- Email: [email protected]
or Intramucosal Carcinoma
Abstracts
complete remission or referral to surgery for residual disease). Demographic and endoscopic data were analyzed using JMP (v8, Cary NC). The pathology reports of each included patient were reviewed for any diagnosis of BBM or submucosal glands during the follow-up period. Results: We identified a total of 112 patients that completed follow-up. A total of 17 patients (15.2%) had evidence of BBM at some point during evaluation. Of these, 4/17 (23.5%) had BBM seen on biopsy prior to RFA. A total of 11/17 (64.7%) patients in the BBM group had evidence of dysplasia (5 LGD, 6 HGD). Of those patients with BBM, 10/17 (58.8%) had received non-RFA treatment in the past (6 received EMR alone, 2 received APC alone, 1 received PDT and EMR, and 1 received PDT, APC, and EMR). Comparatively, 19/95 (20%) of patients without the finding of BBM during follow-up had undergone non-RFA therapy for BE. All 17 cases of BBM showed no evidence of BBM at final endoscopic and pathologic evaluation and all were classified in the complete remission group (108/112). The average age of this subset was 70 years and average BMI was 29 (similar to patients without BBM). Conclusion: Our results show that the incidence of BBM in patients with BE prior to RFA are similar to data from prior studies (25-36%). More than half of patients found to have BBM were initially categorized as BE with dysplasia. We found that most of the patients with BBM had a prior history of another therapy for BE (i.e. PDT) compared to the non-BBM cohort. Our findings confirm that BBM is found uncommonly in patients who are followed long term after RFA. In our study, all patients with previously appreciated BBM were completely cleared of disease at final follow-up evaluation.
Sa1544 How Is Early Barrett’s Cancer Currently Diagnosed and Treated Throughout Western Europe? Results of a Survey At 107 University Hospitals in 8 Western European Countries Dominik Heuberger, Hendrik Manner, Christian Ell, Oliver Pech Department of Internal Medicine 2, HSK Wiesbaden, Wiesbaden, Germany Introduction: Endoscopic therapy (ET) of early Barrett’s cancer (EBC) is gaining increasing acceptance because it is associated with a low complication rate and an almost absent mortality rate in combination with excellent long-term results. Radical surgical resection of the esophagus carries a significant risk for morbidity and mortality. Aim of this study was to investigate current standards and treatment strategies of early Barrett’s cancer throughout Western Europe. Methods: A standardised questionnaire was developed consisting of 11 “multiple choice questions” asking for the respective hospital’s diagnostic and therapeutic standard in patients with early Barrett’s cancer. It included case histories with different stages of disease. The questionnaire was sent to the departments of gastroenterology at 108 University hospitals in 8 Western European countries. Data analysis was carried out anonymously. Results: The percentage of returned questionnaires was 49% (52/107). Diagnostics: 94% of hospitals use quadrantbiopsies as well as targeted biopsies. NBI/FICE is utilised in 67% and other advanced imaging techniques in 65% (acetic acid and methylene blue staining). Prior treatment 63% of the hospitals recommend conventional endosonography (EUS), 6% are using miniprobe-EUS and 19% are combining both methods. Treatment: Endoscopic resection is carried out at 98% of all responding University hospitals. 80% are using argon plasma coagulation or radiofrequency ablation. Photodynamic therapy is only used in 32% of departments. An 80-year old patient with localised mucosal Barrett’s carcinoma would be treated by 100% of polled hospitals endoscopically. However, ET in a 50-year old patient with mucosal EBC is recommended by 87%. In case of multifocal EBC 15% (80 year old patient) and 63% (50 year old patient) of all respondents, respectively, would recommend esophageal resection. Conclusions: By now ET is accepted as the therapeutic standard of localised mucosal Barrett’s cancer in Western Europe. If there are multifocal lesions of mucosal Barrett’s cancer the majority of the polled departments would still recommend surgical resection of the esophagus. The use of high-resolution endoscopes and of advanced imaging techniques is standard in most of the European academic GI departments.
Sa1545 Evaluating the Accuracy of Endoscopic Staging for Barrett’s Esophagus With High-Grade Dysplasia and/or Intramucosal Carcinoma Robert T. Kavitt1, James C. Slaughter2, Patrick S. Yachimski1 1 Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN; 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN Introduction: Patients with Barrett’s esophagus containing high-grade dysplasia (HGD) and/or intramucosal carcinoma (IMC) are candidates for curative endoscopic therapy, however accurate endoscopic staging is essential to exclude the presence of occult invasive carcinoma. The aim of this study was to determine the accuracy of endoscopic staging, using postoperative esophagectomy specimens as the reference standard. Methods: An institutional
www.giejournal.org
database was queried to identify subjects with an ICD-9 code for Barrett’s esophagus and CPT code for esophagectomy. Deidentified medical records were manually reviewed to extract demographic and clinical data. Results: The cohort consisted of 85 subjects. 92% were male, 95% Caucasian, with a mean age of 59 years and median BMI 28.4. The majority (85%) had been diagnosed by upper endoscopy at an outside medical facility, prompting referral to our center. 62 (73%) underwent endoscopic ultrasound and 3 (3.5%) underwent endoscopic mucosal resection (EMR) for staging prior to esophagectomy. Preoperative staging diagnosed 21 (25%) with HGD, 12 (14%) with T1a disease, 5 (6%) with T1b disease, 20 (23%) with T2 disease, 26 (31%) with T3 disease, and 1 (1%) with T4 disease. No subjects with HGD, T1a, or T1b as their preoperative diagnosis received neoadjuvant therapy prior to esophagectomy.Among 21 patients with a preoperative diagnosis of HGD, postoperative staging based on the resected specimens documented 2 with low-grade dysplasia, 14 with HGD, 3 with T1a, 1 with T1b, and 1 with T2 disease. Among 12 subjects with a preoperative diagnosis of T1a, postoperative staging documented 1 with no evidence of malignancy, dysplasia, or Barrett’s, 3 with HGD, 5 with T1a, and 3 with T1b disease. 28 out of 33 subjects (85%) with HGD/IMC were therefore accurately staged endoscopically as without evidence of invasive disease, and therefore could have been appropriate candidates for definitive endoscopic therapy instead of surgery. Univariate analysis failed to identify significant predictors of understaging, albeit statistical power was limited due to the size of the cohort. Conclusions: Among patients undergoing esophagectomy for Barrett’s esophagus containing HGD and/or IMC at a tertiary referral center, the majority (85%) had disease confined to the mucosa and would have been candidates for EMR or ablation as an alternative therapeutic modality. Not all patients underwent endoscopic ultrasound and relatively few underwent EMR for staging; increased utilization of these techniques may have increased the accuracy of endoscopic detection of invasive disease. Further prospective studies should be undertaken to identify predictors of invasive disease, in an effort to risk-stratify and select appropriate patients for endoscopic versus surgical management.
Sa1546 Trends in Endoscopy for Dyspepsia 2000-2008: Declining Trend of Barrett’s Esophagus in the Age of Over the Counter Proton Pump Inhibitors (2004-2008) Akhil Raghuram, Jennifer L. Holub, David A. Lieberman Oregon Health and Science University, Portland, OR Background: Barrett’s esophagus (BE) is an important risk factor for esophageal adenocarcinoma. It is closely linked to gastroesophageal reflux disease (GERD). Endoscopic (EGD) screening has been advocated to identify patients with BE who would be candidates for surveillance and those with dysplasia who would be candidates for treatment. We hypothesize that the prevalence of BE in patients undergoing EGD for GERD may have declined after proton pump inhibitors (PPI) became available over the counter (OTC) in 2003 and with increased use of prescription strength PPIs. Aim: The aim of this study was to determine if there was a decline in prevalence of BE in patients with reflux presenting for EGD between two time periods, 2000-2002 and 2004-2008. A secondary aim was to describe risk factors for BE in the study population. Methods: Data from unique patients from the Clinical outcomes research initiative (CORI) consortium consisting of 65 diverse practice settings was used. Patients with reflux dyspepsia as the indication for EGD were included. Those with known BE and dysphagia were excluded. A comparison was then made with previously reported data from the January 1st 2000 - June 30th 2002 time period. The diagnosis of BE was based on endoscopic suspicion, and not confirmed by histology. Previous work has shown a high correlation between the two. Multiple logistic regression was used to adjust for demographic differences between the two populations, and to identify risk factors for BE. Results: The 2004-2008 population consisted of 70461 unique patients with reflux dyspepsia compared with 18106 patients in the January 2000 and June 2002 population. There were small demographic differences in age and race between the two populations, however there was a highly significant difference in gender prevalence. The prevalence of BE declined in the 2004-2008 period, even after adjustment for age, race and gender differences. Risk factors for BE were advancing age (peaking with odds ratio (OR) 1.96 in the 60-69 age group compared with age ⬍40) and male gender (OR 2.53, 95% CI 2.32-2.76). Compared with Whites, Black race (OR 0.43; 95% CI 0.23-0.61) and Hispanic ethnicity (OR 0.53, 95% CI 0.44-0.63) were associated with a lower prevalence of BE. Risk factors were similar for the two time periods. Discussion: Among patients undergoing EGD with reflux symptoms and no dysphagia, there was a significant decline in prevalence of BE in the 2004-2008 time period compared with 2000-2002. Risk factors for BE are advancing age, male gender and white race. Prevalence of BE > 2cm in 2000-2002 and 2004-2008 Endoscopy Findings Barrett’s Esophagus ⬎ 2cm
Volume 73, No. 4S : 2011
Jan 2000-June 2002 (nⴝ18,106)
Jan 2004-Dec 2008 (nⴝ70,461)
p value
882 (4.9%)
1743 (2.5%)
⬍.0001
GASTROINTESTINAL ENDOSCOPY
AB203
complete remission or referral to surgery for residual disease). Demographic and endoscopic data were analyzed using JMP (v8, Cary NC). The pathology reports of each included patient were reviewed for any diagnosis of BBM or submucosal glands during the follow-up period. Results: We identified a total of 112 patients that completed follow-up. A total of 17 patients (15.2%) had evidence of BBM at some point during evaluation. Of these, 4/17 (23.5%) had BBM seen on biopsy prior to RFA. A total of 11/17 (64.7%) patients in the BBM group had evidence of dysplasia (5 LGD, 6 HGD). Of those patients with BBM, 10/17 (58.8%) had received non-RFA treatment in the past (6 received EMR alone, 2 received APC alone, 1 received PDT and EMR, and 1 received PDT, APC, and EMR). Comparatively, 19/95 (20%) of patients without the finding of BBM during follow-up had undergone non-RFA therapy for BE. All 17 cases of BBM showed no evidence of BBM at final endoscopic and pathologic evaluation and all were classified in the complete remission group (108/112). The average age of this subset was 70 years and average BMI was 29 (similar to patients without BBM). Conclusion: Our results show that the incidence of BBM in patients with BE prior to RFA are similar to data from prior studies (25-36%). More than half of patients found to have BBM were initially categorized as BE with dysplasia. We found that most of the patients with BBM had a prior history of another therapy for BE (i.e. PDT) compared to the non-BBM cohort. Our findings confirm that BBM is found uncommonly in patients who are followed long term after RFA. In our study, all patients with previously appreciated BBM were completely cleared of disease at final follow-up evaluation.
Sa1544 How Is Early Barrett’s Cancer Currently Diagnosed and Treated Throughout Western Europe? Results of a Survey At 107 University Hospitals in 8 Western European Countries Dominik Heuberger, Hendrik Manner, Christian Ell, Oliver Pech Department of Internal Medicine 2, HSK Wiesbaden, Wiesbaden, Germany Introduction: Endoscopic therapy (ET) of early Barrett’s cancer (EBC) is gaining increasing acceptance because it is associated with a low complication rate and an almost absent mortality rate in combination with excellent long-term results. Radical surgical resection of the esophagus carries a significant risk for morbidity and mortality. Aim of this study was to investigate current standards and treatment strategies of early Barrett’s cancer throughout Western Europe. Methods: A standardised questionnaire was developed consisting of 11 “multiple choice questions” asking for the respective hospital’s diagnostic and therapeutic standard in patients with early Barrett’s cancer. It included case histories with different stages of disease. The questionnaire was sent to the departments of gastroenterology at 108 University hospitals in 8 Western European countries. Data analysis was carried out anonymously. Results: The percentage of returned questionnaires was 49% (52/107). Diagnostics: 94% of hospitals use quadrantbiopsies as well as targeted biopsies. NBI/FICE is utilised in 67% and other advanced imaging techniques in 65% (acetic acid and methylene blue staining). Prior treatment 63% of the hospitals recommend conventional endosonography (EUS), 6% are using miniprobe-EUS and 19% are combining both methods. Treatment: Endoscopic resection is carried out at 98% of all responding University hospitals. 80% are using argon plasma coagulation or radiofrequency ablation. Photodynamic therapy is only used in 32% of departments. An 80-year old patient with localised mucosal Barrett’s carcinoma would be treated by 100% of polled hospitals endoscopically. However, ET in a 50-year old patient with mucosal EBC is recommended by 87%. In case of multifocal EBC 15% (80 year old patient) and 63% (50 year old patient) of all respondents, respectively, would recommend esophageal resection. Conclusions: By now ET is accepted as the therapeutic standard of localised mucosal Barrett’s cancer in Western Europe. If there are multifocal lesions of mucosal Barrett’s cancer the majority of the polled departments would still recommend surgical resection of the esophagus. The use of high-resolution endoscopes and of advanced imaging techniques is standard in most of the European academic GI departments.
Sa1545 Evaluating the Accuracy of Endoscopic Staging for Barrett’s Esophagus With High-Grade Dysplasia and/or Intramucosal Carcinoma Robert T. Kavitt1, James C. Slaughter2, Patrick S. Yachimski1 1 Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN; 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN Introduction: Patients with Barrett’s esophagus containing high-grade dysplasia (HGD) and/or intramucosal carcinoma (IMC) are candidates for curative endoscopic therapy, however accurate endoscopic staging is essential to exclude the presence of occult invasive carcinoma. The aim of this study was to determine the accuracy of endoscopic staging, using postoperative esophagectomy specimens as the reference standard. Methods: An institutional
www.giejournal.org
database was queried to identify subjects with an ICD-9 code for Barrett’s esophagus and CPT code for esophagectomy. Deidentified medical records were manually reviewed to extract demographic and clinical data. Results: The cohort consisted of 85 subjects. 92% were male, 95% Caucasian, with a mean age of 59 years and median BMI 28.4. The majority (85%) had been diagnosed by upper endoscopy at an outside medical facility, prompting referral to our center. 62 (73%) underwent endoscopic ultrasound and 3 (3.5%) underwent endoscopic mucosal resection (EMR) for staging prior to esophagectomy. Preoperative staging diagnosed 21 (25%) with HGD, 12 (14%) with T1a disease, 5 (6%) with T1b disease, 20 (23%) with T2 disease, 26 (31%) with T3 disease, and 1 (1%) with T4 disease. No subjects with HGD, T1a, or T1b as their preoperative diagnosis received neoadjuvant therapy prior to esophagectomy.Among 21 patients with a preoperative diagnosis of HGD, postoperative staging based on the resected specimens documented 2 with low-grade dysplasia, 14 with HGD, 3 with T1a, 1 with T1b, and 1 with T2 disease. Among 12 subjects with a preoperative diagnosis of T1a, postoperative staging documented 1 with no evidence of malignancy, dysplasia, or Barrett’s, 3 with HGD, 5 with T1a, and 3 with T1b disease. 28 out of 33 subjects (85%) with HGD/IMC were therefore accurately staged endoscopically as without evidence of invasive disease, and therefore could have been appropriate candidates for definitive endoscopic therapy instead of surgery. Univariate analysis failed to identify significant predictors of understaging, albeit statistical power was limited due to the size of the cohort. Conclusions: Among patients undergoing esophagectomy for Barrett’s esophagus containing HGD and/or IMC at a tertiary referral center, the majority (85%) had disease confined to the mucosa and would have been candidates for EMR or ablation as an alternative therapeutic modality. Not all patients underwent endoscopic ultrasound and relatively few underwent EMR for staging; increased utilization of these techniques may have increased the accuracy of endoscopic detection of invasive disease. Further prospective studies should be undertaken to identify predictors of invasive disease, in an effort to risk-stratify and select appropriate patients for endoscopic versus surgical management.
Sa1546 Trends in Endoscopy for Dyspepsia 2000-2008: Declining Trend of Barrett’s Esophagus in the Age of Over the Counter Proton Pump Inhibitors (2004-2008) Akhil Raghuram, Jennifer L. Holub, David A. Lieberman Oregon Health and Science University, Portland, OR Background: Barrett’s esophagus (BE) is an important risk factor for esophageal adenocarcinoma. It is closely linked to gastroesophageal reflux disease (GERD). Endoscopic (EGD) screening has been advocated to identify patients with BE who would be candidates for surveillance and those with dysplasia who would be candidates for treatment. We hypothesize that the prevalence of BE in patients undergoing EGD for GERD may have declined after proton pump inhibitors (PPI) became available over the counter (OTC) in 2003 and with increased use of prescription strength PPIs. Aim: The aim of this study was to determine if there was a decline in prevalence of BE in patients with reflux presenting for EGD between two time periods, 2000-2002 and 2004-2008. A secondary aim was to describe risk factors for BE in the study population. Methods: Data from unique patients from the Clinical outcomes research initiative (CORI) consortium consisting of 65 diverse practice settings was used. Patients with reflux dyspepsia as the indication for EGD were included. Those with known BE and dysphagia were excluded. A comparison was then made with previously reported data from the January 1st 2000 - June 30th 2002 time period. The diagnosis of BE was based on endoscopic suspicion, and not confirmed by histology. Previous work has shown a high correlation between the two. Multiple logistic regression was used to adjust for demographic differences between the two populations, and to identify risk factors for BE. Results: The 2004-2008 population consisted of 70461 unique patients with reflux dyspepsia compared with 18106 patients in the January 2000 and June 2002 population. There were small demographic differences in age and race between the two populations, however there was a highly significant difference in gender prevalence. The prevalence of BE declined in the 2004-2008 period, even after adjustment for age, race and gender differences. Risk factors for BE were advancing age (peaking with odds ratio (OR) 1.96 in the 60-69 age group compared with age ⬍40) and male gender (OR 2.53, 95% CI 2.32-2.76). Compared with Whites, Black race (OR 0.43; 95% CI 0.23-0.61) and Hispanic ethnicity (OR 0.53, 95% CI 0.44-0.63) were associated with a lower prevalence of BE. Risk factors were similar for the two time periods. Discussion: Among patients undergoing EGD with reflux symptoms and no dysphagia, there was a significant decline in prevalence of BE in the 2004-2008 time period compared with 2000-2002. Risk factors for BE are advancing age, male gender and white race. Prevalence of BE > 2cm in 2000-2002 and 2004-2008 Endoscopy Findings Barrett’s Esophagus ⬎ 2cm
Volume 73, No. 4S : 2011
Jan 2000-June 2002 (nⴝ18,106)
Jan 2004-Dec 2008 (nⴝ70,461)
p value
882 (4.9%)
1743 (2.5%)
⬍.0001
GASTROINTESTINAL ENDOSCOPY
AB203