Elsevier

Gastrointestinal Endoscopy

Volume 80, Issue 6, December 2014, Pages 971-983.e1
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Detection and staging of esophageal cancers within Barrett's esophagus is improved by assessment in specialized Barrett's units

https://doi.org/10.1016/j.gie.2014.03.051Get rights and content

Background

Identification and resection of mucosal abnormalities are critical in managing dysplastic Barrett's esophagus (BE) because these areas may harbor esophageal adenocarcinoma (EAC).

Objectives

To compare mucosal lesion and EAC detection rates in dysplastic BE in the community versus a BE unit and assess the impact of EMR on disease staging and management.

Setting

Tertiary referral center.

Patients

Patients with dysplastic BE.

Interventions

Reassessment with high-definition white-light endoscopy (HD-WLE), narrow-band imaging (NBI), and Seattle protocol biopsies. EMR performed in lesions thought to harbor neoplasia. Review of referral histology and endoscopies.

Main Outcome Measurements

Mucosal lesion and EAC detection rates in a BE unit versus the community. Impact of EMR on management.

Results

Sixty-nine patients were referred (88% male; median age, 69 years). At referral, HD-WLE/NBI use was 57%/14%, and Seattle protocol adherence was 20%. Eighteen patients had intramucosal cancer. Lesions were detected in 65 patients in the BE unit versus 29 patients at referral (P < .001). EMR was performed in 47 patients. BE unit assessment confirmed EAC in all 18 patients and identified 10 additional patients (56% increased cancer detection, P = .036); all 10 had lesions identified in the BE unit (vs 3 identified at referral). EMR in these patients found submucosal cancer (n = 4) and intramucosal cancer (n = 6), resulting in esophagectomy (n = 4) and chemoradiotherapy (n = 1).

Limitation

Academic center.

Conclusion

BE assessment at a BE unit resulted in increased lesion and EAC detection. EMR of early cancers was critical in optimizing patient management. These data suggest that BE unit referral be considered in patients with dysplastic BE.

Section snippets

Aims

In a cohort of patients with dysplastic BE identified in the community setting, we aimed to determine the additional detection rate of mucosal abnormalities and EACs identified in a BE unit. We aimed to compare endoscopy methods used in the community versus those used in a BE unit to see which factors contributed to overall lesion and cancer detection rates. We also aimed to assess the impact of EMR on histopathological staging and subsequent patient management.

Referrals

Consecutive patients referred to St. Vincent's Hospital Melbourne from November 2008 to September 2011 for management of dysplastic BE were prospectively entered into a central database. Patient demographic characteristics and the most advanced histology at and before referral and referral endoscopy details were recorded. These details, where provided, included BE extent, NBI use, presence and size of a hiatal hernia, and description of any mucosal abnormality.

Assessment

Systematic assessment by using

Patient details and histology at referral

Sixty-nine patients (61 male) were included in this study. Demographic and clinical details and the most advanced pathology at referral are summarized in Table 1.

The cases of 65 of 69 patients were reviewed by our GI pathologist (R.W.), with 4 unavailable for review. Fifty-five reviews resulted in agreement with the original histological grade. In 7 cases, there was downgrading (1 low-grade dysplasia [LGD] to IM, 6 HGD to LGD), and in 3 cases, there was upgrading (3 HGD to IMC). As such, the

Discussion

This is a large single-center experience of assessment and management of patients with dysplastic BE. Three important conclusions can be inferred from our results. The first is that systematic assessment of BE segments by experienced endoscopists with access to HD-WLE and NBI results in increased detection rates of mucosal abnormalities. Second, this increased detection correlates with an increased cancer detection rate. Finally, EMR of mucosal lesions harboring cancer is critical in staging

Conclusion

Assessment of patients with dysplastic BE at a BE unit resulted in improved detection of mucosal abnormalities and EAC. EMR of these early cancers was a critical step in determining a patient's appropriateness for endoscopic therapy. We currently recommend that referral to a BE unit be considered in all patients with dysplastic BE to optimize detection of the most advanced histopathology and to perform EMR for staging of early cancers where necessary before embarking on a definitive management

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this article.

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