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94
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Kahn A, Al-Qaisi M, Kommineni VT, Callaway JK, Boroff ES, Burdick GE, Lam-Himlin DM, Temkit M, Vela MF, Ramirez FC. Longitudinal outcomes of radiofrequency ablation versus surveillance endoscopy for Barrett's esophagus with low-grade dysplasia. Dis Esophagus 2018; 31:4259167. [PMID: 29036431 DOI: 10.1093/dote/dox120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/08/2017] [Indexed: 12/11/2022]
Abstract
Radiofrequency ablation of Barrett's esophagus with low-grade dysplasia is recommended in recent American College of Gastroenterology guidelines, with endoscopic surveillance considered a reasonable alternative. Few studies have directly compared outcomes of radiofrequency ablation to surveillance and those that have are limited by short duration of follow-up. This study aims to compare the long-term effectiveness of radiofrequency ablation versus endoscopic surveillance in a large, longitudinal cohort of patients with Barrett's esophagus, and low-grade dysplasia.We conducted a retrospective analysis of patients with confirmed low-grade dysplasia at a single academic medical center from 1991 to 2014. Patients progressing to high-grade dysplasia or esophageal adenocarcinoma within one year of index LGD endoscopy were defined as missed dysplasia and excluded. Risk factors for progression were assessed via Cox proportional hazards model. Comparison of progression risk was conducted using a Kaplan-Meier analysis. Subset analyses were conducted to examine the effect of reintroducing early progressors and excluding patients diagnosed prior to the advent of ablative therapy. Of 173 total patients, 79 (45.7%) underwent radiofrequency ablation while 94 (54.3%) were untreated, with median follow up of 90 months. Seven (8.9%) patients progressed to high-grade dysplasia or adenocarcinoma despite ablation, compared with 14 (14.9%) undergoing surveillance (P = 0.44). This effect was preserved when patients diagnosed prior to the introduction of radiofrequency ablation were excluded (8.9% vs 13%, P = 0.68). Reintroduction of patients progressing within the first year of follow-up resulted in a trend toward significance for ablation versus surveillance (11.1% vs 23.8%, P = 0.053).In conclusion, progression to high-grade dysplasia or adenocarcinoma was not significantly reduced in the radiofrequency ablation cohort when compared to surveillance. Despite recent studies suggesting the superiority of radiofrequency ablation in reducing progression, diligent endoscopic surveillance may provide similar long-term outcomes.
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Affiliation(s)
- A Kahn
- Division of Gastroenterology and Hepatology
| | - M Al-Qaisi
- Division of Gastroenterology and Hepatology
| | | | | | - E S Boroff
- Division of Gastroenterology and Hepatology
| | | | | | - M Temkit
- Division of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona, USA
| | - M F Vela
- Division of Gastroenterology and Hepatology
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Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. About 10-15% of patients with GERD will develop Barrett's esophagus (BE). AIMS The aims of this study were to review the available evidence of the pathophysiology of BE and the role of anti-reflux surgery in the treatment of this disease. RESULTS The transformation of the squamous epithelium into columnar epithelium with goblet cells is due to the chronic injury produced by repeated reflux episodes. It involves genetic mutations that in some patients may lead to high-grade dysplasia and cancer. There is no strong evidence that anti-reflux surgery is associated with resolution or improvement in BE, and its indications should be the same as for other GERD patients without BE. CONCLUSIONS Patients with BE without dysplasia require endoscopic surveillance, while those with low- or high-grade dysplasia should have consideration of endoscopic eradication therapy followed by surveillance. New endoscopic treatment modalities are being developed, which hold the promise to improve the management of patients with BE.
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96
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Ravanshad R, Karimi Zadeh A, Amani AM, Mousavi SM, Hashemi SA, Savar Dashtaki A, Mirzaei E, Zare B. Application of nanoparticles in cancer detection by Raman scattering based techniques. NANO REVIEWS & EXPERIMENTS 2017; 9:1373551. [PMID: 30410710 PMCID: PMC6171787 DOI: 10.1080/20022727.2017.1373551] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/25/2017] [Indexed: 12/15/2022]
Abstract
In vitro detection technique Raman spectroscopy (Rs), in one number times another Rs based expert ways of art and so on, are useful instruments for cancer discovery. top gave greater value to Raman spectroscopy sers is a relatively new careful way for in vitro and in vivo discovery that takes away bad points of simple Raman spectroscopy (Rs). Raman spectroscopy (RS) and in particular, multiple RS-based techniques are useful for cancer detection. Surface enhanced Raman spectroscopy (SERS) is a relatively new method for both in vitro and in vivo detection, which eliminates the drawbacks of simple RS. Using nanoparticles has elevated the sensitivity and specificity of SERS. SERS has the potential to increase sensitivity, specificity and spatial resolution in cancer detection, especially in cooperation with other diagnostic imaging tools such as magnetic resonance imaging (MRI) and PET-scan polyethylene terephthalate. Developing a hand held instrument for detecting cancer or other illnesses may also be feasible by using SERS. Frequently, novel nanoparticles are used in SERS. With a focus on nanoparticle utilization, we review the benefits of RS in cancer detection and related biomarkers. With a focus on nanoparticles utilizations, the benefits of RS in cancer detection and related biomarkers were reviewed. In addition, Raman applications to detect some of prevalent were discussed. Also more investigated cancers such as breast and colorectal cancer, multiple nanostructures and their possible special biomarkers, especially as SERS nano-tag have been reviewed. The main purpose of this article is introducing of most popular nanotechnological approaches in cancer detection by using Raman techniques. Moreover, have been caught up on detection and reviewed some of the most prevalent and also more investigated cancers such as breast, colorectal cancer, multiple intriguing nanostructures, especially as SERS nano-tag, special cancer biomarkers and related approaches. The main purpose of this article is to introduce the most popular nanotechnological approaches in cancer detection by using Raman techniques.
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Affiliation(s)
- Rouhallah Ravanshad
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ayoob Karimi Zadeh
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Mohammad Amani
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyyed Mojtaba Mousavi
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyyed Alireza Hashemi
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Savar Dashtaki
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Esmail Mirzaei
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bijan Zare
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Medical Biotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
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Voltaggio L, Montgomery EA. Diagnosis and Management of Barrett-Related Neoplasia in the Modern Era. Surg Pathol Clin 2017; 10:781-800. [PMID: 29103533 DOI: 10.1016/j.path.2017.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Whereas in the past, pathologists were hesitant to diagnose high-grade dysplasia in patients with Barrett esophagus, because this diagnosis prompted esophagectomy, current international consensus is that endoscopic treatment is the management for high-grade dysplasia and intramucosal carcinoma. Furthermore, many centers advocate endoscopic ablation for low-grade dysplasia. As such, establishing a diagnosis of dysplasia has become the key step; separation between the grades of dysplasia is less critical. This article offers some criteria for separating dysplasia from reactive changes, discusses pitfalls in interpreting endoscopic mucosal resection specimens, and outlines management strategies.
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Affiliation(s)
- Lysandra Voltaggio
- Department of Pathology, Johns Hopkins Medical Institutions, 401 North Broadway, Baltimore, MD 21231, USA
| | - Elizabeth A Montgomery
- Department of Pathology, Johns Hopkins Medical Institutions, 401 North Broadway, Baltimore, MD 21231, USA.
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98
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van der Wel MJ, Duits LC, Seldenrijk CA, Offerhaus GJ, Visser M, Ten Kate FJ, de Boer OJ, Tijssen JG, Bergman JJ, Meijer SL. Digital microscopy as valid alternative to conventional microscopy for histological evaluation of Barrett's esophagus biopsies. Dis Esophagus 2017; 30:1-7. [PMID: 28881901 DOI: 10.1093/dote/dox078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/25/2017] [Indexed: 12/11/2022]
Abstract
Management of Barrett's esophagus (BE) relies heavily on histopathological assessment of biopsies, associated with significant intra- and interobserver variability. Guidelines recommend biopsy review by an expert in case of dysplasia. Conventional review of biopsies, however, is impractical and does not allow for teleconferencing or annotations. An expert digital review platform might overcome these limitations. We compared diagnostic agreement of digital and conventional microscopy for diagnosing BE ± dysplasia. Sixty BE biopsy glass slides (non-dysplastic BE (NDBE); n = 25, low-grade dysplasia (LGD); n = 20; high-grade dysplasia (HGD); n = 15) were scanned at ×20 magnification. The slides were assessed four times by five expert BE pathologists, all practicing histopathologists (range: 5-30 years), in 2 alternating rounds of digital and conventional microscopy, each in randomized order and sequence of slides. Intraobserver and pairwise interobserver agreement were calculated, using custom weighted Cohen's kappa, adjusted for the maximum possible kappa scores. Split into three categories (NDBE, IND, LGD+HGD), the mean intraobserver agreement was 0.75 and 0.84 for digital and conventional assessment, respectively (p = 0.35). Mean pairwise interobserver agreement was 0.80 for digital and 0.85 for conventional microscopy (p = 0.17). In 47/60 (78%) of digital microscopy reviews a majority vote of ≥3 pathologists was reached before consensus meeting. After group discussion, a majority vote was achieved in all cases (60/60). Diagnostic agreement of digital microscopy is comparable to that of conventional microscopy. These outcomes justify the use of digital slides in a nationwide, web-based BE revision platform in the Netherlands. This will overcome the practical issues associated with conventional histologic review by multiple pathologists.
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Affiliation(s)
- M J van der Wel
- Departments of Pathology, and Gastroenterology and Hepatology.,Gastroenterology and Hepatology
| | | | - C A Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein
| | - G J Offerhaus
- Department of Pathology, University Medical Center, Utrecht
| | - M Visser
- Department of Pathology, Zaans Medical Center, Zaandam, the Netherlands
| | - F J Ten Kate
- Department of Pathology, University Medical Center, Utrecht
| | - O J de Boer
- Departments of Pathology, and Gastroenterology and Hepatology
| | - J G Tijssen
- Cardiology, Academic Medical Center, Amsterdam
| | | | - S L Meijer
- Departments of Pathology, and Gastroenterology and Hepatology
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Hamade N, Sharma P. Ablation Therapy for Barrett's Esophagus: New Rules for Changing Times. Curr Gastroenterol Rep 2017; 19:48. [PMID: 28819902 DOI: 10.1007/s11894-017-0589-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss different endoscopic techniques in the eradication of Barrett's esophagus (BE) as well as some controversies in the field of treatment. RECENT FINDINGS Patients with T1a esophageal adenocarcinoma and BE of high-grade dysplasia should undergo endoscopic ablative therapy. The most studied technique to date is radiofrequency ablation. It can be combined with endoscopic mucosal resection in cases containing nodular and flat lesions. Cryotherapy and APC have shown promise with good efficacy and safety profiles so far, but are not mainstream as more studies are needed. Surveillance is still required post-ablation since recurrence is common. Low-grade dysplasia can be treated with either endo-ablative therapy or surveillance. Non-dysplastic BE treatment is controversial and so far, only surveillance is recommended. Research is ongoing to better risk stratify these patients. Our ability to diagnose and treat BE has come a long way in the past few years with the goal of preventing its progression into malignancy. The advent of endoscopic techniques in the eradication of BE has provided a less invasive and safer modality of treatment as compared to surgical esophagectomy. Data in the form of randomized trials and high-volume registries has provided good evidence to support the efficacy of these techniques and their long-term durability.
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Affiliation(s)
- Nour Hamade
- Department of Internal Medicine, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MI, USA
| | - Prateek Sharma
- Department of Internal Medicine, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MI, USA. .,Department of Gastroenterology, Department of Veterans Affairs Medical Center, 4801 E. Linwood Boulevard, Kansas City, MI, 64128, USA.
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Amadi C, Gatenby P. Barrett’s oesophagus: Current controversies. World J Gastroenterol 2017; 23:5051-5067. [PMID: 28811703 PMCID: PMC5537175 DOI: 10.3748/wjg.v23.i28.5051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/03/2017] [Accepted: 07/04/2017] [Indexed: 02/06/2023] Open
Abstract
Oesophageal adenocarcinoma is rapidly increasing in Western countries. This tumour frequently presents late in its course with metastatic disease and has a very poor prognosis. Barrett’s oesophagus is an acquired condition whereby the native squamous mucosa of the lower oesophagus is replaced by columnar epithelium following prolonged gastro-oesophageal reflux and is the recognised precursor lesion for oesophageal adenocarcinoma. There are multiple national and society guidelines regarding screening, surveillance and management of Barrett’s oesophagus, however all are limited regarding a clear evidence base for a well-demonstrated benefit and cost-effectiveness of surveillance, and robust risk stratification for patients to best use resources. Currently the accepted risk factors upon which surveillance intervals and interventions are based are Barrett’s segment length and histological interpretation of the systematic biopsies. Further patient risk factors including other demographic features, smoking, gender, obesity, ethnicity, patient age, biomarkers and endoscopic adjuncts remain under consideration and are discussed in full. Recent evidence has been published to support earlier endoscopic intervention by means of ablation of the metaplastic Barrett’s segment when the earliest signs of dysplasia are detected. Further work should concentrate on establishing better risk stratification and primary and secondary preventative strategies to reduce the risk of adenocarcinoma of the oesophagus.
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