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S1480: Risk Factors for Developing Synchronous Esophageal Neoplasia in Patients With Head and Neck Cancer
Abstracts with and without dysplasia. However, a subset of patients undergoing RFA will require prolonged therapy, defined as requiring ⬎ 4 RFA treatments, before achieving eradication of all IM. We sought to identify factors that would better identify this group of patients prior to planned RFA treatment.METHODS: The medical records of all patients who underwent RFA for BE at a single center from April 2004 through October 2009 were reviewed. Those who required more than 4 RFA treatments were identified and compared to those who successfully attained complete ablation of all IM in 4 or fewer sessions. Patients receiving prior or subsequent photodynamic or cryoablation therapy were excluded. The following variables were assessed: age, sex, BE length, the presence and length of a hiatal hernia, esophageal tortuosity, interval length between RFA treatments, mean gastric pH, use of sucralfate after RFA, prior endoscopic mucosal resection, a history of stricture/esophageal dilation, or prior surgery (fundoplication, esophageal/gastric resection). RESULTS: A total of 116 patients were identified, of which 65 had either achieved complete IM ablation or had required ⬎ 4 treatments during the study period. Their mean age was 62.5 years; 110 (91%) were men. Twelve patients ( 6-no dysplasia (ND), 3 - low grade dysplasia (LGD), 3- indefinite for dysplasia (ID)) required ⬎4 RFA treatments, while 53 patients (25 ND, 10 LGD, 13 - high grade dysplasia, 2 - intramucosal carcinoma, 3 - ID) achieved complete IM ablation with ⬍⫽4 RFA treatments. Of the factors evaluated, BE length (8.1 cm vs. 4.5 cm; p⫽ 0.0018), hiatal hernia length (3.1 cm vs. 1.9 cm; p⫽0.012), and the presence of a tortuous esophagus (8/12 (67%) vs.9/53 (17%); p⫽0.001), were significantly different between the groups. No differences in age (59.3 vs. 63.5 years), sex (% male: 100 vs. 91), treatment interval (178.7 d vs. 133.4 d), average pH (5.1 vs. 5.0), carafate use after RFA (58.3% vs. 47.2%), prior surgery (16% vs. 18.9%), prior EMR (8.3% vs. 17%), history of stricture/esophageal dilation (8.3% vs. 9.4%), or in the maximal degree of dysplasia were seen between the groups. CONCLUSIONS: This single center retrospective study showed that the risk factors predicting the need for repeated (⬎4) RFA treatments to achieve complete ablation of IM included long-segment BE (⬎ 8 cm), the presence of a large hiatal hernia (⬎ 3 cm), and the presence of a tortuous esophagus. Larger, multi-center studies are needed to confirm these results.
S1480 Risk Factors for Developing Synchronous Esophageal Neoplasia in Patients With Head and Neck Cancer Wen-Lun Wang, Ching-Tai Lee, Yi-Chia Lee, Chi-Ming Tai, Chi-Yang Chang, Jaw-Town Lin Background:This study investigated the risk factors for synchronous esophageal neoplasia in patients with squamous cell carcinoma of the head and neck (HNSCC) .Methods:All 315 consecutive patients at two large hospitals in Taiwan with newly-diagnosed HNSCC, seen from May 2007 to June 2009, received endoscopic esophageal screening with conventional white-light, narrow band imaging and Lugol chromoendoscopy.Results: Sixty-nine patients (21.9%) had synchronous esophageal neoplasia, 53.6% with superficial neoplasia and 30.4% with multiple esophageal lesions. Univariate analysis revealed age ⬍ 50 years, drinking alcohol and location of index HNSCC were significant risk factors for developing synchronous esophageal neoplasia. In multivariate analysis, drinking alcohol (odds ratio [OR] 3.792, p⫽0.0035), index oropharynx cancers (OR 3.618, p⫽0.0045) and hypopharynx cancers (OR 2.627, p⫽0.0029) were independent risk factors. Drinking alcohol was clearly dose-response related (p⫽0.001).Conclusions: Alcohol consumption and index tumor location are associated with development of synchronous esophageal neoplasia in HNSCC patients. Because of high prevalence, routine endoscopic examination of the esophagus should be recommended as a part of pre-treatment evaluation for newly diagnosed head and neck cancers, especially in patients with the risk factors identified. Demographic characteristics of 315 patients with HNSCC With Synchronous EN*(Nⴝ69)
Without synchronous EN* (Nⴝ246)
No. of patients (%) 32 (46%) 17 (25%) 15 (22%) 5 (7%) 15 (22%)
No. of patients (%) 74 (30%) 85 (35%) 52 (21%) 35 (14%) 89 (36%)
Odds Ratio (95% CI) 1.0 0.46(0.24;0.90) 0.67(0.33;1.36) 0.33 (0.12;0.92) 1.0
12 (17%) 40 (58%) 2 (3%) 6 (9%)
21 (9%) 99 (40%) 20 (8%) 74 (30%)
4.04(1.66;9.85) 2.86(1.49;5.49) 0.70(0.15;3.33) 1.0
14 (20%) 49 (71%) 20 (29%)
43 (18%) 129(52%) 71 (29%)
4.02(1.44;11.22) 4.69(1.92;11.46) 1.0
12(17%) 37 (54%)
56 (23%) 119 (48%)
0.76(0.34;1.69) 1.10 (0.60;2.05)
Age (years) ⬍51 51-60 61-70 ⬎70 Location of index HNSCC Oral cavity Oropharynx Hypopharynx Larynx Alcohol drinking (drink years)* Nondrinker 1-20 ⬎20 Betel nut chewing (pack years)* Nonchewer 1-20 ⬎20
www.giejournal.org
Cigarette smoking (pack years)* Nonsmoker 1-20 ⬎20 Gender Male
With Synchronous EN*(Nⴝ69)
Without synchronous EN* (Nⴝ246)
3(4%)
31 (13%)
1.0
32 (46%) 34 (49%) 68 (98.5%
98 (40%) 117 (47%) 238 (97%)
3.37(0.97;11.78) 3.00(0.87;10.43)
* EN: Esophageal neoplasia * drink years ⫽ number of drinks times years reported. * pack years ⫽ number of packs times years reported. For betel nut chewers, one pack ⫽ 10 quid and for smokers, one pack ⫽ 20 cigarettes.
S1481 A Novel Biopsy Protocol for Assessment of Neosquamous Epithelium After Radiofrequency Ablation of Barrett’s Esophagus With High Grade Dysplasia Srinadh Komanduri, Kumar Krishnan, Shriram Jakate, Guang-Yu Yang Introduction: Radiofrequency ablation (RFA) has altered the management paradigm of Barrett’s esophagus with high grade-dysplasia (HGD). However, three specific dilemmas remain regarding tissue sampling technique after ablative therapy: 1) accurate determination of the original extent of intestinal metaplasia (IM), 2) achieving adequate depth, inclusive of muscularis mucosa (MM), to ensure proper specimen orientation and inclusion of the lamina propria for assessment of buried glands, and 3) differentiating post-ablative IM at the squamocolumnar junction (SCJ) from IM of the gastric cardia. Toward these ends, we implemented a novel biopsy protocol with jumbo biopsy forceps for identification of neosquamous epithelium (NE) after ablative therapy for dysplastic BE.Methods: We prospectively evaluated 20 patients undergoing RFA for HGD. All patients had staging EUS prior to ablative therapy. 5/20 patients had prior mucosal resection. At the time of EUS, biopsies were taken from the gastric cardia, extending 2 cm distal to the squamocolumnar junction (SCJ). Two months, after completion of RFA, all patients underwent endoscopy and biopsy with jumbo biopsy forceps. Biopsies were taken from 2cm proximal to the original orad extent of IM to the cardia, in a 4-quadrant 1cm protocol. Each level was submitted in an individual specimen jar. In addition to routine histology, all samples were assessed with a standardized depth grade scale (DGS) and were immunostained with Ki-67 (marker of cell proliferation). Results: All samples contained MM (DGS ⬎3) allowing for proper sample orientation. None of the 20 patients had dysplasia or buried glands. The mean number of cell layers stained by Ki-67 was 5.0 (4-6) vs. 1.5 (1-2) in the ablated NE and native squamous mucosa respectively (p⬍0.001, Fig 1). 18/20 patients (90%) achieved a complete response, while two patients had focal IM at the SCJ. None of the 20 patients had IM of the cardia before RFA.Conclusion: Tissue acquisition with jumbo biopsy forceps facilitates assessment for buried glands after RFA. In addition, we have shown that Ki-67 staining distinguishes between native squamous epithelium and ablated NE, allowing for accurate identification of the proximal extent of the original IM. Biopsies obtained from the cardia prior to ablative therapy further help stratify post ablative IM at the SCJ. This novel protocol for tissue sampling after ablative therapy utilizing jumbo biopsy forceps, Ki-67 immunostaining, and sampling of the gastric cardia allows for optimal assessment of NE.
S1482 Endoscopic Interventions for Barrett’s Esophagus With LowGrade Dysplasia to Prevent Progression: A Meta-Analysis of Randomized Controlled Trials Abhishek Choudhary, Nicholas M. Szary, Vanessa K. Kuwajima, Murtaza Arif, Ghassan M. Hammoud, Matthew L. Bechtold, Jamal A. Ibdah Background:Barrett’s esophagus is associated with an increased risk of esophageal adenocarcinoma and risk increases with dysplasia. Optimal management of patients with Barrett’s esophagus and low-grade dysplasia (LGD) is still unclear. Various randomized controlled trials (RCTs) have been performed to assess the role and utility of various endoscopic interventions to prevent progression of Barrett’s esophagus with low-grade dysplasia to high-grade dysplasia (HGD) but with controversial results. Therefore, we conducted metaanalysis to assess the role of various endoscopic interventions to prevent progression of Barrett’s esophagus.Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (10/09). RCTs comparing endoscopic ablative methods for Barrett’s esophagus with LGD versus follow-up to prevent progression to HGD were included. Standard forms were used to extract data by two independent reviewers. The effects of ablation were analyzed by calculating pooled estimates of secondary progression, complete eradication of Barrett’s epithelium, and complications. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB173
S1480 Risk Factors for Developing Synchronous Esophageal Neoplasia in Patients With Head and Neck Cancer Wen-Lun Wang, Ching-Tai Lee, Yi-Chia Lee, Chi-Ming Tai, Chi-Yang Chang, Jaw-Town Lin Background:This study investigated the risk factors for synchronous esophageal neoplasia in patients with squamous cell carcinoma of the head and neck (HNSCC) .Methods:All 315 consecutive patients at two large hospitals in Taiwan with newly-diagnosed HNSCC, seen from May 2007 to June 2009, received endoscopic esophageal screening with conventional white-light, narrow band imaging and Lugol chromoendoscopy.Results: Sixty-nine patients (21.9%) had synchronous esophageal neoplasia, 53.6% with superficial neoplasia and 30.4% with multiple esophageal lesions. Univariate analysis revealed age ⬍ 50 years, drinking alcohol and location of index HNSCC were significant risk factors for developing synchronous esophageal neoplasia. In multivariate analysis, drinking alcohol (odds ratio [OR] 3.792, p⫽0.0035), index oropharynx cancers (OR 3.618, p⫽0.0045) and hypopharynx cancers (OR 2.627, p⫽0.0029) were independent risk factors. Drinking alcohol was clearly dose-response related (p⫽0.001).Conclusions: Alcohol consumption and index tumor location are associated with development of synchronous esophageal neoplasia in HNSCC patients. Because of high prevalence, routine endoscopic examination of the esophagus should be recommended as a part of pre-treatment evaluation for newly diagnosed head and neck cancers, especially in patients with the risk factors identified. Demographic characteristics of 315 patients with HNSCC With Synchronous EN*(Nⴝ69)
Without synchronous EN* (Nⴝ246)
No. of patients (%) 32 (46%) 17 (25%) 15 (22%) 5 (7%) 15 (22%)
No. of patients (%) 74 (30%) 85 (35%) 52 (21%) 35 (14%) 89 (36%)
Odds Ratio (95% CI) 1.0 0.46(0.24;0.90) 0.67(0.33;1.36) 0.33 (0.12;0.92) 1.0
12 (17%) 40 (58%) 2 (3%) 6 (9%)
21 (9%) 99 (40%) 20 (8%) 74 (30%)
4.04(1.66;9.85) 2.86(1.49;5.49) 0.70(0.15;3.33) 1.0
14 (20%) 49 (71%) 20 (29%)
43 (18%) 129(52%) 71 (29%)
4.02(1.44;11.22) 4.69(1.92;11.46) 1.0
12(17%) 37 (54%)
56 (23%) 119 (48%)
0.76(0.34;1.69) 1.10 (0.60;2.05)
Age (years) ⬍51 51-60 61-70 ⬎70 Location of index HNSCC Oral cavity Oropharynx Hypopharynx Larynx Alcohol drinking (drink years)* Nondrinker 1-20 ⬎20 Betel nut chewing (pack years)* Nonchewer 1-20 ⬎20
www.giejournal.org
Cigarette smoking (pack years)* Nonsmoker 1-20 ⬎20 Gender Male
With Synchronous EN*(Nⴝ69)
Without synchronous EN* (Nⴝ246)
3(4%)
31 (13%)
1.0
32 (46%) 34 (49%) 68 (98.5%
98 (40%) 117 (47%) 238 (97%)
3.37(0.97;11.78) 3.00(0.87;10.43)
* EN: Esophageal neoplasia * drink years ⫽ number of drinks times years reported. * pack years ⫽ number of packs times years reported. For betel nut chewers, one pack ⫽ 10 quid and for smokers, one pack ⫽ 20 cigarettes.
S1481 A Novel Biopsy Protocol for Assessment of Neosquamous Epithelium After Radiofrequency Ablation of Barrett’s Esophagus With High Grade Dysplasia Srinadh Komanduri, Kumar Krishnan, Shriram Jakate, Guang-Yu Yang Introduction: Radiofrequency ablation (RFA) has altered the management paradigm of Barrett’s esophagus with high grade-dysplasia (HGD). However, three specific dilemmas remain regarding tissue sampling technique after ablative therapy: 1) accurate determination of the original extent of intestinal metaplasia (IM), 2) achieving adequate depth, inclusive of muscularis mucosa (MM), to ensure proper specimen orientation and inclusion of the lamina propria for assessment of buried glands, and 3) differentiating post-ablative IM at the squamocolumnar junction (SCJ) from IM of the gastric cardia. Toward these ends, we implemented a novel biopsy protocol with jumbo biopsy forceps for identification of neosquamous epithelium (NE) after ablative therapy for dysplastic BE.Methods: We prospectively evaluated 20 patients undergoing RFA for HGD. All patients had staging EUS prior to ablative therapy. 5/20 patients had prior mucosal resection. At the time of EUS, biopsies were taken from the gastric cardia, extending 2 cm distal to the squamocolumnar junction (SCJ). Two months, after completion of RFA, all patients underwent endoscopy and biopsy with jumbo biopsy forceps. Biopsies were taken from 2cm proximal to the original orad extent of IM to the cardia, in a 4-quadrant 1cm protocol. Each level was submitted in an individual specimen jar. In addition to routine histology, all samples were assessed with a standardized depth grade scale (DGS) and were immunostained with Ki-67 (marker of cell proliferation). Results: All samples contained MM (DGS ⬎3) allowing for proper sample orientation. None of the 20 patients had dysplasia or buried glands. The mean number of cell layers stained by Ki-67 was 5.0 (4-6) vs. 1.5 (1-2) in the ablated NE and native squamous mucosa respectively (p⬍0.001, Fig 1). 18/20 patients (90%) achieved a complete response, while two patients had focal IM at the SCJ. None of the 20 patients had IM of the cardia before RFA.Conclusion: Tissue acquisition with jumbo biopsy forceps facilitates assessment for buried glands after RFA. In addition, we have shown that Ki-67 staining distinguishes between native squamous epithelium and ablated NE, allowing for accurate identification of the proximal extent of the original IM. Biopsies obtained from the cardia prior to ablative therapy further help stratify post ablative IM at the SCJ. This novel protocol for tissue sampling after ablative therapy utilizing jumbo biopsy forceps, Ki-67 immunostaining, and sampling of the gastric cardia allows for optimal assessment of NE.
S1482 Endoscopic Interventions for Barrett’s Esophagus With LowGrade Dysplasia to Prevent Progression: A Meta-Analysis of Randomized Controlled Trials Abhishek Choudhary, Nicholas M. Szary, Vanessa K. Kuwajima, Murtaza Arif, Ghassan M. Hammoud, Matthew L. Bechtold, Jamal A. Ibdah Background:Barrett’s esophagus is associated with an increased risk of esophageal adenocarcinoma and risk increases with dysplasia. Optimal management of patients with Barrett’s esophagus and low-grade dysplasia (LGD) is still unclear. Various randomized controlled trials (RCTs) have been performed to assess the role and utility of various endoscopic interventions to prevent progression of Barrett’s esophagus with low-grade dysplasia to high-grade dysplasia (HGD) but with controversial results. Therefore, we conducted metaanalysis to assess the role of various endoscopic interventions to prevent progression of Barrett’s esophagus.Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (10/09). RCTs comparing endoscopic ablative methods for Barrett’s esophagus with LGD versus follow-up to prevent progression to HGD were included. Standard forms were used to extract data by two independent reviewers. The effects of ablation were analyzed by calculating pooled estimates of secondary progression, complete eradication of Barrett’s epithelium, and complications. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB173