Endoscopic treatment of Barrett's esophagus: What can we learn from the Western perspective?

Epigenetic Alterations from Barrett's Esophagus to Esophageal Adenocarcinoma

Barrett's esophagus (BE) is a disease entity that is a sequela of chronic gastroesophageal reflux disease that may result in esophageal adenocarcinoma (EAC) due to columnar epithelial dysplasia. The histological degree of dysplasia is the sole biomarker frequently utilized by clinicians. However, the cost of endoscopy and the fact that the degree of dysplasia does not progress in many patients with BE diminish the effectiveness of histological grading as a perfect biomarker. Multiple or more quantitative biomarkers are required by clinicians since early diagnosis is crucial in esophageal adenocancers, which have a high mortality rate. The presence of epigenetic factors in the early stages of this neoplastic transformation holds promise as a predictive biomarker. In this review, current studies on DNA methylations, histone modifications, and noncoding RNAs (miRNAs) that have been discovered during the progression from BE dysplasia to EAC were collated.

Endoscopic management of Barrett's esophagus: Western perspective of current status and future prospects

Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma and current practice is to establish endoscopic surveillance once diagnosed, in order to identify early dysplasia and neoplasia that has the potential to undergo endoscopic eradication therapy (EET). Before embarking upon EET the clinical team has a duty to consider all viable options and come to a plan based on recent evidence. The therapeutic approach varies greatly but largely adheres to the mantra of 'Detect-Resect-Ablate', in which high-quality endoscopy identifies BE associated pathology, associated lesions (if present) undergo safe endoscopic resection and remaining intestinal metaplasia in the esophagus is ablated to prevent recurrence of dysplasia. In this review, current practice, pitfalls, complications, and the future perspectives on practice in this field are discussed. The Western perspective is focused on here, with an outline of the differences in clinical practice with Asian nations and attempts to bridge these differences.

Diagnostic utility of a novel magnifying endoscopic classification system for superficial Barrett's esophagus-related neoplasms: a nationwide multicenter study

BACKGROUND

Currently, no classification system using magnification endoscopy for the diagnosis of superficial Barrett's esophagus (BE)-related neoplasia has been widely accepted. This nationwide multicenter study aimed to validate the diagnostic accuracy and reproducibility of the magnification endoscopy classification system, including the diagnostic flowchart developed by the Japan Esophageal Society-Barrett's esophagus working group (JES-BE) for superficial Barrett's esophagus-related neoplasms.

METHODS

The JES-BE acquired high-definition magnification narrow-band imaging (HM-NBI) images of non-dysplastic and dysplastic BE from 10 domestic institutions. A total of 186 high-quality HM-NBI images were selected. Thirty images were used for the training phase and 156 for the validation (test) phase. We invited five non-experts and five expert reviewers. In the training phase, the reviewers discussed how to correctly predict the histology based on the JES-BE criteria. In the validation phase, they evaluated whether the criteria accurately predicted the histology results according to the diagnostic flowchart. The validation phase was performed immediately after the training phase and at 6 weeks thereafter.

RESULTS

The sensitivity and specificity for all reviewers were 87% and 97%, respectively. Overall accuracy, positive predictive value, and negative predictive value were 91%, 98%, and 83%, respectively. The overall strength of inter-observer and intra-observer agreements for dysplastic histology prediction was κ = 0.77 and κ = 0.83, respectively. No significant difference in diagnostic accuracy and reproducibility between experts and non-experts was found.

CONCLUSION

The JES-BE classification system, including the diagnostic flowchart for predicting dysplastic BE, is acceptable and reliable, regardless of the clinician's experience level.

Endoscopic submucosal dissection is associated with less pathologic uncertainty than endoscopic mucosal resection in diagnosing and staging Barrett's-related neoplasia

BACKGROUND & AIMS

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have demonstrated similar efficacy in removal of neoplastic esophageal lesions. However, significant controversy exists over the preferred resection technique. Our primary aim was to compare the pathologic specimens produced via EMR and ESD and secondarily gauge their effect on clinical decision making and patient outcomes.

METHODS

Using a retrospective cohort study design, all esophageal Barrett's-associated neoplastic lesions resected by a single provider from 2012 to 2017 were reviewed. The pathology was re-reviewed by two blinded authors for diagnosis, margins, and adverse outcomes and recurrence rates were also collected.

RESULTS

Thirty-one EMR and 20 ESD cases were identified. Baseline demographics and lesion characteristics were similar. ESD produced more R0 resections and more en bloc resections compared to EMR. EMR produced more equivocal lateral (13/31, 41.9% vs 1/20, 5.0%) and vertical margins (13/31, 41.9% vs. 0/20, 0%, both P < 0.05). This led to an inability to reach a definitive diagnosis in 13/31 EMR vs 0/20 ESD pathology specimens (P = 0.003). Of the 13 EMR specimens with equivocal pathology, 11 were noted to have 'at least intramucosal adenocarcinoma'. Four of the 11 patients chose to undergo elective esophagectomy with final surgical pathology demonstrating ≤T1a disease in 2, and ≥T1b disease in two.

CONCLUSION

Compared to ESD, EMR was associated with greater pathologic uncertainty in Barrett's-associated neoplasia.