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Barrett's Esophagus: Emerging Knowledge and Management Strategies.

Bhardwaj A, McGarrity TJ, Stairs DB, Mani H - Patholog Res Int (2012)

Bottom Line: Patients with BE have a greater than 40 folds higher risk of EAC compared with the general population.There is paucity of prospective data showing a survival benefit of screening or surveillance for BE.There is a need for identification of reliable clinical predictors or molecular biomarkers to risk-stratify patients who might benefit the most from screening or surveillance for BE.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center, 500 University Drive, P.O. Box 850, HU33, Hershey, PA 17033, USA.

ABSTRACT
The incidence of esophageal adenocarcinoma (EAC) has increased exponentially in the last 3 decades. Barrett's esophagus (BE) is the only known precursor of EAC. Patients with BE have a greater than 40 folds higher risk of EAC compared with the general population. Recent years have witnessed a revolution in the clinical and molecular research related to BE. However, several aspects of this condition remain controversial. Data regarding the true prevalence of BE have varied widely. Recent studies have suggested a lower incidence of EAC in nondysplastic BE (NDBE) than previously reported. There is paucity of prospective data showing a survival benefit of screening or surveillance for BE. Furthermore, the ever-increasing emphasis on healthcare cost containment has called for reexamination of the screening and surveillance strategies for BE. There is a need for identification of reliable clinical predictors or molecular biomarkers to risk-stratify patients who might benefit the most from screening or surveillance for BE. Finally, new therapies have emerged for the management of dysplastic BE. In this paper, we highlight the key areas of controversy and uncertainty surrounding BE. The paper discusses, in detail, the current literature about the molecular pathogenesis, biomarkers, histopathological diagnosis, and management strategies for BE.

No MeSH data available.


Related in: MedlinePlus

(a) Schematic representation of the Prague criteria for endoscopically suspected esophageal columnar metaplasia/Barrett's esophagus, Step 1: recognize the presence of hiatal hernia; Step 2: identify GEJ and record depth of scope insertion; Step 3: recognize suspected BE mucosa above the GEJ; Step 4: record the depth of scope insertion at the most proximal circumferential extent of BE; Step 5: record the depth of scope insertion at maximum extent of BE; Step 6: subtract the depth of insertion for circumferential and maximum extents from the depth of scope insertion at the GEJ to calculate C and M, respectively. *Endoscopically suspected columnar mucosa. Adapted from [16]. (b) endoscopic image of Barrett's esophagus for circumferential (C) and maximum (M) extent of columnar mucosa, corresponding to the schematic representation shown in Figure 1(a), (c) another endoscopic image of BE using narrow-band imaging (NBI). NBI is a high-resolution endoscopic tool that enhances mucosal surface details without the need for special dyes (electronic chromoendoscopy).
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fig1: (a) Schematic representation of the Prague criteria for endoscopically suspected esophageal columnar metaplasia/Barrett's esophagus, Step 1: recognize the presence of hiatal hernia; Step 2: identify GEJ and record depth of scope insertion; Step 3: recognize suspected BE mucosa above the GEJ; Step 4: record the depth of scope insertion at the most proximal circumferential extent of BE; Step 5: record the depth of scope insertion at maximum extent of BE; Step 6: subtract the depth of insertion for circumferential and maximum extents from the depth of scope insertion at the GEJ to calculate C and M, respectively. *Endoscopically suspected columnar mucosa. Adapted from [16]. (b) endoscopic image of Barrett's esophagus for circumferential (C) and maximum (M) extent of columnar mucosa, corresponding to the schematic representation shown in Figure 1(a), (c) another endoscopic image of BE using narrow-band imaging (NBI). NBI is a high-resolution endoscopic tool that enhances mucosal surface details without the need for special dyes (electronic chromoendoscopy).

Mentions: Historically, BE has been classified into short-segment (<3 cm) and long-segment BE (≥3 cm), based on the length of metaplastic epithelium seen on endoscopy [38]. A more recent classification takes into consideration the circumferential (C) and maximum (M) extent of the endoscopically visualized BE, above the GEJ. This system is called the Prague “C” and “M” criteria (Figures 1(a), 1(b) and 1(c)). The original C&M criteria were developed by an international working group using videoendoscopic recordings in 29 patients. To validate these standardized criteria, a separate panel of 29 expert endoscopists scored these recordings. The overall reliability coefficients (RCs) for the assessment of C and M extent were 0.95 and 0.94, respectively. The RCs for recognizing the location of the GEJ and the diaphragmatic hiatus were 0.88 and 0.85, respectively [16]. A recent multicenter study of gastroenterology trainees demonstrated correlation coefficients of 0.94 and 0.96, respectively, for assessment of the C and M extent of the endoscopically visualized BE. The correlation coefficients for recognition of GEJ and diaphragmatic hiatus were 0.92 and 0.90, respectively [39]. Kinjo et al. prospectively compared endoscopic BE diagnoses using the Japanese criteria (GEJ defined as the distal limit of the longitudinal or palisade vessels in the lamina propria of the esophagus) and Prague C&M criteria in 110 Japanese patients. A higher proportion of patients were diagnosed with endoscopic BE using the Japanese criteria (39%) compared with C&M criteria (26%) (P = 0.044). The GEJ identification rates were also higher using the Japanese criteria than with C&M criteria (95% versus 86% (P = 0.039)). The authors concluded that, in the Japanese population, the Japanese criteria may be more suitable for the diagnosis of endoscopic BE and for recognition of GEJ than the C&M criteria. The important limitations of this study are that only 2 endoscopists interpreted the findings, and the study was not designed to assess interobserver correlation for the 2 criteria [40]. No formal studies have evaluated the “clinical benefit” of using any standardized classification for the assessment of the endoscopic extent of BE segment. However, data suggest a direct relationship between the endoscopic extent of BE and the probability of finding IM on histology. Greater BE surface area may translate into greater cancer risk [29, 41]. Major professional societies recommend that information about the extent of metaplasia should be recorded using standardized methods [8, 21].


Barrett's Esophagus: Emerging Knowledge and Management Strategies.

Bhardwaj A, McGarrity TJ, Stairs DB, Mani H - Patholog Res Int (2012)

(a) Schematic representation of the Prague criteria for endoscopically suspected esophageal columnar metaplasia/Barrett's esophagus, Step 1: recognize the presence of hiatal hernia; Step 2: identify GEJ and record depth of scope insertion; Step 3: recognize suspected BE mucosa above the GEJ; Step 4: record the depth of scope insertion at the most proximal circumferential extent of BE; Step 5: record the depth of scope insertion at maximum extent of BE; Step 6: subtract the depth of insertion for circumferential and maximum extents from the depth of scope insertion at the GEJ to calculate C and M, respectively. *Endoscopically suspected columnar mucosa. Adapted from [16]. (b) endoscopic image of Barrett's esophagus for circumferential (C) and maximum (M) extent of columnar mucosa, corresponding to the schematic representation shown in Figure 1(a), (c) another endoscopic image of BE using narrow-band imaging (NBI). NBI is a high-resolution endoscopic tool that enhances mucosal surface details without the need for special dyes (electronic chromoendoscopy).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3369502&req=5

fig1: (a) Schematic representation of the Prague criteria for endoscopically suspected esophageal columnar metaplasia/Barrett's esophagus, Step 1: recognize the presence of hiatal hernia; Step 2: identify GEJ and record depth of scope insertion; Step 3: recognize suspected BE mucosa above the GEJ; Step 4: record the depth of scope insertion at the most proximal circumferential extent of BE; Step 5: record the depth of scope insertion at maximum extent of BE; Step 6: subtract the depth of insertion for circumferential and maximum extents from the depth of scope insertion at the GEJ to calculate C and M, respectively. *Endoscopically suspected columnar mucosa. Adapted from [16]. (b) endoscopic image of Barrett's esophagus for circumferential (C) and maximum (M) extent of columnar mucosa, corresponding to the schematic representation shown in Figure 1(a), (c) another endoscopic image of BE using narrow-band imaging (NBI). NBI is a high-resolution endoscopic tool that enhances mucosal surface details without the need for special dyes (electronic chromoendoscopy).
Mentions: Historically, BE has been classified into short-segment (<3 cm) and long-segment BE (≥3 cm), based on the length of metaplastic epithelium seen on endoscopy [38]. A more recent classification takes into consideration the circumferential (C) and maximum (M) extent of the endoscopically visualized BE, above the GEJ. This system is called the Prague “C” and “M” criteria (Figures 1(a), 1(b) and 1(c)). The original C&M criteria were developed by an international working group using videoendoscopic recordings in 29 patients. To validate these standardized criteria, a separate panel of 29 expert endoscopists scored these recordings. The overall reliability coefficients (RCs) for the assessment of C and M extent were 0.95 and 0.94, respectively. The RCs for recognizing the location of the GEJ and the diaphragmatic hiatus were 0.88 and 0.85, respectively [16]. A recent multicenter study of gastroenterology trainees demonstrated correlation coefficients of 0.94 and 0.96, respectively, for assessment of the C and M extent of the endoscopically visualized BE. The correlation coefficients for recognition of GEJ and diaphragmatic hiatus were 0.92 and 0.90, respectively [39]. Kinjo et al. prospectively compared endoscopic BE diagnoses using the Japanese criteria (GEJ defined as the distal limit of the longitudinal or palisade vessels in the lamina propria of the esophagus) and Prague C&M criteria in 110 Japanese patients. A higher proportion of patients were diagnosed with endoscopic BE using the Japanese criteria (39%) compared with C&M criteria (26%) (P = 0.044). The GEJ identification rates were also higher using the Japanese criteria than with C&M criteria (95% versus 86% (P = 0.039)). The authors concluded that, in the Japanese population, the Japanese criteria may be more suitable for the diagnosis of endoscopic BE and for recognition of GEJ than the C&M criteria. The important limitations of this study are that only 2 endoscopists interpreted the findings, and the study was not designed to assess interobserver correlation for the 2 criteria [40]. No formal studies have evaluated the “clinical benefit” of using any standardized classification for the assessment of the endoscopic extent of BE segment. However, data suggest a direct relationship between the endoscopic extent of BE and the probability of finding IM on histology. Greater BE surface area may translate into greater cancer risk [29, 41]. Major professional societies recommend that information about the extent of metaplasia should be recorded using standardized methods [8, 21].

Bottom Line: Patients with BE have a greater than 40 folds higher risk of EAC compared with the general population.There is paucity of prospective data showing a survival benefit of screening or surveillance for BE.There is a need for identification of reliable clinical predictors or molecular biomarkers to risk-stratify patients who might benefit the most from screening or surveillance for BE.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center, 500 University Drive, P.O. Box 850, HU33, Hershey, PA 17033, USA.

ABSTRACT
The incidence of esophageal adenocarcinoma (EAC) has increased exponentially in the last 3 decades. Barrett's esophagus (BE) is the only known precursor of EAC. Patients with BE have a greater than 40 folds higher risk of EAC compared with the general population. Recent years have witnessed a revolution in the clinical and molecular research related to BE. However, several aspects of this condition remain controversial. Data regarding the true prevalence of BE have varied widely. Recent studies have suggested a lower incidence of EAC in nondysplastic BE (NDBE) than previously reported. There is paucity of prospective data showing a survival benefit of screening or surveillance for BE. Furthermore, the ever-increasing emphasis on healthcare cost containment has called for reexamination of the screening and surveillance strategies for BE. There is a need for identification of reliable clinical predictors or molecular biomarkers to risk-stratify patients who might benefit the most from screening or surveillance for BE. Finally, new therapies have emerged for the management of dysplastic BE. In this paper, we highlight the key areas of controversy and uncertainty surrounding BE. The paper discusses, in detail, the current literature about the molecular pathogenesis, biomarkers, histopathological diagnosis, and management strategies for BE.

No MeSH data available.


Related in: MedlinePlus