Barrett's oesophagus--to screen or not to screen?

The evolution and outcome of surveillance of Barrett's oesophagus over four decades in a UK District General Hospital

INTRODUCTION

We present the long-term outcome of Barrett's oesophagus (BO) at a District General Hospital set against the increasing numbers of patients with gastro-oesophageal reflux disease (GORD).

METHODS

Data were collected prospectively over 37 years. Comparison of GORD without Barrett's (NoBO) versus BO was performed from 1/1/1977 to 31/12/2001 when the NoBO database closed and outcomes of all cases of BO diagnosed until 31/12/2011 and followed up until 31/12/2013 have been reported.

RESULTS

During the period 1977-2001 the number of GORD NoBO cases was 11 610, and that of BO cases was 764 (6.2% of all GORD); total number of BO cases in 1977-2011 was 1468. NoBO patients were younger than BO patients: 52.2 versus 61.6 years. There was a male predominance in both groups: NoBO 55% and BO 62% (P<0.0001). The prevalence of oesophageal adenocarcinoma (OAC) was 87/1468 (5.9%) BO cases. Its incidence was 54/1381 (3.9%); the mean interval between the diagnosis of BO and incident OAC was 9 years (range 13 months-25.4 years); there was one OAC per 192 patient-years of follow-up (0.52% per year). Mortality was significantly lower in 37 patients under endoscopic surveillance at the time OAC was diagnosed (51 vs. 88% P=0.0141) partly because of older age and comorbidity of the other 17, in whom serial endoscopy was contraindicated. A proportional hazards model to allow for age estimated that the hazard rate ratio was lower in the surveillance group; however, this difference did not reach statistical significance (0.64, 95% confidence interval 0.30-1.48, P=0.08). Excluding prevalent cancers from both groups, mortality in BO was double that in NoBO (47 vs. 24%).

CONCLUSION

These 37 years of observation suggest, but do not confirm, that endoscopic surveillance may reduce the risk of death from OAC. Modern technology is likely to yield better results, but larger prospective studies are needed to confirm the benefits.

Diagnostic accuracy of magnifying chromoendoscopy with detection of intestinal metaplasia and dysplasia using acetic acid in Barrett's esophagus

OBJECTIVES

Endoscopy with systematic randomized biopsies aims to improve the detection of intestinal metaplasia (IM) and dysplasia in Barrett's esophagus (BE). Magnifying chromoendoscopy with alcoholic acetic acid might allow directed biopsies to improve detection of IM and dysplasia.

PATIENTS AND METHODS

Twenty-eight patients were studied with magnifying chromoendoscopy (Optical power zoom x 115, alcoholic acetic acid). Endoscopy biopsies were performed on one or several zones of BE chosen randomly, for which the chromoendoscopic pattern was determined according to Guelrud's classification.

RESULTS

Among seventy-two biopsies, the agreement between magnifying chromoendoscopy and histology and the positive predictive value of the association of patterns III and IV for the diagnosis of IM were 72.4%; sensibility and specificity were respectively 95.5% and 42.9%. The diagnostic accuracy was 75%. Among the six biopsies that showed high-grade dysplasia, three were suspected because of two particular patterns: local loss of ridged cerebriform pattern due to the disorganization of the mucosal folds and hypervascularization of the mucosa.

CONCLUSION

Magnifying chromoendoscopy with acetic acid allows targeted biopsies of the IM in BE and may help to detect high-grade dysplasia.

Barrett's mucosa, Barrett's dysplasia and Barrett's carcinoma: diagnostic endoscopy without biopsy-taking does not suffice

Many gastroenterologists are of the opinion that endoscopic diagnosis of gastro-oesophageal reflux disease (GORD) suffices and that additional biopsies are not necessary. The data obtained from 1068 consecutive patients with histologically confirmed Barrett's oesophagus were analysed retrospectively. In 37.9% of the patients, the histological diagnosis of Barrett's oesophagus was an incidental finding, whereas 32.7% of Barrett's carcinomas were diagnosed only at histology but not during endoscopy. Of the Patients with dysplasia, 92.4% were diagnosed only by the pathologist. Our analysis shows that an endoscopic diagnosis suspicious for Barrett's mucosa is made in 62.1% of the cases, carcinoma in 70%, and dysplasia in only 7.6% of the cases. Also, because neoplasia is detected for the most part at the invasive carcinoma state, but not in the dysplasia stage, the diagnosis of Barrett's oesophagus, with and without dysplasia, needs to be improved by additional biopsies for histopathological investigation.

Surveillance for Barrett's oesophagus in the UK

BACKGROUND

Endoscopic screening for Barrett's oesophagus is being offered without evidence of efficacy Barrett's oesophagus is not an ideal candidate for a screening programme, as the natural history is unclear, uncertainties surround the indication for intervention and the treatment is associated with high morbidity and mortality rates.

METHODS

To determine the practices that clinicians employ in the management of Barrett's oesophagus in the UK, postal questionnaires were sent in May 1997 to 297 randomly selected members of the British Society of Gastroenterology asking for details of their current practice.

RESULTS

Of 152 respondents, 106 (70 per cent) performed surveillance for Barrett's oesophagus; 46 (30 per cent) did not carry out screening. There was no difference in the practices carried out by physicians or surgeons, teaching or acute general hospital clinicians, or those with an upper gastrointestinal interest. There was a wide disparity in screening interval: just over half (52 per cent) screen at yearly intervals. Only nine (8 per cent) took four quadrant biopsies per 2 cm of Barrett's oesophagus. Nearly half (49 per cent) manage mild dysplasia by increasing the frequency of endoscopy; only seven (7 per cent) prescribed patients a proton pump inhibiting agent. Faced with severe dysplasia, 33 (31 per cent) offered surgery immediately; 22 (21 per cent) simply followed the patient by endoscopy. Those not choosing to perform screening most frequently cited lack of evidence of efficacy as the reason behind their decision.

CONCLUSION

There is wide variation in surveillance practices for Barrett's oesophagus. Some methods are ineffectual. The recommendations made by the Barrett's Oesophagus Working Party in 1991 are not followed, possibly because they are not practical. New workable guidelines based on available evidence and a consensus of expert opinion should be established; this was suggested by 38 per cent of respondents who performed screening.

Expression of p53, PCNA, and C-erbB-2 in Barrett's metaplasia and adenocarcinoma

We sought to determine if an immunohistochemical panel of p53, PCNA, and c-erbB-2 was a useful biomarker of transformation in Barrett's metaplasia. P53, PCNA, and c-erbB-2 immunohistochemistry was performed on resected Barrett's specimens selected to show discrete grades of dysplasia and then on prospectively obtained biopsies. In resection specimens, p53 was positive in 36% with no dysplasia, in 30% with low-grade dysplasia, in 85% with high-grade dysplasia, and in 90% of adenocarcinomas. While an evaluation of proliferation throughout the specimen did not differ between groups, surface proliferation was significantly higher in high-grade dysplasia than in low-grade or no dysplasia. All high-grade dysplasia specimens were positive for at least one marker, compared to 44% with no or low-grade dysplasia. C-erbB-2 was only seen in 31% with high-grade dysplasia and in 10% of adenocarcinomas. Prospectively, the panel had a sensitivity of 100%, a specificity of 81% and an overall accuracy of 83% in identifying patients who developed high-grade dysplasia or cancer. Thus, overexpression of p53 occurs early in the malignant transformation of Barrett's and increases with histologic progression, and proliferation at the surface of Barrett's epithelium increases with progressive grades of dysplasia. An immunohistochemical panel of p53 and PCNA is a useful biomarker for Barrett's metaplasia.

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.

Expansion of the Ki-67 proliferative compartment correlates with degree of dysplasia in Barrett's esophagus

BACKGROUND

Barrett's esophagus is a histologically defined premalignant lesion of the esophagus in which normal squamous epithelium is replaced by intestinalized columnar epithelium. In a multistep progression from Barrett's esophagus to fully developed carcinoma, accelerated proliferation may indicate or precede genomic instability and, therefore, may be an important factor in the pathogenesis and/or prediction of malignant transformation. Ki-67 is a nuclear antigen expressed in proliferating cells, (G1, S, G2, and M phases) but not in resting cells (G0 phase). This study was undertaken to determine if Ki-67 expression correlates with the degree of dysplasia and if Ki-67 expression can help to differentiate those patients with or without dysplasia.

METHODS

The Ki-67 proliferation fraction in 87 paraffin embedded esophageal biopsies from 43 patients with the Ki-67 antibody (MIB-1) was analyzed using immunohistochemistry. Using a computerized proliferation index program (QNA v2.54, Becton Dickinson Cellular Imaging Systems, Inc., Elmhurst, IL), a Ki-67 score was derived for the luminal surface, upper esophageal crypt, lower crypt, and underlying glandular zone of the columnar-lined esophagus.

RESULTS

Significant differences in Ki-67 scores were noted in each zone among different histologic categories: normal gastric ([NG] n = 17); Barrett's without dysplasia ([ND] n = 17); low grade dysplasia ([LG] n = 21); high grade dysplasia ([HG] n = 14); and adenocarcinoma ([CA] n = 5). The pattern of Ki-67 expression was associated strongly with each histologic category. The percentage of Ki-67 positive nuclei in each mucosal zone statistically separated high grade from low grade dysplasia (P < 0.001). In high grade dysplastic tissues, the Ki-67 positive nuclei were found predominantly on the surface epithelium and upper crypt zones, whereas in low grade dysplasia, the majority of Ki-67 positive nuclei were found in the lower crypt zone. The number of Ki-67 positive nuclei in each mucosal component also was significantly different in Barrett's esophagus without dysplasia when compared with Barrett's esophagus with low grade dysplastic tissues. (P < 0.001) Staining patterns of indefinite for dysplasia by H & E staining separated into several distinct patterns (five LG, seven ND, one NG) whereas six biopsies with low grade dysplasia had a Ki-67 expression pattern more consistent with that of high grade dysplasia.

CONCLUSION

The Ki-67 staining pattern correlated with histologic findings in Barrett's esophagus and may represent an additional parameter for differentiating patients with or without dysplasia.

Review article: Barrett's oesophagus--cancer risk, biology and therapeutic management

Barrett's oesophagus is receiving increasing scrutiny as the rates of adenocarcinoma of the oesophagus rise. Because clinical features are not predictive of the presence of Barrett's oesophagus and most individuals with Barrett's oesophagus go undetected, a case can be made for surveillance endoscopy in patients with chronic reflux. Once Barrett's oesophagus is diagnosed patients should be entered into a surveillance programme despite lack of proof of efficacy. Scientific study of putative biological markers of increased risk has added dramatically to the understanding of the biology of the lesion, but currently the finding of high grade dysplasia remains the best marker predicting the presence of greatly increased risk of developing cancer. It is likely that newer molecular biology techniques will become clinically applicable biological markers in the future. Currently there is no effective medical nor surgical therapy to cause regression of the metaplastic Barrett's epithelium, however the application of novel de-differentiating agents or ablation of the metaplastic epithelium while controlling oesophageal acid exposure and other environmental abnormalities offer hope that effective treatment of Barrett's oesophagus may someday be reality.

The gastroenterologist's approach to dysphagia

In the gastroenterological diagnostic armamentarium, dysphagia is considered as an important symptom for diseases of the esophagus. Concerning the history of illness, symptoms such as retrosternal pain and heartburn are often associated with gastroesophageal reflux disease. Morphological changes of the mucosa can be diagnosed by flexible endoscopy and radiographic examinations. Investigation with 24-h pH monitoring, manometry, and pharmacological tests is necessary for the diagnosis of functional disorders. Additionally, dysphagia can be associated with multiple internal diseases, including muscular diseases such as dermatomyositis, progressive systemic sclerosis, as well as lupus erythematosus. Difficulties in swallowing associated with hypo- and hyperthyroidism can also be interpreted as muscular lesions. Metabolic disorders such as alcoholism, and diabetes mellitus can be the cause of dysphagia. Increasing importance in the differential diagnosis of dysphagia is attached to infections of the upper GI tract. Especially in immunocompromised patients, infections of Candida albicans, mycobacterias, herpes, varicella zoster, and cytomegaloviruses can produce dysphagia and odynophagia. The differential diagnosis of the "angina-like chest pain" has to differentiate between cardiac disease and a noncardiac genesis. Therefore, besides the cardiac diagnostic investigation, endoscopy, radiography, and manometry are often indicated.

Photodynamic therapy of the normal rat stomach: a comparative study between di-sulphonated aluminium phthalocyanine and 5-aminolaevulinic acid

Dysplasia in the upper gastrointestinal tract carries a risk of invasive malignant change. Surgical excision of the affected organ is the only treatment available. Photodynamic therapy has been shown to be promising in the treatment of early and superficial tumours and may be useful for the ablation of dysplastic mucosa. Because of the diffuse nature of the disease, such treatment would necessarily involve destruction of large areas of mucosa and it is desirable to confine its effect to the mucosa in order that safe healing can take place. By means of photometric fluorescence microscopy, we have studied the pattern of photosensitisation in the normal rat stomach using di-sulphonated aluminium phthalocyanine (AlS2Pc) and 5-aminolaevulinic acid (ALA) as photosensitisizers. AlS2Pc resulted in a panmural photosensitisation of the gastric wall with the highest level encountered in the submucosa. The mucosa and muscularis propria were sensitised to equal extent. Following light exposure, a full thickness damage resulted. ALA is a natural porphyrin precursor and exogenous administration gave rise to accumulation of protoporphyrin IX (PPIX) in the cells. The resultant pattern of photosensitisation was predominantly mucosal and its photodynamic effect was essentially confined to the mucosa. ALA produced a selective photosensitisation of the gastric mucosa for its photodynamic ablation with sparing the underlying tissue layers.

The neoplastic potential of columnar-lined (Barrett's) esophagus

Reflux of gastric contents is the most important factor contributing to the development of a columnar-lined esophagus (CLE). CLE should be considered a "mosaic" of cells, glands, and architectural types showing variable degrees of maturation towards intestinal and gastric epithelium. Dysplasia refers to an unequivocally neoplastic alteration in the epithelium. High-grade (severe) dysplasia consists of neoplastic cellular and/or architectural changes within the columnar epithelium, without invasion through the basement membrane. The prevalence of dysplasia is usually 5% to 10%. Dysplasia has been found in the vast majority in the specialized columnar-type or intestinal-type epithelium. Adenocarcinoma in CLE is most often seen in males. At the time of diagnosis transmural tumor infiltration is found in 60% to 88% of patients, and lymph node invasion in 55% to 74% of patients. The prognosis is poor with a low 5 year survival. Estimates of incidence of cancer vary from 1 case per 52 patients years of follow-up to 1 case per 441 patient years of follow-up.

Flow-cytometric analysis of growth-regulatory peptides and their receptors in Barrett's oesophagus and oesophageal adenocarcinoma

The conventional assessment of the premalignant potential of Barrett's oesophagus is unsatisfactory. However, it has recently been shown that abnormalities of growth-regulatory peptides and their receptors may be important in the pathogenesis of this condition. In an attempt to improve the diagnostic and prognostic criteria we have studied 21 consecutive patients with Barrett's oesophagus and 7 others with adenocarcinoma of the oesophagus. In each patient biopsy specimens were taken from the columnarlined oesophagus or the adenocarcinoma and from the gastric cardiac mucosa for routine histologic evaluation. Immediately adjacent specimens were taken from both the Barrett's mucosa or adenocarcinoma and from the gastric mucosa for flow-cytometric study. The latter samples were disaggregated and labelled with antibodies to epidermal growth factor (EGF), transforming growth factor alpha (TGF-alpha), and epidermal growth factor receptor (EGF-R). The flow cytometer selected cells labelled with each antibody and expressed them as a percentage of the total number of disaggregated cells (average, 5500 cells). Epidermal growth factor receptors were expressed in a greater number of cells from Barrett's mucosa, with the intestinal type or those with dysplasia, than in gastric cardiac mucosa (p less than 0.05). All seven adenocarcinoma had many more cells expressing EGF, TGF-alpha, and EGF-R than normal gastric mucosa (p less than 0.01). We conclude that flow-cytometric evaluation of EGF-R can help in the understanding of the pathogenesis of Barrett's oesophagus.

Histopathologic characteristics of early adenocarcinoma in Barrett's esophagus

To elucidate the early events of cancer development in the columnar cell-lined lower esophagus, 13 esophagectomy specimens with early adenocarcinoma (T1) were histopathologically studied and the morphometry of the lesion was performed on a histologic map. Eleven (84.6%) of the 13 early Barrett's carcinomas were contiguous to both the distinctive specialized-type Barrett's mucosa and squamous epithelium. Furthermore, ten (76.9%) of the 13 tumors had residual squamous islands on the surface. These data suggest that carcinomas in Barrett's esophagus mostly develop at a place very close to the squamocolumnar epithelial border. The distance from the tumor center to the nearest squamous epithelium, including squamous islands, was 2 cm or less in all cases but one. Therefore, the authors conclude that the primary site of cancer development in Barrett's esophagus is the metaplastic columnar-lined area, particularly of specialized type, within 2 cm from the squamocolumnar epithelial border.

Adenocarcinoma arising in Barrett's esophagus

A review of nine adenocarcinomas of the esophagus arising in Barrett's epithelium was undertaken. We found the disease among white males disproportionately. Risk factors and incidence rate remain to be clarified. Only one patient was in a surveillance program and only he had carcinoma discovered "early." He still survives while only one of the eight whose diagnosis followed investigation of symptoms remains alive.

Carcinoma of the esophagus. Evaluation and palliation of a deadly disease

Treatment of squamous cell carcinoma of the esophagus depends on accurate staging of the disease at presentation. Current therapeutic options for patients with localized disease include surgery, radiation therapy, chemotherapy, and endoscopic therapy. Most patients undergo a combination of these therapies. For patients who present with widespread disease, close attention must be paid to palliation of symptoms.

Superficial adenocarcinoma of the oesophagus arising in Barrett's mucosa with dysplasia: a clinico-pathological study of 12 patients

Superficial adenocarcinoma of the oesophagus is defined as carcinoma limited to the mucosa or submucosa regardless of lymph node status. Columnar epithelium lined lower oesophagus, now generally referred to as Barrett's oesophagus, is probably the main cause of adenocarcinoma in the lower oesophagus. Twelve cases of superficial adenocarcinoma arising in Barrett's oesophagus are presented. They were observed over a 6 year period and taken from a series of 50 cases of patients with Barrett's oesophagus and adenocarcinoma, a prevalence of 24%. Endoscopic diagnosis of malignancy was made in six patients. The initial biopsies showed an adenocarcinoma in six patients and some degrees of dysplasia in the other six patients. Prior to surgery, a histological diagnosis of adenocarcinoma was made in all twelve patients. In four patients the adenocarcinoma was confined to the mucosa, and in eight it extended to the submucosa. One patient had a metastatic lymph node. Ten patients are alive without evidence of tumour spread after a mean follow-up of 30 months.