I-SCAN targeted versus random biopsies in Barrett's oesophagus

Usefulness of optical enhancement endoscopy combined with magnification to improve detection of intestinal metaplasia in the stomach

Background and study aims  The light blue crest observed in narrow band imaging endoscopy has high diagnostic accuracy for diagnosis of gastric intestinal metaplasia (GIM). The objective of this prospective study was to evaluate the diagnostic accuracy of magnifying i-scan optical enhancement (OE) imaging for diagnosing the LBC sign in patients with different levels of risk for gastric cancer in a Mexican clinical practice. Patients and methods  Patients with a history of peptic ulcer and symptoms of dyspepsia or gastroesophageal reflux disease were enrolled. Diagnosis of GIM was made at the predetermined anatomical location and white light endoscopy and i-scan OE Mode 1 were captured at the two predetermined biopsy sites (antrum and pyloric regions). Results  A total of 328 patients were enrolled in this study. Overall GIM prevalence was 33.8 %. The GIM distribution was 95.4 % in the antrum and 40.5 % in the corpus. According to the Operative Link on Gastritis/Intestinal-Metaplasia Assessment staging system, only two patients (1.9 %) were classified with high-risk stage disease. Sensitivity, specificity, positive​ and negative predictive values, positive and negative likelihood ratios, and accuracy of both methods (95 % C. I.) were 0.50 (0.41-0.60), 0.55 (0.48-0.62), 0.36 (0.31-0.42), 0.68 (0.63-0.73), 1.12 (0.9-1.4), 0.9 (0.7-1.1), and 0.53 (0.43-0.60) for WLE, and 0.96 (0.90-0.99), 0.91 (0.86-0.94), 0.84 (0.78-0.89), 0.98 (0.94-0.99), 10.4 (6.8-16), 0.05 (0.02-0.12), and 0.93 (0.89-0.95), respectively. The kappa concordance was 0.67 and the reliability coefficient was 0.7407 for interobserver variability. Conclusions  Our study demonstrated the high performance of magnifying i-scan OE imaging for endoscopic diagnosis of GIM in Mexican patients.

Developing patient-orientated Barrett's oesophagus services: the role of dedicated services

Introduction

Barrett’s oesophagus (BO) is common and is a precursor to oesophageal adenocarcinoma with a 0.33% per annum risk of progression. Surveillance and follow-up services for BO have been shown to be lacking, with studies showing inadequate adherence to guidelines and patients reporting a need for greater disease-specific knowledge. This review explores the emerging role of dedicated services for patients with BO.

Methods

A literature search of PubMed, MEDLINE, Embase, Emcare, HMIC, BNI, CiNAHL, AMED and PsycINFO in regard to dedicated BO care pathways was undertaken.

Results

Prospective multicentre and randomised trials were lacking. Published cohort data are encouraging with improvements in guideline adherence with dedicated services, with one published study showing significant improvements in dysplasia detection rates. Accuracy of allocation to surveillance endoscopy has been shown to hold cost savings, and a study of a dedicated clinic showed increased discharges from unnecessary surveillance. Training modalities for BO surveillance and dysplasia detection exist, which could be used to educate a BO workforce. Qualitative and quantitative studies have shown patients report high levels of cancer worry and poor disease-specific knowledge, but few studies have explored follow-up care models despite being a patient and clinician priority for research.

Conclusions

Cost–benefit analysis for dedicated services, considering both financial and environmental impacts, and more robust clinical data must be obtained to support this model of care in the wider health service. Greater understanding is needed of the root causes for poor guideline adherence, and disease-specific models of care should be designed around clinical and patient-reported outcomes to address the unmet needs of patients with BO.

Modern Diagnosis of Early Esophageal Cancer: From Blood Biomarkers to Advanced Endoscopy and Artificial Intelligence

Simple Summary

Esophageal cancer (EC) has a poor prognosis when the diagnosis is delayed, but curative treatment is possible if the diagnosis is timely. The disease subtly progresses before symptoms prompt patients to seek medical attention. Effective pre-symptomatic screening strategies may improve the outcome of the disease. Recent evidence provided insights into early diagnosis of EC via blood tests, advanced endoscopic imaging, and artificial intelligence. Accordingly, we reviewed available strategies to diagnose early EC.

Abstract

Esophageal cancer (EC) is the seventh most common cancer and the sixth cause of cancer death worldwide. Histologically, esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) account for up to 90% and 20% of all ECs, respectively. Clinical symptoms such as dysphagia, odynophagia, and bolus impaction occur late in the natural history of the disease, and the diagnosis is often delayed. The prognosis of ESCC and EAC is poor in advanced stages, being survival rates less than 20% at five years. However, when the diagnosis is achieved early, curative treatment is possible, and survival exceeds 80%. For these reasons, mass screening strategies for EC are highly desirable, and several options are currently under investigation. Blood biomarkers offer an inexpensive, non-invasive screening strategy for cancers, and novel technologies have allowed the identification of candidate markers for EC. The esophagus is easily accessible via endoscopy, and endoscopic imaging represents the gold standard for cancer surveillance. However, lesion recognition during endoscopic procedures is hampered by interobserver variability. To fill this gap, artificial intelligence (AI) has recently been explored and provided encouraging results. In this review, we provide a summary of currently available options to achieve early diagnosis of EC, focusing on blood biomarkers, advanced endoscopy, and AI.

The importance of a second opinion in the diagnosis of Barrett's esophagus: a "real life" study

BACKGROUND

Barrett's esophagus is a precancerous lesion, and its identification with the early detection of dysplasia is of paramount importance to prevent adenocarcinoma onset. However, there is still debate on the correct pathological identification of Barrett's esophagus (and of associated dysplasia), and most studies have been conducted in an experimental setting.

AIMS

To assess previous uncertain diagnoses of Barrett's (with and without dysplasia) via a second opinion of an expert pathologist in a real life setting.

PATIENTS AND METHODS

Histological sections of 32 suspected Barrett's patients from ten general Pathology units were centralized into one single unit in which an expert pathologist reviewed the slides blindly.

RESULTS

Overall, in 78% of cases there was diagnostic discordance; in particular, in 64% of cases the presence of low grade dysplasia was not confirmed. Of interest, 28% of cases with the original diagnosis were reclassified as non-Barrett's.

CONCLUSIONS

The pathological diagnosis of Barrett's esophagus, especially with regard to the presence of dysplasia, is still misinterpreted, particularly in the setting of general Pathology units. Thus, a second opinion from an experienced pathologist may help in the interpretation of the results and in starting appropriate follow-up programs.

Role of endoscopy in early oesophageal cancer

Incidence of oesophageal adenocarcinoma has increased exponentially in the West over the past few decades. Following detection of advanced cancers, 5-year survival rates remain bleak, making identification of early neoplasia, which has a better outcome, important. Detection of subtle oesophageal lesions during endoscopy can be challenging, and advanced imaging techniques might improve their detection. High-definition endoscopy has become a standard in most endoscopy centres, and this technology probably provides better delineation of mucosal features than standard-definition endoscopy. Various image enhancement techniques are now available with the development of new electronics and software systems. Image enhancement with chromoendoscopy using dyes has been a cost-effective option for many years, yet these techniques have been replaced in some contexts by electronic chromoendoscopy, which can be used with the press of a button. However, Lugol's chromoendoscopy remains the gold standard to identify squamous dysplasia. Identification and characterization of subtle neoplastic lesions could help to target biopsies and perform endoscopic resection for better local staging and definitive therapy. In vivo histology with techniques such as confocal endomicroscopy could make endotherapy feasible within a shorter timescale than when relying on histology on tissue samples. Once early neoplasia is identified, treatments include endoscopic resection, endoscopic submucosal dissection or various ablative techniques. Endotherapy has the advantage of being a less invasive technique than oesophagectomy, and is associated with lower mortality and morbidity. Endoscopic ablation therapies have evolved over the past few years, with radiofrequency ablation showing the best results in terms of success rates and complications in Barrett dysplasia.

Advances in the endoscopic diagnosis and treatment of Barrett's neoplasia

Barrett's oesophagus is a well-recognised precursor of oesophageal adenocarcinoma. The incidence of oesophageal adenocarcinoma is continuing to rise in the Western world with dismal survival rates. In recent years, efforts have been made to diagnose Barrett's earlier and improve surveillance techniques in order to pick up cancerous changes earlier. Recent advances in endoscopic therapy for early Barrett's cancers have shifted the paradigm away from oesophagectomy and have yielded excellent results.

Endoscopic diagnosis of early Barrett's neoplasia: perspectives for advanced endoscopic technology

Barrett's esophagus (BE) is a metaplastic condition that occurs secondary to gastroesophageal reflux disease. BE is also a precursor to esophageal adenocarcinoma, which, although still rare in Japan, is one of the most rapidly increasing cancers in Western countries. However, the prevalence of gastroesophageal reflux disease has increased significantly over the past few decades in Japan, possibly leading to an incremental rise in BE and the associated inherent risk of adenocarcinoma. Given the poor prognosis of advanced-stage Barrett's adenocarcinoma, endoscopic surveillance is recommended for subjects with BE to detect early neoplasias including dysplasia. However, endoscopic identification of dysplastic lesions is still not sufficiently reliable or subjective, making targeted therapy extremely difficult. Over the past few years, improvements in image resolution, image processing software, and optical filter technology have enabled identification of dysplasia and early cancer in BE patients. We retrieved as many studies on advanced endoscopic technologies in BE as possible from MEDLINE and PubMed. The present review focuses on the emergent clinically available technologies to provide an overview of the technologies, their practical applicability, current status, and future challenges.