Barrett’s esophagus and adenocarcinoma of the esophagus and gastroesophageal junction

Computing lifetime incidence of esophageal adenocarcinoma and age-specific prevalence of Barrett's esophagus

Barrett's esophagus is the precursor to esophageal adenocarcinoma. Esophageal adenocarcinoma detected from endoscopic surveillance programs accounts for <10% of all cases, suggesting majority of patients with Barrett's esophagus are likely unaccounted for. Previous observational studies have estimated the observed prevalence of Barrett's esophagus to be approximately 1%, but others suggest may be an underestimate. The aim of this study was twofold: (i) calculate lifetime risk of esophageal adenocarcinoma and (ii) estimate overall and age-specific prevalence of Barrett's esophagus. A tree cohort model was created for progression to esophageal adenocarcinoma from birth to death (100 years) for USA and Australian population. Lifetime risk of esophageal cancer and adenocarcinoma were necessary for calculating Barrett's esophagus prevalence. The model incorporated age- and sex-specific incidence data from national cancer registries: the Australian Institute of Health and Welfare and the Surveillance, Epidemiology, and End Results database for the USA. The model was calibrated using an optimization algorithm, which matched progression rates from Barrett's esophagus to esophageal adenocarcinoma with known national cancer data. A Monte Carlo simulation, with 10,000 iterations, was conducted to derive error margins. Estimates of age-specific and overall prevalence of Barrett's esophagus in the population were generated through a similar process. Results: The lifetime risk of esophageal cancer and adenocarcinoma in USA non-Hispanic White population was 0.56% and 0.36%, respectively, while it was somewhat higher at 0.81% and 0.61% (range 0.57%-0.65%) in the Australian population. Estimated overall prevalence of Barrett's esophagus was ~3% (±0.3%) and ~ 5.4% (±0.6%) in USA White and Australian populations (male and female). Prevalence for age brackets was estimated at 0.06% (±0.02%), 1.6% (±0.7%), 3.2% (±1.3%), 8% (±3%), and 12% (±4%) for USA, and 0.05% (±0.02%), 0.9% (±0.5%), 2.8% (±1.2%), 7% (±3%), and 12% (±4%) for Australian population for ages 0-29, 30-44, 45-59, 60-74, and 75+, respectively. Observed estimates of Barrett's esophagus prevalence are likely lower than projected overall prevalence. This study also presents age-specific prevalence estimates of Barrett's esophagus, which are key in developing screening programs for esophageal adenocarcinoma.

Epidemiology of Barrett's Esophagus and Esophageal Adenocarcinoma: Implications for Screening and Surveillance

In the United States, the incidence of esophageal adenocarcinoma increased markedly since the 1970s with a recent stabilization. Despite evolving screening and surveillance strategies to diagnose, risk triage, and intervene in Barrett's esophagus patients to prevent esophageal adenocarcinoma, most cases present with advanced disease and poor resultant survival. Epidemiologic studies have identified the main risk factors for these conditions, including increasing age, male sex, white race, gastroesophageal reflux disease, abdominal obesity, cigarette smoking, and lack of infection with Helicobacter pylori. This review summarizes the current epidemiologic evidence with implications for screening and surveillance in Barrett's esophagus and esophageal adenocarcinoma.

Systematic review with meta-analysis: prevalence of prior and concurrent Barrett's oesophagus in oesophageal adenocarcinoma patients

BACKGROUND

The proportions of patients with oesophageal adenocarcinoma (OAC) diagnosed by Barrett's oesophagus surveillance or with pre-existing Barrett's oesophagus are unclear.

AIM

To estimate the prevalence of prior and concurrent Barrett's oesophagus diagnosis among patients with OAC or oesophagogastric junction adenocarcinomas (OGJAC).

METHODS

We searched PubMed and Embase to identify studies published 1966-1/8/2020 that examined the prevalence of prior (≥6 months) or concurrent Barrett's diagnosis (at cancer diagnosis) among OAC and OGJAC patients. Random effects models estimated overall and stratified pooled prevalence rates.

RESULTS

A total of 69 studies, including 33 002 OAC patients (53 studies) and 2712 patients with OGJAC (28 studies) were included. The pooled prevalence of prior Barrett's oesophagus diagnosis in OAC was 11.8% (95% confidence interval [CI] 8.4%-15.6%). The prevalence of prior Barrett's oesophagus diagnosis was higher in single-centre resection studies (16.0%, 95% CI 8.7%-24.9%) than population-based cancer registry studies (8.4%, 95% CI 5.5%-11.9%). The prevalence of concurrent Barrett's oesophagus in OAC was 56.6% (95% CI 48.5%-64.6%). Studies with 100% early stage OAC had higher prevalence of concurrent Barrett's oesophagus (91.3%, 95% CI 82.4%-97.6%) than studies with <50% early OAC (39.7%, 95% CI 33.7%-45.9%). In OGJAC, the prevalence of prior and concurrent Barrett's oesophagus was 23.2% (95% CI 7.5%-44.0%) and 26.3% (95% CI 17.8%-35.7%), respectively.

CONCLUSIONS

Most patients with OAC have Barrett's oesophagus. Our meta-analysis found ~12% of OAC patients had prior Barrett's diagnosis, but concurrent Barrett's oesophagus was found in ~57% at the time of OAC diagnosis. This represents a considerable missed opportunity for Barrett's oesophagus screening.

Advances in biomarkers for esophageal cancer

Cancer of the esophagus is an aggressive disease with early lymphatic and hematogenous dissemination and at present often considered as one clinical entity because of their comparable increasing incidence, prognosis and optimal treatment options. However, it is still a matter of debate whether these malignancies have the same pathogenesis and genotype. Despite recent advances, treatment of upper gastrointestinal malignancies remains a significant challenge. Molecular pathology has revealed many molecular mechanisms of disease progression, which are related to prognosis. Better knowledge of molecular bases may lead to new paradigms, improved prognostication, early diagnosis and individually tailored therapeutic options. This review summarizes the rationale, preclinical evidence, retrospective clinical analyses and the interim clinical data pertaining HER2 therapy and many other molecular pathways.

The dichotomy in carcinogenesis of the distal esophagus and esophagogastric junction: intestinal-type vs cardiac-type mucosa-associated adenocarcinoma

Adenocarcinoma of the distal esophagus and esophagogastric junction continues to rise in incidence. An intestinal metaplasia (Barrett esophagus)-dysplasia-carcinoma sequence induced by gastroesophageal reflux disease is well established. However, a significant number of adenocarcinomas in the vicinity of the esophagogastric junction are seen in the background of gastric/cardiac-type mucosa without intestinal metaplasia. Thus, the aim of this study was to investigate the role of Barrett esophagus (intestinal-type mucosa) in the classification and prognosis of tumors of the distal esophagus and esophagogastric junction. Clinicopathological and molecular characteristics were examined in 157 consecutively resected adenocarcinomas of the distal esophagus and esophagogastric junction and were compared between tumors arising in association with intestinal-type and cardiac-type mucosa. Intestinal-type mucosa-associated adenocarcinomas were more likely to be associated with younger age (P=0.0057), reflux symptoms (P<0.0001), proximal location (P=0.0009), lower T stage (P<0.0001), fewer nodal metastases (P=0.0001), absence of lymphatic (P<0.0001), venous (P=0.0060) or perineural (P<0.0001) invasion. Histologically, intestinal-type mucosa-associated tumors were more likely to be low-grade glandular tumors (P=0.0095) of intestinal or mixed immunophenotype (P=0.015) and express nuclear β-catenin (P=0.0080), whereas tumors arising in a background of cardiac-type mucosa were more frequently associated with EGFR amplification (P=0.0051). Five-year overall survival rate was significantly higher in patients with intestinal-type mucosa-associated tumors (28 vs 9%, P=0.0015), although no survival benefit was seen after adjusting for potential confounders. Our findings support the theory that multiple distinct pathways of tumorigenesis exist in the vicinity of the esophagogastric junction, including one in which tumors arise from dysplastic intestinal metaplasia (intestinal pathway), and one potentially involving dysplasia of the cardiac-type mucosa (non-intestinal pathway). Additional studies are warranted to further clarify their pathogenesis and the molecular mechanisms involved.

The incidence of esophageal cancer and high-grade dysplasia in Barrett's esophagus: a systematic review and meta-analysis

Barrett's esophagus is a well-recognized precursor of esophageal adenocarcinoma. Surveillance of Barrett's esophagus patients is recommended to detect high-grade dysplasia (HGD) or early cancer. Because of wide variation in the published cancer incidence in Barrett's esophagus, the authors undertook a systematic review and meta-analysis of cancer and HGD incidence in Barrett's esophagus. Ovid Medline (Ovid Technologies, Inc., New York, New York) and EMBASE (Elsevier, Amsterdam, the Netherlands) databases were searched for papers published between 1950 and 2006 that reported the cancer/HGD risk in Barrett's esophagus. Where possible, early incident cancers/HGD were excluded, as were patients with HGD at baseline. Forty-seven studies were included in the main analysis, and the pooled estimate for cancer incidence in Barrett's esophagus was 6.1/1,000 person-years, 5.3/1,000 person-years when early incident cancers were excluded, and 4.1/1,000 person-years when both early incident cancer and HGD at baseline were excluded. Corresponding figures for combined HGD/cancer incidence were 10.0 person-years, 9.3 person-years, and 9.1/1,000 person-years. Compared with women, men progressed to cancer at twice the rate. Cancer or HGD/cancer incidences were lower when only high-quality studies were analyzed (3.9/1,000 person-years and 7.7/1,000 person-years, respectively). The pooled estimates of cancer and HGD incidence were low, suggesting that the cost-effectiveness of surveillance is questionable unless it can be targeted to those with the highest cancer risk.

Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction

The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.

Have patients with esophagitis got an increased risk of adenocarcinoma? Results from a population-based study

AIM

To examine an increased risk of esophageal adenocarcinoma is restricted to patients who develop Barrett's esophagus or whether esophagitis per se is a risk factor for adenocarcinoma.

METHODS

A population-based cohort of patients with histological evidence of esophagitis without Barrett's esophagus was constructed using electronic pathology reports relating to all esophageal biopsies in Northern Ireland between 1993 and 1996. Person-years of follow-up and incident cases of esophageal cancer were calculated by linking the cohort to death files and the Northern Ireland Cancer Registry records. Standardized incidence ratios (SIR) were calculated for esophageal cancers (adenocarcinoma, squamous cell carcinoma (SCC), and histologically unspecified cancers).

RESULTS

A total of 2 013 patients in the cohort provided 13 559 patient-years of follow-up (mean follow-up 6.7 years). None of the patients developed adenocarcinoma. Three patients developed SCC, and six developed histologically unspecified cancers. The SIR for all esophageal cancers and for SCC were 2.73 (95%CI 1.25-5.19) and 2.93 (95%CI 0.61-8.59), respectively. In a sensitivity analysis in which all unspecified esophageal cancers were treated as adenocarcinomas, the SIR for adenocarcinoma was 2.64 (0.97-5.75).

CONCLUSION

The risk of adenocarcinoma is not elevated in patients with histological evidence of esophagitis without Barrett's esophagus; however, these patients may have a moderately increased risk of SCC. Further studies are required to confirm these findings, which suggest that Barrett's esophagus, not esophagitis, is the key precursor lesion in the development of adenocarcinoma.

Barrett esophagus: update for radiologists

Barrett esophagus is a well-recognized entity in which there is progressive columnar metaplasia of the lower esophagus due to longstanding gastroesophageal reflux and reflux esophagitis [1]. This condition is important because it is associated with an increased risk of developing esophageal adenocarcinoma by a well-established sequence from dysplasia to carcinoma [2]. During the past decade, however, an explosion of new data has dramatically affected our understanding of Barrett esophagus. Not only have revised histopathologic criteria been developed for this condition, but it is currently believed that patients with Barrett esophagus should be classified as having "short-segment" or "long-segment" disease based on the extent of columnar metaplasia in the distal esophagus. This distinction has important implications for the risk of developing esophageal adenocarcinoma and subsequent need for endoscopic surveillance. The purpose of this article is to present these new concepts about Barrett esophagus and provide radiologists with a more current framework for diagnosing this condition.

High-grade dysplasia in Barrett's esophagus. The case for esophagectomy

The main principles for optimal management of HGD arising in Barrett's esophagus are that unequivocal diagnosis of HGD is a prerequisite for making the decision of any kind of treatment. HGD must be resected because of the presence of neoplastic cells in the lamina propria in 40% of patients. No reliable endoscopic or endosonographic feature exists that allows accurate prediction of the existence of neoplastic cells within the lamina propria of a patient having HGD in endoscopic biopsy material. Prompt decision to remove an HGD lesion as soon as unequivocal histologic diagnosis has been settled prevents the development of extraesophageal neoplastic spread. Esophagectomy is preferable to endoscopic mucosal excision because approximately 20% of patients who have HGD in preoperative biopsy material carry neoplastic cells beyond the muscularis mucosae. Esophagectomy can be limited to the removal of the esophageal tube without extended lymphadenectomy because 96% of patients who have HGD in endoscopic biopsy samples have a neoplastic process confined to the esophageal wall. Esophageal resection must encompass all the Barrett's area because of the risk for the further development of a second cancer in the metaplastic remnant. Vagus-sparing esophagectomy with colon interposition or elevation of the antrally innervated stomach up to the neck is preferable to conventional esophagectomy with gastric pull up because the former procedure maintains gastric function intact, whereas the latter exposes patients to the risk for the long-term development of reflux esophagitis and even of metaplastic transformation of the proximal esophageal remnant. Subtle details in the understanding of a given patient's clinical course may be critical for making the decision of the most relevant mode of therapy; therefore, patients who have HGD should be treated in dedicated centers, the experience of which offers the best chances of uneventful recovery if the surgical option is retained.

The adoption of ablation therapy for Barrett's esophagus: a cohort study of gastroenterologists

OBJECTIVES

Although ablation therapy may be useful in the treatment of Barrett's esophagus. evidence of effectiveness is scarce, and little is known about current utilization of ablation. We aimed to determine whether the use of ablation was increasing in a cohort of gastroenterologists, and to identify physician beliefs and characteristics associated with ablation use.

METHODS

We surveyed a national sample of gastroenterologists about ablation use, with an 18-month follow-up. The self-administered instrument included questions about demographic characteristics, attitudes about ablation therapy, and prior experience with ablation. Case scenarios were also included. We used logistic regression to identify factors associated with the use of ablation in patients with Barrett's esophagus.

RESULTS

Two hundred seventy-nine (50.3% of those eligible) responded to the baseline survey. Few agreed that ablation lowers the risk of adenocarcinoma (15%) or is supported by the medical literature (19%). However, 25% of respondents reportedly had used ablation at baseline, and this increased to 36% in the follow-up survey (p = 0.0003). The use of ablation was significantly associated with physician age greater than 54 yr (odds ratio [OR] = 2.77, 95% CI = 1.04-7.37) and the belief that ablation was used by colleagues (OR = 13.27, 95% CI = 4.44-39.64) or decreases medical costs (OR = 5.07, 95% CI = 1.00-25.74).

CONCLUSIONS

Although few gastroenterologists agreed that ablation is effective, a significant proportion had adopted its use. There was a significant increase in ablation use during our study period, and the characteristic that was most strongly associated with ablation use was the belief that colleagues used it.

Preoperative prevalence of Barrett's esophagus in esophageal adenocarcinoma: a systematic review

BACKGROUND & AIMS

The public health impact of past screening and surveillance practices on the outcomes of Barrett's related cancers has not previously been quantified. Our purpose was to determine the prior prevalence of Barrett's esophagus in reported cases of incident adenocarcinoma undergoing resection, as an indirect measure of impact.

METHODS

We performed a systematic review of the literature from 1966 to 2000. Studies were included if they reported: (1) the number of consecutive adenocarcinomas resected, and (2) the number of those resected who had a previously known diagnosis of Barrett's. We generated summary estimates using a random effects model.

RESULTS

We identified and reviewed 752 studies. Twelve studies representing a total of 1503 unique cases of resected adenocarcinomas met inclusion criteria. Using a random effects model, the overall percentage of patients undergoing resection who had a prior diagnosis of Barrett's was 4.7% +/- 2.9%.

CONCLUSIONS

The low prior prevalence (approximately 5%) of Barrett's esophagus in this study population provides indirect evidence to suggest that recent efforts to identify patients with Barrett's-whether through endoscopic screening or evaluation of symptomatic patients-have had minimal public health impact on esophageal adenocarcinoma outcomes. The potential benefits of endoscopic surveillance seem to have been limited to only a fraction of those individuals at risk. These data thus provide a clear and compelling rationale for the development of effective screening strategies to identify patients with Barrett's esophagus.

Prospective evaluation of the prevalence of gastric Helicobacter pylori infection in patients with GERD, Barrett's esophagus, Barrett's dysplasia, and Barrett's adenocarcinoma

OBJECTIVE

This study was undertaken to prospectively determine the prevalence of gastric H. pylori infection in Barrett's esophagus and Barrett's complicated by dysplasia or adenocarcinoma.

METHODS

The prevalence of H. pylori was determined in Barrett's esophagus patients compared to a control population of patients with gastroesophageal reflux disease (GERD) only. All patients had a minimum of 10 gastric surveillance biopsies obtained. H. pylori colonization was determined upon the basis of hematoxylin and eosin and use of a modified Giemsa and or Steiner's silver stain of all gastric biopsy specimens.

RESULTS

Two hundred and eighty-nine Barrett's patients and 217 GERD control patients were included in the study. H. pylori was found in 95/289 (32.9%) of the Barrett's patients, compared with 96/217 (44.2%) of the GERD controls (NS). Forty-seven of the Barrett's patients had low-grade dysplasia/indefinite dysplasia, 14 high-grade dysplasia, and 20 Barrett's adenocarcinoma. When Barrett's was subgrouped according to absence of dysplasia, and presence of low-grade dysplasia, high-grade dysplasia, or adenocarcinoma, H. pylori prevalence was found to be significantly less for patients with Barrett's high-grade dysplasia (14.3%) and adenocarcinoma (15.0%) versus patients with GERD alone (44.2%), Barrett's alone (35.1%), or Barrett's with low-grade dysplasia (36.2%) (p = 0.016). This difference could not be explained by differences between Barrett's esophagus patients infected with H. pylori and those who were not with respect to gender, smoking history, alcohol consumption, use of proton pump inhibitor, or length of Barrett's mucosa.

CONCLUSIONS

Barrett's high-grade dysplasia and adenocarcinoma are significantly more prevalent in patients who are not infected with H. pylori. H. pylori appears to have a protective effect against the development of Barrett's adenocarcinoma.

Three-field lymphadenectomy and pattern of lymph node spread in T3 adenocarcinoma of the distal esophagus and the gastro-esophageal junction

OBJECTIVE

Lymph node metastasis in carcinoma of the esophagus and the gastro-esophageal junction is often underestimated by clinical staging. It is the aim of this study to provide support to the fact that three-field lymphadenectomy leads to a better pathological staging also in adenocarcinoma.

METHODS

The pattern of lymph node metastasis in adenocarcinoma of the gastro-esophageal junction (GEJ) and the distal esophagus was charted in a prospective way by using a database. An analysis was performed with regard to lymphatic spread in T3, N+ adenocarcinomas of the distal esophagus and the GEJ junction, which were treated with a radical resection including a three-field lymphadenectomy. Out of 324 patients with adenocarcinoma of the esophagus and GEJ, we selected a group of 37 patients with an adenocarcinoma T3, N+ of the distal (n = 17) or GEJ junction (n = 20), treated with a radical resection and three-field lymphadenectomy ( > 25 lymph nodes resected).

RESULTS

In total, 2240 lymph nodes were removed, with a mean of 59.5 per patient. In the GEJ group the ratio of positive nodes was 15.9, in the distal 1/3 group this ratio was 12.7%. Abdominal lymph nodes were positive in all GEJ tumors and in 70% of the distal third carcinomas. Thoracic lymph nodes were positive in 40% of GEJ tumors, and 70.6% of the distal group. Cervical lymph nodes were positive in 20% of the GEJ tumors and in 35.3% of the distal tumors. In six patients only right-sided cervical nodes were affected. Three patients in the GEJ group had positive lymph nodes in the neck without any involvement of thoracic lymph nodes.

CONCLUSIONS

(1) Three-field lymphadenectomy improves accuracy of staging. (2) Cervical nodes are frequently involved. (3) Especially in tumors of the GEJ there is an important skipping phenomenon, i.e. positive lymph nodes in the neck in the absence of involvement of thoracic nodes. (4) Clinical staging remains deficient in regard to lymph node metastasis, especially cervical nodes. (5) The frequent unforeseen involvement of cervical lymph nodes in adenocarcinoma of the distal esophagus and GEJ tumors makes the interpretation of results of induction chemoradiotherapy questionable. (6) For the same reason, cervical lymph nodes should be included in the radiation field in case of induction chemoradiotherapy. (7) The similar pattern of lymph node involvement suggests similar oncological behavior of adenocarcinoma of the distal esophagus and the GEJ, questioning the actual TNM classification of these tumors as gastric carcinomas.

Adenocarcinomas of the distal oesophagus and gastric cardia are one clinical entity. Rotterdam Oesophageal Tumour Study Group

BACKGROUND

Adenocarcinomas of the distal third of the oesophagus and the gastric cardia have similar characteristics but different staging criteria are being used. In the present study the question is addressed whether these tumours should be regarded and staged as one clinical entity.

METHODS

From January 1987 to January 1997, 252 patients with an adenocarcinoma of the oesophagus (n = 111) or gastric cardia (n = 141) underwent transhiatal resection. Pathology, pathological tumour node metastasis (pTNM) stage and survival were analysed retrospectively, and a comparison was made between tumours of the oesophagus and gastric cardia.

RESULTS

Barrett's epithelium was diagnosed in 54 per cent of oesophageal adenocarcinomas compared with 13 per cent of adenocarcinomas of the gastric cardia (P < 0. 001). Oesophageal carcinomas had a more favourable pT stage, fewer positive locoregional lymph nodes (pN1-2 56 versus 62 per cent; P = 0.3), but more distant metastases accounted for by positive lymph nodes around the coeliac axis (pM1 19 versus 4 per cent; P < 0.001). Five-year overall survival (26 versus 27 per cent; P = 0.9) and survival according to tumour stage were no different between the groups. Multivariate analysis showed that the location of the primary tumour was not an independent prognostic factor.

CONCLUSION

Adenocarcinomas of the distal oesophagus and gastric cardia should be regarded as one clinical entity. Uniform staging criteria for both malignancies are recommended.

Adenocarcinoma of the esophagus and Barrett's esophagus: a population-based study

OBJECTIVE

We described incidence rates of esophageal adenocarcinoma in Denmark in a 20-yr period and determined the proportion of patients diagnosed with esophageal adenocarcinoma who had a previous diagnosis of Barrett's esophagus, making them potential candidates for endoscopic surveillance.

METHODS

Rates of esophageal and gastric cancers were collected from the Danish Cancer registry for the period 1970-1991. The registry was used to identify all cases of esophageal adenocarcinoma in the period 1987-1992. Medical records were retrieved and details concerning previous diagnosis of reflux disease and Barrett's esophagus were recorded.

RESULTS

The age- and gender-adjusted incidence of esophageal adenocarcinoma increased eightfold, from 0.3/10(5)/yr in 1970 to 2.3/10(5)/yr in 1990. This increase could not be explained by changes in classification or diagnostic routines. Medical data were retrieved for 524 of the 578 cases of esophageal adenocarcinoma reported during the period 1987-1992. A history of reflux symptoms or a diagnosis compatible with reflux was reported in 113 of 524 patients. A total of 119 patients (23%) had previously been investigated for dyspepsia or reflux symptoms, most often by endoscopy. A previous diagnosis of Barrett's esophagus was found in only 1.3% of the cancer patients.

CONCLUSIONS

The rate of esophageal adenocarcinoma in Denmark has increased eightfold over a 20-yr period, and this increase is not explained by changes in classification or diagnostic routines. More than 98% of esophageal adenocarcinomas were found in patients who could not have entered endoscopic surveillance, as Barrett's esophagus had not been diagnosed before the cancer diagnosis. Endoscopic surveillance to detect dysplasia may be an option for the individual patient with Barrett's esophagus, but these screening programs are not likely to reduce the death rate from esophageal adenocarcinomas in the general population.

Is Barrett's esophagus the precursor of most adenocarcinomas of the esophagus and cardia? A biochemical study

OBJECTIVE

To obtain biochemical evidence that Barrett's esophagus (BE) is the precursor of most adenocarcinomas (Adc) of the esophagus and cardia.

SUMMARY BACKGROUND DATA

Based on morphologic data, BE was previously proposed as the precursor of most Adc of the esophagus. This hypothesis would receive strong support if biochemical evidence were found to demonstrate a pattern common to BE and Adc of the esophagus and cardia.

METHODS

We studied the presence of intestinal-type proteins sucrase-isomaltase (SI) and crypt Cell Antigen (CCAg) in BE, Barrett's Adc, and esophageal-cardial Adc without BE. In each case specimens were collected from normal esophagus, stomach, tumor, and BE mucosa when present. To study related conditions, five specimens of peptic esophagitis and of squamous cell carcinoma were also analyzed. An indirect immunofluorescence technique was employed and sections were analyzed with laser confocal microscopy imaging.

RESULTS

Most Barrett's mucosa specimens stained positively for SI (93%) and CCAg (89%). These proteins were detected in BE independently of the type of metaplasia, the coexistence of dysplasia, or the presence of associated Adc. SI and CCAg were present in 25 (96%) and 24 (92%) of the cases of Adc respectively. No statistical difference was detected in SI and CCAg expression between Adc samples with and without BE, between BE and Adc samples with or without BE, and between tumors located in the esophagus versus the cardia. No staining for these proteins was detected in stomach or esophageal mucosa, in submucosal glands of the esophagus, in peptic esophagitis or squamous cell carcinoma.

CONCLUSION

These data show that BE and Adc of the esophagus and cardia have a similar phenotype and support the hypothesis that most of these tumors probably originate from preexisting BE.

Radical esophageal resection for adenocarcinoma arising in Barrett's esophagus

BACKGROUND

Esophagectomy with extensive lymph node dissection is the best way to give Barrett's patients with locally advanced adenocarcinoma a good chance of cure.

MATERIAL AND METHODS

Fifty-five patients underwent subtotal (n = 47) or distal (n = 8) esophagectomy for Barrett's adenocarcinoma (n = 43) or high-grade dysplasia (HGD) (n = 12). Thirteen patients (23.6%) never had had any reflux symptom before disclosure of the neoplastic lesion, and 20 patients (36.4%) had esophageal shortening. Ro resections (n = 50) included removal of the esophageal tube en bloc with the locoregional lymph nodes.

RESULTS

An invasive carcinoma was found in the resected specimen of 4 of the 12 patients operated on for HGD. Two of the 5 patients whose metaplasia was surveyed endoscopically were operated on for an advanced lesion (T2N1, T3N1) because they had not strictly complied with the proposed schedule. One of the 4 patients whose HGD was followed up endoscopically until disclosure of deeper mucosal invasion had positive lymph nodes at operation. The prevalence of early lesions (Tis, T1, T2, No) was 7.4% in patients with tumor-related symptoms versus 85.7% in those having unrelated symptoms (P = 0.0000), which resulted in a 5-year survival rate of 33.8% and 82.4%, respectively (P = 0.0012). Five-year survival rate after Ro resection made for invasive carcinoma was 59.3% (all cases), 73.1% (No), 61.5% (< or =5 positive lymph nodes), and 0% (>5 positive lymph nodes).

CONCLUSIONS

High-grade dysplasia is an indication for esophageal resection. Early detection of the neoplastic transformation of Barrett's metaplasia prior to the onset of obstructive symptoms gives the best chance of cure. Esophagectomy with radical lymph node clearance is capable of curing a large proportion of the patients having no or a limited number of metastatic lymph nodes.

Methylene blue selectively stains intestinal metaplasia in Barrett's esophagus

BACKGROUND

Specialized columnar epithelium in Barrett's esophagus resembles gastric intestinal metaplasia, which selectively stains with methylene blue.

METHODS

We prospectively evaluated the safety, accuracy, reproducibility, cost, and diagnostic yield of methylene blue-directed biopsy in detecting specialized columnar epithelium and dysplasia in Barrett's esophagus. We performed upper endoscopy with methylene blue-directed biopsy and obtained 236 large cup biopsy specimens (145 stained, 91 unstained) from 14 patients with Barrett's esophagus of any length (Group 1) and 12 control patients. Biopsy specimens were independently examined by two pathologists unaware of the endoscopic results.

RESULTS

Methylene blue stained specialized columnar epithelium in 18 of the 26 patients, including those with intramucosal carcinoma (1), high-grade dysplasia (1), and indefinite/low-grade dysplasia (6). Methylene blue staining pattern, which was focal in 72% and diffuse in 28% of patients, was reproduced in 8 patients who had repeat staining within 4 weeks. The overall accuracy of methylene blue staining for detecting specialized columnar epithelium was 95%. The diagnostic yield of methylene blue staining for specialized columnar epithelium in "control" patients was 42%. The risk for dysplasia in stained biopsy specimens was greater than in unstained ones (odds ratio 17.7, p = .0004).

CONCLUSIONS

Methylene blue mucosal staining is a safe, inexpensive, reproducible, and highly accurate method of diagnosing specialized columnar epithelium in Barrett's esophagus.

Tumors of the esophagogastric junction. Long-term survival in relation to the pattern of lymph node metastasis and a critical analysis of the accuracy or inaccuracy of pTNM classification

From 1983 to 1989, 95 patients with carcinoma of the esophagogastric junction underwent resection. Overall hospital mortality rate was 6.2% (6/95). Actuarial survival analysis showed 5- and 10-year survivals of 33% and 31%, respectively. Five- and 10-year survivals of patients according to TNM stages were as follows: stage I (n = 13), 90% at both 5 and 10 years; stage II (n = 13), 70% at both intervals; stage III (n = 28), 28% at both intervals; and stage IV (n = 40), 11% and 8%, respectively. For patients with undiseased nodes (n = 26), 5- and 10-year survivals were 72% and 72%, compared with 18% and 16% for patients with diseased nodes (n = 68; p < 0.005). In patients who had involvement of both the abdominal and thoracic lymph nodes (n = 28), 5- and 10-year survivals were 13% and 13%, compared with 26% and 26% if metastases were confined to the abdomen (n = 37; p > 0.05). Grouping patients with diseased intrathoracic nodes together with patients with N2 abdominal nodes showed survivals of 14% at both 5 and 10 years. When tumors were staged as an esophageal carcinoma, classification of individual patients changed, as did the 5- and 10-year survivals. Five- and 10-year survivals were as follows: stage I (n = 8), 100% for both 5 and 10 years; stage II (n = 18), 68% for both 5 and 10 years; stage III (n = 27), 37% for both 5 and 10 years; and stage IV (n = 41), 10% for 5 years and 6% for 10 years. These data indicate that tumors of the esophagogastric junction tend to spread to both abdominal and thoracic nodes. However, reasonably good 5- and 10-year survivals can be obtained even in patients with nodal metastases in both areas. We suggest that N2 labeling be included for thoracic node metastases instead of the actual M+Ly label, because the N2 label better reflects the potential for curative surgery. Finally, staging tumors as gastric or esophageal carcinoma makes no significant difference in survival analysis, which raises the question whether these tumors behave more like esophageal carcinoma than gastric carcinoma.

The management of high grade dysplasia and early cancer in Barrett's esophagus. A multidisciplinary problem

BACKGROUND

The incidence of Barrett's-associated esophageal adenocarcinoma is rising, but experience in the treatment of high-grade dysplasia (HGD) or early cancer is limited. Based on an endoscopic surveillance program, the authors developed a systematic multidisciplinary approach to this problem.

METHODS

Surgical resection was considered if biopsies of the Barrett's segment, performed according to a published protocol, showed invasive cancer, intramucosal carcinoma, or repeated evidence of HGD. The type of resection was based on the length of the Barrett's segment and included an en bloc lymph node dissection for staging purposes. Careful intraoperative pathologic evaluation ensured that all of the Barrett's mucosa was resected.

RESULTS

From 1984 to 1993, 27 consecutive patients (23 men, 4 women), with median age of 61 years (range, 45-75 years) underwent surgical exploration. Indications for operation were invasive cancer in 17 patients, intramucosal carcinoma in 5 patients, and HGD in 5 patients. Median length of the Barrett's segment was 9 cm (range, 1-17 cm). Only 15 patients (55%) had abnormalities visible with endoscopic examination that were potentially suspicious for malignancy. Twenty-six patients underwent resection with complete removal of the Barrett's mucosa, 20 by Ivor Lewis esophagogastrectomy, and 6 by transhiatal esophagectomy. Pathologic tumor stages were: TisN0M0 in 10 patients; T1N0M0 in 11 patients; T2N0M0 in 2 patients; T3N0M0 in 3 patients; and T1NXM1 in 1 patient. There were no postoperative deaths or anastomotic leaks. Major complications occurred in 4 patients. With a median follow-up of 3.7 years, 22 patients were alive, and only 2 patients had recurrences.

CONCLUSIONS

This increasingly important group of patients with HGD or early carcinoma in the Barrett's esophagus has a high chance of cure but requires careful multidisciplinary treatment by the surgeon, gastroenterologist, and pathologist.

Adenocarcinomas of esophagus and cardia in comparison with gastric carcinoma

Since the carcinomas of the cardia and the adenocarcinomas of the esophagus show many similarities in their histological and morphological descriptions, a detailed comparative study was attempted on the basis of 66 esophageal carcinomas in adenoid differentiation, 359 carcinomas of the cardia, 1288 gastric carcinomas in infracardial localisation, and 492 squamous carcinomas of the esophagus. The evaluation yielded no significant differences between the adenocarcinomas of the esophagus and the cardia neither in age and sex distribution nor with regard to the classifications of Borrmann, WHO, Ming, and Laurén, but a significant discrimination was possible between esophageal and cardial adenocarcinoma together, on the one hand, and infracardial gastric carcinoma on the other. Furthermore, esophageal adenocarcinomas were localized preferentially in the lower third, unlike squamous carcinomas of the same organ. These results suggest that esophageal adenocarcinoma and carcinoma of the cardia must be considered as one separate entity, probably originating from a common stem cell. They further suggest that the cardia belongs to the esophagus rather than to the stomach.