Dysplastic Barrett's Esophagus Research Articles

Subsquamous Intestinal Metaplasia Is a Common Finding in Ablation-Naïve Patients with Dysplastic Barrett's Esophagus, and Significantly Decreases in Prevalence After Radiofrequency Ablation

Background: Subsquamous intestinal metaplasia (SSIM) has been reported as an adverse outcome of endoscopic ablative therapy for dysplastic Barrett's esophagus (BE). However, the prevalence of SSIM in ablation-naïve patients with dysplastic BE is unknown, as is the response of SSIM to ablative therapy. Aim: To assess the prevalence of SSIM in ablation-naïve patients with BE containing HGD or LGD, and then to assess the prevalence of SSIM after ablative therapy. Methods: The AIM Dysplasia Trial is a U.S.

W1876 Are Biopsies After Ablation for Dysplastic Barrett's Esophagus of Adequate Depth to Detect Glandular Mucosa Beneath the Neosquamous Epithelium? - Comparative Histopathological Outcomes from a Randomized, Sham-Controlled Trial (Aim Dysplasia Trial)

W1876 Are Biopsies After Ablation for Dysplastic Barrett's Esophagus of Adequate Depth to Detect Glandular Mucosa Beneath the Neosquamous Epithelium? - Comparative Histopathological Outcomes from a Randomized, Sham-Controlled Trial (Aim Dysplasia Trial)

Predictors and Quantitative Assessment of Incomplete Response After Radiofrequency Ablation for Dysplastic Barrett's Esophagus: Analysis of Randomized Sham-Controlled Clinical Trial (The AIM Dysplasia Trial)

Background: Radiofrequency ablation (RFA) has been shown to completely eradicate dysplastic intestinal metaplasia (IM) in most patients, yet residual IM may persist in some. Aims: The primary endpoint for RFA therapy is complete response-IM (CR-IM, no histological evidence of IM). We sought to describe pt characteristics related to incomplete response-IM (IR-IM, any residual IM). We also assessed dysplasia grade, and extent/location of any residual IM. Methods: We enrolled 127 pts with dysplastic BE (63 HGD, 64 LGD) in a multi-center trial of RFA. Pts were randomized 2:1 (RFA vs. sham) then biopsied q 3 or 6 mo, with centralized path review. RFA was performed until CR-IM or max 4 sessions. Results: 52 pts (35 RFA, 17 sham) have evaluable 12 mo histology. This sub-analysis of the RF group compares CR-IM to IR-IM at 12 mo. The groups had similar hiatal hernia size. IR-IM had a longer pre-treatment period with dysplasia (p < 0.05). They were also older and had higher BMI, more years with BE, longer BE cm, and more multi-focal dysplasia, but given the small sample size of IR-IM, none of these was significant (table). All IR-IM pts had downgrading of dysplasia. For the 3 IR-IM pts with baseline HGD, the worst grade of residual IM was non-dysplastic (1), indefinite (1), or LGD (1). For the 3 IR-IM pts with baseline LGD, all were downgraded to non-dysplastic IM. Of the 6 IR-IM pts at 12 mo, 4 had a single-level IM focus, while 2 had multi-level disease. Five of 6 IR-IM pts had IM only within 1 cm of the top of gastric folds (TGF), while 1 pt had more proximal IM (4-5 cm from the TGF). One IR-IM pt had persistent GERD esophagitis, 1 had ibuprofen-induced ulceration, and 1 had a baseline stricture preventing focal balloon contact. Conclusions: All IR-IM had downgrading of dysplasia and substantial reduction of IM burden. IR-IM pts had a longer pre-treatment period with dysplasia than CR-IM. IR-IM also had insig increases in age, baseline BE length, BMI and % multi-focal. Follow-up RFA is planned for these pts, with the goal to eliminate residual disease. Tabled 1 CR-IM IR-IM Patients (n, %) 29 (83%) 6 (17%) Male (n, %) 24 (83%) 5 (83%) Age years (median, IQR) 64 (59-69) 70.5 (64-74) BMI (median, IQR) 26.5 (25-31) 28.9 (27-32) Years with BE / dysplasia (median) 3.4 / 0.6 6.0 / 2.2 ∗ p < 0.05 Baseline Prague (CM) median 1.5 / 4.0 4.5 / 6.5 Baseline multifocal dysplasia (n, %) 21 (72%) 6 (100%) Baseline HGD (n, %) 9 (31%) 3 (50%) RFA procedures (median) 4 4 12 mo fragments (n) 806 266 12 mo fragments with IM (n, % total) 0 (0%) 25 (9.3%) ∗ p < 0.05 Open table in a new tab

Diagnostic Accuracy of Methylene Blue Guided Chromoendoscopy in Patients with Suspicion of Dysplastic Barrett's Oesophagus

Background: The use of chromoendoscopy with methylene blue (CEMB) is controversial for the detection of dysplasia in standard Barrett's surveillance. (Canto 2000, Ragunath 2003). We aimed to assess the diagnostic accuracy of CEMB in relocalizing dysplastic areas in patients referred with suspected Barrett's dysplasia. Methods: Consecutive patients with suspected Barrett's dysplasia (high grade (HGD), low grade (LGD) or p53 positivivity) were referred for CEMB. After regular high resolution endoscopy (Olympus 160Q/180Q/180HQ series, Fujinon EG 250 WR), the oesophagus was rinsed with 50 ml of tap water.

M1933 Biopsy Yield of Dysplastic Barrett's Esophagus Based On Location Within the Barrett's Segment

M1933 Biopsy Yield of Dysplastic Barrett's Esophagus Based On Location Within the Barrett's Segment

Interobserver Variability of Methylene Blue Guided Chromoendoscopy in Patients with Suspicion of Dysplastic Barrett's Oesophagus

Background: Inter and intra-observer variability of magnification chromoendoscopy for detecting intestinal metaplasia is poor (Mening 2004). The use of chromoendoscopy with methylene blue (CEMB) is controversial for the detection of dysplasia in standard Barrett's surveillance (Canto 2000, Ragunath 2003). No data are available on interobserver variability for CEMB without magnification. We aimed to assess the interobserver agreement of CEMB for classification of the staining pattern and decision making on the site of biopsy taking. Methods: 37 pictures of CEMB cases of patients with suspected Barrett's dysplasia (high grade, low grade or p53 positivivity) were presented to three endoscopists independently. Observer 1 had recently followed training in chromoendoscopy by observer 3. Observer 2 and 3 regularly performed CEMB in Barrett's patients. They were asked to grade the staining pattern as 1) uniform uptake of methylene blue 2) patchy distribution or 3) no uptake. Subsequently the endoscopists were asked to indicate which sites they considered unstained and would target for biopsy. Results: The classification of the staining pattern was considered uniform in 6, 11 and 12 pictures, patchy in 30,20 and 23 pictures and unstained in 1,6 and 2 pictures respectively by observer 1, 2 and 3. Interobserver agreement for the classification of the staining pattern was overall moderate and best between observers performing CEMB regularly (Kappa 0,57 (95% CI, 0,32-0,81). Interobserver agreement was worst between observer 1 and 2 (Kappa 0,42, 95% CI, 0,13-0,7) , but better between the trainer and trainee (0,51, 95% CI, 0,21-0,81). The number of targets for biopsies indicated on all 37 pictures was 85, 44 and 47 for observer 1,2 and 3 respectively. This difference was due to a significant higher proportion of pictures classified as “patchy distribution” by observer 1 (Fischer's exact p < 0,05). When observers agreed on a patchy distribution and indicated sites to target for biopsy, the proportion of target agreement was 67%, 74% and 68% between observer 1/2, observer 2/3 and observer 1/3 respectively and not significantly different(Fisher's exact, NS). Conclusion: Interobserver variability for the classification of CEMB is only moderate and better between endoscopists performing chromoendoscopy regularly. The agreement between different observers to target a site for biopsy is ±70%.

Small cell carcinoma arising in Barrett's esophagus: a case report and review of the literature

IntroductionGastrointestinal tract small cell carcinoma is an infrequent and aggressive neoplasm that represents 0.1–1% of gastrointestinal malignancies. Very few cases of small cell esophageal carcinoma arising in Barrett's esophagus have been reported in the literature. An extremely rare case of primary small cell carcinoma of the distal third of the esophagus arising from dysplastic Barrett's esophagus is herein presented.Case presentationA 62-year-old man with gastroesophageal reflux history presented with epigastric pain, epigastric fullness, dysphagia, anorexia, and weight loss. Esophagogastroscopy revealed an ulceroproliferative, intraluminar mass in the distal esophagus obstructing the esophageal lumen. Biopsy showed small cell esophageal carcinoma. Contrast-enhanced chest and abdominal computed tomography demonstrated a large tumor of the distal third of the esophagus without any lymphadenopathy or distant metastasis. Preoperative chemotherapy with cisplatine and etoposide for 3 months resulted in a significant reduction of the tumor. After en block esophagectomy with two field lymph node dissection, proximal gastrectomy, and cervical esophagogastric anastomosis, the patient was discharged on the 14th postoperative day. Histopathology revealed a primary small cell carcinoma of the distal third of the esophagus arising from dysplastic Barrett's esophagus. The patient received another 3 month course of postoperative chemotherapy with the same agents and remained free of disease at 12 month review.ConclusionAlthough small cell esophageal carcinoma is rare and its association with dysplastic Barrett's esophagus is extremely infrequent, the high carcinogenic risk of Barrett's epithelium should be kept in mind. Prognosis is quite unfavorable; a better prognosis might be possible with early diagnosis and treatment strategies incorporating chemotherapy along with oncological radical surgery and/or radiotherapy as part of a multimodality approach. Since treatment protocols are not well established due to the rarity of the neoplasm, multi-institutional studies are needed to obtain sufficiently large populations for investigation and optimization of therapy of the disease.

Hypermethylation of Tachykinin-1 Is a Potential Biomarker in Human Esophageal Cancer

Our aim was to investigate whether and at what stage hypermethylation of the tachykinin-1 (TAC1) gene is associated with human esophageal neoplastic transformation. TAC1 promoter hypermethylation was examined by real-time methylation-specific PCR in 258 human esophageal specimens and 126 plasma samples from patients or tissues at various stages of neoplastic evolution. TAC1 hypermethylation in tissue samples showed highly discriminative receiver-operator characteristic curve profiles, clearly distinguishing esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) from normal esophagus (P < 0.0001). Both frequencies and normalized methylation values of TAC1 tissue methylation were significantly higher in Barrett's metaplasia (BE), dysplastic Barrett's esophagus, EAC, and ESCC than in normal esophagus (P < 0.01). The frequency of TAC1 hypermethylation increased dramatically and early during neoplastic progression, from 7.5% in normal esophagus to 55.6% in BE from patients with Barrett's metaplasia alone, 57.5% in dysplastic Barrett's esophagus, and 61.2% in EAC. There was a significant relationship between TAC1 hypermethylation and BE segment length, a known clinical risk factor for neoplastic progression. Twelve (50%) of 24 ESCC exhibited TAC1 hypermethylation. Overall patient survival correlated significantly with TAC1 methylation status in ESCC patients (mean survival, 22 versus 110 months; P = 0.0102, log-rank test), but not in EAC patients. Both mean normalized methylation values and frequency of TAC1 hypermethylation in plasma samples were significantly higher in EAC patients than in control subjects. Treatment of KYSE220 ESCC and BIC EAC cells with 5-aza-2'-deoxycytidine reduced TAC1 methylation and increased TAC1 mRNA expression. TAC1 promoter hypermethylation is a common event in both major histologic types of human esophageal carcinoma, occurs early, correlates with other progression risk factors in esophageal adenocarcinogenesis, and is a tissue biomarker of a poor prognosis in ESCC. Circulating methylated TAC1 promoter DNA also offers potential as a biomarker for the diagnosis of EAC.

Characterization of tissue autofluorescence in Barrett's esophagus by confocal fluorescence microscopy

High grade dysplasia and early cancer in Barrett's esophagus can be distinguished in vivo by endoscopic autofluorescence point spectroscopy and imaging from non-dysplastic Barrett's mucosa. We used confocal fluorescence microscopy for ex vivo comparison of autofluorescence in non-dysplastic and dysplastic Barrett's esophagus. Unstained frozen sections were obtained from snap-frozen Barrett's esophagus biopsy samples and scanned with confocal fluorescence microscopy (458 nm excitation; 505-550 nm [green] and > 560 nm [red] emission). Digital micrographs were taken from areas with homogenous and specific histopathology. Visual inspection and statistical analysis were used to evaluate the image datasets. Dysplastic and non-dysplastic Barrett's esophagus epithelia fluoresced mainly in the green spectrum and the main sources of autofluorescence were the cytoplasm and lamina propria. High-grade dysplasia was differentiated from non-dysplastic Barrett's esophagus by microstructural tissue changes. However, there were no specific changes in either the locations or average intensities of intrinsic green and red autofluorescence at the epithelial level that could differentiate between dysplastic and non-dysplastic Barrett's esophagus epithelia, ex vivo. Detectable differences in autofluorescence between BE and dysplasia/cancer in vivo are probably not caused by specific changes in epithelial fluorophores but are likely due to other inherent changes (e.g. mucosal thickening and increased microvascularity) attenuating autofluorescence from the collagen-rich submucosa. Furthermore, confocal fluorescence microscopy provides 'histology-like' imaging of Barrett's tissues and may offer a unique opportunity to exploit microstructural tissue changes occurring during neoplastic transformation for in vivo detection of high-grade dysplasia in Barrett's patients using newly developed confocal fluorescence microendoscopy devices.

Radiofrequency Ablation for Dysplastic Barrett's Esophagus Including Post-PDT Salvage Therapy Using the HALO360 and HALO90 Ablation Systems - The Duke Experience

Background & Aim: Barrett's esophagus (BE) is a well-known premalignant condition that can be associated with the development of dysplasia and adenocarcinoma. A number of endoscopic ablative therapies have been attempted in BE. These include thermal modalities that use laser irradiation, multipolar electrocoagulation, argon plasma coagulation (APC), photodynamic therapy (PDT), or radiofrequency energy (RFA). The aim of this study is to report our outcomes using the HALO360 and HALO90 RFA Systems (BÂRRX Medical, Sunnyvale, CA) for the endoscopic ablation of BE with dysplasia, including a report on patients who previously have undergone ablation with PDT without complete endoscopic response (CER) and/or complete histologic response (CHR). Methods: A retrospective analysis from our electronic database of patients with BE and dysplasia who have undergone treatment with the HALO360 and HALO90 RFA Systems was performed. Inclusion criteria included patients with BE and either low-grade (LGD) or high-grade dysplasia (HGD) diagnosed after adequate acid suppressive therapy with a PPI. Histopathology was confirmed by expert pathologists. Patients who had previously undergone treatment with PDT were also included. Following RFA therapy, esophageal biopsies were obtained as per the Seattle protocol every 3 months to assess for residual BE and dysplasia. Results: 12 patients with dysplasia were treated for a total of 25 RFA sessions. 9 patients had at least one follow-up endoscopy with biopsies. All subjects were males with a mean age of 59 yrs and an age range of 38 to 77 yrs. Prior to RFA therapy, 6/12 (50%) patients had LGD and 6/12 (50%) had at least focal HGD. The mean length of BE with LGD was 7.33 cm and the mean length of BE with at least focal HGD was 4.5 cm. The mean # of ablation sessions was 2.08. The mean # of post-ablation biopsy sessions was 1.66. Following RFA therapy, 8/9 (89%) patients had some favorable endoscopic response, and 5/9 (55.5%) had some favorable histologic response. Further analysis revealed that 4/9 (44%) had CER and CHR, and a further 4/9 (44%) had partial endoscopic response (PER). Also, 3/9 (33%) status post PDT for HGD who had residual disease (both non-CER and non-CHR) were treated with RFA. Following RFA in this post-PDT subset, 2/3 (66.6%) were found to have PER and partial histologic response (PHR), and one patient had a CER and CHR. No significant adverse events were reported. Conclusions: Radiofrequency ablation for dysplastic Barrett's esophagus utilizing the HALO360 and HALO90 ablation system is safe and effective. This therapy also appears to be promising in patients with residual BE and dysplasia following PDT.

Chromoendoscopy with Methylene Blue Helps to Localize Dysplasia in Patients with Suspicion of Dysplastic Barrett's Esophagus

Background: Chromoendoscopy with methylene blue (MB) has yielded controversial results in the detection of dysplasia in Barrett's esophagus. Some studies showed a significant better detection of dysplasia using MB directed biopsies (Canto et al 2000, Gossner et al 2000), but this was not confirmed by others (Ragunath et al 2003, Lim et al 2006). The aim of the current study was to test chromoendoscopy with MB as a means of localizing dysplasia in patients referred with suspected Barrett's dysplasia.

Barrettʼs esophagus

Barrett's esophagus continues to be a popular topic among clinicians and researchers alike. Population based studies have finally been undertaken to better identify subset populations at high risk of developing Barrett's esophagus, and possible better tolerated alternatives to standard endoscopy for cost-effective screening. In addition, several studies over the past year have marked a transition from identifying those with Barrett's esophagus and in need of intensive surveillance, to an increasing number of novel treatment therapies that are now primed to move from experimental protocols to clinical practice. Obesity's role as a risk factor for the development of Barrett's esophagus continues to be better defined. Various disorders affecting the motility of the gastrointestinal tract, such as celiac sprue and scleroderma, and their relationship with Barrett's esophagus development are becoming more widely recognized. The use of endoscopic mucosal resection and photodynamic therapy for treatment of dysplastic Barrett's esophagus continues to gain increased acceptance, with an additional wealth of supportive data for its effectiveness becoming available. The past year has brought many advances in the epidemiology and endoscopic treatment of those with Barrett's esophagus. Clinicians will benefit from this review of these advances to ensure better patient outcomes.

Uses of Photodynamic Therapy in Premalignant and Malignant Lesions of the Gastrointestinal Tract Beyond the Esophagus

Much has recently been written regarding the use of photodynamic therapy for the treatment of esophageal carcinoma and dysplastic Barrett's esophagus. This review, however, describes the clinical experience using photodynamic therapy with various photosensitizer agents for the treatment of diseases in other areas of the gut, especially the pancreaticobiliary tract where European studies have established the role of porfimer sodium photodynamic therapy in the management of patients with cholangiocarcinoma.

Advances in Barrett’s Esophagus and Esophageal Adenocarcinoma

Despite advances in diagnosis and therapy, esophageal adenocarcinoma remains an aggressive and usually lethal tumor. This review focuses on the epidemiology of esophageal adenocarcinoma and its presumed precursor lesion, Barrett's esophagus; the pathogenesis of the cancer; advances in treatment of adenocarcinoma and Barrett's esophagus; and strategies for cancer prevention. Emphasis is placed on recent literature. Although the absolute number of cases of adenocarcinoma in the United States is still small, the incidence of this cancer has increased dramatically in the last 40 years, and adenocarcinoma is now the predominant form of esophageal cancer in this country. Recent evidence suggests that Barrett's esophagus is more prevalent in asymptomatic individuals than previously appreciated. The pathogenesis of Barrett's esophagus is poorly understood. Given that some subjects will have repeated bouts of severe erosive esophagitis and never develop Barrett's esophagus, host factors must play an important role. The utility of neoadjuvant radiation and chemotherapy in those with adenocarcinoma, although they are widely practiced, is not of clear benefit, and some authorities recommend against it. Ablative therapies, as well as endoscopic mucosal resection, hold promise for those with superficial cancer or high-grade dysplasia. Most series using these modalities feature relatively short follow-up, and longer-term data will be necessary to better describe the effects of these therapies. The value of chemoprevention in subjects with dysplastic Barrett's esophagus by use of cyclooxygenase 2 inhibitors, nonsteroidal anti-inflammatory drugs, or proton pump inhibitors is unknown. Similarly, although endoscopic screening is widely practiced, its value in patients with chronic gastroesophageal reflux disease symptoms is of unproven value, and recommending bodies are divided as to its practice.

Endoscopic ablation of dysplastic Barrett's oesophagus comparing argon plasma coagulation and photodynamic therapy: A randomized prospective trial assessing efficacy and cost-effectiveness

ObjectiveEndoscopic 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.Material and methodsTwenty-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.ResultsAll 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 for every percentage reduction in Barrett's length and £146 per percentage reduction in dysplasia compared with APC treatment.ConclusionsAPC 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.

Molecular evaluation of ablative therapy of Barrett's oesophagus

Barrett's oesophagus is a major risk factor for developing oesophageal adenocarcinoma. Ablation by argon plasma coagulation (APC) and photodynamic therapy (PDT) is currently under investigation for the removal of metaplastic and dysplastic Barrett's oesophagus. This study examined the effect of ablative therapy on Barrett's oesophagus at cell-cycle and genetic levels. The premalignant potential of residual or recurring Barrett's oesophagus was assessed by p53 immunohistochemistry, Ki67-related proliferative capacity, and DNA ploidy status (ie an abnormal chromosome 1 number) as measured by interphase in situ hybridization. Twenty-nine patients with Barrett's oesophagus (23 male and 6 female, mean age 58 years, mean length of Barrett's oesophagus 4 cm) were treated with APC or PDT. Intestinal metaplasia without dysplasia was present in 16 patients, low-grade dysplasia in five, and high-grade dysplasia in eight patients. Biopsy samples were obtained at regular intervals (mean follow-up 20 months, range 6-36 months). One month after the first ablation, Barrett's oesophagus was no longer identified, either endoscopically or histologically, in nine patients (32%). At this time point, significant down-grading was achieved for abnormal chromosome 1 numbers (p = 0.020) and Ki67-defined proliferation (p = 0.002). Patients with residual Barrett's oesophagus were additionally treated with APC, resulting in the elimination of Barrett's oesophagus in 76% of all patients. However, at the last follow-up endoscopy, metaplasia without dysplasia was still present in five patients, and low- and high-grade dysplasia were each present in one patient. An abnormal chromosome 1 number and p53 protein overexpression were detected only in the high-grade dysplastic lesion, but increased proliferation was still present in the majority of these persisting cases. Although endoscopic removal of Barrett's oesophagus by ablative therapies is possible in the majority of patients, histologically complete elimination cannot be achieved in all cases. Persistent Barrett's oesophagus may still harbour molecular aberrations and must therefore be considered still to be at risk of progression to adenocarcinoma.

Photodynamic therapy for dysplastic Barrett's oesophagus and early cancer

Cancer in the columnar-lined oesophagus develops through a multi-step process initiated by chronic gastro-oesophageal reflux progressing through metaplasia, low-grade dysplasia to high-grade dysplasia, which currently remains the best marker of cancer risk. Destruction of dysplasia using photodynamic therapy and other endoscopic methods may prevent cancer development. The potential problem in the columnar-lined oesophagus is surface limited to a depth of 0.6mm. Re-surfacing the oesophagus eradicates the disease and offers the possible prevention of progression. Mucosal ablation with lasers, electro- and argon plasma coagulators, photodynamic therapy and endoscopic mucosal resection can remove dysplasia and allow regeneration of neo-squamous mucosa following acid reflux control usually with high-dose proton pump inhibitor therapy. Endoscopic mucosal resection is very effective when there is a localised visible mucosal abnormality. Multifocal dysplasia carries a greater chance of malignant degeneration, and photodynamic therapy is more useful for widespread and potentially extensive disease. The only randomised partially blinded trial for prevention of cancer in Barrett's oesophagus has demonstrated a significant reduction in cancer progression following endoscopic photodynamic therapy. A multimodal approach to the management of dysplasia in Barrett's oesophagus is necessary combining endoscopic mucosal resection, photodynamic therapy and thermal ablation. Currently dysplastic Barrett's is the major target of therapy, the treatment of metaplasia should currently be part of an investigative study.

Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease

Endoscopic screening and periodic surveillance for patients with Barrett's esophagus has been shown to be cost-effective in patients with esophageal dysplasia, with treatment for esophageal cancer limited to esophagectomy. Most gastroenterologists refer patients with high-grade dysplasia for esophagectomy, and effective endoscopic therapies are available for nonoperative patients with esophageal cancer. The cost-effectiveness of screening strategies that incorporate these nonsurgical treatment modalities has not been determined. We designed a Markov model to compare lifetime costs and life expectancy for a cohort of 50-year-old men with chronic reflux symptoms. We compared 10 clinical strategies incorporating combinations of screening and surveillance protocols (no screening, screening with periodic surveillance for both dysplastic and nondysplastic Barrett's esophagus, or periodic surveillance for dysplasia only), treatment for high-grade dysplasia (esophagectomy or intensive surveillance), and treatment for cancer (esophagectomy or surgical and endoscopic treatment options). Screening and surveillance of patients with both dysplastic and nondysplastic Barrett's esophagus followed by esophagectomy for surgical candidates with high-grade dysplasia or esophageal cancer and endoscopic therapy for cancer patients who were not operative candidates cost $12,140 per life-year gained compared to no screening. Other screening strategies, including strategies that had no endoscopic treatment options, were either less effective at the same cost, or equally effective at a higher cost. The cost-effectiveness of screening and subsequent surveillance of patients with dysplastic as well as nondysplastic Barrett's esophagus followed by endoscopic or surgical therapy in patients who develop cancer compares favorably to many widely accepted screening strategies for cancer.

Photodynamic Therapy for Dysplastic Barrett's Esophagus and Mucosal Adenocarcinoma

Photodynamic Therapy for Dysplastic Barrett's Esophagus and Mucosal Adenocarcinoma

Narrow Band Imaging Endoscopy for the Detection of Dysplastic and Non Dysplastic Barrett's Esophagus

The distribution of metaplastic (IM) and dysplastic epithelium within the Barrett's esophagus (BE) segment is patchy requiring random biopsies. The use of new techniques to identify these high yield areas would be helpful.The sequential lighting method in video endoscopes have a rotation disk with RGB (red,green,blue) optical filters in front of a white light source (xenon lamp). Narrow Band Imaging (NBI) is a novel technique which changes these optical filters to spectral narrow band filters. The penetration depth of light is dependent on its wavelength with visible blue light penetrating only superficial areas of the tissue. Therefore, use of blue light with the help of a special NB filter (415 nm, 445 nm, 500 nm) will enable imaging of the superficial tissue structures. AIM: To study the clinical utility of NBI endoscopy in pts with suspected BE. METHODS: Patients suspected with BE were studied with a standard magnification endoscope (Olympus GIF 240Z,115×) using a NBI light source. NBI endoscopy provided a striking contrast between the squamous and columnar mucosa in the distal esophagus without dye spraying. Specific capillary and mucosal patterns within the BE segment were identified, biopsied and read by pathologists blinded to endoscopic findings. RESULTS: 51 patients with a mean age of 64 years (range: 43-85 yrs) and a mean BE length of 3.5 cms (range: 0.5-16 cms) have been studied using NBI. 24 patients had IM without dysplasia,10 had low grade dysplasia (LGD), 9 had high grade dysplasia (HGD) and 8 without IM/dysplasia. All patients with IM without dysplasia had a fine capillary pattern showing a normal size, shape and distribution of small blood vessels and a ridge/villous mucosal pattern; whereas all 9 HGD patients had an abnormal capillary pattern- increased number, tortous, dilated, corkscrew type small blood vessels. All except 1 LGD patient had a similar pattern as IM. The sensitivity and specificity of the ‘normal capillary pattern’ to rule out HGD were 97.8% and 100% respectively; whereas it's sensitivity and specificity to detect non dysplastic tissue were 100% and 53% respectively. All long BE and 71% of short BE patients were identified with NBI. CONCLUSIONS: By changing the spectral feature of the observation light, NBI endoscopy provides a high quality and sharp contrast image of the BE segment without using dye spray (chromoscopy). It also provides a detailed image of the capillary and mucosal patterns in BE patients with a high accuracy for the detection of dysplastic and non dysplastic tissue.