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Is Their a Preferred Location of Intestinal Metaplasia in Barrett's Esophagus?
Abstracts
S1359 Multi-Modal Endoluminal Eradication Therapy for Specialized Intestinal Metaplasia of the Esophagus and the Esophagogastric Junction with High-Grade Dysplasia and/or Intramucosal Carcinoma Gregory G. Ginsberg, Emma E. Furth, Jennifer Ginsberg, Colleen Brensiger, Steve Hahn Esophageal and esophagogastric junction (EGJ) multi-modal endoluminal eradication therapy (MELET) incorporates ablation (photodynamic therapy [PDT], argon plasma coagulation [APC]), and limited or wide area endoluminal resection (ELR) to achieve eradication of pre- and early cancer associated with specialized intestinal metaplasia (SIM). Aim: Complete eradication of SIM with high-grade dysplasia (HGD) and/or intramucosal carcinoma (ImCa) using MELET in a selected cohort. Methods: Patients referred for consideration were included if they underwent repeat endoscopy with detailed mapping, had histopathologic confirmation of HGD and/or ImCa on index or repeat endoscopy, EUS confirmation of T0-1, N0 stage, and were deemed unfit or unwilling to undergo esophagectomy after surgical consultation. MELET was individualized based on the length and configuration of SIM, uni- or multi-focality of HGD/ImCa, presence or absence of macroscopically recognizable lesion, and response to therapies. MELET was applied every 6-24 weeks until complete eradication of all SIM and HGD/ImCa. Thereafter, follow up endoscopy with targeted and four-quadrant biopsies was performed every 3-6 months for two years and then annually. Patients were maintained on high dose acid suppression therapy. Results: Among 135 patients, 105 met inclusion criteria and have O12 mo follow-up (mean: 32 mo, r: 12-108 mo; sex: 80% male; age: mean 69 yr, r: 35-87 yr). Two-thirds were deemed poor operative candidates. SIM was long-segment (LS Z O2 cm) in 52 (mean: 6.14 cm, r: 3-13 cm); shortsegment (SS Z 1-2 cm) in 38; and EGJ in 15. SIM was confluent in 64 and nonconfluent in 41. There was HGD in 52, ImCa in 19, and HGD and ImCa in 34. HGD/ ImCa was uni-focal in 62 and multi-focal in 43. Macroscopic lesions were present in 71. MELET was individualized and consisted of PDT 12, ELR 39, APC 4, PDT/ELR 9, PDT/APC 8, ELR/APC 25, PDT/ELR/APC 8. Complete eradication was achieved in 93 (89%) with a mean 2.2 sessions (r: 1-9). There was persistent SIM in 4 and HGD/ ImCa in 8. There was recurrent non-dysplastic SIM in 10, HGD in5, and ImCa in 2 (mean 23 mo, r: 6-60 mo), all effectively eradicated with ELR or APC. There is failure to follow up in 8 patients. There were 24 complications in 21 patients including 2 treatment related deaths (exsanguination 2 wk after PDT in 1, invasive cancer incident cancer in 1). Conclusions: MELET is safe, effective, and durable when individualized and applied selectively for eradication of SIM with HGD/ImCa. Meticulous surveillance is indicated. Recurrence of SIM, HGD, and ImCa are uncommon and can be managed with additional MELET.
S1360 Barett’s Esophagus Diagnosis and Lugol Staining. An Additional Result of a National Prospective Study of the French Digestive Endoscopy Society (SFED) Jean-Louis Legoux, Johann Dubuc, Maria Winnock, JacquesArnaud Seyrig, Jean-Philippe Barbier, Thierry Barrioz, Rene´ Laugier, Guy Boulay, Denis Grasset, Denis Sautereau, Dan Grigoresco, Joe¨l Butel, Thierry Ponchon Introduction: The aim of this national prospective study was to determine the prevalence of esophageal squamous cell carcinoma in high-risk patients and the advantage of lugol staining during the upper intestinal endoscopy. Lugol esophageal staining increased the sensitivity of esophageal endoscopy for the detection of high-grade dysplasias and cancers. The other abnormalities viewed before and after lugol staining were also notified. Patients and Methods: The French prospective study was undertaken in 62 endoscopy centers, including 1095 patients without esophageal symptoms, who presented either a past or recent head and neck or tracheobronchial squamous cell carcinoma (group 1), alcoholic chronic pancreatitis (group 2), alcoholic cirrhosis (group 3), or were alcohol and tobacco addicts (group 4). The endoscopists performed a meticulous examination of the esophagus followed by a lugol staining. Results: A Barrett’s mucosa was observed in 5.9% of the cases (table), with a similar prevalence in the 4 groups (5 to 6%). A few low-grade dysplasias (4) were observed and any high-grade dysplasia. The lugol staining allowed an additional diagnosis of Barret’s mucosa in 7 patients, i.e. 11% among the 62 diagnosed (p Z 0.023). Conclusions: Lugol esophageal staining increases the sensitivity of esophageal endoscopy for the detection of Barrett’s esophagus. This additional effect of this staining could heighten its indications among patients with alcohol and tabacco addiction, which increases the acid gastro´f: Esophageal Squamous Cell Carcinoma Screening in Highesophageal reflux. Re Risk Patients: a French Endoscopic Prospective Study. Dubuc J et al. Endoscopy 2006,38:690-5.
AB154 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
Results: number and (%)
Number of patients Barrett’s metaplasia before Lugol staining Barrett’s metaplasia after Lugol staining Total
Group I
Group II
Group III
Group IV
Total
N Z 393 17 (4.2)
N Z 76 4 (5)
N Z 218 12 (5)
N Z 408 22 (5.7)
N Z 1095 55 (5.3)
1 (0.5)
2 (0.5)
7 (0.6)
24 (6.2)
62 (5.9)
4 (1) 21 (5.2)
0 4 (5)
13 (6)
S1361 Is Their a Preferred Location of Intestinal Metaplasia in Barrett’s Esophagus? Vikram Boolchand, Lisa Camargo, Anil Prasad, Richard E. Sampliner Background: Intestinal Metaplasia (IM) is the presumed precursor of esophageal adenocarcinoma. It has been suggested that IM may not be uniformally distributed in long segment Barrett’s esophagus (BE) and that IM is significantly more common in the proximal portion than the distal portion of Barrett’s appearing mucosa. This would have important implications for surveillance biopsy sampling. The aim of this study was to compare the incidence of proximal and distal intestinal metaplasia in long segment Barrett’s patients. Methods: Thirty patients with known long segment Barrett’s esophagus were reviewed in a retrospective fashion. In order to detect a 30% difference in incidence of IM with 95% power, 29 pairs (proxmial, distal) would be needed. Demographic information, BMI, length of BE at endoscopy, and use of proton pump inhibitors were collected on each patient. Endoscopy was performed at a single center, by a single endoscopist with the standard four quadrant, every 2 cm biopsy protocol. Biopsies from the most proximal and distal portion of Barrett’s appearing mucosa were reviewed by a single pathologist for correlation. Each biopsy from the 2 sites was assessed for the presence of goblet cells, i.e. intestinal metaplasia. Results: The study group was 96% male, 97% white, had an average age of 69 years and BMI of 29 at endoscopy. The average length of BE endoscopically was 6.8 cm. The average distance between proximal and distal biopsies reviewed was 5.4 cm. 93% of the patients had proximal IM and 90% of the patients had distal IM. A total of 216 biopsies were reviewed. 80.4% (78/97) of the proximal biopsies showed IM and 70.5% (84/119) of the distal biopsies showed IM (p Z 0.11, fisher test). 90% of the patients were taking a proton pump inhibitor. Conclusion: The location of IM in the proximal Barrett’s segment does not seem different from the distal. This would support current biopsy sampling techniques including taking equal proximal and distal biopsies.
S1362 In Vivo 3D Comprehensive Microscopy of the Human Distal Esophagus Melissa J. Suter, Benjamin J. Vakoc, Norman S. Nishioka, Patrick S. Yachimski, Milen Shishkov, Reza Motaghiannezam, Brett E. Bouma, Guillermo J. Tearney Given the mortality rate associated with esophageal adenocarcinoma it is apparent that further advancements in methods for detecting, diagnosing and tracking patients with Barrett’s esophagus are required. Current evaluation involves endoscopy followed by the collection multiple random biopsies, however this form of assessment is invasive and susceptible to sampling errors. Optical coherence tomography (OCT) provides high-resolution (w10 mm resolution) cross-sectional images of esophageal microstructure, enabling accurate differentiation of specialized intestinal metaplasia, dysplasia, and intramucosal carcinoma. To date, the clinical utility of this technology has been limited by imaging speeds and optical probe design. Optical frequency domain imaging (OFDI) is a new imaging technology that is based on frequency domain interferometry and is capable of improving imaging speed over traditional OCT techniques by orders of magnitude without sacrificing image quality. We have developed a catheter based OFDI system that acquires comprehensive three-dimensional microscopic images of the entire distal esophagus (w5.0 cm) with resolutions in cylindrical coordinates of 25 mm (4) 8 mm (r) 33 mm (z). Comprehensive microscopy of the distal esophagus has been performed in over 20 patients with the OFDI system and balloon catheter. The acquired volumetric OFDI datasets were visualized using both volume rendering and longitudinal and transverse cross-sectional imaging, and were correlated with histopathology. We anticipate that comprehensive volumetric microscopy with OFDI will significantly improve the management of patients with Barrett’s esophagus by providing a relatively non-invasive means for screening the entire distal esophagus for intestinal metaplasia, dysplasia, and adenocarcinoma.
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S1359 Multi-Modal Endoluminal Eradication Therapy for Specialized Intestinal Metaplasia of the Esophagus and the Esophagogastric Junction with High-Grade Dysplasia and/or Intramucosal Carcinoma Gregory G. Ginsberg, Emma E. Furth, Jennifer Ginsberg, Colleen Brensiger, Steve Hahn Esophageal and esophagogastric junction (EGJ) multi-modal endoluminal eradication therapy (MELET) incorporates ablation (photodynamic therapy [PDT], argon plasma coagulation [APC]), and limited or wide area endoluminal resection (ELR) to achieve eradication of pre- and early cancer associated with specialized intestinal metaplasia (SIM). Aim: Complete eradication of SIM with high-grade dysplasia (HGD) and/or intramucosal carcinoma (ImCa) using MELET in a selected cohort. Methods: Patients referred for consideration were included if they underwent repeat endoscopy with detailed mapping, had histopathologic confirmation of HGD and/or ImCa on index or repeat endoscopy, EUS confirmation of T0-1, N0 stage, and were deemed unfit or unwilling to undergo esophagectomy after surgical consultation. MELET was individualized based on the length and configuration of SIM, uni- or multi-focality of HGD/ImCa, presence or absence of macroscopically recognizable lesion, and response to therapies. MELET was applied every 6-24 weeks until complete eradication of all SIM and HGD/ImCa. Thereafter, follow up endoscopy with targeted and four-quadrant biopsies was performed every 3-6 months for two years and then annually. Patients were maintained on high dose acid suppression therapy. Results: Among 135 patients, 105 met inclusion criteria and have O12 mo follow-up (mean: 32 mo, r: 12-108 mo; sex: 80% male; age: mean 69 yr, r: 35-87 yr). Two-thirds were deemed poor operative candidates. SIM was long-segment (LS Z O2 cm) in 52 (mean: 6.14 cm, r: 3-13 cm); shortsegment (SS Z 1-2 cm) in 38; and EGJ in 15. SIM was confluent in 64 and nonconfluent in 41. There was HGD in 52, ImCa in 19, and HGD and ImCa in 34. HGD/ ImCa was uni-focal in 62 and multi-focal in 43. Macroscopic lesions were present in 71. MELET was individualized and consisted of PDT 12, ELR 39, APC 4, PDT/ELR 9, PDT/APC 8, ELR/APC 25, PDT/ELR/APC 8. Complete eradication was achieved in 93 (89%) with a mean 2.2 sessions (r: 1-9). There was persistent SIM in 4 and HGD/ ImCa in 8. There was recurrent non-dysplastic SIM in 10, HGD in5, and ImCa in 2 (mean 23 mo, r: 6-60 mo), all effectively eradicated with ELR or APC. There is failure to follow up in 8 patients. There were 24 complications in 21 patients including 2 treatment related deaths (exsanguination 2 wk after PDT in 1, invasive cancer incident cancer in 1). Conclusions: MELET is safe, effective, and durable when individualized and applied selectively for eradication of SIM with HGD/ImCa. Meticulous surveillance is indicated. Recurrence of SIM, HGD, and ImCa are uncommon and can be managed with additional MELET.
S1360 Barett’s Esophagus Diagnosis and Lugol Staining. An Additional Result of a National Prospective Study of the French Digestive Endoscopy Society (SFED) Jean-Louis Legoux, Johann Dubuc, Maria Winnock, JacquesArnaud Seyrig, Jean-Philippe Barbier, Thierry Barrioz, Rene´ Laugier, Guy Boulay, Denis Grasset, Denis Sautereau, Dan Grigoresco, Joe¨l Butel, Thierry Ponchon Introduction: The aim of this national prospective study was to determine the prevalence of esophageal squamous cell carcinoma in high-risk patients and the advantage of lugol staining during the upper intestinal endoscopy. Lugol esophageal staining increased the sensitivity of esophageal endoscopy for the detection of high-grade dysplasias and cancers. The other abnormalities viewed before and after lugol staining were also notified. Patients and Methods: The French prospective study was undertaken in 62 endoscopy centers, including 1095 patients without esophageal symptoms, who presented either a past or recent head and neck or tracheobronchial squamous cell carcinoma (group 1), alcoholic chronic pancreatitis (group 2), alcoholic cirrhosis (group 3), or were alcohol and tobacco addicts (group 4). The endoscopists performed a meticulous examination of the esophagus followed by a lugol staining. Results: A Barrett’s mucosa was observed in 5.9% of the cases (table), with a similar prevalence in the 4 groups (5 to 6%). A few low-grade dysplasias (4) were observed and any high-grade dysplasia. The lugol staining allowed an additional diagnosis of Barret’s mucosa in 7 patients, i.e. 11% among the 62 diagnosed (p Z 0.023). Conclusions: Lugol esophageal staining increases the sensitivity of esophageal endoscopy for the detection of Barrett’s esophagus. This additional effect of this staining could heighten its indications among patients with alcohol and tabacco addiction, which increases the acid gastro´f: Esophageal Squamous Cell Carcinoma Screening in Highesophageal reflux. Re Risk Patients: a French Endoscopic Prospective Study. Dubuc J et al. Endoscopy 2006,38:690-5.
AB154 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
Results: number and (%)
Number of patients Barrett’s metaplasia before Lugol staining Barrett’s metaplasia after Lugol staining Total
Group I
Group II
Group III
Group IV
Total
N Z 393 17 (4.2)
N Z 76 4 (5)
N Z 218 12 (5)
N Z 408 22 (5.7)
N Z 1095 55 (5.3)
1 (0.5)
2 (0.5)
7 (0.6)
24 (6.2)
62 (5.9)
4 (1) 21 (5.2)
0 4 (5)
13 (6)
S1361 Is Their a Preferred Location of Intestinal Metaplasia in Barrett’s Esophagus? Vikram Boolchand, Lisa Camargo, Anil Prasad, Richard E. Sampliner Background: Intestinal Metaplasia (IM) is the presumed precursor of esophageal adenocarcinoma. It has been suggested that IM may not be uniformally distributed in long segment Barrett’s esophagus (BE) and that IM is significantly more common in the proximal portion than the distal portion of Barrett’s appearing mucosa. This would have important implications for surveillance biopsy sampling. The aim of this study was to compare the incidence of proximal and distal intestinal metaplasia in long segment Barrett’s patients. Methods: Thirty patients with known long segment Barrett’s esophagus were reviewed in a retrospective fashion. In order to detect a 30% difference in incidence of IM with 95% power, 29 pairs (proxmial, distal) would be needed. Demographic information, BMI, length of BE at endoscopy, and use of proton pump inhibitors were collected on each patient. Endoscopy was performed at a single center, by a single endoscopist with the standard four quadrant, every 2 cm biopsy protocol. Biopsies from the most proximal and distal portion of Barrett’s appearing mucosa were reviewed by a single pathologist for correlation. Each biopsy from the 2 sites was assessed for the presence of goblet cells, i.e. intestinal metaplasia. Results: The study group was 96% male, 97% white, had an average age of 69 years and BMI of 29 at endoscopy. The average length of BE endoscopically was 6.8 cm. The average distance between proximal and distal biopsies reviewed was 5.4 cm. 93% of the patients had proximal IM and 90% of the patients had distal IM. A total of 216 biopsies were reviewed. 80.4% (78/97) of the proximal biopsies showed IM and 70.5% (84/119) of the distal biopsies showed IM (p Z 0.11, fisher test). 90% of the patients were taking a proton pump inhibitor. Conclusion: The location of IM in the proximal Barrett’s segment does not seem different from the distal. This would support current biopsy sampling techniques including taking equal proximal and distal biopsies.
S1362 In Vivo 3D Comprehensive Microscopy of the Human Distal Esophagus Melissa J. Suter, Benjamin J. Vakoc, Norman S. Nishioka, Patrick S. Yachimski, Milen Shishkov, Reza Motaghiannezam, Brett E. Bouma, Guillermo J. Tearney Given the mortality rate associated with esophageal adenocarcinoma it is apparent that further advancements in methods for detecting, diagnosing and tracking patients with Barrett’s esophagus are required. Current evaluation involves endoscopy followed by the collection multiple random biopsies, however this form of assessment is invasive and susceptible to sampling errors. Optical coherence tomography (OCT) provides high-resolution (w10 mm resolution) cross-sectional images of esophageal microstructure, enabling accurate differentiation of specialized intestinal metaplasia, dysplasia, and intramucosal carcinoma. To date, the clinical utility of this technology has been limited by imaging speeds and optical probe design. Optical frequency domain imaging (OFDI) is a new imaging technology that is based on frequency domain interferometry and is capable of improving imaging speed over traditional OCT techniques by orders of magnitude without sacrificing image quality. We have developed a catheter based OFDI system that acquires comprehensive three-dimensional microscopic images of the entire distal esophagus (w5.0 cm) with resolutions in cylindrical coordinates of 25 mm (4) 8 mm (r) 33 mm (z). Comprehensive microscopy of the distal esophagus has been performed in over 20 patients with the OFDI system and balloon catheter. The acquired volumetric OFDI datasets were visualized using both volume rendering and longitudinal and transverse cross-sectional imaging, and were correlated with histopathology. We anticipate that comprehensive volumetric microscopy with OFDI will significantly improve the management of patients with Barrett’s esophagus by providing a relatively non-invasive means for screening the entire distal esophagus for intestinal metaplasia, dysplasia, and adenocarcinoma.
www.giejournal.org