Current management of Barrett esophagus and esophageal adenocarcinoma
Release date: November 1, 2019
Expiration date: October 31, 2020
Estimated time of completion: 1 hour
Click here to start this CME/MOC activity.
ABSTRACT
Barrett esophagus is found in 5% to 15% of patients with gastroesophageal reflux disease and is a precursor of esophageal adenocarcinoma, yet the condition often goes undiagnosed. Patients with reflux disease who are male, over age 50, or white, and who smoke or have central obesity or a family history of Barrett esophagus or esophageal adenocarcinoma, should undergo initial screening endoscopy and, if no dysplasia is noted, surveillance endoscopy every 3 to 5 years. Dysplasia is treated with endoscopic eradication by ablation, resection, or both. Chemoprotective agents are being studied to prevent progression to dysplasia in Barrett esophagus. The authors discuss current recommendations for screening and management.
KEY POINTS
- Screening is recommended for patients with long-standing reflux symptoms (> 5 years) and 1 or more key risk factors: male sex, age over 50, white race, central obesity, and history of smoking.
- In Barrett esophagus without dysplasia, surveillance endoscopy is recommended every 3 to 5 years to detect dysplasia and early esophageal adenocarcinoma.
- The recommended treatment of dysplasia is endoscopic eradication followed by surveillance endoscopy.
LOW-GRADE DYSPLASIA: RECOMMENDED MANAGEMENT
Most patients with low-grade dysplasia (73%) are down-staged to nondysplastic Barrett esophagus or to indefinite for dysplasia after review by expert pathologists.42 Patients with confirmed and persistent low-grade dysplasia are at higher risk of progression.43
Once low-grade dysplasia is confirmed by a second gastrointestinal pathologist, the patient should undergo endoscopic ablation. A landmark study by Shaheen et al44 demonstrated the benefit of radiofrequency ablation in achieving complete eradication of dysplasia (90.5% vs 22.7% for a sham procedure) and complete eradication of intestinal metaplasia (77.4% vs 2.3% for a sham procedure). In another trial of 136 patients with low-grade dysplasia followed for 3 years, Phoa et al45 demonstrated that radiofrequency ablation reduced the rate of progression to high-grade dysplasia by 25% and to adenocarcinoma by 7.4% compared with endoscopic surveillance.
Patients with confirmed low-grade dysplasia who do not undergo eradication therapy should have surveillance endoscopy every 6 to 12 months (Table 1).
,HIGH-GRADE DYSPLASIA: RECOMMENDED MANAGEMENT
As with low-grade dysplasia, the diagnosis of high-grade dysplasia needs to be confirmed by a second pathologist with gastrointestinal expertise. In the past, the treatment was esophagectomy, but due to lower morbidity and equivalent efficacy of radiofrequency ablation,46 the current treatment of choice is endoscopic mucosal resection of raised lesions, followed by radiofrequency ablation of the entire affected segment.
In the study by Shaheen et al,44 42 patients with high-grade dysplasia were randomized to radiofrequency ablation and 21 to a sham procedure, and 81% of ablation patients achieved complete eradication of dysplasia vs 19% with the sham procedure. Eradication of intestinal metaplasia was achieved in 77% of ablation patients vs 2% of patients with the sham therapy. Results of 3-year follow-up from the same cohort showed complete eradication of dysplasia in 98% and of intestinal metaplasia in 91%.47
Endoscopic eradication therapy is recommended for all patients with Barrett esophagus and high-grade dysplasia without a life-limiting comorbidity. Alternatively, surveillance every 3 months is an option if the patient does not wish to undergo eradication therapy. Radiofrequency ablation is more cost-effective than esophagectomy or endoscopic surveillance followed by treatment once patients develop adenocarcinoma.48,49
EARLY ESOPHAGEAL ADENOCARCINOMA: RECOMMENDED MANAGEMENT
Adenocarcinoma limited to the mucosa and without evidence of nodal involvement can be resected endoscopically. In patients with localized cancer, mucosal resection is done not only for therapeutic purposes but also for staging. Ideal management is multidisciplinary, including a gastroenterologist, thoracic surgeon, oncologist, pathologist, and radiation oncologist.
If lesions have features suggesting submucosal invasion or are greater than 1.5 cm in size, or if it is difficult to separate (ie, lift) the mucosa from the submucosal layer with injection of saline, then submucosal dissection is recommended.50 Because of the risk of metachronous lesions, ablation of the remaining Barrett esophagus mucosa is recommended after resection of cancer.
Endoscopic eradication is highly effective and durable for the treatment of intramucosal esophageal adenocarcinoma. In a study of 1,000 patients, 963 patients (96.3%) had achieved a complete response; 12 patients (3.7%) underwent surgery after eradication failed during a follow-up of almost 5 years.51 Metachronous lesions or recurrence of cancer developed during the follow-up period in 140 patients (14.5%) but were successfully treated endoscopically in 115, resulting in a long-term complete remission rate of 93.8%.
POSTABLATION MANAGEMENT
Because of the risk of recurrence of dysplasia after ablation, long-term PPI therapy and surveillance are recommended.
Surveillance endoscopy involves 4-quadrant biopsies taken every 1 cm from the entire length of segment where Barrett esophagus had been seen before ablation.
The timing of surveillance intervals depends on the preablation grade of dysplasia. For low-grade dysplasia, the recommendation is every 6 months for the first year after ablation and, if there is no recurrence of dysplasia, annually after that.2 After treatment of high-grade dysplasia or intramucosal adenocarcinoma, the recommendation is every 3 months for the first year, every 6 months in the second year, and then annually.2
