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van Munster SN, Verheij EPD, Ozdemir Ö, Toes-Zoutendijk E, Lansdorp-Vogelaar I, Nieuwenhuis EA, Cotton CC, Weusten BLAM, Alvarez Herrero L, Alkhalaf A, Schenk BE, Schoon EJ, Curvers WL, Koch AD, de Jonge PJF, Tang TJ, Nagengast WB, Westerhof J, Houben MHMG, Shaheen NJ, Bergman JJGHM, Pouw RE. Incidence and Prediction of Unrelated Mortality After Successful Endoscopic Eradication Therapy for Barrett's Neoplasia. Gastroenterology 2024; 166:1058-1068. [PMID: 38447738 DOI: 10.1053/j.gastro.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND & AIMS Follow-up (FU) strategies after endoscopic eradication therapy (EET) for Barrett's neoplasia do not consider the risk of mortality from causes other than esophageal adenocarcinoma (EAC). We aimed to evaluate this risk during long-term FU, and to assess whether the Charlson Comorbidity Index (CCI) can predict mortality. METHODS We included all patients with successful EET from the nationwide Barrett registry in the Netherlands. Data were merged with National Statistics for accurate mortality data. We evaluated annual mortality rates (AMRs, per 1000 person-years) and standardized mortality ratio for other-cause mortality. Performance of the CCI was evaluated by discrimination and calibration. RESULTS We included 1154 patients with a mean age of 64 years (±9). During median 59 months (p25-p75 37-91; total 6375 person-years), 154 patients (13%) died from other causes than EAC (AMR, 24.1; 95% CI, 20.5-28.2), most commonly non-EAC cancers (n = 58), cardiovascular (n = 31), or pulmonary diseases (n = 26). Four patients died from recurrent EAC (AMR, 0.5; 95% CI, 0.1-1.4). Compared with the general Dutch population, mortality was significantly increased for patients in the lowest 3 age quartiles (ie, age <71 years). Validation of CCI in our population showed good discrimination (Concordance statistic, 0.78; 95% CI, 0.72-0.84) and fair calibration. CONCLUSION The other-cause mortality risk after successful EET was more than 40 times higher (48; 95% CI, 15-99) than the risk of EAC-related mortality. Our findings reveal that younger post-EET patients exhibit a significantly reduced life expectancy when compared with the general population. Furthermore, they emphasize the strong predictive ability of CCI for long-term mortality after EET. This straightforward scoring system can inform decisions regarding personalized FU, including appropriate cessation timing. (NL7039).
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Affiliation(s)
- Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Özge Ozdemir
- University of Amsterdam, Amsterdam, The Netherlands
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Cary C Cotton
- Department of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, The Netherlands
| | - B Ed Schenk
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Pieter-Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Thjon J Tang
- Ijsselland Ziekenhuis, Gastroenterology and Hepatology, Capelle aan den IJssel, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Zuid-Holland, The Netherlands
| | - Nicholas J Shaheen
- Department of Medicine, Department of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands.
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Rajendra S, Sharma P, Gautam SD, Saxena M, Kapur A, Sharma P, Merrett N, Yang T, Santos LD, Pavey D, Sharaiha O, McKay O, Dixson H, Xuan W. Association of Biomarkers for Human Papillomavirus With Survival Among Adults With Barrett High-grade Dysplasia and Esophageal Adenocarcinoma. JAMA Netw Open 2020; 3:e1921189. [PMID: 32058552 DOI: 10.1001/jamanetworkopen.2019.21189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE The presence of high-risk human papillomavirus (HPV) has been associated with a favorable outcome in Barrett high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). Nevertheless, the prognostic significance of other HPV-related biomarkers (ie, retinoblastoma protein [pRb], cyclin D1 [CD1], minichromosome maintenance protein [MCM2] and Ki-67) is unknown. OBJECTIVE To examine the association between HPV-related biomarkers and survival in adult patients with Barrett HGD and EAC. DESIGN, SETTING, AND PARTICIPANTS This retrospective case-control study examined the hypothesis that the HPV-related cell cycle markers (pRb, CD1, and Ki-67) and the viral surrogate marker (MCM2) may be associated with a favorable prognosis in Barrett HGD and EAC. Pretreatment biopsies were used for HPV DNA determination via polymerase chain reaction and immunohistochemistry for the HPV-related biomarkers. Recruitment of patients occurred in secondary and tertiary referral centers, with 151 patients assessed for eligibility. The study period was from December 1, 2002, to November 28, 2017, and the dates of analysis were from September 9, 2011, to November 28, 2017. MAIN OUTCOMES AND MEASURES Disease-free survival and overall survival. RESULTS Of 151 patients assessed for eligibility, 9 were excluded. Among the 142 patients with Barrett HGD or EAC (126 [88.7%] men; mean [SD] age, 66.0 [12.1] years; 142 [100%] white), 37 were HPV positive and 105 were HPV negative. No association with disease-free survival was noted for pRb, CD1, Ki-67, and MCM2. In regard to overall survival, only low expression of CD1 had a favorable prognosis (hazard ratio [HR], 0.53; 95% CI, 0.30-0.95; adjusted P = .03). All the biomarkers stratified by HPV status showed significant associations with survival. Patients with HPV-positive, low-expression pRb esophageal tumors were associated with a significantly improved disease-free survival compared with the HPV-negative, high-expression Rb tumors (HR, 0.33; 95% CI, 0.12-0.93; adjusted P = .04). Similarly, HPV-positive, low-expression CD1 was associated with a significantly favorable disease-free survival (HR, 0.26; 95% CI, 0.09-0.76; adjusted P = .01), as was HPV-positive, high-expression MCM2 (HR, 0.27; 95% CI, 0.09-0.78; adjusted P = .02). In regard to overall survival, HPV was significantly associated only with low CD1 (HR, 0.38; 95% CI, 0.15-0.94; adjusted P = .04). CONCLUSIONS AND RELEVANCE This study's findings suggest that low expression of CD1 appears to be an independent prognostic marker in Barrett HGD and EAC. Human papillomavirus positivity in combination with pRb, CD1, MCM2, and Ki-67 was associated with a survival benefit in esophageal tumors. These findings suggest the possibility of personalization of therapy for Barrett HGD and EAC based on viral status.
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Affiliation(s)
- Shanmugarajah Rajendra
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, Sydney, New South Wales, Australia
| | - Preeti Sharma
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Sydney, New South Wales, Australia
| | - Shweta Dutta Gautam
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Sydney, New South Wales, Australia
| | - Manoj Saxena
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- Department of Intensive Care, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, Sydney, New South Wales, Australia
| | - Amit Kapur
- Graduate School of Medicine, The University of Wollongong, Wollongong, New South Wales, Australia
| | - Prateek Sharma
- Veterans Affairs Medical Center, Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Missouri
| | - Neil Merrett
- Discipline of Surgery, Western Sydney University School of Medicine, Penrith, New South Wales, Australia
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Bankstown, Sydney, New South Wales, Australia
| | - Tao Yang
- SydPath, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Leonardo D Santos
- Department of Anatomical Pathology, Sydney South West Pathology Service, Liverpool Hospital, Liverpool, Sydney, New South Wales, Australia
| | - Darren Pavey
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, Sydney, New South Wales, Australia
| | - Omar Sharaiha
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, Sydney, New South Wales, Australia
| | - Owen McKay
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, Sydney, New South Wales, Australia
| | - Hugh Dixson
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- Department of Nuclear Medicine, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, Sydney, New South Wales, Australia
| | - Wei Xuan
- Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
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Shimizu T, Fujisaki J, Omae M, Yamasaki A, Horiuchi Y, Ishiyama A, Yoshio T, Hirasawa T, Yamamoto Y, Tsuchida T. Treatment Outcomes of Endoscopic Submucosal Dissection for Adenocarcinoma Originating from Long-Segment Barrett's Esophagus versus Short-Segment Barrett's Esophagus. Digestion 2018. [PMID: 29539629 DOI: 10.1159/000486197] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In recent years, effective outcomes of endoscopic submucosal dissection (ESD) for esophagogastric junction cancer including short-segment Barrett's esophagus (SSBE) cancer have been reported. However, the efficacy of ESD for long-segment Barrett's esophagus (LSBE) cancer is unknown. AIM To clarify the treatment outcomes of ESD for LSBE cancer versus SSBE cancer. METHODS A total of 86 patients with 91 superficial Barrett's esophageal adenocarcinomas who underwent ESD were enrolled; of these, 68 had underlying SSBE and 18 had LSBE. Procedure outcomes and prognosis were compared. RESULTS There was no significant difference in age and tumor diameter among patients. The only complication observed was stricture, but it was not significant (2 vs. 9%). No significant difference was observed in the negative horizontal margin rates (94.1 vs. 95.7%), R0 resection rates (83.8 vs. 82.6%), curative resection rates (72.1 vs. 73.9%), and noncurative factors. Both LSBE and SSBE cancer showed favorable 3-year overall survival rates (95.0 vs. 94.4%) in the median observation period of 28.5 months. CONCLUSIONS ESD for LSBE cancer achieved procedure outcomes and short-term prognosis comparable to SSBE. ESD has the potential to be an effective therapeutic option for esophageal neoplasms in patients with LSBE.
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Rajendra S, Xuan W, Merrett N, Sharma P, Sharma P, Pavey D, Yang T, Santos LD, Sharaiha O, Pande G, Cosman P, Wu X, Wang B. Survival Rates for Patients With Barrett High-grade Dysplasia and Esophageal Adenocarcinoma With or Without Human Papillomavirus Infection. JAMA Netw Open 2018; 1:e181054. [PMID: 30646096 PMCID: PMC6324261 DOI: 10.1001/jamanetworkopen.2018.1054] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE High-risk human papillomavirus (HPV) has been associated with Barrett dysplasia and esophageal adenocarcinoma. Nevertheless, the prognostic significance of esophageal tumor HPV status is unknown. OBJECTIVE To determine the association between HPV infection and related biomarkers in high-grade dysplasia or esophageal adenocarcinoma and survival. DESIGN, SETTING, AND PARTICIPANTS Retrospective case-control study. The hypothesis was that HPV-associated esophageal tumors would show a favorable prognosis (as in viral-positive head and neck cancers). Pretreatment biopsies were used for HPV DNA determination via polymerase chain reaction, in situ hybridization for E6 and E7 messenger RNA (mRNA), and immunohistochemistry for the proteins p16INK4A and p53. Sequencing of TP53 was also undertaken. The study took place at secondary and tertiary referral centers, with 151 patients assessed for eligibility and 9 excluded. The study period was from December 1, 2002, to November 28, 2017. MAIN OUTCOMES AND MEASURES Disease-free survival (DFS) and overall survival (OS). RESULTS Among 142 patients with high-grade dysplasia or esophageal adenocarcinoma (126 [88.7%] male; mean [SD] age, 66.0 [12.1] years; 142 [100%] white), 37 were HPV positive and 105 were HPV negative. Patients who were HPV positive mostly had high p16INK4A expression, low p53 expression, and wild-type TP53. There were more Tis, T1, and T2 tumors in HPV-positive patients compared with HPV-negative patients (75.7% vs 54.3%; difference, 21.4%; 95% CI, 4.6%-38.2%; P = .02). Mean DFS was superior in the HPV-positive group (40.3 vs 24.1 months; difference, 16.2 months; 95% CI, 5.7-26.8; P = .003) as was OS (43.7 vs 29.8 months; difference, 13.9 months; 95% CI, 3.6-24.3; P = .009). Recurrence or progression was reduced in the HPV-positive cohort (24.3% vs 58.1%; difference, -33.8%; 95% CI, -50.5% to -17.0%; P < .001) as was distant metastasis (8.1% vs 27.6%; difference, -19.5%; 95% CI, -31.8% to -7.2%; P = .02) and death from esophageal adenocarcinoma (13.5% vs 36.2%; difference, -22.7%; 95% CI, -37.0% to -8.3%; P = .01). Positive results for HPV and transcriptionally active virus were both associated with a superior DFS (hazard ratio [HR], 0.33; 95% CI, 0.16-0.67; P = .002 and HR, 0.44; 95% CI, 0.22-0.88; P = .02, respectively [log-rank test]). Positivity for E6 and E7 mRNA, high p16INK4A expression, and low p53 expression were not associated with improved DFS. On multivariate analysis, superior DFS was demonstrated for HPV (HR, 0.39; 95% CI, 0.18-0.85; P = .02), biologically active virus (HR, 0.36; 95% CI, 0.15-0.86; P = .02), E6 and E7 mRNA (HR, 0.36; 95% CI, 0.14-0.96; P = .04), and high p16 expression (HR, 0.49; 95% CI, 0.27-0.89; P = .02). CONCLUSIONS AND RELEVANCE Barrett high-grade dysplasia and esophageal adenocarcinoma in patients who are positive for HPV are distinct biological entities with a favorable prognosis compared with viral-negative esophageal tumors. Confirmation of these findings in larger cohorts with more advanced disease could present an opportunity for treatment de-escalation in the hope of reducing toxic effects without deleteriously affecting survival.
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Affiliation(s)
- Shanmugarajah Rajendra
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, New South Wales, Australia
- Department of Gastroenterology & Hepatology, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, New South Wales, Australia
| | - Wei Xuan
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Neil Merrett
- Discipline of Surgery, School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Preeti Sharma
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri
| | - Darren Pavey
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, New South Wales, Australia
- Department of Gastroenterology & Hepatology, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, New South Wales, Australia
| | - Tao Yang
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, New South Wales, Australia
- SydPath, St Vincent’s Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Leonardo D. Santos
- Department of Anatomical Pathology, Sydney South West Pathology Service, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Omar Sharaiha
- South Western Sydney Clinical School, University of New South Wales, Kensington, New South Wales, Australia
- Department of Gastroenterology & Hepatology, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network, Bankstown, New South Wales, Australia
| | - Girish Pande
- Department of Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Peter Cosman
- Graduate School of Medicine and Illawara Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Xiaojuan Wu
- Immunohistochemistry and Molecular Pathology Unit, NSW Health Pathology, Liverpool, New South Wales, Australia
| | - Bin Wang
- Gastro-Intestinal Viral Oncology Group, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, New South Wales, Australia
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Shimoyama S, Ogawa T, Toma T. Trajectories of endoscopic Barrett esophagus: Chronological changes in a community-based cohort. World J Gastroenterol 2016; 22:8060-8066. [PMID: 27672300 PMCID: PMC5028819 DOI: 10.3748/wjg.v22.i35.8060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 06/30/2016] [Accepted: 08/05/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To elucidate longitudinal changes of an endoscopic Barrett esophagus (BE), especially of short segment endoscopic BE (SSBE).
METHODS This study comprised 779 patients who underwent two or more endoscopies between January 2009 and December 2015. The intervals between the first and the last endoscopy were at least 6 mo. The diagnosis of endoscopic BE was based on the criteria proposed by the Japan Esophageal Society and was classified as long segment (LSBE) and SSBE, the latter being further divided into partial and circumferential types. The potential background factors that were deemed to affect BE change included age, gender, antacid therapy use, gastroesophageal reflux disease-suggested symptoms, esophagitis, and hiatus hernia. Time trends of a new appearance and complete regression were investigated by Kaplan-Meier curves. The factors that may affect appearance and complete regression were investigated by χ2 and Student-t tests, and multivariable Cox regression analysis.
RESULTS Incidences of SSBE and LSBE were respectively 21.7% and 0%, with a mean age of 68 years. Complete regression of SSBE was observed in 61.5% of initial SSBE patients, while 12.1% of initially disease free patients experienced an appearance of SSBE. Complete regressions and appearances of BE occurred constantly over time, accounting for 80% and 17% of 5-year cumulative rates. No LSBE development from SSBE was observed. A hiatus hernia was the only significant factor that facilitated BE development (P = 0.03) or hampered (P = 0.007) BE regression.
CONCLUSION Both appearances and complete regressions of SSBE occurred over time. A hiatus hernia was the only significant factor affecting the BE story.
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Koppert LB, Wijnhoven BPL, Tilanus HW, Stijnen T, Van Dekken H, Dinjens WNM. Neuroendocrine Cells in Barrett’s Mucosa and Adenocarcinomas of the Gastroesophageal Junction. Int J Surg Pathol 2016; 12:117-25. [PMID: 15173916 DOI: 10.1177/106689690401200204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
We estimated the prevalence and prognostic significance of neuroendocrine (NE) cells in a series of 208 resection specimens containing gastroesophageal junction (GEJ) adenocarcinomas, with 56 specimens containing Barrett’s mucosa. Immunohistochemically, chromogranin A (CGA) was positive in 49% (102/208) of GEJ adenocarcinomas and in 68% (38/56) of Barrett’s mucosas. CGA in GEJ tumors correlated with pTNM stage. CGA in Barrett correlated with pTNM stage and tumor grade of the adjacent carcinoma. Patients with CGA in Barrett had better survival than patients without CGA in Barrett, with 5-year survival percentages of 56% and 9%, respectively. In multivariate analysis, CGA in Barrett was an independent prognostic factor for survival after surgery. Therefore CGA in Barrett adjacent to GEJ adenocarcinoma might be helpful in the assessment of patient outcome.
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Affiliation(s)
- Linetta B Koppert
- Department of Surgery, Josephine Nefkens Institute, University Medical Center Rotterdam, The Netherlands
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Rayner CJ, Gatenby P. Effect of antireflux surgery for Barrett's esophagus: long-term results. MINERVA CHIR 2016; 71:180-191. [PMID: 26976731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Barrett's esophagus is a metaplastic change in the lower esophagus that results from long-standing gastro-esophageal reflux disease, associated with a risk of development of esophageal adenocarcinoma. This review examines the role of antireflux surgery in the management of Barrett's esophagus. EVIDENCE ACQUISITION A systematic review of the EMBASE and MEDLINE databases (1974-2016) was undertaken to identify studies with long-term follow-up examining the role of antireflux surgery in Barrett's esophagus. Outcomes examined were: number of subjects, follow-up, rates of progression, regression and adenocarcinoma. Symptomatic outcomes, surgical morbidity and rates of surgical failure were included when available. EVIDENCE SYNTHESIS A total of 2403 articles were identified of which 9 met the inclusion criteria for this study using the PRISMA methodology. Citation tracking identified 3 further studies for inclusion. There were 962 patients included in this study, 731 who were found to have completed endoscopic follow up with a total of 3736 years of follow up. Annual incidence of esophageal adenocarcinoma was found to be 0.18%. Thirty-five percent of patients (260 patients) had regression. Progression was seen in 8% (57 patients) postoperatively. There was no mortality. CONCLUSIONS There is insufficient evidence to recommend surgery over medical therapy to reduce cancer risk in Barrett's esophagus. Regression of features associated with cancer risk was more common after surgery than medical therapy. Surgery has been shown to improve patients' gastroesophageal reflux disease-specific quality of life. Long-term, antireflux surgery represents a cost effective method to manage Barrett's Esophagus with continued endoscopic surveillance.
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Affiliation(s)
- Charles J Rayner
- Department of General Surgery, Royal Surrey County Hospital, Guildford, UK -
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Gordon LG, Hirst NG, Mayne GC, Watson DI, Bright T, Cai W, Barbour AP, Smithers BM, Whiteman DC, Eckermann S. Modeling the cost-effectiveness of strategies for treating esophageal adenocarcinoma and high-grade dysplasia. J Gastrointest Surg 2012; 16:1451-61. [PMID: 22644445 DOI: 10.1007/s11605-012-1911-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/07/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study aims to synthesize cost and health outcomes for current treatment pathways for esophageal adenocarcinoma and high-grade dysplasia (HGD) and to model comparative net clinical and economic benefits of alternative management scenarios. METHODS A decision-analytic model of real-world practices for esophageal adenocarcinoma treatment by tumor stage was constructed and validated. The model synthesized treatment probabilities, survival, quality of life, and resource use extracted from epidemiological datasets, published literature, and expert opinion. Comparative analyses between current practice and five hypothetical scenarios for modified treatment were undertaken. RESULTS Over 5 years, outcomes across T stage ranged from 4.06 quality-adjusted life-years and costs of $3,179 for HGD to 1.62 quality-adjusted life-years and costs of $50,226 for stage T4. Greater use of endoscopic mucosal resection for stage T1 and measures to reduce esophagectomy mortality to 0-3 % produced modest gains, whereas a 20 % reduction in the proportion of patients presenting at stage T3 produced large incremental net benefits of $4,971 (95 % interval, $1,560-8,368). CONCLUSION These findings support measures that promote earlier diagnosis, such as developing risk assessment processes or endoscopic surveillance of Barrett's esophagus. Incremental net monetary benefits for other strategies are relatively small in comparison to predicted gains from early detection strategies.
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Affiliation(s)
- Louisa G Gordon
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131, Australia.
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Peters JH. SSAT controversies intramucosal esophageal cancer and high-grade dysplasia: which treatment? Surgical therapy: improved outcomes and piece of mind. J Gastrointest Surg 2009; 13:1179-81. [PMID: 19294473 DOI: 10.1007/s11605-009-0863-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 02/26/2009] [Indexed: 01/31/2023]
Affiliation(s)
- Jeffrey H Peters
- Department of Surgery, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box Surg, Rochester, NY 14642, USA.
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Cook MB, Wild CP, Everett SM, Hardie LJ, Bani-Hani KE, Martin IG, Forman D. Mortality risks associated with Barrett's oesophagus. Aliment Pharmacol Ther 2008; 27:852-3; author reply 853-4. [PMID: 18380800 DOI: 10.1111/j.1365-2036.2008.03645.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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11
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Munítiz V, Martínez de Haro LF, Ortiz MA, Ruiz de Angulo D, Molina J, Bermejo J, Serrano A, Parrilla P. [Surgical treatment of high-grade dysplasia in Barrett's esophagus]. Cir Esp 2008; 82:214-8. [PMID: 17942046 DOI: 10.1016/s0009-739x(07)71709-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Barrett's esophagus undergoes malignant transformation in 0.5-1% of patients per year following the sequence of low-grade dysplasia, high-grade dysplasia and adenocarcinoma. The aim of the present study was to present our experience in the surgical treatment of Barrett's esophagus with high-grade dysplasia. PATIENTS AND METHOD Of a group of 128 patients with a diagnosis of Barrett's esophagus, 8 (6.2%) developed high-grade dysplasia during a median follow-up of 7 years (2-25). A further 5 patients with high-grade dysplaing out side the study were referred for evaluation and surgical treatment. Eight patients were under medical treatment with omeprazole (40 mg daily) while the remaining 5 patients had undergone open Nissen fundoplication, with a diagnosis of high-grade dysplasia at a median of 5 years (1-16) after treatment initiation. After confirmation of the diagnosis by a second pathologist and tumoral staging, transthoracic esophagectomy with anastomosis at the apex of the thorax was performed in all patients. RESULTS Postoperative mortality was nil. Morbidity was 36% (5 patients). Definitive histological analysis of the surgical specimen revealed high-grade dysplasia in 7 patients (54%) and adenocarcinoma in 6 (46%). All patients remain alive after a median follow-up of 4.7 years (1-14). CONCLUSIONS In patients with Barrett's esophagus with high-grade dysplasia, the best therapeutic option is surgical resection, which can be performed with nil mortality in experienced centers. In almost half of surgical patients, the surgical specimen shows adenocarcinoma. Five-year survival is higher than 90%.
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Affiliation(s)
- Vicente Munítiz
- Unidad de Patología Esofágica, Servicio de Cirugía General I, Hospital Universitario Virgen de la Arrixaca, Murcia, España
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Larghi A, Lightdale CJ, Ross AS, Fedi P, Hart J, Rotterdam H, Noffsinger A, Memeo L, Bhagat G, Waxman I. Long-term follow-up of complete Barrett's eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma. Endoscopy 2007; 39:1086-91. [PMID: 17701854 DOI: 10.1055/s-2007-966788] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS In patients with Barrett's esophagus (BE), targeted endoscopic mucosal resection (EMR) of visible lesions of high grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) is effective, but carries the risk of leaving in place synchronous lesions and Barrett's epithelium with the potential for recurrent disease. We evaluated the safety and long-term efficacy of complete Barrett's eradication EMR (CBE-EMR) for the treatment of patients with HGD or IMC, independently of the presence of macroscopically visible lesions or surgical risk. PATIENTS AND METHODS 26 consecutive patients with BE and HGD or IMC underwent CBE-EMRs, which were performed with the endoscopic cap suction method and/or a 2.3-mm monofilament mucosectomy snare. Endoscopic follow up after completion of resection was carried out to assess the rate of residual or recurrent BE with or without HGD or IMC. RESULTS 24 patients completed the study. They underwent a total of 44 EMR sessions with a median of 3 pieces (range 1-8) removed per session. Two patients with immediate bleeding were successfully managed endoscopically. Three patients developed an early esophageal stricture that was completely resolved with a single endoscopic dilation. After a median follow-up of 28 months (range 15-51 months), persistent endoscopic and histologic eradication of BE was demonstrated in 21 patients (87.5 %). In two patients, Barrett's epithelium was detected beneath the neosquamous epithelium 3 months after completion of the resection. In the remaining patient, IMC was found in a nodule seen and removed by EMR at 12-month surveillance endoscopy. CONCLUSIONS CBE-EMR is a safe and highly effective long-term treatment that should be offered to all patients with Barrett's esophagus with HGD and IMC.
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Affiliation(s)
- A Larghi
- Section of Endoscopy and Therapeutics and the Cancer Research Center, The University of Chicago, Chicago, Illinois 60637, USA
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Abstract
In surgical therapy for upper gastrointestinal cancer, adequate lymphadenectomy together with R0 resection of the primary tumour is one of the most important prognostic factors which can be influenced by the surgeon. Recommendations for localization- and stage-adapted lymphadenectomy can be made according to histopathologic and anatomic investigations of the patient collectives of large centres. After neoadjuvant radiochemotherapy in cancer of the cervical oesophagus, the absence of lymph nodes on the resected specimen seems to be of less prognostic value. In squamous cell cancer of the suprabifurcal oesophagus, radical lymphadenectomy is recommended. Despite significant morbidity, in specialized centres this procedure yields good results with low mortality. For infrabifurcal oesophageal cancer, two-field lymphadenectomy during the so-called Ivor-Lewis operation is the method of choice. Locally advanced Barrett carcinoma is also an indication for classic two-field lymphadenectomy together with abdominothoracic oesophagectomy and creation of a stomach tube with intrathoracic anastomosis. The lymphadenectomy should however include the area of retroperitoneal lymphatic drainage at the pedicle of the left kidney. Submucosal cancer in this area can be treated with luminal limited resection of the oesophagogastric junction with adequate lymphadenectomy. Adenocarcinoma of the cardia and subcardial gastric cancer including the cardia both require lymphadenectomy analogous to that performed in gastric cancer, with special attention paid to the retroperitoneal lymphatic drainage towards the left kidney pedicle. For therapy of gastric cancer, a systematic D2 lymphadenectomy should always be performed.
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Affiliation(s)
- C Schuhmacher
- Chirurgische Klinik der TU München, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 München.
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Cook MB, Wild CP, Everett SM, Hardie LJ, Bani-Hani KE, Martin IG, Forman D. Risk of mortality and cancer incidence in Barrett's esophagus. Cancer Epidemiol Biomarkers Prev 2007; 16:2090-6. [PMID: 17890521 DOI: 10.1158/1055-9965.epi-07-0432] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There are very few prospective follow-up studies of Barrett esophagus (BE) cohorts assessing the risk of extraesophageal cancer incidence or mortality. Such studies are necessary in order to understand the overall risks of cancer and death experienced by patients with BE. METHODS A cohort of 502 patients with BE were identified at Leeds General Infirmary, England. Mortality and cancer incidence information were provided by the Office for National Statistics. Standardized mortality ratios (SMR) and standardized incidence ratios (SIR) were calculated using indirect standardization. RESULTS All-cause mortality was found to be elevated in patients with BE [SMR, 1.21; 95% confidence interval (95% CI), 1.06, 1.37] and remained so after esophageal cancers were excluded (SMR, 1.16; 95% CI, 1.01-1.32). Increased mortality risks were also found for malignant neoplasms of the esophagus (SMR, 7.26; 95% CI, 3.87-12.42) and diseases of the digestive system (SMR, 2.03; 95% CI, 1.11-3.40). The remaining disease categories produced no altered risk estimates. Circulatory disease mortality was borderline statistically significant (SMR, 1.24; 95% CI, 1.00-1.52; P = 0.053) for those with a specialized intestinal metaplasia diagnosis of BE. In the cancer incidence analyses, esophageal malignancies (SIR, 8.66; 95% CI, 4.73-14.53) and esophageal adenocarcinomas (SIR, 14.29; 95% CI, 7.13-22.56) were found to be increased in BE. All remaining analyses provided unaltered risks, including that of colorectal cancer. CONCLUSIONS This study has shown evidence of an increased risk of esophageal cancer incidence and mortality in BE. It has also shown that those who have a histologic BE diagnosis may also have an increased risk of circulatory disease mortality.
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Affiliation(s)
- Michael B Cook
- Centre for Epidemiology and Biostatistics, Leeds Institute of Genetics, Health, and Therapeutics, University of Leeds, Arthington House, Cookridge Hospital, Leeds LS16 6QB, United Kingdom
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Overholt BF, Wang KK, Burdick JS, Lightdale CJ, Kimmey M, Nava HR, Sivak MV, Nishioka N, Barr H, Marcon N, Pedrosa M, Bronner MP, Grace M, Depot M. Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett's high-grade dysplasia. Gastrointest Endosc 2007; 66:460-8. [PMID: 17643436 DOI: 10.1016/j.gie.2006.12.037] [Citation(s) in RCA: 278] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Accepted: 12/18/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND Barrett's esophagus (BE) with high-grade dysplasia (HGD) is a risk factor for development of esophageal carcinoma. Photodynamic therapy (PDT) with Photofrin (PHO) has been used to eliminate HGD in BE. OBJECTIVE Our purpose was to compare PHOPDT plus omeprazole with omeprazole only (OM). DESIGN Five-year follow-up of a randomized, multicenter, multinational, pathology-blinded HGD trial. SETTING 30 sites in 4 countries. PATIENTS 208. INTERVENTIONS Patients with BE and HGD were randomized (2:1) to PHOPDT (n=138) or OM (n=70) into a 2-year trial followed up for 3 more years. PHOPDT patients received 2 mg/kg PHO intravenously followed by endoscopic laser light exposure of Barrett's mucosa at a wavelength of 630 nm within 40 to 50 hours to a maximum of 3 courses at least 90 days apart. Both groups received 20 mg of OM twice daily. Pathologists at one center assessed biopsy specimens in a blinded fashion. MAIN OUTCOME MEASUREMENT HGD ablation status over 5 years of follow-up. RESULTS At 5 years PHOPDT was significantly more effective than OM in eliminating HGD (77% [106/138] vs 39% [27/70], P<.0001). A secondary outcome measure preventing progression to cancer showed a significant difference (P=.027) with about half the likelihood of cancer occurring in PHOPDT (21/138 [15%]) compared with OM (20/70 [29%]), with a significantly (P=.004) longer time to progression to cancer favoring PHOPDT. LIMITATIONS Not all patients were available for follow-up. CONCLUSIONS This 5-year randomized trial of BE patients with HGD demonstrates that PHOPDT is a clinically and statistically effective therapy in producing long-term ablation of HGD and reducing the potential impact of cancer compared with OM.
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16
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Rabenstein T, Ell C. [Strategies for monitoring patients with Barrett's esophagus--pro]. Dtsch Med Wochenschr 2007; 132:1768. [PMID: 17713887 DOI: 10.1055/s-2007-984964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- T Rabenstein
- Klinik Innere Medizin II, Dr.-Horst-Schmidt-Klinik, Wiesbaden, Germany.
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17
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Koop H. Überwachungsstrategien beim Barrett-Ösophagus - contra. Dtsch Med Wochenschr 2007; 132:1769. [PMID: 17713888 DOI: 10.1055/s-2007-984965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- H Koop
- II. Innere Klinik-Gastroenterologie, HELIOS Klinikum Berlin-Buch, Berlin, Germany.
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Keeley SB, Pennathur A, Gooding W, Landreneau RJ, Christie NA, Luketich J. Photodynamic therapy with curative intent for Barrett's esophagus with high grade dysplasia and superficial esophageal cancer. Ann Surg Oncol 2007; 14:2406-10. [PMID: 17534685 DOI: 10.1245/s10434-007-9392-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 09/07/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND Photodynamic therapy (PDT) has been used to palliate advanced, obstructing, or bleeding esophageal cancers (ECs) and Barrett's high-grade dysplasia (HGD). Few investigators, though, have described using PDT to cure either disease. METHODS We performed a retrospective review from 1997-2005 of 50 patients with HGD or EC. All patients refused surgical resection or were physiologically unfit. They were instead treated using PDT with curative intent. Clinical follow-up, long-term survival, complications, and recurrence were evaluated. RESULTS Thirteen patients (26%) had Barrett's HGD, 6 (12%) had small, intramural carcinomas, 16 (32%) had T1 N0 tumors, 14 (28%) had T2 N0 tumors, and 1 (2%) had a small, polypoid T3 lesion. The mean length of follow-up was 28.1 months. Sixteen patients (32%) are alive without recurrence, 15 (30%) are living with residual or recurrent disease and have received additional PDT, and the remainder (38%) died of recurrent EC or other causes and had known recurrence. Sixteen (32%) patients received adjuvant chemotherapy, radiation, or both. Esophageal stricture occurred in 21 (42%) patients. There was no procedure-related mortality. CONCLUSIONS PDT may represent a reasonable alternate to esophagectomy for high-risk patients with HGD or superficial esophageal cancer. Due to superior survival and local control, we still favor esophagectomy for patients without physiologic impairment. However, PDT appears to potentially cure approximately one-third of superficial esophageal cancers and provide local control of high-grade dysplasia in a similar subset of patients.
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Affiliation(s)
- Samuel B Keeley
- University of Pittsburgh Medical Center, Heart, Lung, and Esophageal Surgery Institute, Pittsburgh, PA, USA.
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Sanders G, Borie F, Husson E, Blanc PM, Di Mauro G, Claus C, Millat B. Minimally invasive transhiatal esophagectomy: lessons learned. Surg Endosc 2007; 21:1190-3. [PMID: 17479333 DOI: 10.1007/s00464-007-9312-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Revised: 01/04/2007] [Accepted: 01/27/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Minimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned. METHODS A retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival. RESULTS Eighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36-79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1-3), and 1 for high-grade dysplasia in Barrett's. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180-450). All anastomoses were end-to-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10-39). The median number of nodes harvested was 10 (range = 2-26). At a median follow-up of 13 months (range = 4-42), 13 patients were alive. CONCLUSIONS Minimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove.
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Affiliation(s)
- Grant Sanders
- Department of Gastrointestinal Surgery, St. Eloi Hospital, University Hospital of Montpellier, Montpellier, France
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Abstract
Esophageal cancer is more than ever a surgical problem. Modern diagnostic procedures facilitate individual staging, and risk analysis is important for adequate patient selection. Using both allows an individualized indication. Under multimodal therapeutic protocols, neoadjuvant treatment can best be evaluated and is recommended in locally advanced tumors: RCTx in SCC, and CTx in Barrett cancer. Here the Ivor-Lewis procedure is the surgical method of choice. Postoperative complications are always possible, but the management now is standardized and has largely decreased mortality.
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Affiliation(s)
- J R Siewert
- Chirurgische Klinik der TU München, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 München, Deutschland.
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Prasad GA, Wang KK, Buttar NS, Wongkeesong LM, Krishnadath KK, Nichols FC, Lutzke LS, Borkenhagen LS. Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett's esophagus. Gastroenterology 2007; 132:1226-33. [PMID: 17408660 PMCID: PMC2646409 DOI: 10.1053/j.gastro.2007.02.017] [Citation(s) in RCA: 231] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2006] [Accepted: 01/04/2007] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS Photodynamic therapy (PDT) for high-grade dysplasia (HGD) in Barrett's esophagus is a Food and Drug Administration-approved alternative to esophagectomy. Critical information regarding overall survival of patients followed up long-term after these therapies is lacking. Our aim was to compare the long-term survival of patients treated with PDT with patients treated with esophagectomy. METHODS We reviewed records of patients with HGD seen at our institution between 1994 and 2004. PDT was performed 48 hours following the intravenous administration of a photosensitizer using light at 630 nm. Esophagectomy was performed by either transhiatal or transthoracic approaches by experienced surgeons. We excluded all patients with evidence of cancer on biopsy specimens. Vital status and death date information was queried using an institutionally approved Internet research and location service. Statistical analysis was performed using Kaplan-Meier curves and Cox proportional hazards ratios. RESULTS A total of 199 patients were identified. A total of 129 patients (65%) were treated with PDT and 70 (35%) with esophagectomy. Overall mortality in the PDT group was 9% (11/129) and in the surgery group was 8.5% (6/70) over a median follow-up period of 59 +/- 2.7 months for the PDT group and 61 +/- 5.8 months for the surgery group. Overall survival was similar between the 2 groups (Wilcoxon test = 0.0924; P = .76). Treatment modality was not a significant predictor of mortality on multivariate analysis. CONCLUSIONS Overall mortality and long-term survival in patients with HGD treated with PDT appears to be comparable to that of patients treated with esophagectomy.
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Affiliation(s)
- Ganapathy A Prasad
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Card TR, Solaymani-Dodaran M, Hubbard R, Logan RFA, West J. Is an internal comparison better than using national data when estimating mortality in longitudinal studies? J Epidemiol Community Health 2007; 60:819-21. [PMID: 16905729 PMCID: PMC2566035 DOI: 10.1136/jech.2005.041202] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Discrepancies between the results of different studies looking at mortality in similar disease cohorts led us to consider the impact of methodology upon outcome. METHODS Cohort studies were carried out using age, sex, practice, and calendar time matched control groups in the general practice research database. Data were used on all subjects with inflammatory bowel disease, coeliac disease, or Barrett's oesophagus. Mortality data for the population of England and Wales were obtained from the UK Office for National Statistics. The study compared hazard ratios (HR) for mortality using the matched controls to those found when an indirect standardisation to the mortality experience of England and Wales was carried out. RESULTS For all three conditions the mortality risk was slightly lower when the national population data were used compared with the internal comparison group (coeliac disease HR 1.33 v standardised mortality ratios (SMR) 1.25, Barrett's oesophagus HR 1.32 v SMR 1.32, inflammatory bowel disease HR 1.50 v SMR 1.34). CONCLUSIONS A bias was found towards underestimating mortality risk when cohort studies use national population death rates as a comparator. Estimates obtained when an internal comparison group has been used are probably more appropriate.
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Affiliation(s)
- T R Card
- Division of Epidemiology and Public Health, University of Nottingham Medical School, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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Bergman JJGHM. Endoscopic resection for treatment of mucosal Barrett's cancer: time to swing the pendulum. Gastrointest Endosc 2007; 65:11-3. [PMID: 17185073 DOI: 10.1016/j.gie.2006.10.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2006] [Accepted: 10/16/2006] [Indexed: 02/08/2023]
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Ell C, May A, Pech O, Gossner L, Guenter E, Behrens A, Nachbar L, Huijsmans J, Vieth M, Stolte M. Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer). Gastrointest Endosc 2007; 65:3-10. [PMID: 17185072 DOI: 10.1016/j.gie.2006.04.033] [Citation(s) in RCA: 411] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 04/27/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND In view of the increasing incidence of adenocarcinoma in Barrett's esophagus and the mortality and high morbidity rates associated with surgical therapy for this condition, safe and effective but less invasive methods of treatment are needed. OBJECTIVE To evaluate efficacy and safety of endoscopic resection in these patients. DESIGN Single-center prospective study. SETTING Teaching hospital, conducted between October 1996 and September 2003. PATIENTS A total of 100 consecutive patients (mean age, 62.1 +/- 10.9 years; range, 31-86 years) with low-risk adenocarcinoma of the esophagus (macroscopic types I, IIa, IIb, and IIc; lesion diameter up to 20 mm; mucosal lesion without invasion into lymph vessels and veins; and histologic grades G1 and G2) arising in Barrett's metaplasia. INTERVENTIONS Endoscopic resection with the suck-and-cut technique. MAIN OUTCOME MEASUREMENTS Complete local remission. RESULTS A total of 144 resections (1.47 per patient) were performed without technical problems. No major complications and only 11 minor ones (bleedings without decrease of Hb >2 g/dL; treated with injection therapy) occurred. Complete local remission was achieved in 99 of the 100 patients after 1.9 months (range, 1-18 months) and a maximum of 3 resections. During a mean follow-up period of 36.7 months, recurrent or metachronous carcinomas were found in 11% of the patients, but successful repeat treatment with endoscopic resection was possible in all of these cases. The calculated 5-year survival rate was 98%. Two patients died of other causes. LIMITATIONS Nonblinded, nonrandomized study. CONCLUSIONS Endoscopic resection is associated with favorable outcomes for low-risk patients with early esophageal adenocarcinoma (Barrett's carcinoma).
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Affiliation(s)
- Christian Ell
- Department of Internal Medicine II, HSK Wiesbaden, Teaching Hospital of the University of Mainz, Wiesbaden, Germany
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25
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Smith CD, Bejarano PA, Melvin WS, Patti MG, Muthusamy R, Dunkin BJ. Endoscopic ablation of intestinal metaplasia containing high-grade dysplasia in esophagectomy patients using a balloon-based ablation system. Surg Endosc 2006; 21:560-9. [PMID: 17180281 DOI: 10.1007/s00464-006-9053-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Revised: 04/14/2006] [Accepted: 04/27/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study aimed to determine the optimal treatment parameters for the ablation of intestinal metaplasia (IM) containing high-grade dysplasia (HGD) using a balloon-based ablation system for patients undergoing esophagectomy. METHODS Immediately before esophagectomy, patients underwent ablation of circumferential segments of the esophagus containing IM-HGD using the HALO360 system. The treatment settings were randomized to 10, 12, or 14 J/cm2 for two, three, or four applications. After esophagectomy, multiple sections from ablation zones were microscopically evaluated. Histologic end points included maximum ablation depth (histologic layer) and complete ablation of all IM-HGD (yes/no). RESULTS Eight men with a mean age of 57 years (range, 45-71 years) were treated, and 10 treatment zones were created. There were no device-related adverse events. At resection, there was no evidence of a transmural thermal effect. Grossly, ablation zones were clearly demarcated sections of ablated epithelium. The maximum ablation depth was the lamina propria or muscularis mucosae. The highest energy (14 J/cm2, 4 applications) incurred edema in the superficial submucosa, but no submucosa ablation. Complete ablation of IM and HGD occurred in 9 of 10 ablation zones (90%), defined as complete removal of the epithelium with only small foci of "ghost cells" representing nonviable, ablated IM-HGD and demonstrating loss of nuclei and cytoarchitectural derangement. One focal area of viable IM-HGD remained at the margin of one ablation zone (12 J/cm2, 2 applications) because of incomplete overlap. CONCLUSION Complete ablation of IM-HGD without ablation of submucosa is possible using the HALO360 system. Ablation depth is dose related and limited to the muscularis mucosae. In one patient, small residual foci of IM-HGD at the edge of the ablation zone were attributable to incomplete overlap, which can be avoided. This study, together with nonesophagectomy IM-HGD trials currently underway, will identify the optimal treatment parameters for IM-HGD patients who would otherwise undergo esophagectomy or photodynamic therapy.
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Affiliation(s)
- C D Smith
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road, NE, Suite H-122, Atlanta, GA 30322, USA
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26
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Affiliation(s)
- Thomas W Rice
- Surgery, Cleveland Clinic Lerner College of Medicine, General Thoracic Surgery Cleveland Clinic Cleveland, Ohio, USA
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Wongsurawat VJ, Finley JC, Galipeau PC, Sanchez CA, Maley CC, Li X, Blount PL, Odze RD, Rabinovitch PS, Reid BJ. Genetic mechanisms of TP53 loss of heterozygosity in Barrett's esophagus: implications for biomarker validation. Cancer Epidemiol Biomarkers Prev 2006; 15:509-16. [PMID: 16537709 DOI: 10.1158/1055-9965.epi-05-0246] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND AIMS 17p (TP53) loss of heterozygosity (LOH) has been reported to be predictive of progression from Barrett's esophagus to esophageal adenocarcinoma, but the mechanism by which TP53 LOH develops is unknown. It could be (a) DNA deletion, (b) LOH without copy number change, or (c) tetraploidy followed by genetic loss. If an alternative biomarker assay, such as fluorescence in situ hybridization (FISH), provided equivalent results, then translation to the clinic might be accelerated, because LOH genotyping is presently limited to research centers. METHODS We evaluated mechanisms of TP53 LOH to determine if FISH and TP53 LOH provided equivalent results on the same flow-sorted samples (n = 43) representing established stages of clonal progression (diploid, diploid with TP53 LOH, aneuploid) in 19 esophagectomy specimens. RESULTS LOH developed by all three mechanisms: 32% had DNA deletions, 32% had no copy number change, and 37% had FISH patterns consistent with a tetraploid intermediate followed by genetic loss. Thus, FISH and LOH are not equivalent (P < 0.000001). CONCLUSIONS LOH develops by multiple chromosome mechanisms in Barrett's esophagus, all of which can be detected by genotyping. FISH cannot detect LOH without copy number change, and dual-probe FISH is required to detect the complex genetic changes associated with a tetraploid intermediate. Alternative biomarker assay development should be guided by appreciation and evaluation of the biological mechanisms generating the biomarker abnormality to detect potential sources of discordance. FISH will require validation in adequately powered longitudinal studies before implementation as a clinical diagnostic for esophageal adenocarcinoma risk prediction.
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Affiliation(s)
- V Jon Wongsurawat
- Divisions of Human Biology and Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
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von Rahden BHA, Feith M, Stein HJ. Limitierte chirurgische Resektion versus lokale endoskopische Therapie beim Frühkarzinom des ösophagogastralen Übergangs. Zentralbl Chir 2006; 131:97-104. [PMID: 16612774 DOI: 10.1055/s-2006-921551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adenocarcinomas of the esophagogastric junction (especially Barrett's cancers) are increasingly diagnosed at early stages. The current standard treatment - radical resection with extensive lymphadenectomy - has been challenged. Limited resection or endoscopic mucosal ablation have been proposed as less invasive alternatives. METHODS Available data regarding limited surgical resections and endoscopic interventional procedures are evaluated with respect to short- and long-term results (mortality, morbidity, oncologic adequacy, quality of life). RESULTS Limited resection of the esophagogastric junction has been proven as safe (low morbidity and mortality) and oncologically adequate procedure (low rate of recurrence/excellent long-term survival) with good quality of life. The procedure meets the oncological requirements (R0-resection, complete resection of potentially tumor-infiltrated lymph nodes and the entire precancerous Barrett's esophagus). Reconstruction with interposition of a pedicled isoperistaltic jejunal loop prevents reflux and is crucial for achieving good postoperative quality of life. In contrast, endoscopic mucosal resection (EMR) carries the risk of high recurrence rates (at least 30 %). This has to be regarded as an effect of the frequent incomplete resection, multicentric tumor growth, the persistence of precancerous Barrett's mucosa and persistence of gastroesophageal reflux. Consequently, from the oncological view point, EMR is only suited for unicentric mucosal tumors (T1a) in short segments of Barrett's esophagus. Reliable preoperative identification of such tumors is, however, currently not possible. CONCLUSION For adequately selected patients with early Barrett's cancer, limited resection of the esophagogastric junction is an appropriate procedure. Endoscopic mucosa resection (EMR) might gain importance as staging tool.
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Affiliation(s)
- B H A von Rahden
- Chirurgische Universitätsklinik, Paracelsus Medizinische Privatuniversität, Salzburg, Osterreich
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Foroulis CN, Thorpe JAC. Photodynamic therapy (PDT) in Barrett's esophagus with dysplasia or early cancer. Eur J Cardiothorac Surg 2005; 29:30-4. [PMID: 16337389 DOI: 10.1016/j.ejcts.2005.10.033] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2005] [Revised: 10/23/2005] [Accepted: 10/24/2005] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Esophagectomy is the standard treatment for high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC) arising within Barrett's esophagus. Results of photodynamic therapy (PDT) were retrospectively studied to evaluate the effectiveness of PDT in ablating HGD and/or IMC complicating Barrett's esophagus. METHODS Thirty-one patients unfit for or refusing esophagectomy (male: 20, mean age: 73.4+/-9.3 years) underwent Porfimer sodium PDT ablation of their HGD (15 patients), HGD plus IMC (10 patients) or submucosal/limited T2 adenocarcinoma (6 patients). The mean Barrett's length was 5.8+/-2.2 cm. Pre-PDT endoscopic mucosal resection or Nd:YAG laser ablation of mucosal nodularity within Barrett's segment was offered in six patients. RESULTS The main PDT complications were esophagitis (16.1%), photoreactions (12.9%) and stricture requiring dilatation (6.25%). The median post-PDT follow-up was 14 months. The long-term results were (a) for HGD/IMC: initial complete response (endoscopic and histologic absence of HGD-IMC) to PDT was observed in 80.95% of patients, partial response (no endoscopic abnormality, residual IMC-HGD on biopsy) in 9.52%, no response in 9.52% (the recurrence rate after an initial complete response was 17.64%) and (b) for T1b/limited T2 tumors: two patients died from cancer after 24 and 46 months, no evidence of tumor was found in two patients after 12 and 19 months and tumor recurrence was seen in two after 15 and 17 months. The mean survival was 22.1+/-12.3 months. CONCLUSIONS PDT is effective in ablating HGD/IMC complicating Barrett's esophagus in the majority of cases, while it also seems to be quite effective in treating T1b/limited T2 carcinomas.
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Solaymani-Dodaran M, Logan RFA, West J, Card T. Mortality associated with Barrett's esophagus and gastroesophageal reflux disease diagnoses-a population-based cohort study. Am J Gastroenterol 2005; 100:2616-21. [PMID: 16393209 DOI: 10.1111/j.1572-0241.2005.00340.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Patients with Barrett's esophagus have a much increased risk of esophageal adenocarcinoma but recent evidence suggests no increase in overall mortality. We have reexamined this surprising finding in a large, prospectively population-based cohort study. METHODS Cohorts of patients having Barrett's esophagus (n=1,677), esophagitis (n=6,392), simple reflux (n=6,328), and a standard reference cohort representing the general population in the United Kingdom (n=13,416) were selected from General Practice Research Database. The last three cohorts were matched to the Barrett's cohort by general practice, age, and sex. Mortality rates and hazard ratios with their 95% confidence intervals were calculated for deaths due to all causes and deaths due to all causes except esophageal cancer occurring beyond the first year of the follow-up. RESULTS A total of 1,725 deaths were analyzed including 49 deaths in subjects having esophageal cancer. Of 111 deaths in the Barrett's cohort, 13 (12%) were in subjects with esophageal cancer. Compared with the reference cohort, hazard ratios for all causes of death were 1.37 (1.12-1.66) for the Barrett's, 1.16 (1.02-1.32) for the esophagitis, and 1.16 (1.01-1.33) for the reflux cohorts. The corresponding figures for deaths due to all causes except esophageal cancer were 1.23 (1.00-1.51), 1.13 (0.99-1.30), and 1.15 (1.00-1.31). Of the excess mortality rates in the Barrett's, esophagitis, and reflux cohorts, at the most 45%, 20%, and 13%, respectively, could be attributed to esophageal cancer. CONCLUSION People with Barrett's esophagus and gastroesophageal reflux disease have higher mortality rates than the general population, and an increase in esophageal cancer risk accounts for less than half the excess mortality in Barrett's.
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Affiliation(s)
- Masoud Solaymani-Dodaran
- University of Nottingham, Division of Epidemiology and Public Health, Medical School, Queen's Medical Centre, Nottingham, UK
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Abstract
Barrett's esophagus is a clearly recognized risk factor for the development of esophageal adenocarcinoma. Despite the rapidly increasing incidence rate of esophageal adenocarcinoma, the vast majority of patients with Barrett's esophagus will never go on to develop this cancer. Furthermore, esophageal adenocarcinoma is a rare cause of death in Barrett's esophagus patients, and most of these patients die from other causes. While some studies demonstrate that the overall survival of patients with Barrett's esophagus is no different than that of the general population, others have suggested that Barrett's esophagus may be associated with increased mortality. Work by Solaymani-Dodran et al., in the current issue of the American Journal of Gastroenterology, found that all cause mortality was increased by 37% and mortality from causes other than esophageal cancer was increased by 23% compared to the general population, differences that were eliminated when adjusted for ischemic heart disease. Findings such as these point out the need for large, well-done epidemiologic studies of Barrett's esophagus cohorts in order to develop a better understanding of the natural history of this disease.
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Affiliation(s)
- Gary W Falk
- Department of Gastroenterology & Hepatology, Center for Swallowing and Esophageal Disorders, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Deschamps C, Nichols FC, Cassivi SD, Allen MS, Pairolero PC. Long-term function and quality of life after esophageal resection for cancer and Barrett's. Surg Clin North Am 2005; 85:649-56, xi. [PMID: 15927658 DOI: 10.1016/j.suc.2005.01.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Esophagectomy is the treatment of choice for cancer or high-grade dysplasia. Although the patients frequently experience symptoms postoperatively, their quality of life is most often comparable to that of a control population. This article provides details of post-esophagectomy symptomatology and examines how quality of life can be measured in these patients.
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Affiliation(s)
- Claude Deschamps
- Division of General Thoracic Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Pech O, Gossner L, May A, Rabenstein T, Vieth M, Stolte M, Berres M, Ell C. Long-term results of photodynamic therapy with 5-aminolevulinic acid for superficial Barrett's cancer and high-grade intraepithelial neoplasia. Gastrointest Endosc 2005; 62:24-30. [PMID: 15990815 DOI: 10.1016/s0016-5107(05)00333-0] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) has proven to be safe and effective in patients with early neoplasia in Barrett's esophagus. However, long-term results in patients with high-grade intraepithelial neoplasia (HGIN) or with early cancer are still lacking. METHODS The aim of the study was to evaluate the efficacy of ALA-PDT and the survival of patients with early Barrett's neoplasia. ALA-PDT was carried out in 66 patients. Protoporphyrin IX induced by oral administration of ALA (60 mg/kg body weight orally applied 4-6 hours before PDT) was used as the photosensitizer. Acid suppression was maintained in all patients. RESULTS Between September 1996 and September 2002, 667 patients with early neoplasia in Barrett's esophagus were referred for local endoscopic therapy. A total of 558 patients fulfilled the criteria for local endoscopic therapy, and 66 patients (mean [standard deviation] age 61.4 [10.2] years) with HGIN (group A; n = 35) and early adenocarcinoma (group B; n = 31) were treated by PDT. A total of 82 ALA-PDT were performed. A total of 34 of the 35 patients in group A (97%) and all patients in group B (100%) achieved a complete response during a median follow-up period of 37 months (interquartile range 23-55) (not significant). One local recurrence was observed in group A and 10 in group B (p < 0.005). Seven patients died during follow-up; but, all deaths were not tumor related. No major complications were observed. Disease-free survival in patients with HGIN was 89%, and, in patients with mucosal cancer, it was 68%. The calculated 5-year survival was 97% in group A and 80% in group B, but there occurred no death related to Barrett's neoplasia. CONCLUSIONS The excellent long-term results of PDT with ALA in patients with HGIN or mucosal cancer might offer PDT with ALA as an alternative to surgical esophagectomy and endoscopic resection, especially in cases with multifocal Barrett's neoplasia.
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Affiliation(s)
- Oliver Pech
- Department of Medicine II, HSK Wiesbaden, Teaching Hospital of the University of Mainz, Germay
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Ragunath K, Krasner N, Raman VS, Haqqani MT, Phillips CJ, Cheung I. Endoscopic ablation of dysplastic Barrett's oesophagus comparing argon plasma coagulation and photodynamic therapy: a randomized prospective trial assessing efficacy and cost-effectiveness. Scand J Gastroenterol 2005; 40:750-8. [PMID: 16118910 DOI: 10.1080/00365520510015737] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic mucosal ablation is a promising technique that is used to treat dysplastic Barrett's oesophagus. The purpose of this study was to investigate the efficacy and cost-effectiveness of two promising techniques, argon plasma coagulation (APC) and photodynamic therapy (PDT), in the ablation of dysplastic Barrett's oesophagus. MATERIALS AND METHODS Twenty-six patients with dysplastic Barrett's oesophagus (21 M, median age 60 years, median length 4 cm, 23 low-grade dysplasia (LGD), 3 high-grade dysplasia (HGD)) were randomized to APC: 13 patients, PDT: 13 patients. APC was performed at a power setting of 65 W and argon gas flow at 1.8 l/min in 1-6 sessions (mean 5). PDT was performed 48 h after intravenous injection of Photofrin 2 mg/kg with a 630 nm red laser light, 200 J/cm through a PDT balloon in one session. All patients received treatment with high-dose proton pump inhibitors. Cost analysis was undertaken and the results were assessed by endoscopy and biopsies at 4 months and 12 months after therapy. RESULTS All patients in both groups showed a reduction in the length of Barrett's oesophagus. The median length of Barrett's oesophagus eradicated at the 4-month follow-up: APC 65%, PDT 57% and at the 12-month follow-up: APC 56%, PDT 60%. Dysplasia eradication at 4 months: APC 62%, PDT 77%, p = 0.03 (95% CI 0.66-0.96) and at 12 months APC 67%, PDT 77%. Buried columnar glands with intestinal metaplasia were seen in both groups, with one patient in the PDT arm developing adenocarcioma under the neo-squamous epithelium. Severe adverse events included APC 2/13 (15%) stricture, 1/13 (8%) odynophagia, chest pain and fever; PDT 2/13 (15%) photosensitivity, 2/13 (15%) stricture. PDT would cost an additional 266 pounds sterling for every percentage reduction in Barrett's length and 146 pounds sterling per percentage reduction in dysplasia compared with APC treatment. CONCLUSIONS APC and PDT are equally effective in eradicating Barrett's mucosa, with PDT being the more expensive treatment. However, PDT is more effective in eradicating dysplasia and the extra benefits of PDT are generated at an extra cost. The occurrence of buried columnar glands and carcinoma warrants caution. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium to justify these interventions.
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Affiliation(s)
- Krish Ragunath
- Department of Gastroenterology, University Hospital Aintree, Liverpool, UK.
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Reed MF, Tolis G, Edil BH, Allan JS, Donahue DM, Gaissert HA, Moncure AC, Wain JC, Wright CD, Mathisen DJ. Surgical Treatment of Esophageal High-Grade Dysplasia. Ann Thorac Surg 2005; 79:1110-5; discussion 1110-5. [PMID: 15797034 DOI: 10.1016/j.athoracsur.2004.09.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2004] [Indexed: 12/14/2022]
Abstract
BACKGROUND Barrett's esophagus, high-grade dysplasia (HGD), and invasive cancer are steps in the progression of esophageal adenocarcinoma. While surgery is recommended for resectable invasive adenocarcinoma, a number of treatment modalities are advocated for HGD. The purpose of this study is to determine the outcomes after surgery for HGD. METHODS We identified cases of HGD based on endoscopic biopsy in a single institution's databases from 1980 through 2001. Records were reviewed for patient characteristics, treatments, staging, and outcomes. RESULTS In a 22-year period, 869 cases of esophageal adenocarcinoma and 1,614 cases of Barrett's esophagus were diagnosed. Of these, 115 had HGD without pretreatment evidence of invasion. Forty-nine patients with HGD underwent resection (mean age, 59 years) as initial treatment. Forty-seven had endoscopic treatment (mean age, 70 years) by photodynamic therapy or endoscopic mucosal resection. Seven of the endoscopically treated patients failed, with three undergoing surgery and four observation. Nineteen patients were initially observed, with six eventually having surgery. For the 49 initially treated surgically, one (2%) operative mortality occurred. Invasive adenocarcinoma was present in 18 (37%). The five-year survival was 83% for all resected HGD patients (91% for those without invasion, 68% with invasion). Three of the eight deaths in those with invasion were from recurrent adenocarcinoma. CONCLUSIONS Surgical resection of esophageal HGD can be performed with low mortality and allows long-term survival. A significant percentage with an initial diagnosis of HGD will have invasive disease at resection. Surgery is the optimal treatment for HGD unless contraindicated by severe comorbidities.
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Affiliation(s)
- Michael F Reed
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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Abstract
This article summarizes the present recommendations for the screening, surveillance and treatment of Barrett's oesophagus, and identifies those areas in which change seems likely within the next decade. As a result of economic constraints and emerging data on ethnic variations in the frequency of Barrett's oesophagus, future screening programmes will probably focus on those individuals most likely to develop Barrett's adenocarcinomas: older white men whose gastro-oesophageal reflux symptoms are of long duration. The present surveillance strategy for patients with Barrett's oesophagus relies heavily on random biopsy sampling of the oesophagus to find dysplasia. In the future, biomarkers other than dysplasia may be used to identify patients at high risk for carcinogenesis, and physicians may use endoscopic techniques, such as fluorescence spectroscopy, to identify areas of dysplasia for biopsy sampling. Indirect evidence suggests that super-aggressive antisecretory therapy and treatment with non-steroidal anti-inflammatory drugs may reduce the risk of cancer in Barrett's oesophagus. Well-designed prospective studies will be needed to determine whether these treatments have sufficient efficacy in cancer prophylaxis to justify the large numbers needed to treat. Finally, recent data are reviewed, which suggest that the gastro-oesophageal junction is exposed repeatedly to concentrated acid and to potentially genotoxic concentrations of nitric oxide generated from dietary nitrate. Future studies on carcinogenesis in Barrett's oesophagus may well focus on the combined roles of nitric oxide and gastric acid.
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Affiliation(s)
- S J Spechler
- Division of Gastroenterology, Dallas VA Medical Center, Dallas, TX 75216, USA.
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Couvelard A, Paraf F, Vidaud D, Dubois S, Vidaud M, Fléjou JF, Degott C. Human chorionic gonadotrophin beta expression in malignant Barrett's oesophagus. Virchows Arch 2004; 445:279-84. [PMID: 15309632 DOI: 10.1007/s00428-004-1078-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2004] [Accepted: 06/14/2004] [Indexed: 12/11/2022]
Abstract
BACKGROUND Human chorionic gonadotrophin beta (hCGbeta) is expressed in several non-trophoblastic tumours, and this is usually associated with aggressive behaviour. Little is known about hCGbeta expression in Barrett's adenocarcinoma. MATERIALS AND METHODS We determined the hCGbeta profile in a large series of surgically resected Barrett's adenocarcinoma (a) at mRNA level using real-time quantitative reverse-transcription polymerase chain reaction analysis and (b) at protein level using immunohistochemistry with a polyclonal antibody and with a monoclonal antibody specific for free hCGbeta. We then sought links between the hCGbeta protein expression pattern and clinical and pathological parameters, including patient outcome as well as vascular endothelial growth factor (VEGF) expression. RESULTS hCGbeta protein expression was observed in 43 of 76 (57%) Barrett's adenocarcinomas. We showed a strong correlation between hCGbeta protein abundance and CGB mRNA level. We observed a statistical link between hCGbeta protein expression and infiltrative tumour type ( P=0.023), perineural neoplastic invasion ( P=0.007) and VEGF protein expression ( P=0.016). hCGbeta expression tended to be associated with a poor outcome (16% versus 36% survival 8 years after resection). CONCLUSION Expression of hCGbeta correlates with specific infiltrative characteristics and is associated with higher VEGF expression. Both molecules may play a co-ordinated role in the development of Barrett's adenocarcinomas.
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Affiliation(s)
- Anne Couvelard
- Service d'Anatomie Pathologique, Hôpital Beaujon, 92118 Clichy cedex, France.
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Iravani S, Zhang HQ, Yuan ZQ, Cheng JQ, Karl RC, Jove R, Coppola D. Modification of insulin-like growth factor 1 receptor, c-Src, and Bcl-XL protein expression during the progression of Barrett's neoplasia. Hum Pathol 2003; 34:975-82. [PMID: 14608530 DOI: 10.1053/s0046-8177(03)00354-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Oncogenes, growth factors, cell surface receptors, and cell-cycle and apoptotic regulatory proteins have been implicated in the growth regulation and progression of Barrett's-associated neoplasia. Among these, insulin-like growth factor 1 receptor (IGF1-R) and c-Src are reported to be key regulators of mitogenesis and tumorigenesis. In addition, c-Src may exert its transforming capability by inducing increased expression of IGF1-R on the neoplastic cells. Bcl-X(L), a member of the Bcl-2 family, blocks apoptosis and has been reported to increase in Barrett's-associated neoplasia. To study the modifications in IGF1-R, c-Src, and Bcl-X(L) protein expression during the progression of Barrett's-associated neoplasia, we analyzed 34 resected gastroesophagectomy specimens by immunohistochemistry using antibodies to human IGF1-R, c-Src, and Bcl-X(L). In these cases, we found 22 intestinal (Barrett's) metaplasias (IMs), 25 low-grade dysplasias (LGDs), 28 high-grade dysplasias (HGDs), 34 invasive adenocarcinomas (CAs), and 19 lymph node metastases. High IGF1-R cytoplasmic staining was present in 14 of 19 (74%) node metastases, in 28 of 34 (82%) CAs, in 18 of 28 (64%) HGDs, in 13 of 25 (52%) LGDs, and in 5 of 22 (23%) IMs. Strong and diffuse c-Src expression was identified in 17 of 19 (89%) node metastases, in 29 of 34 (85%) Cas, in 26 of 28 (93%) HGDs, in 18 of 25 (72%) LGDs, and in 9 of 22 (41%) IMs. Bcl-X(L) cytoplasmic staining was evident in 12 of 19 (63%) node metastases, in 20 of 34 (59%) Cas, in 20 of 28 (71%) HGDs, in 15 of 25 (60%) LGDs, and in 6 of 22 (27%) IMs. In 11 cases, c-Src activity was measured by kinase assay and reflected the immunohistochemical results. Our data indicate that expression levels of IGF1-R, c-Src, and Bcl-X(L) proteins are coordinately elevated in Barrett's-associated neoplasia. These findings indicate important roles of these growth regulatory proteins in the malignant progression of Barrett's-associated neoplasia.
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Affiliation(s)
- Shohreh Iravani
- Department of Surgery, Moffitt Cancer Center and Research Institute, University of South Florida, Tampa 33612, USA
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Schuchert MJ, Luketich JD. Barrett's esophagus: current status of treatment. Adv Surg 2003; 37:179-96. [PMID: 12953633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Affiliation(s)
- Matthew J Schuchert
- Division of Thoracic and Foregut Surgery, Department of Surgery, UPMC Health System, Pittsburgh, Pennsylvania, USA
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Abstract
The incidence of adenocarcinoma arising from Barrett's esophagus is dramatically increasing in Western countries. The purpose of this study was to report our experience in the surgical management of these patients. Between November 1992 and December 2000, 330 consecutive patients with adenocarcinoma of the esophagogastric junction were observed in our institution. Of these, 105 (31.8%) had Barrett's carcinoma. In 12 individuals (11.4%) adenocarcinoma was discovered during endoscopic surveillance for Barrett's esophagus. Twelve patients with doubtful cleavage planes at preoperative investigation were treated with neoadjuvant chemotherapy. Overall, 80 patients (76.2%) underwent esophagectomy without operative mortality. The Ivor Lewis approach was used in 70 patients; of these, 31 underwent extended mediastinal lymph node dissection. Seventy-four patients (92.5%) had R0 resection. The overall 5-year survival rate was 48%. Survival was significantly associated with stage, lymph node status, and completeness of resection. Early diagnosis remains the prerequisite for curative treatment of esophageal carcinoma. An extended mediastinal lymphadenectomy does not increase morbidity, allows precise tumor staging, and may prove effective in preventing local recurrences. Neoadjuvant therapy requires major improvement before it can be unconditionally recommended outside clinical trials.
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Affiliation(s)
- Luigi Bonavina
- Department of Surgery, University of Milano, Istituto Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milano, Italy.
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Affiliation(s)
- R C Heading
- Centre for Liver and Digestive Disorders, Royal Infirmary, Edinburgh, UK.
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Abstract
BACKGROUND Patients with Barrett's oesophagus have an increased risk of oesophageal adenocarcinoma but this cancer only accounts for a small proportion of deaths in these patients. Other causes of death are reportedly raised in this group. We examined cause specific mortality among individuals in a population based Barrett's oesophagus register. METHODS We constructed a register of all patients diagnosed with columnar mucosa (including specialised intestinal metaplasia) of the oesophagus within Northern Ireland between 1993 and 1999. Deaths occurring within this cohort until 31 December 2000 were identified and mortality rates were compared with the general population. RESULTS Overall mortality was not raised in Barrett's patients. During 7413 person years of follow up in 2373 patients there were 253 deaths (standardised mortality ratio (SMR) 96 (95% confidence interval (CI) 84-107)). Mortality from oesophageal cancer was raised in patients with specialised intestinal metaplasia (SMR 774 (95% CI 317-1231)) but only 4.7% of patients died from this cancer. Mortality from stroke (SMR 65 (95% CI 37-93)) was significantly lower than the general population while mortality from non-cancerous digestive system diseases was significantly higher (SMR 211 (95% CI 111-311)). Mortality rates from all other causes were similar to those of the general population. CONCLUSIONS This study demonstrates that the overall mortality rate in patients with Barrett's oesophagus is closely similar to that of the general population. Oesophageal cancer mortality was raised but is an uncommon cause of death in these patients who also appear to have a reduced risk of death from stroke.
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Affiliation(s)
- L A Anderson
- Northern Ireland Cancer Registry, Department of Epidemiology and Public Health, The Queen's University Belfast, UK.
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Abstract
BACKGROUND & AIMS Patients with high-grade dysplasia in Barrett's esophagus have a high chance of developing adenocarcinoma. Previously these patients have undergone resection, however, the management of patients unsuitable for surgical resection is unclear. We have studied the long-term outcome of patients who have undergone endoscopic Argon ablation for high-grade dysplasia in Barrett's. METHODS Twenty-nine patients (median age, 64 yr; range, 43-85 yr) with high-grade dysplasia in Barrett's, who were unfit or had declined surgery, underwent Argon ablation and received follow-up evaluation over 7 years (mean follow-up, 37 mo; range, 7-78 mo). Treatment was stopped once there was no further histologic evidence of dysplasia. The patients then went on to receive a surveillance endoscopy at 3, 6, and 12 months after ablation, then annually thereafter. RESULTS High-grade dysplasia responded to treatment in 25 patients (86%); 22 of these had complete regression to neosquamous esophageal mucosa. During follow-up evaluation, no patients died of esophageal adenocarcinoma. Four patients developed cancer, 3 of whom continue with ablation therapy. The fourth patient died of unrelated causes. A single esophageal perforation was the only significant adverse event attributable to therapy. No esophageal strictures occurred and patients returned to normal activity after 24 hours in the majority of cases. Patients who received Argon ablation showed no difference in survival to that of the general population. CONCLUSIONS Argon beam ablation for high-grade dysplasia in Barrett's esophagus is an effective and safe treatment, especially in patients unfit for surgical resection.
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Affiliation(s)
- Stephen E A Attwood
- Department of Upper Gastro-intentinal Surgery, Hope Hospital, Stott Lane, Manchester M6 8HD, UK
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45
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Stein HJ, Feith M, Siewert JR. [Lymph node excision in invasive Barrett carcinoma]. Kongressbd Dtsch Ges Chir Kongr 2003; 119:844-9. [PMID: 12704934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Similar to squamous cell esophageal cancer, the lymph node status constitutes the major prognostic factor after complete tumor resection (R0-resection) in patients with adenocarcinoma of the distal esophagus (the so-called Barrett's cancer). Lymphatic spread in patients with Barrett's cancer, however, appears to follow certain rules. Lymphatic spread is closely correlated to the pT-category of the primary tumor, starts only after infiltration of the submucosa und is initially limited to the regional lymph nodes. Distant lymph node metastases are almost exclusively found in patients with multiple positive regional nodes, skipping of regional lymph nodes is rare. These observations set the stage for tailored lymphadenectomy-strategies based on the, sentinel-lymphadenectomy' concept.
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Affiliation(s)
- H J Stein
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, 81677 München.
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Abstract
We updated our surgical results and long-term outcome for prophylactic esophagectomy in patients with Barrett's esophagus and high-grade dysplasia (HGD) and determined the incidence of occult adenocarcinoma. Sixty consecutive patients with HGD who underwent esophagectomy had pre- and postoperative pathology examined at our institution from 1982 to 2001. We reviewed medical records to determine patient characteristics, surgical approach, operative morbidity and mortality, pathology, and length of stay. Patients and/or referring physicians were contacted to determine long-term outcome. Fifty-three men (88%) and 7 women (12%) were followed up for a median of 4.6 years. Transhiatal esophagectomy was performed in the majority of patients (82%). There was one operative death (1.7%) and 15 complications (29%). Median length of stay was 9 days. In 18 patients (30%), invasive adenocarcinoma was detected in the resected specimen. When examined by time periods, 43% (13/30) of patients were diagnosed with occult cancer from 1982-1994, whereas 17% (5/30) harbored occult malignancy from 1994-2001. All patients with adenocarcinoma in the recent interval had stage I disease, as opposed to only 61.5% of patients from the earlier study. Operative mortality declined from 3.3% to 0% over the two intervals as did mean length of stay from 14 days to 10 days. Five-year survival was excellent at 88%. Age and amount of preoperative weight loss were preoperative predictors of survival, whereas major postoperative complications and stage were postoperative predictors of outcome. Barrett's esophagus with high-grade dysplasia continues to be an indication for prophylactic esophagectomy. Overall prevalence of occult adenocarcinoma remains high. We have demonstrated a declining incidence of occult cancer and treatment of earlier stage adenocarcinoma when found in this population of patients treated with esophagectomy.
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Affiliation(s)
- Elaine E Tseng
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Abstract
OBJECTIVE To evaluate our results using photodynamic therapy (PDT) for the treatment of dysplasia or superficial cancer (T1 N0 M0) in patients with Barrett esophagus. PATIENTS AND METHODS We retrospectively reviewed our clinical experience with 48 patients (34 patients with high-grade dysplasia and 14 patients with superficial cancer in Barrett esophagus) who had been referred for PDT. Initial evaluation included computed tomography and standard and high-frequency catheter endosonography. Follow-up endoscopy was performed 4 to 6 weeks after PDT with ablation of any residual glandular mucosa, using the argon plasma coagulator. Patients were then followed up indefinitely every 3 to 6 months with computed tomography, endosonography, and endoscopic surveillance. RESULTS The median series follow-up was 18.5 months (range, 1-56 months). Apparent complete photoablation of Barrett mucosa and/or superficial neoplasm was documented in 47 of 48 cases. Complications included symptomatic strictures (11 patients), photosensitivity (7 patients), atrial fibrillation (1 patient) or recurrent congestive heart failure (1 patient), and self-limited esophageal perforation (1 patient). Failure to ablate T1 N0 M0 adenocarcinoma occurred in 1 patient. CONCLUSIONS Porfimer sodium PDT appears to eradicate dysplastic Barrett mucosa and neoplasia. These results are promising; however, long-term studies are needed to document the efficacy of PDT in reducing the morbidity and mortality in such patients.
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Affiliation(s)
- Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Fla 32224, USA.
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Abstract
The incidence of adenocarcinoma of the esophagus has increased dramatically over recent years. Because Barrett's epithelium is recognized as a risk factor for adenocarcinoma there is an interest in reversing this metaplasia. A number of endoscopic methods of destruction of esophageal columnar epithelium have been described. The purpose of this article is to review the currently available methods of managing Barrett's epithelium with particular reference to the role of ablative therapy in reducing the risk of adenocarcinoma.
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Affiliation(s)
- P Urosevic
- The University of Melbourne, Department of Clinical and Biomedical Sciences, The Geelong Hospital, Victoria, Australia
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Abstract
OBJECTIVES Practice guidelines recommend surveillance for Barrett's esophagus (BE) because of the risk of esophageal cancer. The quality of life of patients undergoing surveillance is unknown. The objectives of this study were to develop a new utility instrument to measure quality of life of patients undergoing BE surveillance and determine if Quality of Life in Reflux and Dyspepsia (QOLRD) scores correlate with utility ratings. METHODS Fifteen patients were administered 16 scenarios describing possible BE surveillance outcomes. Each scenario was rated from 0 (equivalent to being dead) to 10 (equivalent to being in perfect health). Each patient also completed the QOLRD, a validated instrument. A t test was performed to compare the QOLRD means with published means. The Spearman's rank correlation coefficient was calculated for the median QOLRD score and the median utility rating. RESULTS QOLRD means ranged from 5.80 to 6.65 (previously published means 4.3-5.4). Lower scores denoted a worsened quality of life. The difference was significant (p < 0.001). The correlation coefficient of median QOLRD score (6.8) and median utility rating (4.0) was 0.10 (p = 0.71). CONCLUSIONS This population of BE patients had significantly higher QOLRD scores than a previously published population referred for endoscopy. Quality of life using the utility measure was reduced. The utility measure did not correlate with the disease-specific instrument, suggesting that the concerns of patients undergoing surveillance are distinct from their reflux symptoms.
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Affiliation(s)
- Deborah Fisher
- Durham Veterans Affairs Medical Center, Institute for Clinical and Epidemiological Research, North Carolina, USA
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Headrick JR, Nichols FC, Miller DL, Allen MS, Trastek VF, Deschamps C, Schleck CD, Thompson AM, Pairolero PC. High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy. Ann Thorac Surg 2002; 73:1697-702; discussion 1702-3. [PMID: 12078755 DOI: 10.1016/s0003-4975(02)03496-3] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophagectomy for high-grade dysplasia in Barrett's esophagus has been advocated. Although long-term survival data exist, little is known about functional outcome and quality of life in this particular subset of patients. METHODS The records of all patients who underwent esophageal resection for high-grade dysplasia from June 1991 through July 1997 were reviewed. Long-term functional outcome and quality of life were assessed using a two-part written survey. RESULTS There were 54 patients (48 men, 6 women). Median age was 64 years (range, 36 to 83 years). Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended esophagectomy in 8 (15%), and other in 2 (4%). Invasive carcinoma was found in 19 patients (35%). Five patients (9%) were stage 0, 7 (13%) stage I, 3 (6%) stage IIA, 1 (2%) stage IIB, and 3 patients (6%) stage III. There was one operative death (1.8%). Complications occurred in 31 patients (57%). Median hospitalization was 13 days (range, 11 to 44 days). Follow-up was complete in all patients and ranged from 6 months to 9 years (median, 63 months). Overall 5-year survival was 86% and did not differ significantly from a population matched for age and gender. Five-year survival for patients with only high-grade dysplasia was 96% and 68% for patients with cancer (p = 0.017). Quality of life was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey. For patients with only high-grade dysplasia, the role-physical and role-emotional scores were better than for the control population (p < 0.03). For patients with cancer, the health perception score was worse than for the control population (p < 0.03). Scores measuring physical-function, social function, mental health, bodily pain, and energy/fatigue were similar. CONCLUSIONS Although perioperative morbidity is significant, surgical resection of high-grade dysplasia in Barrett's esophagus provides excellent long-term survival with acceptable function and quality of life.
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Affiliation(s)
- James R Headrick
- Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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