Adenocarcinoma of the lower esophagus. A disease primarily of white men with Barrett's esophagus

Gastroesophageal and Laryngopharyngeal Reflux Associated With Laryngeal Malignancy: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Gastric reflux may lead to chronic mucosal inflammation and contribute to development of laryngeal malignancies, although there is controversy over this association. We performed a systematic review and meta-analysis to assess this relationship and determine the risk of laryngeal malignancy in patients with reflux disease.

METHODS

We performed a systematic review and meta-analysis, searching MEDLINE, EMBASE, and Web of Science databases from 1900 through April 9, 2018, for observational studies of adults reporting associations between gastroesophageal reflux disease (GERD) and/or laryngopharyngeal reflux and the risk of having or developing laryngeal malignancies. An itemized assessment of the risk of bias was conducted for each study that met inclusion criteria. The meta-analysis was performed using the Mantel-Haenszel method with random effects to account for heterogeneity. We performed subgroup analyses to determine the effect of reflux type, study design, diagnostic method, and confounding variables on the overall risk.

RESULTS

Of the 957 studies that were identified during systematic review, 18 case-control studies met the criteria for analysis. Our meta-analysis showed that reflux disease significantly increased the risk of laryngeal malignancy (odds ratio, 2.47; 95% CI, 1.90-3.21; P < .00001; I² = 94%). This association remained when controlling for patient smoking and drinking (odds ratio, 2.07; 95% CI, 1.26-3.41). There was no statistically significant difference in risk of laryngeal malignancies between patients with GERD vs laryngopharyngeal reflux (P = .44).

CONCLUSIONS

In a systematic review and meta-analysis, we found a significant association between reflux disease and the presence of laryngeal malignancy. Prospective studies should be performed to examine this relationship.

Racial Disparity in the Sex Distribution, the Prevalence, and the Incidence of Dysplasia in Barrett's Esophagus

GOALS

Our aim was to study the prevalence of dysplasia and progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in African Americans (AA) with Barrett's esophagus (BE) and compare it with that of non-Hispanic white (NHW) controls.

BACKGROUND

BE, a precursor of EAC, is a disease of predominantly white men and is uncommon in AA. The prevalence of dysplasia and progression to HGD and EAC in AA patients with BE is not clearly known.

STUDY

All AA or NHW patients with confirmed BE, that is specialized intestinal metaplasia, seen between 2002 and 2013 at our institution were included. Variables such as age, gender, medication use, the body mass index, the date of endoscopy, the hiatal hernia size, the BE length, and histologic findings were noted. Progression to HGD/EAC was evaluated.

RESULTS

Fifty-two AA and 2394 NHW patients with BE were identified. There was a higher percentage of women in the AA cohort (46.2%) than in the NHW cohort (24.9%, P<0.001). Nondysplastic BE was more prevalent in AA than in NHW (80.8% vs. 68.4%, P=0.058). In the surveillance cohort of 20 AA and 991 NHW, no racial differences in progression to HGD/EAC were observed during a median follow-up of 43 months.

CONCLUSIONS

This study includes the largest number of AA with histologically confirmed BE reported so far. About 46.2% of the AA cohort with BE in our study consisted of women. There was a trend toward a higher prevalence of nondysplastic BE in AA compared with NHW.

Recent advances in proximal gastric carcinoma

The American Joint Committee on Cancer (AJCC) staging scheme requires staging proximal gastric carcinoma (PGC) as esophageal adenocarcinoma (EAC), which has been shown to be controversial by recent research results. To update the current research findings on PGC, we systematically reviewed and analyzed the scientific evidence on key arguments related to PGC. The data of high-quality research articles showed that PGC arised in the cardiac mucosa in the proximal stomach within 3 cm below the gastroesophageal junction. Its incidence is rising in East Asian countries, but decreasing in the West, and plateaued at a low level in the United States. PGC is a slowly progressive cancer with unknown independent risk factors and the mechanisms of pathogenesis. This carcinoma exhibits a wide histopathological spectrum and heterogeneous post-resection patient survival characteristics, and cannot be adequately staged for prognotic stratification by the current AJCC staging classification. The results on PGC genomics reveal unique genetic profiles, especially in East Asian populations. In conclusion, mounting evidence defies a simple placement of PGC in a single category of EAC for disease classification; further investigations on the mechanisms of PGC pathogenesis are urgently needed.

Personal and family history of cancer and the risk of Barrett's esophagus in men

The association between Barrett's esophagus (BE) and a personal or family history of cancer other than gastroesophageal remains unknown. To evaluate the effect of personal and family history of certain cancers and cancer treatments on the risk of BE, we analyzed data from a Veterans Affairs case-control study that included 264 men with definitive BE (cases) and 1486 men without BE (controls). Patients with history of esophageal or gastric cancer were excluded. Patients underwent elective esophagogastroduodenoscopy or a study esophagogastroduodenoscopy concurrently with screening colonoscopy to determine BE status. Personal and family history of several types of cancer was obtained from self-reported questionnaires, supplemented and verified by electronic medical-record reviews. We estimated the association between personal and family history of cancer or radiation/chemotherapy, and BE. Personal history of oropharyngeal cancer (1.5% vs. 0.4%) or prostate cancer (7.2% vs. 4.4%) was more frequently present in cases than controls. The association between BE and prostate cancer persisted in multivariable analyses (adjusted odds ratio 1.90; 95% confidence interval 1.07-3.38, P = 0.028) while that with oropharyngeal cancer (adjusted odds ratio 3.63; 95% confidence interval 0.92-14.29, P = 0.066) was attenuated after adjusting for retained covariates of age, race, gastroesophageal reflux disease, hiatal hernia, and proton pump inhibitor use. Within the subset of patients with cancer, prior treatment with radiation or chemotherapy was not associated with BE. There were no significant differences between cases and controls in the proportions of subjects with several specific malignancies in first- or second-degree relatives. In conclusion, the risk of BE in men may be elevated with prior personal history of oropharyngeal or prostate cancer. However, prior cancer treatments and family history of cancer were not associated with increased risk of BE. Further studies are needed to elucidate if there is a causative relationship or shared risk factors between prostate cancer and BE.

Barrett's oesophagus: frequency and prediction of dysplasia and cancer

The incidence of oesophageal adenocarcinoma is continuing to increase at an alarming rate in the Western world today. Barrett's oesophagus is a clearly recognized risk factor for the development of oesophageal adenocarcinoma, but the overwhelming majority of patients with Barrett's oesophagus will never develop oesophageal cancer. A number of endoscopic, histologic and epidemiologic risk factors identify Barrett's oesophagus patients at increased risk for progression to high-grade dysplasia and oesophageal adenocarcinoma. Endoscopic factors include segment length, mucosal abnormalities as seemingly trivial as oesophagitis and the 12 to 6 o'clock hemisphere of the oesophagus. Both intestinal metaplasia and low grade dysplasia, the latter only if confirmed by a pathologist with expertise in Barrett's oesophagus pathologic interpretation are the histologic risk factors for progression. Epidemiologic risk factors include ageing, male gender, obesity, and smoking. Factors that may protect against the development of adenocarcinoma include a diet rich in fruits and vegetables, and the use of proton pump inhibitors, aspirin/NSAIDs and statins.

Managing Barrett's esophagus with radiofrequency ablation

Barrett's esophagus (BE) is a well-established pre-malignant lesion for esophageal adenocarcinoma, a condition that carries a dismal five-year overall survival rate of less than 15%. Among several available methods to eliminate BE, radiofrequency ablation (RFA) provides the most efficient modality, since it has been demonstrated to successfully eradicate BE with or without dysplasia with acceptable safety, efficacy and durability profiles. In conjunction with proton pump therapy, this new technology has quickly become the standard care for patients with dysplastic BE. However, several technical questions remain about how to deploy RFA therapy for maximum effectiveness and long-term favorable outcomes for all stages of the disease. These include how to select patient for therapy, what the best protocol for RFA is, when to use other modalities, such as endoscopic mucosal resection, and what should be considered for refractory BE. This review addresses these questions with the perspective of the best available evidence matched with the authors' experience with the technology.

Clinical implications of molecular changes in pediatric Barrett's esophagus

Barrett's esophagus (BE) is a preneoplastic condition that predisposes to esophageal adenocarcinoma. Although data on the occurrence of BE in children are limited, recent studies have suggested an increase in the pediatric population. BE is thought to be a complex disease in which individual genetic predisposition interacts with environmental stimuli. Early premalignant clones produce biological and genetic heterogeneity, resulting in stepwise changes in differentiation, proliferation, and apoptosis, allowing disease progression under selective pressure. The value of endoscopic surveillance biopsy for dysplasia and carcinoma in patients with BE is controversial. Thus, the recognition of early and objective alternative risk markers, less susceptible of sampling error, will be of relevance in the management of BE patients. The possibility of performing molecular genetics on paraffin-embedded biopsies will expand our understanding of the natural history of BE and may lead to the use of biomarkers to inform treatment strategies.

Risk factors for neoplastic progression in Barrett’s esophagus

Barrett’s esophagus (BE) confers a significant increased risk for development of esophageal adenocarcinoma (EAC), with the pathogenesis appearing to progress through a “metaplasia-dysplasia-carcinoma” (MDC) sequence. Many of the genetic insults driving this MDC sequence have recently been characterized, providing targets for candidate biomarkers with potential clinical utility to stratify risk in individual patients. Many clinical risk factors have been investigated, and associations with a variety of genetic, specific gastrointestinal and other modifiable factors have been proposed in the literature. This review summarizes the current understanding of the mechanisms involved in neoplastic progression of BE to EAC and critically appraises the relative roles and contributions of these putative risk factors from the published evidence currently available.

DNA copy number profile discriminates between esophageal adenocarcinoma and squamous cell carcinoma and represents an independent prognostic parameter in esophageal adenocarcinoma

We report multiplex ligation-dependent probe amplification analysis (MLPA) of DNA copy number alterations in 59 esophageal cancer samples, stratified by histotype. Results showed that squamous cell carcinoma (SCC) samples present clustered abnormalities with several genes altered at high frequency. Instead, esophageal adenocarcinoma (ADC) samples are characterized by a more widespread genomic instability, and in these patients total DNA copy number alterations resulted to be an independent prognostic factor. The detection of characteristic molecular changes represents a step towards a better understanding of the molecular basis of esophageal tumorigenesis, and might offer the potential for the discovery of tumor-specific biomarkers.

Barrett's esophagus, esophageal and esophagogastric junction adenocarcinomas: the role of diet

Identification of modifiable risk factors is an attractive approach to primary prevention of esophageal adenocarcinoma (EAC) and esophagogastric junction adenocarcinoma (EGJAC). We conducted a review of the literature to investigate the association between specific dietary components and the risk of Barrett’s esophagus (BE), EAC and EGJAC, supposing diet might be a risk factor for these tumors. Consumption of meat and high-fat meals has been found positively associated with EAC and EGJAC. An inverse association with increased intake of fruit, vegetables and antioxidants has been reported but this association was not consistent across all studies reviewed. Few studies have examined the association between diet and BE. Additional research is needed to confirm the aforementioned association and clarify the mechanisms by which dietary components affect the risk of developing EAC and EGJAC. Future studies could advance our knowledge by emphasizing prospective designs to reduce recall bias, by using validated dietary intake questionnaires and biological measures and by considering important confounders such as gastro-esophageal reflux disease (GERD) symptoms, tobacco and alcohol use, biometrics, physical activity, and socioeconomic factors.

Epidemiology of adenocarcinoma of the esophagus, gastric cardia, and upper gastric third

The incidence of adenocarcinoma of the esophagus and esophagogastric junction (gastric cardia) has risen rapidly over the past three decades in the United States and northern Europe. This increase had been most dramatic among White males. The majority of these cancers arise from Barrett's esophagus. However, less than 10% of the patients with esophageal adenocarcinoma were known to have Barrett's esophagus before. Current evidence indicates that gastroesophageal reflux and obesity are major risk factors for adenocarcinoma of the esophagus. Abdominal obesity, more prevalent in males, and independent of body mass index, seems to be associated with an increased risk of esophageal adenocarcinoma but not of cardia adenocarcinoma. This observation may explain the high male:female ratio observed in esophageal adenocarcinoma. Tobacco use has also been found as a possible risk factor for adenocarcinoma of the esophagus and gastric cardia. Infection with Helicobacter pylori and the use of nonsteroidal anti-inflammatory drugs might reduce the risk. On the other hand, low intake of fruits, vegetables, and cereal fibers seem to increase the risk of esophageal adenocarcinoma. Currently, there is no evidence that strongly supports any specific strategy to screen a subgroup of the population at risk for adenocarcinoma of the esophagus or esophagogastric junction. Future strategies to decrease obesity and tobacco use might help to reduce the burden of esophageal adenocarcinoma at least partially.

Risk factors for esophageal cancer development

The incidence of esophageal adenocarcinoma is increasing at a rate greater than that of any other cancer in the Western world today. Barrett's esophagus is a clearly recognized risk factor for the development of esophageal adenocarcinoma, but the overwhelming majority of patients with Barrett's esophagus will never develop esophageal cancer. To date, dysplasia remains the only factor useful for identifying patients at increased risk for the development of esophageal adenocarcinoma in clinical practice. Other epidemiologic risk factors include aging, gender, race, obesity, reflux symptoms, smoking, and diet. Factors that may protect against the development of adenocarcinoma include infection with Helicobacter pylori, a diet rich in fruits and vegetables, and consumption of aspirin and NSAIDs.

Screening and surveillance of Barrett's esophagus

Esophageal adenocarcinoma (EAC) is the most rapidly increasing cancer in the Western world and Barrett's esophagus (BE) is the only known precursor lesion for this lethal cancer. Long-term survival may be improved if EAC is diagnosed early, providing an opportunity for early intervention. Screening for BE in patients with gastroesophageal reflux disease is not routinely recommended; however, if diagnosed, enrollment into a surveillance program may be beneficial. Surveillance of all patients with known BE is probably not cost-effective and factors predictive of BE progression to dysplasia/EAC are poorly understood. Screening and surveillance examinations are also faced with challenges in the endoscopic detection of intestinal metaplasia and dysplasia. Future application of molecular biomarkers may help identify the patients with BE most likely to progress, and the use of novel imaging methods may improve outcomes of BE screening and surveillance.

Barrett's esophagus on repeat endoscopy: should we look more than once?

BACKGROUND

Barrett's esophagus (BE) is the precursor lesion for esophageal adenocarcinoma. The major risk factor for BE is chronic gastroesophageal reflux disease (GERD). Screening patients with longstanding GERD for BE with upper esophagogastroduodenoscopy (EGD) has become the standard practice, and guidelines from national gastrointestinal (GI) societies recommend only a single screening EGD because of limited evidence, suggesting that BE develops early in the course of GERD. We hypothesized that BE may be present in patients in whom initial endoscopy was negative, either due to a missed diagnosis or due to the later development of BE.

AIM

The purpose of the study was to determine how often BE is identified on repeat endoscopy performed after an initial negative examination.

METHODS

The Clinical Outcomes Research Initiative (CORI) National Endoscopic Database was searched for all patients who had more than one EGD during the 5-yr period between January 1, 2000, and December 31, 2004. Patients who had either procedure for an indication of surveillance of BE were excluded. The primary outcome was a finding of newly suspected BE on repeat examination after an initial negative examination.

RESULTS

In total, 24,406 patients underwent more than one endoscopy during the study period. Five hundred sixty-one (2.3%) were found to have suspected BE on repeat EGD following an initial negative examination. More men than women had BE on repeat examination (3.1%vs 1.2%, P < 0.0001). BE on repeat examination was more common in patients with reflux as an indication for endoscopy than in patients with any other indication (5%vs 1.6%, P< or =0.0001). In reflux patients with esophagitis on initial examination, 9.9% were found to have suspected BE on repeat examination versus 1.8% of reflux patients with no esophagitis on initial examination (P < 0.0001).

CONCLUSIONS

BE is rarely found on second endoscopy performed less than 5 yr after an initial negative examination except in patients with esophagitis on the first endoscopy. Repeat EGD for Barrett's screening should not be performed out of concern for a missed diagnosis except when BE may have been obscured by overlying esophageal inflammation.

Barrett's columnar-lined oesophagus: demographic and lifestyle associations and adenocarcinoma risk

OBJECTIVES

Lifestyle and demographic risk factors for the development of oesophageal adenocarcinoma developing from columnar-lined oesophagus are not well defined.

METHODS

Demographic and lifestyle factors, endoscopy and histology reports were extracted from 1,761 subjects from seven UK centres. The associations of columnar-lined oesophagus with demographic and lifestyle factors and the development of adenocarcinoma were examined.

RESULTS

5.5% of patients had prevalent adenocarcinoma (more common in males, older patients, patients diagnosed earlier in the cohort and current or recent smokers). Adenocarcinoma incidence was 23 patients in 3,912 years or 0.59% per annum. Only increased age at diagnosis correlated with an increased risk of incident adenocarcinoma. There was no association with obesity or alcohol history.

CONCLUSIONS

Oesophageal adenocarcinoma occurs more commonly in older patients and is more frequent in males than females. Once columnar-lined oesophagus had been diagnosed, there were no other demographic or lifestyle factors which were predictive of the development of incident adenocarcinoma in this cohort.

Epidemiology of esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma has risen rapidly over the past 25 years in the United States as well as in several Western European countries. This increase had been most dramatic among white males. The majority of these cancers arise from a background of premalignant Barrett esophagus. However, less than 10% of the patients with esophageal adenocarcinoma were known to have Barrett esophagus previously. It is uncertain which risk factors contribute to the increasing incidence of esophageal adenocarcinoma, although gastroesophageal reflux disease, cigarette smoking, and obesity have been implicated. Whereas infection with Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are associated with reduced risk, low intakes of fruit, vegetables, and cereal fibers seem to increase the risk of esophageal adenocarcinoma. Presently there is no evidence that strongly supports any specific strategy to screen a subgroup of the population at risk for Barrett esophagus and adenocarcinoma of the esophagus.

Characteristics of patients with columnar-lined Barrett’s esophagus and risk factors for progression to esophageal adenocarcinoma

AIM: To determine the risk factors for the development of esophageal adenocarcinoma in these patients with columnar-lined esophagus (CLE).

METHODS: Data collected retrospectively on 597 consecutive patients diagnosed at endoscopy and histology to have CLE at Leeds General Infirmary between 1984 and 1995 were analyzed. Factors evaluated included age, sex, length of columnar segment, smoking, and drinking habits, history of non-steroidal ingestion, presence of endoscopic esophagitis, ulceration or benign strictures and presence of Helicobacter pylori in esophageal biopsies. Univariate and multivariate analyses were performed to identify risk factors for the development of adenocarcinoma.

RESULTS: Forty-four patients presented or developed esophageal adenocarcinoma during follow-up. Independent risk factors for the development of adenocarcinoma in patients with CLE were males (OR 5.12, 95%CI 2.04-12.84, P = 0.0005), and benign esophageal stricture (OR 4.37, 95%CI 2.02-9.45, P = 0.0002). Male subjects and patients who developed benign esophageal stricture constituted 86% (n = 38) of all patients who presented or developed esophageal adenocarcinoma. The presence of esophagitis was associated with a significant reduction in the development of esophageal carcinoma (OR 0.28, 95%CI 0.13-0.57, P = 0.0006). No other clinical characteristics differentiate between the non-malignant and malignant group.

CONCLUSION: In patients with CLE, endoscopic surveillance for the early detection of adenocarcinoma may be restricted to male subjects, as well as patients who develop benign esophageal strictures.

Dedifferentiation precedes invasion in the progression from Barrett's metaplasia to esophageal adenocarcinoma

PURPOSE

Adenocarcinoma arises in Barrett's esophagus by progression from metaplasia to cancer through grades of dysplasia. Our aim in this exploratory study was to characterize the broad changes in gene expression that underlie this histologic progression to cancer and assess the potential for using these gene expression changes as a marker predictive of malignant progression in Barrett's epithelium.

EXPERIMENTAL DESIGN

Microarray analysis was used to obtain individual gene expression profiles from endoscopic biopsies of nine esophageal adenocarcinomas and the Barrett's epithelia from which three of the cancers had arisen. Pooled samples from the Barrett's epithelia of six patients without cancer or dysplasia served as a reference.

RESULTS

Barrett's epithelia from which cancer had arisen differed from the reference Barrett's epithelia primarily by underexpression of genes, many of which function in governing cell differentiation. These changes in gene expression were found even in those specimens of Barrett's epithelia from which cancer had arisen that lacked dysplasia. Each cancer differed from the Barrett's epithelium from which it had arisen primarily by an overexpression of genes, many of which were associated with tissue remodeling and invasiveness. Cancers without identifiable Barrett's epithelium differed from cancers that had arisen from a Barrett's epithelium by having an even greater number of these overexpressed genes.

CONCLUSIONS

Histologic progression from Barrett's epithelium to cancer is associated with a gradient of increasing changes in gene expression characterized by an early loss of gene function governing differentiation that begins before histologic change; gain in function of genes related to remodeling and invasiveness follows later. This correlation of histologic progression with increasing changes in gene expression suggests that gene expression changes in biopsies taken from Barrett's epithelium potentially could serve as a marker for neoplastic progression that could be used to predict risk for developing cancer.

Epidemiologic risk factors for Barrett's esophagus and associated adenocarcinoma

The incidence of esophageal adenocarcinoma (AC) has increased dramatically in the Western world over the past 20 years and the majority of these cancers arise on the background of the preinvasive lesion Barrett's esophagus. The epidemiologic factors that contribute to an individual's susceptibility for Barrett's esophagus and associated cancer are likely to be multifactorial. However, the short time frame over which the incidence of adenocarcinoma has increased, and the increase across populations, provides a strong argument for environmental factors as etiologic agents, perhaps interacting with genetically determined characteristics that define personal susceptibility. In this review we discuss the epidemiologic evidence for the proposed demographic and environmental risk factors for the development of both Barrett's esophagus and AC. The current evidence suggests that significant risk factors include male sex, Caucasian race, and the presence of duodenogastroesophageal reflux disease. The susceptibility for reflux disease may in turn be influenced by factors such as obesity, the use of drugs that lower the lower-esophageal sphincter tone, and a protective effect of Helicobacter pylori colonization. There appears to be a weak association between smoking and AC. The role of dietary factors has not been studied adequately and deserves further attention. An understanding of the factors that predispose to the development and progression of Barrett's esophagus is crucial to the implementation of effective screening and prevention programs.

Trends in incidence and prevalence of specialized intestinal metaplasia, barrett's esophagus, and adenocarcinoma of the gastroesophageal junction

Most available information on the epidemiology of Barrettacute;s esophagus (BE) relates to patients with long segments (> 3 cm) of specialized intestinal metaplasia (SIM). Its prevalence is 3% in patients undergoing endoscopy for reflux symptoms and 1% in those undergoing endoscopy for any clinical indication. The latter prevalence is similar to the 1% found in autopsy series. A "silent majority" with BE remain unrecognized in the general population. BE is more common in men, and the prevalence rises with age. Recent endoscopic series document a rise in the diagnosis of endoscopically apparent short segments (< 3 cm) of BE (SSBE). The prevalence of SSBE in both unselected and reflux patients is 8% to 12%. Specialized intestinal metaplasia at the cardia, below a normal-appearing squamocolumnar junction, has been reported to vary from 6% to 25% in patients presenting for upper endoscopy. Unlike patients with long segment Barrett's esophagus (LSBE), the role of gastroesophageal reflux disease in the pathogenesis of SSBE and SIM of the cardia is controversial. Recent data suggest that the etiology of SIM of the cardia might be secondary to Helicobacter pylori infection, although the role of other environmental factors cannot be ruled out. The incidence of adenocarcinoma of the esophagus and esophagogastric juction (EGJ) has been increasing over the past 15 years in Western countries. Surgical series and population-based studies show that by 1994 adenocarcinomas of the esophagus accounted for half of all esophageal cancer among white men. LSBE and SSBE predispose to the development of adenocarcinoma of the esophagus and EGJ. The role of SIM of the cardia as a precursor lesion for EGJ adenocarcinoma is still unclear. The prevalences of dysplasia in LSBE and SSBE are around 6% and 8%, respectively. The incidence of adenocarcinoma in patients with LSBE is about 1 in 100 patient-years. Cancer risk for SSBE and SIM at the cardia is unknown. Smoking and obesity increase the risk for esophageal and EGJ adenocarcinomas.

Preoperative therapy with concurrent paclitaxel/carboplatin/infusional 5-FU and radiation therapy in locoregional esophageal cancer: final results of a Minnie Pearl Cancer Research Network phase II trial

PURPOSE

This phase II study was designed to determine the feasibility, toxicity, and therapeutic efficacy of a novel outpatient combined-modality preoperative regimen in patients with localized esophageal cancer.

PATIENTS AND METHODS

One hundred twenty-nine eligible patients with previously untreated, potentially resectable, clinical stage I-III carcinoma of the esophagus were treated between July 1995 and July 1999. Combined-modality treatment included: paclitaxel, 200 mg/m2, 1-hour i.v. infusion, days 1 and 22; carboplatin, an area under the concentration time curve 6.0 i.v., days 1 and 22; 5-fluorouracil, 225 mg/m2/day, continuous i.v. infusion, days 1-42; and radiation therapy, 45 Gy, 1.8-Gy single daily fractions 5 days weekly, beginning day 1. All patients underwent surgical resection 4-8 weeks after completion of the preoperative therapy.

RESULTS

One hundred twenty-three patients (95%) completed preoperative therapy, 105 patients (81%) underwent attempted resection, and 96 patients (74%) had definitive resection. A pathological complete response was achieved in 47 of 123 evaluable patients (38%); an additional 30 patients (24%) had only microscopic residual tumor. With a median follow-up of 45 months, the median survival is 22 months (95% CI = 15-32 months), with actuarial 1-, 2-, and 3-year survivals of 71%, 47%, and 41%, respectively. The most frequent grade 3/4 toxicities of the neoadjuvant program were leukopenia (73%) and esophagitis (43%). Although 73 patients (57%) required brief hospitalizations during preoperative therapy, there were no treatment-related deaths, and 94% of patients remained candidates for resection after the completion of treatment. Six patients (6%) died after surgery.

CONCLUSIONS

This novel combined-modality regimen is highly active in the treatment of locoregional esophageal cancer, producing an actuarial 3-year survival of 41%. Although this preoperative regimen produced moderate acute toxicity, there were no treatment-related deaths and the large majority of patients were able to undergo subsequent esophageal resection. These results, obtained in a community-based setting and involving multiple surgeons, radiation oncologists, and medical oncologists, compare favorably with those of previous single-center and multicenter results. Further evaluation of novel combined-modality programs is warranted, as is the incorporation of epidermal growth factor receptor antagonists or other targeted agents.

Screening for esophageal adenocarcinoma: an evidence-based approach

Adenocarcinoma of the esophagus and the gastroesophageal junction is the twentieth most common malignancy in the United States. In developed countries, the incidence of esophageal adenocarcinoma is increasing 5% to 10% per year. Despite the use of endoscopy for earlier detection, mortality from esophageal adenocarcinoma has not declined. Using an evidence-based approach, we review screening methods for esophageal adenocarcinoma, including the use of a symptom questionnaire, identification of patients with a family history of Barrett's esophagus, peroral or transnasal endoscopy, barium swallow, fecal occult blood testing, and brush and balloon cytology. Screening has not been shown to reduce rate of progression of Barrett's esophagus to esophageal cancer. Many treatment options for dysplastic Barrett's esophagus or early carcinoma appear effective, but long-term follow-up data are not available. There is currently insufficient evidence supporting population-based screening for Barrett's esophagus. Several risk factors, including severe reflux symptoms, male sex, and obesity, may identify patients with gastroesophageal reflux disease who are at the greatest risk of the development of cancer.

Hiatal hernia size, Barrett's length, and severity of acid reflux are all risk factors for esophageal adenocarcinoma

OBJECTIVE

The reasons for the development of dysplasia and adenocarcinoma in Barrett's mucosa are not well understood. The aims of this study were to characterize risk factors for the transition from Barrett's esophagus without dysplasia to Barrett's esophagus with high-grade dysplasia or esophageal adenocarcinoma.

METHODS

A group of 131 patients with high-grade dysplasia or esophageal adenocarcinoma were selected as case subjects. A first population of 2170 patients without gastroesophageal reflux disease (GERD) and a second population of 1189 patients with Barrett's esophagus served as two control groups. Logistic regression analyses were used to compare the risk factors associated with the occurrence of high-grade dysplasia or esophageal adenocarcinoma.

RESULTS

Patients with high-grade dysplasia or esophageal adenocarcinoma shared many characteristics with other forms of severe GERD, such as older age, male gender, and white ethnicity. The length of Barrett's esophagus and the size of hiatus hernia increased the risk for both conditions. Subjects with high-grade dysplasia and adenocarcinoma had more severe acid reflux than patients with other forms of GERD. Smoking and alcohol consumption did not affect the risk for developing high-grade dysplasia or adenocarcinoma in patients with Barrett's esophagus.

CONCLUSIONS

High-grade dysplasia and esophageal adenocarcinoma seem to stem from an extreme and unfavorable constellation of all risk factors that are generally held responsible for the development of GERD and Barrett's esophagus.

Barrett's esophagus: clinical characteristics

Barrett's metaplasia develops in 6-14% of individuals with gastroesophageal reflux. Barrett's adenocarcinomas are increasing in epidemic proportions for as yet unknown reasons, approximately 0.5-1% of patients with Barrett's will develop adenocarcinoma. Heartburn duration and frequency (but not severity), male gender, and Caucasian race are major risk factors for developing cancer. Obesity and smoking are weak risk factors. Survival is determined by depth of tumor invasion (stage). Once invasion of the muscularis propia occurs, the vast majority of patients will have developed widespread metastasis, even when clinical staging studies are negative. No currently available therapy results in prolonged survival once metastases develop. Thus, the more widespread use of effective surveillance strategies is the only currently available means for reducing the morbidity and mortality associated with Barrett's adenocarcinoma.

Appearance and prognosis of dysplasia in Barrett's esophagus

Dysplasia in a patient who has Barrett's esophagus (BE) is the first step in the neoplastic process. The grade of dysplasia correlates with the likelihood of developing adenocarcinoma of the esophagus during follow-up surveillance endoscopy and biopsy. Surveillance intervals are proposed based on the existing data of the likelihood of developing adenocarcinoma. In the future these intervals will be refined as a result of better definition of the risk factors the development of adenocarcinoma of the esophagus. Risk stratification of the individual patients by age, gender, grade of dysplasia, length of BE, length of hiatal hernia, and presence of genetic mutations will be possible.

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.

Life expectancy and cancer risk in patients with Barrett's esophagus: a prospective controlled investigation

BACKGROUND

It has been suggested that patients with Barrett's esophagus have a substantially increased risk of esophageal and possibly extra-esophageal cancers. We compared the incidence of cancer and the survival rates of patients with Barrett's esophagus with those observed in patients with achalasia, with Schatzki's ring, and in the general population.

PATIENTS AND METHODS

From 1980 through 1994, 60 consecutive patients with newly diagnosed long-segment Barrett's esophagus without dysplasia were seen in a single gastroenterology consultation office and followed until the Fall of 1999. Cancer incidence and survival rates were compared with age- and sex-matched patients with symptomatic Schatzki's ring (n = 60) and achalasia (n = 60). Survival data were also compared with those of the German population.

RESULTS

During a mean (+/-SD) observation period of 10 +/- 5 years, 2 patients with Barrett's esophagus (3%; 95% confidence interval [CI]: 0% to 11%) developed esophageal cancer, and 9 (15%; 95% CI: 7% to 27%) developed extra-esophageal cancers. These data differed only slightly from those of patients with Schatzki's ring (esophageal cancer: n = 1, 2%; 95% CI: 0% to 9%; extra-esophageal cancers: n = 9, 15%; 95% CI: 7%-27%) and achalasia (no esophageal cancers, extra-esophageal cancers: n = 3, 5%; 95% CI: 1% to 4%). Estimated 10-year survival was similar in patients with Barrett's esophagus (83%), patients with symptomatic Schatzki's ring (80%), patients with achalasia (87%), and in the general population (82%).

CONCLUSIONS

The cancer risk in patients with Barrett's esophagus has been overestimated. If patients with nondysplastic epithelium are followed, the risk of esophageal cancer is about 1 per 300 patient-years.

Epidemiology of esophageal cancer, especially adenocarcinoma of the esophagus and esophagogastric junction

The incidence of adenocarcinoma of the esophagus and esophagogastric junction (EGJ) has been increasing over the past 15 years in western countries. Surgical series and population-based studies show that, by 1994, adenocarcinomas of the esophagus accounted for half of all esophageal cancer among white men. The causes of this increase in incidence remain to be elucidated. Esophageal adenocarcinomas and a portion of EGJ adenocarcinomas arise from long and short segments of specialized intestinal metaplasia (Barrett's esophagus). The prevalence of long segments of Barrett's esophagus (> 3 cm) in patients having endoscopy for reflux symptoms is 3%, and 1% in those undergoing endoscopy for any clinical indication. However, a silent majority of patients with Barrett's esophagus remain unrecognized in the general population and may not be diagnosed unless adenocarcinoma develops. Recent studies document a rise in the diagnosis of specialized intestinal metaplasia of the cardia. Nearly all these patients have associated carditis, and Helicobacter pylori infection has been linked to this condition. The possible origin of EGJ adenocarcinomas in the sequence carditis--specialized intestinal metaplasia needs to be clarified. Smoking and obesity are additional risk factors for adenocarcinoma of the esophagus and EGJ. Current data does not confirm H. pylori as a risk factor for cancer of the EGJ.

Epidemiology of columnar-lined esophagus and adenocarcinoma

Barrett's esophagus is found in about 1% of the older population and in 3% to 5% of persons with gastroesophageal reflux. It is acquired more commonly by men and the prevalence increases with age. Most cases in the population remain undiagnosed. The incidence of adenocarcinoma of the esophagus and esophagogastric junction is increasing, both being related to Barrett's esophagus. Small areas of intestinal metaplasia are common but of uncertain significance.

Studies on experimental animals involving surgical procedures and/or nitrosamine treatment related to the etiology of esophageal adenocarcinoma

After a brief review of the epidemiology and etiology of lower esophageal adenocarcinoma (EAC), this paper describes long-term experiments on animals (mostly rats) demonstrating that reflux of duodenal contents into the stomach can induce gastric and pancreatic cancer, that gastric reflux into the esophagus can induce Barrett's esophagus; that esophagoduodenostomy to facilitate duodenal reflux into the esophagus, together with administration of carcinogenic nitrosamines, induces squamous cancer and EAC in the lower esophagus; that both pancreatic juice and bile are involved in this induction of EAC; that a high-fat diet increases EAC induction; and that esophagoduodenostomy with gastrectomy and nitrosamine treatment or esophagojejunostomy without a carcinogen can produce up to an 88% incidence of EAC. Short-term animal experiments are reviewed in which bile salts and trypsin have damaged the esophagus and duodenal reflux has produced lipid peroxidation in the lower esophagus. Finally, I review arguments mostly derived from the animal experiments that reflux of unacidified duodenal juice via the stomach into the lower esophagus may help cause Barrett's esophagus and EAC, that excessive use of acid blockers might contribute to EAC induction, and that EAC induction may be reduced by surgery to repair the lower esophageal sphincter or perhaps by taking non-steroidal anti-inflammatory drugs.

Epidemiology and molecular biology of Barrett's adenocarcinoma

In the United States, the incidence of esophageal adenocarcinoma has risen faster than any other malignancy in recent years, and now represents the most common histologic type of esophageal cancer observed in major institutions. The precise etiology of this malignancy, and the epidermiologic variables responsible for its dramatically rising incidence, remains obscure. Elucidation of the molecular biology of malignant transformation in Barrett's esophagus may improve the management of patients with advanced esophageal adenocarcinomas. Furthermore, appreciation of the molecular events associated with esophageal adenocarcinomas. Furthermore, appreciation of the molecular events associated with esophageal adenocarcinogenesis may facilitate early detection of occult carcinomas, and enable therapeutic interventions designed to prevent these otherwise highly lethal neoplasms.

Barrett's cancer: indications, extent, and results of surgical resection

In the Western world, the prevalence of Barrett's carcinoma, i.e., adenocarcinoma of the distal esophagus arising from specialized columnar epithelial metaplasia, has risen dramatically in the past two decades. High-grade dysplasia in the columnar epithelium has been identified as the precursor of malignant carcinoma. Whether an esophagectomy should be performed in patients with high-grade dysplasia remains controversial. Surgical resection is the mainstay of therapy in patients with invasive adenocarcinoma who are fit for surgery. Complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the distal esophagus. In patients with tumors located in the distal esophagus, this can be achieved by a radical transhiatal esophagectomy and proximal gastric resection with en bloc removal of the lymphatic drainage in the lower posterior mediastinum and along the celiac axis. Early adenocarcinoma can be cured by this approach. The value of multimodality therapy in patients with advanced tumors needs to be confirmed in well-designed randomized prospective trials.

Prognostic factors of resected adenocarcinoma of the esophagus

BACKGROUND

The main purpose of this study was to determine prognostic factors in patients with surgical treatment of adenocarcinoma of the esophagus.

METHODS

Within a 12.5-year period, esophageal adenocarcinoma was resected in 165 patients by radical transhiatal esophagectomy (n = 134) or transthoracic en bloc esophagectomy (n = 31). Tumors were analyzed according to the 1992 UICC classification with respect to pTNM stage, residual tumor (R) status, grading, and ratio of infiltrated to resected lymph nodes (lymph node ratio); both univariate and multivariate analysis of prognostic factors were performed.

RESULTS

The 30-day mortality rate was 6.1%. A complete removal of the tumor was achieved in 83% of the patients. Lymph node metastases were not detected in mucosal cancer (pT1a) but were detected in 18% of submucosal cancer (pT1b), 77% of pT2, 83% of pT3, and 96% of pT4. The overall 5-year survival rate was 34%; for patients without postoperative residual tumor (R0) it was 41%, and for those without lymph node metastases (pN0, R0) 63%. The 5-year survival rate for patients (pN1) with less than 30% invaded lymph nodes was 45%, compared with 0% for more than 30% invaded nodes. Independent prognostic factors for R0 resected patients excluding postoperative fatal outcome were pT and lymph node ratio.

CONCLUSIONS

Long-term survival after resection of esophageal adenocarcinoma is mainly associated with complete tumor removal, limited esophageal wall penetration, and ratio of infiltrated to removed lymph nodes of less than 0.3.

Effect of gastroduodenal juice and dietary fat on the development of Barrett's esophagus and esophageal neoplasia: an experimental rat model

BACKGROUND

Reflux of duodenal content into the lower esophagus of rats enhances the formation of nitrosamine-induced esophageal cancer and results in the induction of adenocarcinoma. We investigated the extent of the mucosal injury that was produced when the lower esophagus of rats was exposed to the reflux of gastroduodenal juice in the presence or absence of a carcinogen and tested the hypothesis that induction of esophageal cancer in this model would be influenced by the intake of dietary fat.

METHODS

Esophagoduodenostomy with gastric preservation was performed in 165 Sprague-Dawley rats in order to expose the lower esophagus to the reflux of gastroduodenal juice. Postoperatively selected groups of rats were treated with the carcinogen methyl-n-amylnitrosamine (MNAN). Subsequently, rats were fed diets of differing fat and calorie content for 20 weeks until they were put to death.

RESULTS

Refluxed gastroduodenal juice, in the absence of MNAN, induced esophageal inflammatory changes (diffuse papillomatosis and hyperkeratosis) in 38 of 39 rats (97%), specialized columnar metaplasia (Barrett's esophagus) in four of 39 (10%), dysplasia in three of 39 (8%), and squamous cell carcinoma in one of 39 (3%). Diet did not influence the incidence of neoplasia in the absence of MNAN treatment. In rats treated with MNAN, refluxed gastroduodenal juice induced inflammation in 110 of 111 rats (99%), columnar metaplasia in 14 of 111 (13%), and cancer in 63 of 111 (57%). Fifty-eight percent of esophageal tumors were squamous cell carcinoma and 42% were adenocarcinoma. The highest incidence of tumors was observed in rats fed the semipurified high-fat diet (24 of 29; 83%) compared with rats fed the semipurified control diet (13 of 29; 45%), semipurified, calorie-restricted diet (15 of 27; 55%), and chow diet (11 of 26; 42%), p < 0.05.

CONCLUSIONS

Reflux of gastroduodenal content into the lower esophagus of rats can induce both Barrett's metaplasia and neoplasia. Addition of a carcinogen increases the tumor yield and results in a proportion of the lesions being adenocarcinoma. This carcinogenic process is promoted by a diet with a high fat content.

Barrett's esophagus: pathogenesis, epidemiology, functional abnormalities, malignant degeneration, and surgical management

Barrett's esophagus (i.e. columnar epithelial metaplasia in the distal esophagus) is an acquired condition that in most patients results from chronic gastroesophageal reflux. It is a disorder of the white male in the Western world with a prevalence of about 1/400 population. Due to the decreased sensitivity of the columnar epithelium to symptoms, Barrett's esophagus remains undiagnosed in the majority of patients. Gastroesophageal reflux disease in patients with Barrett's esophagus has a more severe character and is more frequently associated with complications as compared with reflux patients without columnar mucosa. This appears to be due to a combination of a mechanically defective lower esophageal sphincter, inefficient esophageal clearance function, and gastric acid hypersecretion. Excessive reflux of alkaline duodenal contents may be responsible for the development of complications (i.e., stricture, ulcer, and dysplasia). Therapy of benign Barrett's esophagus is directed towards treatment of the underlying reflux disease. Barrett's esophagus is associated with a 30- to 125-fold increased risk for adenocarcinoma of the esophagus. The reasons for the dramatic rise in the incidence of esophageal adenocarcinoma, which occurred during the past years, are unknown. High grade dysplasia in a patient with columnar mucosa is an ominous sign for malignant degeneration. Whether an esophagectomy should be performed in patients with high grade dysplasia remains controversial. Complete resection of the tumor and its lymphatic drainage is the procedure of choice in all patients with a resectable carcinoma who are fit for surgery. In patients with tumors located in the distal esophagus, this can be achieved by a transhiatal en-bloc esophagectomy and proximal gastrectomy. Early adenocarcinoma can be cured by this approach. The value of multimodality therapy in patients with advanced tumors needs to be shown in randomized prospective trials.

Increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction

BACKGROUND

The aim of this study was to determine whether the incidence of adenocarcinoma of the esophagus and esophagogastric junction in a well-defined population was higher than previously recognized.

METHODS

Clinical records and original histological slides from patients residing in Olmsted County, Minnesota, were reviewed and compared with a previous study in the same population.

RESULTS

The incidence of esophageal adenocarcinoma rose from 0.13 for 1935-1971 to 0.74 for 1974-1989, and the incidence of adenocarcinoma of the esophagogastric junction rose from 0.25 to 1.34 per 100,000 person-years. Histological review of preserved surgical specimens showed associated intestinal metaplasia (Barrett's esophagus) in 2 of 2 esophageal and in 5 of 9 esophagogastric adenocarcinomas.

CONCLUSIONS

The incidence of adenocarcinoma in each location increased five to sixfold compared with the earlier study. This increase could not be explained by improved diagnostic methods or classification changes. The association with Barrett's esophagus and the parallel increased incidence of cancer in each location is evidence that adenocarcinoma of the esophagus and of the esophagogastric junction are related disorders.

The increasing frequency of adenocarcinoma of the esophagus

Adenocarcinoma of the esophagus has been considered an uncommon tumor, accounting for fewer than 8% of all cases of esophageal cancer. To determine the current frequency of adenocarcinoma of the esophagus, we reviewed data from the tumor registries of the Commonwealth of Massachusetts, the University Hospital (UH), and the Boston VA Medical Center (BVAMC). From 1982 to 1984, 868 esophageal cancers were reported in Massachusetts, of which 231 (27%) were adenocarcinomas. In comparison with squamous cell carcinomas of the esophagus, esophageal adenocarcinomas occurred more frequently in males (P less than 0.01) and were uncommon among blacks (P less than 0.01). From 1980 to 1986, 262 cases of esophageal cancer were seen at the UH and the BVAMC, of which 81 (31%) were adenocarcinomas. An analysis of the latter group to identify true esophageal adenocarcinomas (tumors confined to the esophagus without gastric involvement) yielded 47 cases. Thus, true esophageal adenocarcinoma accounted for 18% of esophageal malignancies at our hospitals, a frequency threefold to fivefold higher than that found in four prior studies that used comparable anatomic diagnostic criteria. We conclude that adenocarcinoma of the esophagus is now being recognized at a substantially higher frequency than reported in the past.

Campylobacter pylori and Barrett's esophagus

Campylobacter pylori is thought to be confined to gastric mucosa; when detected in the duodenum in association with duodenal ulceration, the organism infects only areas of gastric metaplasia. Barrett's esophagus is a metaplastic condition of the esophagus, in which areas or islands of "gastric-type" epithelium are found. To determine whether C. pylori colonized the esophagus of patients with Barrett's esophagus, we studied retrospectively 23 unselected patients who had endoscopic and biopsy evidence of Barrett's esophagus. Mucosal biopsy specimens were stained by the Warthin-Starry silver technique and reviewed by an experienced, "blinded" histopathologist. Of the 23 patients, 12 (52%) had C. pylori in the esophagus. Patients with and those without C. pylori were of similar age and gender, had similar scores for acute and chronic inflammation, and had similar lengths of tubular esophagus with metaplastic gastric mucosa. These observations suggest that C. pylori commonly infects Barrett's esophagus. The clinical importance of this finding is unknown.

Prevalence and characteristics of Barrett esophagus in patients with adenocarcinoma of the esophagus or esophagogastric junction

The prevalence and characteristics of Barrett esophagus in patients with adenocarcinoma of the esophagus or esophagogastric junction are uncertain. We studied 61 consecutive esophagogastrectomy specimens with adenocarcinoma, which were subjected to extensive histopathologic examination. Barrett esophagus was found in 64% of the cases (39 of 61), but had been recognized in only 38% of the patients with Barrett-associated carcinoma who had undergone preoperative endoscopy with biopsy (13 of 34). The median extent of Barrett esophagus with adenocarcinoma was 5 cm (range, 1 cm to 12 cm), and distinctive-type ("specialized") Barrett mucosa predominated (35 of 39; 90%). The Barrett adenocarcinomas were centered in the distal esophagus 2 cm +/- 0.3 cm above the esophagogastric junction. The patients with Barrett adenocarcinoma showed a striking predominance of white men (34 of 39; 87%) in contrast to gastric adenocarcinoma cases (21 of 69; 30%) and to Barrett patients without carcinoma or dysplasia (75 of 149; 50%), but similar to patients having adenocarcinoma of the esophagus or esophagogastric junction without demonstrable Barrett esophagus (16 of 22; 73%). Our findings suggest that most adenocarcinomas of the esophagus or esophagogastric junction are Barrett carcinomas, rather than gastric cardiac cancers or other types of esophageal adenocarcinoma; most Barrett adenocarcinomas occur in short segments of Barrett esophagus, which may be difficult to detect at endoscopy; and white men with Barrett esophagus may constitute a clinically identifiable at-risk group suitable for surveillance.