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Effective Barrett's Surveillance - A Retrospective Analysis of 13 Years Surveillance
Abstracts
S1286 The Prevalence of Gastric Adenocarcinoma Between Japanese Patients with Reflux Esophagitis and Those with Normal Esophagus Seiji Kimura, Masanori Tanaka
S1288 Most Esophageal Adenocarcinomas Are Missed By Routine Surveillance Programs Timothy Wong, Jianmin Tian, Anil B. Nagar
Background and Aims: In the West gastroesophageal reflux disease is considered to be the risk factor for adenocarcinoma of the gastric cardia which is increasing recently. In contrast most Japanese patients with gastric carcinoma have disease located in the distal stomach, and carcinomas of the gastric cardia are still extremely rare. The study aimed to evaluate the relationship between reflux esophagitis and noncardia gastric adenocarcinoma in Japanese subjects. Methods: The study included 534 patients with reflux esophagitis (Group A) and 4925 with normal esophagus (Group B) diagnosed by routine esophagogastroduodenoscopy during past 5 years in our hospital. The prevalences of adenoma, adenocarcinoma of the distal stomach between Group A and B were compared with each other by chi-square test. Results: Mean age and sex ratio were 65.6 13.6 yr, M:F Z 282:252 (Group A), and 62.4 14.4 yr, M:F Z 2239:2686 (Group B), respectively. Patients in Group A revealed to have a more advanced age and a male-dominant proportion compared to those in Group B (P!0.005). The severity of esophagitis according to LA classification in Group A was 51.5% (grade A), 35.8% (grade B), 9.6% (grade C), and 3.2% (grade D). The percentage of hiatal hernia was markedly higher in Group A (57.7%) than Group B (10.9%) (P ! 0.0001). Gastroduodenal findings of upper GI endoscopy between Group A and B were as follows; atrophic gastritis (30.1% in Group A vs 39.6% in Group B), superficial gastritis (10.0% vs 6.7%), erosive gastritis (15.3% vs 8.6%), erosive duodenitis (4.6% vs 1.5%), gastric ulcer (7.5% vs 9.6%), duodenal ulcer (8.8% vs 8.5%), hemorrhagic gastroduodenitis (4.3% vs 3.5%), benign gastric polyp (5.8% vs 6.0%), submucosal gastric tumor (1.0% vs 2.7%) gastric adenoma (0.0% vs 1.0%), gastric adenocarcinoma (0.4% vs 1.3%), and others (12.2% vs 11.0%), respectively. None of adenomas and only two of adenocarcinomas of the distal stomach were found in patients in Group A, although 48 adenomas and 62 adenocarcinomas of the distal stomach were found in Group B. The incidence of gastric adenoma and adenocarcinoma in patients with reflux esophagitis were lower than those in patients with normal esophagus (P Z 0.04, and P Z 0.11), although the latter did not reach statistical significance. Conclusion: In Japanese subjects the prevalence of gastric adenocarcinoma was rather low in patients with reflux esophagitis when compared to those with normal esophagus. Reflux esophagitis is not considered to be a risk factor for adenocarcinoma of the distal stomach, and the different etiology between cardia and noncardia adenocarcinoma of the stomach should be emphasized.
Background: Current guidelines suggest that patients with chronic gastroesophageal reflux disease(GERD) should undergo endoscopy and further recommend Barrett’s esophagus(BE) should undergo surveillance for esophageal adenocarcinoma(EAC). Our aim was to: 1) Assess the effectiveness of BE surveillance-that is, what percentage of EAC are identified by surveillance? 2) Identify factors that may influence the progression from BE to EAC; and 3) Assess the prognosis of patients with BE and EAC. Methods: Retrospective review of all patients with BE and EAC identified at a single institution from 1999 to 2005. Patients were part of a BE surveillance program following standard guidelines. Charts were reviewed for presenting symptoms, history of GERD, use of proton pump inhibitors(PPI), aspirin, statin medications, alcohol, cigarette smoking, body mass index, presence of anemia, length of BE segments, presence of dysplasia and stage of cancer if present. Results: 248 patients were identified with BE. During surveillance, only 5(2.0%) developed EAC. However, 46 patients were diagnosed with new onset EAC without previous BE (despite similar access to healthcare). GERD was a significantly more common initial complaint in patients with BE than in EAC (54% vs 6%), while dysphagia and weight loss were more common in EAC patients (59% vs 14% and 6% vs 1%, respectively). Multivariate analysis showed age R55 and smoking were positive and independent risk factors for EAC. PPI use was a negative risk factor. Only 22 of 51(43%) patients with new onset EAC had BE at the time of diagnosis. Subgroup analysis of EAC patients with documented BE showed BE length O2 cm to be an additional risk factor; 80% of cancer in surveillance patients was stage I cancer compared to 6.5% in non-surveillance patients. Mortality at 2 years was 2%, 0% and 46% in the BE group (unrelated to disease), EAC with surveillance group and EAC without surveillance group, respectively. Mean survival time for BE and EAC were 7.6 years and 2.0 years, respectively (p ! 0.001). Conclusions: BE surveillance programs do not identify most patients with EAC since a history of GERD is insufficient to identify patients at risk for BE and EAC. These findings may also suggest that not all EAC originates from BE epithelium. BE patients who were involved with regular surveillance benefited from earlier stage cancer diagnosis and reduced mortality. Among patients with BE, it may be more cost-effective to aggressively survey the ones who have risk factors such as age R55, BE segment length O2 cm, and history of smoking. Patients without these risk factors and have protective factors such as PPI use may need less frequent monitoring.
S1287 Effective Barrett’s Surveillance - A Retrospective Analysis of 13 Years Surveillance Victoria Switzer-Taylor, Ralf Lubcke, Martin Schlup, Michael Schultz
S1289 Efficacy of a New Jumbo Biopsy Forcep On Histopathology in Barrett’s Esophagus Garth Swanson, Michael Brown, Shriram Jakate, Srinadh Komanduri
Background: The sequential progression of gastro-esophageal reflux disease (GERD) to intestinal metaplasia (Barrett’s esophagus (BE)), low grade (LGD) to high grade dysplasia (HGD), and adenocarcinoma is well recognized. Over the last 40 years, the incidence of esophageal adenocarcinoma has increased significantly and is now the predominant form of esophageal cancer in the U.S. with approx. 2.5/100.000 population. Early cancer has a 5-year survival of 83-90%, vs. 10-15% 5-year survival of late stage cancers. Since the prevalence of GERD is very high but only few patients (pts) with BE progress to malignancy, surveillance and screening are controversial. Aim: This retrospective analysis reviews the 13 year outcome for pts entered into a surveillance program. Methods: Data from pts with histologically proven BE (1992-2003) were identified. Pts suitable for potential esophagectomy were entered into a surveillance program and analyzed retrospectively until 2005 regarding the frequency of gastroscopies, report details, histology and surveillance intervals. Results: During 1992-2003, 536 pts were screened and 404 had BE confirmed histologically. 212 (53%) were entered into the surveillance program (mean surveillance 3.95 years/pt). 749 gastroscopies were performed (3.5/pt) with 28% index gastroscopies. 69% of pts under surveillance were male (vs. 64% non-surveillance; ns). Age distribution was 56.8 11.9 vs. 72.2 10.4 yrs (p%0.05; surveillance vs. non-surveillance) and metaplasia length was 59.8 31.2 mm (vs. 64.9 33.7 mm; ns). Histologically, BE only was seen in 54%, LGD in 18%, ulcerations in 9%, HGD in 2%. No metaplasia was seen in 13% and no biopsy was obtained in 3%. 9/212 pts (1%) under surveillance developed esophageal cancer; 2 presented symptomatically, requiring gastroscopy outside the surveillance program (1/2 was operated successfully, one had advanced disease). In the remaining 7/9 asymptomatic pts, cancer was detected on routine surveillance; curative esophagectomy was performed in 6, one was not fit for surgery. All pts who developed cancer were male and all but one pt had dysplasia or ulcerations on index endoscopy. Summary: During 13 years of surveillance of 212 pts with BE, 88% of all adenocarcinoma occurred in a subset of 11% pts. Asymptomatic tumor detected on routine surveillance was seen in 7 pts and was more likely treated by esophagectomy than symptomatic tumor. Conclusion: To stratify BE surveillance, programs should be focused on male pts with dysplasia or ulcerations on index endoscopy who have been shown to have a particular high risk of developing esophageal adenocarcinoma and for whom curative surgery can be attempted.
Background: Patients with Barrett’s Esophagus (BE) are at risk for the development of dysplasia and adenocarcinoma. Dysplasia may develop in any area of BE and may endoscopically appear flat and inconspicuous. Endoscopic surveillance with random biopsies is currently recommended for all patients with BE with four quadrant biopsies every 2 centimeters to limit the miss rate of dysplasia. The aim of this study was to assess the histopathologic differences between a new jumbo biopsy forcep and the standard biopsy forcep currently utilized. Methods: We recruited 10 patients with a previous biopsy proven diagnosis of BE. All patients underwent endoscopic surveillance for dysplasia with four quadrant biopsies taken every 2 centimeters. Biopsies were obtained with a standard Radial JawÒ 3 biopsy forcep (RJ3) alternating with the jumbo Radial JawÒ 4 biopsy forcep (RJ4). Randomization of initial forcep selection was performed by our technician. Fifteen paired specimens were analyzed by a blinded GI pathologist for depth, width, tissue crush artifact, fixation, and presence of dysplasia. If dysplasia was detected, the findings were confirmed by a second pathologist from our institution. The MannWhitney U test was used for comparison between the two groups. Results: The mean depth of the biopsy specimens with the RJ3 was 909 mm (833 to 1089) compared to 1778 mm (1329 to 1921) for the RJ4 (p ! 0.001). The mean width was 1800 mm (1689 to 1921) for the RJ3 compared to 2747 mm (2244 to 3250) for the RJ4 (p ! 0.001). The jumbo forcep appears to sample 50% of the depth of the submucosa while standard forceps do not traverse the lamina propria. Dysplasia was seen in 4 of 10 patients (2 low grade, 2 high grade) with jumbo biopsies and not in the standard forceps. There was a single patient in which the standard forceps identified a foci of high grade dysplasia, while the RJ4 did not. However, this was in a raised lesion and the RJ3 forcep was selected first. There was no difference in fixation or crush artifact between both forceps. All samples were adequate for diagnosis. There were no complications associated with the jumbo forceps and in all cases a standard upper endoscope was utilized. Conclusions: Our data suggests that the new jumbo biopsy forcep (RJ4) appears to be more effective in tissue sampling for dysplasia in BE than standard forceps. The RJ4 sampled greater width and depth and detected dysplasia which was missed by the standard forcep. The significant increase in size of each specimen also provides a theoretical advantage for detection of intramucosal carcinoma and ‘‘buried’’ glands after endoscopic ablative therapy.
AB134 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
www.giejournal.org
S1286 The Prevalence of Gastric Adenocarcinoma Between Japanese Patients with Reflux Esophagitis and Those with Normal Esophagus Seiji Kimura, Masanori Tanaka
S1288 Most Esophageal Adenocarcinomas Are Missed By Routine Surveillance Programs Timothy Wong, Jianmin Tian, Anil B. Nagar
Background and Aims: In the West gastroesophageal reflux disease is considered to be the risk factor for adenocarcinoma of the gastric cardia which is increasing recently. In contrast most Japanese patients with gastric carcinoma have disease located in the distal stomach, and carcinomas of the gastric cardia are still extremely rare. The study aimed to evaluate the relationship between reflux esophagitis and noncardia gastric adenocarcinoma in Japanese subjects. Methods: The study included 534 patients with reflux esophagitis (Group A) and 4925 with normal esophagus (Group B) diagnosed by routine esophagogastroduodenoscopy during past 5 years in our hospital. The prevalences of adenoma, adenocarcinoma of the distal stomach between Group A and B were compared with each other by chi-square test. Results: Mean age and sex ratio were 65.6 13.6 yr, M:F Z 282:252 (Group A), and 62.4 14.4 yr, M:F Z 2239:2686 (Group B), respectively. Patients in Group A revealed to have a more advanced age and a male-dominant proportion compared to those in Group B (P!0.005). The severity of esophagitis according to LA classification in Group A was 51.5% (grade A), 35.8% (grade B), 9.6% (grade C), and 3.2% (grade D). The percentage of hiatal hernia was markedly higher in Group A (57.7%) than Group B (10.9%) (P ! 0.0001). Gastroduodenal findings of upper GI endoscopy between Group A and B were as follows; atrophic gastritis (30.1% in Group A vs 39.6% in Group B), superficial gastritis (10.0% vs 6.7%), erosive gastritis (15.3% vs 8.6%), erosive duodenitis (4.6% vs 1.5%), gastric ulcer (7.5% vs 9.6%), duodenal ulcer (8.8% vs 8.5%), hemorrhagic gastroduodenitis (4.3% vs 3.5%), benign gastric polyp (5.8% vs 6.0%), submucosal gastric tumor (1.0% vs 2.7%) gastric adenoma (0.0% vs 1.0%), gastric adenocarcinoma (0.4% vs 1.3%), and others (12.2% vs 11.0%), respectively. None of adenomas and only two of adenocarcinomas of the distal stomach were found in patients in Group A, although 48 adenomas and 62 adenocarcinomas of the distal stomach were found in Group B. The incidence of gastric adenoma and adenocarcinoma in patients with reflux esophagitis were lower than those in patients with normal esophagus (P Z 0.04, and P Z 0.11), although the latter did not reach statistical significance. Conclusion: In Japanese subjects the prevalence of gastric adenocarcinoma was rather low in patients with reflux esophagitis when compared to those with normal esophagus. Reflux esophagitis is not considered to be a risk factor for adenocarcinoma of the distal stomach, and the different etiology between cardia and noncardia adenocarcinoma of the stomach should be emphasized.
Background: Current guidelines suggest that patients with chronic gastroesophageal reflux disease(GERD) should undergo endoscopy and further recommend Barrett’s esophagus(BE) should undergo surveillance for esophageal adenocarcinoma(EAC). Our aim was to: 1) Assess the effectiveness of BE surveillance-that is, what percentage of EAC are identified by surveillance? 2) Identify factors that may influence the progression from BE to EAC; and 3) Assess the prognosis of patients with BE and EAC. Methods: Retrospective review of all patients with BE and EAC identified at a single institution from 1999 to 2005. Patients were part of a BE surveillance program following standard guidelines. Charts were reviewed for presenting symptoms, history of GERD, use of proton pump inhibitors(PPI), aspirin, statin medications, alcohol, cigarette smoking, body mass index, presence of anemia, length of BE segments, presence of dysplasia and stage of cancer if present. Results: 248 patients were identified with BE. During surveillance, only 5(2.0%) developed EAC. However, 46 patients were diagnosed with new onset EAC without previous BE (despite similar access to healthcare). GERD was a significantly more common initial complaint in patients with BE than in EAC (54% vs 6%), while dysphagia and weight loss were more common in EAC patients (59% vs 14% and 6% vs 1%, respectively). Multivariate analysis showed age R55 and smoking were positive and independent risk factors for EAC. PPI use was a negative risk factor. Only 22 of 51(43%) patients with new onset EAC had BE at the time of diagnosis. Subgroup analysis of EAC patients with documented BE showed BE length O2 cm to be an additional risk factor; 80% of cancer in surveillance patients was stage I cancer compared to 6.5% in non-surveillance patients. Mortality at 2 years was 2%, 0% and 46% in the BE group (unrelated to disease), EAC with surveillance group and EAC without surveillance group, respectively. Mean survival time for BE and EAC were 7.6 years and 2.0 years, respectively (p ! 0.001). Conclusions: BE surveillance programs do not identify most patients with EAC since a history of GERD is insufficient to identify patients at risk for BE and EAC. These findings may also suggest that not all EAC originates from BE epithelium. BE patients who were involved with regular surveillance benefited from earlier stage cancer diagnosis and reduced mortality. Among patients with BE, it may be more cost-effective to aggressively survey the ones who have risk factors such as age R55, BE segment length O2 cm, and history of smoking. Patients without these risk factors and have protective factors such as PPI use may need less frequent monitoring.
S1287 Effective Barrett’s Surveillance - A Retrospective Analysis of 13 Years Surveillance Victoria Switzer-Taylor, Ralf Lubcke, Martin Schlup, Michael Schultz
S1289 Efficacy of a New Jumbo Biopsy Forcep On Histopathology in Barrett’s Esophagus Garth Swanson, Michael Brown, Shriram Jakate, Srinadh Komanduri
Background: The sequential progression of gastro-esophageal reflux disease (GERD) to intestinal metaplasia (Barrett’s esophagus (BE)), low grade (LGD) to high grade dysplasia (HGD), and adenocarcinoma is well recognized. Over the last 40 years, the incidence of esophageal adenocarcinoma has increased significantly and is now the predominant form of esophageal cancer in the U.S. with approx. 2.5/100.000 population. Early cancer has a 5-year survival of 83-90%, vs. 10-15% 5-year survival of late stage cancers. Since the prevalence of GERD is very high but only few patients (pts) with BE progress to malignancy, surveillance and screening are controversial. Aim: This retrospective analysis reviews the 13 year outcome for pts entered into a surveillance program. Methods: Data from pts with histologically proven BE (1992-2003) were identified. Pts suitable for potential esophagectomy were entered into a surveillance program and analyzed retrospectively until 2005 regarding the frequency of gastroscopies, report details, histology and surveillance intervals. Results: During 1992-2003, 536 pts were screened and 404 had BE confirmed histologically. 212 (53%) were entered into the surveillance program (mean surveillance 3.95 years/pt). 749 gastroscopies were performed (3.5/pt) with 28% index gastroscopies. 69% of pts under surveillance were male (vs. 64% non-surveillance; ns). Age distribution was 56.8 11.9 vs. 72.2 10.4 yrs (p%0.05; surveillance vs. non-surveillance) and metaplasia length was 59.8 31.2 mm (vs. 64.9 33.7 mm; ns). Histologically, BE only was seen in 54%, LGD in 18%, ulcerations in 9%, HGD in 2%. No metaplasia was seen in 13% and no biopsy was obtained in 3%. 9/212 pts (1%) under surveillance developed esophageal cancer; 2 presented symptomatically, requiring gastroscopy outside the surveillance program (1/2 was operated successfully, one had advanced disease). In the remaining 7/9 asymptomatic pts, cancer was detected on routine surveillance; curative esophagectomy was performed in 6, one was not fit for surgery. All pts who developed cancer were male and all but one pt had dysplasia or ulcerations on index endoscopy. Summary: During 13 years of surveillance of 212 pts with BE, 88% of all adenocarcinoma occurred in a subset of 11% pts. Asymptomatic tumor detected on routine surveillance was seen in 7 pts and was more likely treated by esophagectomy than symptomatic tumor. Conclusion: To stratify BE surveillance, programs should be focused on male pts with dysplasia or ulcerations on index endoscopy who have been shown to have a particular high risk of developing esophageal adenocarcinoma and for whom curative surgery can be attempted.
Background: Patients with Barrett’s Esophagus (BE) are at risk for the development of dysplasia and adenocarcinoma. Dysplasia may develop in any area of BE and may endoscopically appear flat and inconspicuous. Endoscopic surveillance with random biopsies is currently recommended for all patients with BE with four quadrant biopsies every 2 centimeters to limit the miss rate of dysplasia. The aim of this study was to assess the histopathologic differences between a new jumbo biopsy forcep and the standard biopsy forcep currently utilized. Methods: We recruited 10 patients with a previous biopsy proven diagnosis of BE. All patients underwent endoscopic surveillance for dysplasia with four quadrant biopsies taken every 2 centimeters. Biopsies were obtained with a standard Radial JawÒ 3 biopsy forcep (RJ3) alternating with the jumbo Radial JawÒ 4 biopsy forcep (RJ4). Randomization of initial forcep selection was performed by our technician. Fifteen paired specimens were analyzed by a blinded GI pathologist for depth, width, tissue crush artifact, fixation, and presence of dysplasia. If dysplasia was detected, the findings were confirmed by a second pathologist from our institution. The MannWhitney U test was used for comparison between the two groups. Results: The mean depth of the biopsy specimens with the RJ3 was 909 mm (833 to 1089) compared to 1778 mm (1329 to 1921) for the RJ4 (p ! 0.001). The mean width was 1800 mm (1689 to 1921) for the RJ3 compared to 2747 mm (2244 to 3250) for the RJ4 (p ! 0.001). The jumbo forcep appears to sample 50% of the depth of the submucosa while standard forceps do not traverse the lamina propria. Dysplasia was seen in 4 of 10 patients (2 low grade, 2 high grade) with jumbo biopsies and not in the standard forceps. There was a single patient in which the standard forceps identified a foci of high grade dysplasia, while the RJ4 did not. However, this was in a raised lesion and the RJ3 forcep was selected first. There was no difference in fixation or crush artifact between both forceps. All samples were adequate for diagnosis. There were no complications associated with the jumbo forceps and in all cases a standard upper endoscope was utilized. Conclusions: Our data suggests that the new jumbo biopsy forcep (RJ4) appears to be more effective in tissue sampling for dysplasia in BE than standard forceps. The RJ4 sampled greater width and depth and detected dysplasia which was missed by the standard forcep. The significant increase in size of each specimen also provides a theoretical advantage for detection of intramucosal carcinoma and ‘‘buried’’ glands after endoscopic ablative therapy.
AB134 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
www.giejournal.org