Management Of High-grade Dysplasia Research Articles

High grade dysplasia or esophageal adenocarcinoma in patients with a history of Roux-en-Y gastric bypass surgery: a case series

Roux-en-Y gastric bypass (RYGB) is the favored bariatric option in patients with gastroesophageal reflux and Barrett's esophagus because it prevents reflux. Weight loss and decreased reflux following RYGB could theoretically minimize the risk of progression to cancer. We aimed to demonstrate the management of high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) developing in patients after RYGB. A prospectively maintained database was searched to identify cases of HGD and cancer in RYGB patients. Charts were reviewed for past history, endoscopic findings, endoscopic therapy, and pathology findings. There were five cases where HGD/EAC developed several years after RYGB. The prior bariatric surgery precluded curative esophagectomy, illustrating the management challenges. All but one of the patients were uniquely and successfully managed with endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). RYGB patients are still at risk of developing esophageal cancer. Patients at risk should be screened prior to RYGB and those with Barret's esophagus need to undergo rigorous endoscopic surveillance following surgery. If detected early, EMR and ESD are invaluable in managing those who progress.

Coding of Barrett’s oesophagus with high-grade dysplasia in national administrative databases: a population-based cohort study

ObjectivesThe International Classification of Diseases 10th Revision (ICD-10) system used in the English hospital administrative database (Hospital Episode Statistics (HES)) does not contain a specific code for oesophageal high-grade dysplasia...

Management of Barrett’s high-grade dysplasia: initial results from a population-based national audit

Previous studies reported significant variation in the management of patients with Barrett's esophagus. However, these are based on self-reported clinical practice. The aim of this study was to examine the management of high-grade dysplasia in Barrett's esophagus in England by using patient-level data and to compare practice with guidelines. From April 2012 to March 2013, National Health Service (NHS) trusts in England prospectively collected data on patients newly diagnosed with high-grade dysplasia (HGD) of the esophagus as part of the National Oesophago-Gastric Cancer Audit. Data were collected on patient characteristics, diagnosis and endoscopic findings, treatment planning, and therapy. Between April 2012 and March 2013, NHS trusts reported 465 cases of HGD. Diagnosis was confirmed by a second pathologist in 79.4% of cases (270/340), and 86.0% (374/465) had their treatment planned at a multidisciplinary team meeting. A total of 290 patients (62.4%) were managed endoscopically (frequently with endoscopic resection or radiofrequency ablation), whereas 26 patients (5.6%) had esophagectomy. The proportion of patients managed by surveillance varied by age (P < .001), ranging from 19.5% in patients aged <65 years to 63.8% in patients aged ≥85 years. More patients received active treatment if their cases were discussed at a multidisciplinary meeting (73.5% vs 44.3%; P < .001) or managed at higher-volume trusts (87.8% vs 55.4%; P < .001). There was marked variation in the management of HGD across England, with a third of patients receiving no active treatment. Patients discussed at a specialist multidisciplinary meeting or managed in high-volume trusts were more likely to receive active treatment.

Management of high grade dysplasia in Barrett's oesophagus with underlying oesophageal varices: A retrospective study

BackgroundEndoscopic treatment of Barrett's oesophagus leading to high grade dysplasia with oesophageal varices may lead to bleeding complications. AimsEstimate effectiveness of endoscopic band-ligation in oesophageal varices patients treated for high grade dysplasia, and compare to endoscopically treated non-oesophageal varices high grade dysplasia patients. MethodsRetrospective comparative study. All 8 high grade dysplasia patients with varices who were treated initially with band-ligation at Mayo Clinic between 8/1/1999 and 2/28/2014 were compared with reference group of 52 high grade dysplasia patients treated endoscopically. ResultsOne high grade dysplasia patients patient with oesophageal varices (12.5%) achieved complete remission of intestinal metaplasia defined by at least one followup endoscopy with normal biopsies, and 3 (37.5%) achieved complete remission of dysplasia defined by at least one followup endoscopy with non-dysplastic biopsies. 39 (75.0%) endomucosal resection/radiofrequency ablation patients experienced at least one followup endoscopy with normal biopsies, and 49 (94.2%) experienced non-dysplastic biopsies. Both of these endpoints occurred significantly more often in the endomucosal resection/radiofrequency ablation group compared to the high grade dysplasia with oesophageal varices group (p=0.016 and p=0.025, respectively). ConclusionsHigh grade dysplastic Barrett's can be safely managed with band-ligation. However, resolution of Barrett's epithelium is rarely achieved with banding alone.

Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma

BackgroundThe introduction of endoscopic techniques has led to debate about optimal management of early oesophageal adenocarcinoma. The aim was to evaluate patient selection and outcomes for endoscopic or surgical treatment at a tertiary referral centre. MethodsA prospectively collected database of consecutive patients staged with high-grade dysplasia (HGD) or T1 oesophageal adenocarcinoma treated with curative intent between 2005 and 2013 was undertaken. All patients were discussed at the multidisciplinary team meeting. Surgical treatment was by thoracoscopic assisted or standard/laparoscopic assisted Ivor Lewis oesophagectomy. Endoscopic treatment was a structured programme of endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA). Outcomes included treatment variables, recurrence and complications. Results83 patients treated; 50 with endoscopic therapy (EMR only-4, EMR then RFA-22, RFA only-24) and 38 by surgery (33 straight to surgery and 5 following EMR). Median age (67) and mean follow-up (21 months) were similar. HGD was more common in the endoscopic group (32/50, 64%, vs.3/33, 9%, p = 0.0001). Significant complications were more common following surgery (13/38, 34%, vs. 1/50, 2%, p = 0.0001). There were two in-hospital deaths following oesophagectomy (1 open, 1 thoracoscopic). Endoscopic treatment beyond 12 months for persisting HGD/intramucosal disease was required in 2 patients. Recurrence of HGD/invasive cancer was diagnosed in 2/36 (5.6%, T1a recurrence) of endoscopic and 1/38 (2.6%, T2N0 - subsequent hepatic metastases) surgical patients. ConclusionA management algorithm including both endoscopic treatment and oesophagectomy provides optimal outcome for these patients. Due to additional morbidity of surgery, endoscopic treatment is appropriate first-line treatment.

PTU-147 Validation Of Updated Barrett’s Oesophagus Guideline Recommendations: Complications And Outcomes Of An ‘adequate’ Case Volume And The Feasibility Of Same Day Discharge

IntroductionRecent advances in the management of high grade dysplasia and early cancer in Barrett’s oesophagus (BO) have led to updated guidelines recommending endoscopic resection (ER) as a first line option...

Su1475 Cost Effectiveness of an ER Dominant Approach in the Management of High Grade Dysplasia in Barrett's Oesophagus

Endoscopic resection (ER) is an established effective treatment in the US and Europe for high grade intraepithelial neoplasia (HGIN) and intramucosal cancer (IMC) arising in Barrett's oesophagus. Little data has been published on the outcome of ER in the UK. Radiofrequency ablation (RFA) is an alternative treatment strategy for the treatment of flat HGIN.

Management of High-Grade Dysplasia and Intramucosal Adenocarcinoma in Barrett's Esophagus

A 62-year-old Caucasian male with chronic long-standing gastroesophageal reflux disease and a history of nondysplastic Barrett's esophagus (BE) undergoes surveillance upper endoscopy with biopsies at an outside facility. Biopsies revealed high-grade dysplasia (HGD) and the patient is referred to a tertiary care referral center for endoscopic eradication therapy (EET). His symptoms are adequately controlled on twice daily proton pump inhibitor therapy, and he denies any alarm symptoms. His physical examination is unremarkable with the exception of mild obesity.

Barrett's Dysplasia Cancer Task Force – Bad Cat: A Global, Multidisciplinary, Consensus on the Management of High Grade Dysplasia and Early Mucosal Cancer in Barrett's Esophagus

Barrett's Dysplasia Cancer Task Force – Bad Cat: A Global, Multidisciplinary, Consensus on the Management of High Grade Dysplasia and Early Mucosal Cancer in Barrett's Esophagus

Is surveillance of Barrett's oesophagus cost-effective when endotherapy is used to treat high grade dysplasia or early cancer in Barrett's oesophagus?

Introduction There is emerging interest in the role of endotherapy in the management of high grade dysplasia (HGD) and intra-mucosal cancer in Barrett9s oesophagus (BO). We have previously shown that stepwise endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) for visible HGD and RFA for flat HGD is cost-effective compared to photo-dynamic therapy or oesophagectomy.1 Aim To assess the cost-effectiveness of surveillance of Barrett9s oesophagus when EMR-RFA for visible HGD and RFA for flat HGD is used to treat HGD or intra-mucosal cancer in BO. Methods A Markov model was created using a base population of 1000 50-year-old Caucasian males with BO followed to 75 years of age. All patients were assumed to be fit for oesophagectomy. Surveillance intervals were compared with strategies of no surveillance and surveillance with oesophagectomy for HGD. Cost-effectiveness was expressed as net amount per quality adjusted life year (QALY) and base-costs for treatment were obtained from the Department of Health HRG tariffs for 2007/2008. Monte Carlo simulation and probabilistic sensitivity analysis were carried out. Results 2-yearly surveillance with endoscopic therapy to treat HGD/intra-mucosal cancer in BO was the most cost-effective option yielding an incremental cost-effectiveness ratio (ICER) of 13,447 compared to no surveillance and other surveillance intervals (1, 2, 3, 4 and 5-yearly) and when no endotherapy was used as a comparative strategy. It was also more cost effective than a strategy of oesophagectomy for HGD/intra-mucosal cancer. Conclusion 2-yearly surveillance of BO is cost-effective when endotherapy is used to treat HGD and intra-mucosal cancer in BO.

S1517: Complete Barrett's Eradication Endoscopic Mucosal Resection (CBE-EMR): Long-Term Results of Management of High Grade Dysplasia (HGD) and Intramucosal Carcinoma (IMC)

CBE-EMR is endoscopic removal of all Barrett epithelium with the intent of eliminating high-grade dysplasia (HGD)/intramucosal carcinoma (IMC) and reducing the risk of metachronous lesion development.

The role of endoscopic ultrasonography in Barrett's esophagus and early esophageal cancer

Endoscopic ultrasonography is established as the most accurate modality for the local staging of esophageal neoplasms. The minimally invasive management of high-grade dysplasia and early intramucosal cancer arising in Barrett's esophagus is in evolution, with the emergence of endoscopically delivered ablative therapies challenging the more conventional treatment of esophagectomy. The precise staging of these patients for depth of tumor penetration, lymph node status, and potential hematogenous metastases, is therefore crucial before considering a minimally invasive treatment strategy. The evidence suggests that endoscopic ultrasonography can successfully differentiate early (T1) from advanced intramural disease, but it is poor at differentiating mucosal from submucosal lesions. Its role in managing patients with early disease therefore appears to be limited, although it does appear valuable for detecting associated malignant lymphadenopathy.

Transoral Endoscopic Inner Layer Esophagectomy: Management of High-Grade Dysplasia and Superficial Cancer with Organ Preservation

IntroductionLimitations of endoscopic therapies for Barrett’s esophagus and superficial cancer include a compromised histological assessment, the need for surveillance, subsequent procedures, and stricture formation. Circumferential en bloc resection of the mucosa–submucosa complex followed by deployment of a biologic scaffold onto the remaining muscularis propria may address these concerns. The objective of this study was to determine technical feasibility of transoral resection of the esophageal lining. Materials and MethodsTransoral endoscopic inner layer esophagectomy was performed in ten swine. Endpoints included procedure duration, hemorrhage, number of perforations, and adequacy of resection length and depth. ResultsProcedures were successfully completed in all animals without perioperative mortality. Procedure times averaged 179 min (range 125–320). No perforations were found, and a mean of 1.7 (0–4) interventions for hemorrhage was required. Complete longitudinal resection was achieved in nine of ten animals. Resection depth included all mucosal layers in 100% of tissue sections, the submucosal layers, SM1 in 100%, and SM2 in 96%. A portion of SM3 was adherent to the muscularis propria in 70%. ConclusionTransoral endoscopic resection of the inner esophageal layers was feasible and reproducible. This technique may facilitate a single-step definitive treatment and staging tool for early neoplastic lesions, obviating the need for esophagectomy.

Hybrid Therapy with EMR and RFA Throughout Treatment Sessions for Barrettʼs Neoplasia

Purpose: Patients with high grade dysplasia (HGD) and intramucosal carcinoma (IMC) in the setting of Barrett's esophagus (BE) may undergo a combination of modalities to achieve total Barrett's eradication (TBE). Initial EMR of any visible lesions followed by a radiofrequency ablation (RFA) in repeated sessions is emerging as a method to achieve TBE. Our aim is to report our initial experience with a combined approach of EMR and RFA to treat both initial and follow up lesions in the management of HGD and IMC in BE. Methods: Patients referred to our institution for the treatment of BE with HGD and IMC were enrolled in a protocol for treating long segment BE with EMR of any suspicious abnormalities in initial or follow up visits and ablation of remaining epithelium with RFA. Detailed white light exams and exams with narrow band imaging and acetic acid were performed to look for suspicious abnormalities. Follow-up sessions were performed at 3-6 month intervals. Results: Sixteen patients entered the hybrid protocol between February 2007 and May 2009 (mean age 66.9 y; 3 F: 13 M). The average length of BE was 7.8 cm. Ten patients had visible lesions. Two patients were referred with a biopsy diagnosis of IMC, and the rest had HGD. A total of 61 treatment sessions were performed with 40 EMR sessions, 20 circumferential RFA sessions, and 21 focal RFA applications. 16 sessions employed a combination of EMR and RFA. An average of 7 EMRs were performed per patient with total of 111 EMR specimens. The 2 patients with IMC had only HGD on their first EMR, whereas 3 patients with a pretreatment diagnosis of HGD were upstaged to IMC after initial EMR. Thirty-five EMR sessions were performed after an RFA session to diagnose and treat the residual BE, and 16 of these yielded pathology of HGD. Eradication of dysplasia has been achieved in 4 patients, 3 of whom also have eradication of BE. The remaining patients were still undergoing treatment sessions. Six patients have experience esophageal stenoses, managed with endoscopic dilations (median 1.5). One patient required multiple dilations and steroid injection. Conclusion: The accurate histopathologic diagnosis and deliberate treatment of neoplasia in BE may require a combination of EMR and RFA not only at the initial sessions, but also in the treatment of follow-up sessions. The most effective way to manage residual areas of neoplasia needs to be addressed.

Endoscopic and Endosonographic Predictors of Cancer in Patients with Barrett's Esophagus and High Grade Dysplasia

Background: Barrett's esophagus (BE) with high grade dysplasia (HGD) may have co-existent esophageal carcinoma and as a result traditional treatment has been esophagectomy. There has been increasing interest in endoscopic therapy as a viable alternative to esophagectomy in the management of HGD but little data exists to correctly guide patients between these treatment options. Aim: We studied patients referred for Endoscopic Ultrasound (EUS)/EGD who had BE with HGD to evaluate the ability of EGD and EUS to determine the presence of co-existing malignancy in HGD before therapy is instituted. Methods: All patients referred for evaluation of HGD in BE from October 2001 to November 2008 for EUS were included. Patients with prior biopsy proven carcinoma were excluded. A total of 53 patients met the above entry criteria. Analysis was performed to see if the findings of endoscopic nodularity, ulcer, stricture, length of BE, focal vs. multifocal HGD, or lesion seen on EUS staging predicted the presence of cancer. Cancer diagnosis was determined by histologic specimen and/or follow-up without evidence of cancer development. Mortality was confirmed for all patients as of November 2008. Results: A total of 30 out of 53 (57%) underwent esophagectomy. 5 patients had continued surveillance, 6 underwent photodynamic therapy, 6 endoscopic mucosal resection, 5 radiofrequency ablation, and 1 chemotherapy and radiation. The average length of follow-up for patients was 43 months (range 1 month to 84 months) with no new cases of adenocarcinoma. 11 patients out of 53 (20%) with HGD had proven esophageal cancer by histology. The mortality rate for the cohort was 2/53 (3.77%), both patients with proven carcinoma. Endoscopic findings of nodularity (p=0.004) and ulceration (p=0.01) predicted the presence of carcinoma. Other findings on endoscopy did not predict carcinoma including stricture (p=0.79), length of BE (p=0.11) or multifocal HGD (p=0.36). EUS stage greater than T0N0 significantly predicted cancer with an odds ratio of 49.4 and p value <0.0000001. One patient with flat HGD and a normal EUS exam was found to have intramucosal carcinoma. Conclusion: 1. The findings of nodularity and ulceration in patients with BE and HGD significantly predicts a co-existent cancer diagnosis. 2. EUS stage is the greatest independent predictor of carcinoma in patients with BE/HGD 3. Patients with flat HGD and negative EUS exam are very unlikely to have invasive cancer present and are thus are the best candidates for endoscopic therapy.

High-Grade Dysplastic Adenoma-like Mass Lesions are Not an Indication for Colectomy in Patients with Ulcerative Colitis

Purpose: The management of polypoid dysplasia in ulcerative colitis (UC) is evolving. Currently, the presence of dysplasia in flat mucosa is regarded to be an indication for colectomy in pts with UC. The management of high grade dysplasia in polypoid lesions is not well characterized. Our previous study observed that the presence of high grade dysplasia (HGD) in (adenoma-like mass lesions) ALMs in the absence of any synchronous flat dysplasia does not mandate colectomy (Scand J Gastroenterol 2008, in press). The aim of this study was to update with 4-years of additional follow-up on this previously reported cohort of 9 pts. Methods: Pathology and clinical databases were systematically searched for the presence of dysplastic lesions in inflammatory bowel disease (IBD) from 1997–2004. Nine previously reported pts were identified with UC who had HGD in DALMs in the absence of any synchronous flat dysplasia. Their pathology, endoscopy and clinical records were reviewed and updated from 2004–2008. Results: Seven of 9 (77%) pts had pancolitis. There were a total of 9 ALMs with HGD (polyps in the area of active colitis) in 8 pts and 1 sporadic adenoma (outside the region of active colits) with high-grade dysplasia in 1 pt. The polyps were found in varied locations in the colon: 1 (10%) in cecum, 3 (30%) in ascending colon, 1 (10%) in descending colon, 3 (30%) in sigmoid colon, and 2 (20%) in rectum. All polyps were adenomatous. The mean duration of disease was 23.3 yrs (10–46 yrs). There were 52 surveillance colonoscopies performed in this cohort (mean 5.8 colonoscopies/patient) between 1997–2008. The pts were followed for a mean of 124.5 months (100–147 months). Three of 9 pts (33%) had colectomy. No pts in this cohort were detected to have carcinoma in surveillance biopsies and/or in their resection specimens. Conclusion: Our follow-up data confirms and strengthens our previous findings that the presence of high grade dysplasia in ALMs does not mandate colectomy. Continued close observation is suggested in this pt cohort after complete excision of polyps is performed. Future prospective studies on large cohort of pts are required to fully validate our findings.

Management of high-grade dysplasia

High-grade dysplasia is the last stage before the development of adenocarcinoma. Despite the fact that the lesion is not yet invasive, it has tremendous potential to become malignant. The approach to the disease has clinicians divided between immediate intervention with surgical resection or continued endoscopic surveillance proof of the unclear natural history. Much knowledge has been acquired recently regarding application of surveillance and outcomes of esophageal resection. Also, many endoscopic techniques for treating high-grade dysplasia have been studied in depth. Results on their safety, efficacy, and complication rates have recently become available. This review analyzes the progress in the understanding and treatment of high-grade dysplasia during the past 24 to 36 months and examines how this new information plays a role in the disease's treatment algorithm.

Current practice in management of high-grade dysplasia in Barrett's oesophagus: The real problem

The management of high-grade dysplasia within Barrett's oesophagus is highly topical and indeed controversial. It is becoming clear that radical surgery may be excessive treatment for many patients. This is because the natural history is not understood with some indicating of rapid degeneration to cancer, others demonstrating a low rate of degeneration over many years. Early detection and optical diagnosis has allowed minimally invasive destruction using endoscopic mucosal resection, thermal ablation and photodynamic therapy. Long-term eradication is possible and is real alternative to surgical excision. The current practice is variable and there is a requirement for randomised evidence comparing endoscopic therapy with surgical excision. This is becoming more appropriate with the development of minimally invasive oesophagectomy.

High-grade dysplastic adenoma-like mass lesions are not an indication for colectomy in patients with ulcerative colitis

Objective. The management of high-grade dysplasia (HGD) in polypoid lesions in patients with ulcerative colitis (UC) is not well characterized. The purpose of this study was to characterize the clinical course of patients with HGD in adenoma-like dysplasia-associated lesion or masses (DALMs) in the absence of any synchronous flat dysplasia. We hypothesize that colectomy is not warranted in patients who undergo complete excision of adenoma-like DALMs with HGD in UC. Material and methods. Pathology and clinical databases were systematically searched for the presence of dysplastic lesions in inflammatory bowel disease from 1997 to 2004. Patients with UC who had adenoma-like DALMs were identified, and a subset with HGD lesions was defined as our study cohort. Results. A total of 102 patients with UC were identified. Thirty of them (29%) had adenoma-like DALMs without synchronous flat dysplasia; 9 of these patients (30%) had HGD in these lesions. Thirty-two surveillance colonoscopies were performed in this cohort (mean 3.6 colonoscopies/patient). The patients were followed for a mean of 76.5 months (52–99 months). Three out of 9 patients (33%) had colectomy. None of the patients in this cohort was detected to have carcinoma in surveillance biopsies and/or in the resection specimens. Conclusions. Our data suggest that the presence of HGD in DALMs does not warrant colectomy. Continued close observation is suggested in this patient cohort after complete excision of polyps. Further prospective evaluation of this patient population is merited.

Management of dysplasia in Barrett’s esophagus

Barrett’s esophagus (BE) is a well-established premalignant condition for the development of esophageal adenocarcinoma, a highly lethal cancer with a dismal 5-year overall survival rate. Histologic classification of dysplasia on endoscopic biopsies is the single most predictive biomarker for progression to cancer. Aggressive therapies for the treatment of low-grade dysplasia cannot be recommended, given its low risk of cancer progression and transient nature. Strategies proposed for the management of high-grade dysplasia include esophagectomy, intensive surveillance, and endoscopic therapies. Endoscopic mucosal resection is being used increasingly as a diagnostic and staging tool and as a treatment option in patients with high-grade dysplasia or mucosal adenocarcinoma. Of the ablative therapies, photodynamic therapy has the most extensive reported experience. Preliminary results of new ablative therapies such as radiofrequency ablation and cryoablation are promising. Future research should focus on long-term follow-up after endoscopic treatment and on the identification of high-risk groups using biomarkers and novel endoscopic tools.