Squamous cell carcinoma after radiofrequency ablation for Barrett’s dysplasia

Barrett’s oesophagus(BO)is a usually indolent condition that occasionally requires endoscopic therapy.Radiofrequency ablation(RFA)is an effective endoscopic treatment for high grade dysplasia(HGD)and intramucosal cancer in BO.It has a good efficacy,durability and safety profile although complications can occur.Here we describe a case of RFA in a patient with high grade dysplasia.Although the response to treatment was initially very good with the development of neosquamous epithelium,the patient very rapidly developed a squamous cell cancer of the oesophagus confirmed on radiology,histology and immunohistochemistry.Sanger sequencing confirmed that the original HGD and the squamous cell cancer(SCC)were derived from separate clonal origins.The report highlights the fact that SCC of the oesophagus has been noted after endoscopic ablation for BO previously and suggest that ablation of BO may encourage the clonal expansion of cells carrying carcinogenic mutations once a dominant clonal population has been eradicated.     

Risk factors associated with Barrett’s epithelial dysplasia

AIM:To elucidate risk factors associated with dysplasia of short-segment Barrett’s esophagus(BE).METHODS:A total of 151 BE patients who underwent endoscopic examination from 2004 to 2008 in Aoyama Hospital,Tokyo Women’s Medical University,Japan and whose diagnosis was confirmed from biopsy specimens were enrolled in the study.BE was diagnosed based on endoscopic findings of gastric-appearing mucosa or apparent columnar-lined esophagus proximal to the esophagogastric junction.Dysplasia was classified into three grades-mild,moderate and severe-according to the guidelines of the Vienna Classification System for gastrointestinal epithelial neoplasia.Anthropometric and biochemical data were analyzed to identify risk factors for BE dysplasia.The prevalence of Helicobacter pylori(H.pylori)infection and the expression of p53 by immunohistological staining were also investigated.RESULTS:Histological examination classified patients into three types:specialized columnar epithelium(SCE)(n=65);junctional(n=38);and gastric fundic(n =48).The incidence of dysplasia or adenocarcinoma from BE of the SCE type was significantly higher than that of the other two types(P<0.01).The univariate analysis revealed that sex,H.pylori infection,body weight,p53 overexpression,and low diastolic blood pressure(BP)were associated with BE dysplasia.In contrast,body mass index,waist circumference,metabolic syndrome complications,and variables related to glucose or lipid metabolism were not associated with dysplasia.Multivariate logistic analysis showed that overexpression of p53[odds ratio(OR)=13.1,P=0.004],H.pylori infection(OR=0.19,P=0.066),and diastolic BP(OR=0.87,P=0.021)were independent risk factors for epithelial dysplasia in BE patients with the SCE type.CONCLUSION:Overexpression of p53 is a risk factor for dysplasia of BE,however,H.pylori infection and diastolic BP inversely associated with BE dysplasia might be protective.     

Radical excision of Barrett’s esophagus and complete recovery of normal squamous epithelium

To treat Barrett’s esophagus(BE),radiofrequency ablation or cryotherapy are effective treatments for eradicating BE with dysplasia and intestinal metaplasia,and reduce the rates of Barrett’s esophageal adenocarcinoma(BAC).However,patients with BE and dysplasia or early cancer who achieved complete eradication of intestinal metaplasia,BE recurred in 5% within a year,requiring expensive endoscopic surveillances.We performed endoscopic submucosal dissection as complete radically curable treatment procedure for BE with dysplasia,intestinal metaplasia and BAC.     

Endoscopic treatment of Barrett’s esophagus:From metaplasia to intramucosal carcinoma

The annual incidence of adenocarcinoma arising from Barrett’s esophagus (BE) is approximately 0.5%. Through a process of gradual transformation from lowgrade dysplasia to high-grade dysplasia (HGD), adenocarcinoma can develop in the setting of BE. The clinical importance of appropriate identifi cation and treatment of BE in its various stages, from intestinal metaplasia to intramucosal carcinoma (IMC) hinges on the dramatically different prognostic status between early neoplasia and more advanced stages. Once a patient has symptoms of adenocarcinoma, there is usually locally advanced disease with an approximate 5-year survival rate of about 20%. Esophagectomy has been the gold standard treatment for BE with HGD, due to the suspected risk of harboring occult invasive carcinoma, which was traditionally estimated to be as high as 40%. In recent years, the paradigm of BE early neoplasia management has recently evolved, and endoscopic therapies (endoscopic mucosal resection, radiofrequency ablation, and cryotherapy) have entered the clinical forefront as acceptable non-surgical alternatives for HGD and IMC. The goal of endoscopic therapy for HGD or IMC is to ablateall BE epithelium (both dysplastic and non-dysplastic) due to risk of synchronous/metachronous lesion development in the remaining BE segment.     

Treatment of dysplastic Barrett’s Oesophagus in lower volume centres after structured training

AIM: To investigate whether dysplastic Barrett’s Oesophagus can be safely and effectively treated endoscopically in low volume centres after structured training. METHODS: After attending a structured training program in Amsterdam on the endoscopic treatment of dysplastic Barrett’s Oesophagus, treatment of these patients was initiated at St Marys Hospital. This is a retrospective case series conducted at a United Kingdom teaching Hospital, of patients referred for endoscopic treatment of Barrett’s oesophagus with high grade dysplasia or early cancer, who were diagnosed between January 2008 and February 2012. Data was collected on treatment provided(radiofrequency ablation and endoscopic resection), and success of treatment both at the end of treatment and at follow up. Rates of immediate and long term complications were assessed. RESULTS: Thirty-two patients were referred to St Marys with high grade dysplasia or intramucosal cancer within a segment of Barrett’s Oesophagus. Twentyseven met the study inclusion criteria, 16 of these had a visible nodule at initial endoscopy. Treatment was given over a median of 5 mo, and patients received a median of 3 treatment sessions over this time. At the end of treatment dysplasia was successfully eradicated in 96% and intestinal metaplasia in 88%, on per protocol analysis. Patients were followed up for a median of 18 mo. At which time complete eradication of dysplasia was maintained in 86%. Complications were rare: 2 patients suffered from post-procedural bleeding, 4 cases were complicated by oesophageal stenosis. Recurrence of cancer was seen in 1 case. CONCLUSION: With structured training good outcomes can be achieved in low volume centres treating dysplastic Barrett’s Oesophagus.     

MicroRNAs, development of Barrett’s esophagus, and progression to esophageal adenocarcinoma

Barrett's esophagus is a premalignant condition caused by gastroesophageal reflux. Once developed, it can progress through varying grades of dysplasia to esoph-ageal adenocarcinoma. Whilst it is well accepted that Barrett's esophagus is caused by gastroesophageal reflux, the molecular mechanisms of its pathogenesis and progression to cancer remain unclear. MicroRNAs (miRNAs) are short segments of RNA that have been shown to control the expression of many human genes. They have been implicated in most cellul...     

Endoscopic imaging of Barrett’s esophagus

The incidence of esophageal adenocarcinoma(EAC) has dramatically increased in the United States as well as Western European countries. The majority of esophageal adenocarcinomas arise from a backdrop of Barrett’s esophagus(BE),a premalignant lesion that can lead to dysplasia and cancer. Because of the increased risk of EAC,GI society guidelines recommend endoscopic surveillance of patients with BE. The emphasis on early detection of dysplasia in BE through surveillance endoscopy has led to the development of advanced endoscopic imaging technologies. These techniques have the potential to both improve mucosal visualization and characterization and to detect small mucosal abnormalities which are difficult to identify with standard endoscopy. This review summarizes the advanced imaging technologies used in evaluation of BE.     

Biomarkers in Barrett’s esophagus and esophageal adenocarcinoma:Predictors of progression and prognosis

Barrett’s esophagus is a well-known premalignant lesion of the lower esophagus that is characterized by intestinal metaplasia of the squamous epithelium. It is clinically important due to the increased risk (0.5% per annum) of progression to esophageal adenocarcinoma (EA), which has a poor outcome unless diagnosed early. The current clinical management of Barrett’s esophagus is hampered by the lack of accurate predictors of progression. In addition, when patients develop EA, the current staging modalities are limited in stratifying patients into different prognostic groups in order to guide the optimal therapy for an individual patient. Biomarkers have the potential to improve radically the clinical management of patients with Barrett’s esophagus and EA but have not yet entered mainstream clinical practice. This is in contrast to other cancers like breast and prostate for which biomarkers are utilized routinely to inform clinical decisions. This review aims to highlight the most promising predictive and prognostic biomarkers in Barrett’s esophagus and EA and to discuss what is required to move the field forward towards clinical application.     

Improved biopsy accuracy in Barrett’s esophagus with a transparent cap

AIM:To evaluate the efficacy of endoscopy with a transparent cap on biopsy positioning in Barrett’s esophagus(BE).METHODS:One hundred and sixty-eight patients with suspected BE at endoscopy were enrolled in our study from November 2007 to December 2009 and divided into two groups:transparent cap group(n=60)and control group(n=108).Endoscopy with or without a transparent cap and subsequent biopsy of suspected lesions were performed by five experienced endoscopists in our hospital.In both groups,two biopsy specimens were taken from each patient,and the columnar epithelium or goblet cells in histological assessment were used as the diagnostic standard for BE.RESULTS:In the transparent cap group,41 cases were tongue type,while 17 and two cases were identified as island type and circumferential type,respectively.In the control group,65 tongue-type cases were confirmed,with 38 island-type and five circumferential-type cases.Moreover,there was no significant difference with regard to the composition of endoscopic BE types in the two groups(P>0.05).In the biopsy specimens,BE was detected in 50 cases in the transparent cap group(83.3%,50/60),whereas the detection rate in the control group(69.4%,75/108)was lower compared to that in the transparent cap group(P<0.05).In addition,goblet cells were recognized in only eight cases(all with columnar epithelium)(8/60,13.3%)in the transparent cap group,with 11 cases in the control group.CONCLUSION:Transparent cap-fitted endoscopy can guide biopsy positioning in BE without other accompanying complications,thus increasing the detection rate of BE.     

Proximal and distal esophageal sensitivity is decreased in patients with Barrett’s esophagus

AIM: To investigate sensations to multimodal pain stimulation in the metaplastic and normal parts of the esophagus in patients with Barrett’s esophagus (BE). METHODS: Fifteen patients with BE and 15 age-matched healthy volunteers were subjected to mechanical, thermal and electrical pain stimuli of the esophagus. Both the metaplastic part and the normal part (4 and 14 cm, respectively, above the esophago-gastric junction) were examined. At sensory thresholds the stimulation intensity, referred pain areas, an...     

Endoscopic options for treatment of dysplasia in Barrett's esophagus

Recent advances in the endoscopic treatment of dysplasia in Barrett's esophagus(BE) have allowed endoscopists to provide effective and durable eradication therapies. This review summarizes the available endoscopic eradication techniques for dysplasia in patients with BE including endoscopic mucosal resection, endoscopic submucosal dissection, photodynamic therapy, argon plasma coagulation, radiofrequency ablation and cryotherapy.     

Meta-analysis of Barrett’s esophagus in China

AIM:To investigate the epidemiology and characteristics of Barrett’s esophagus(BE)in China and compare with cases in the west.METHODS:Studies were retrieved from the China National Knowledge Infrastructure and PubMed databases using the terms"Barrett"and"Barrett AND China",respectively,as well as published studies about BE in China from 2000 to 2011.The researchers reviewed the titles and abstracts of all search results to determine whether or not the literature was relevant to the current topic of this research.The references listed in the studies were also searched.Inclusion and exclusion criteria for the literature were appropriately established,and the data reported in the selected studies were analyzed.Finally,a meta-analysis was performed.RESULTS:The current research included 3873 cases of BE from 69 studies.The endoscopic detection rate of BE in China was 1%.The ratio of male to female cases was 1.781 to 1,and the average age of BE patients was 49.07±5.09 years.Island-type and shortsegment BE were the most common endoscopic manifestations,accounting for 4.48%and 80.3%,respectively,of all cases studied.Cardiac-type BE was observed in 40.0%of the cases,representing the most common histological characteristic of the condition.Cancer incidence was 1.418 per 1000 person-years.CONCLUSION:Average age of BE patients in China is lower than in Western countries.Endoscopic detection and cancer incidence were also lower in China.     

Magnifying endoscopy for the diagnosis of specialized intestinal metaplasia in short-segment Barrett’s esophagus

AIM:To determine whether magnified observation of short-segment Barrett’s esophagus(BE)is useful for the detection of specialized intestinal metaplasia(SIM).METHODS:Thirty patients with suspected short-segment BE underwent magnifying endoscopy up to×80.The magnified images were analyzed with respect to their pit-patterns,which were simultaneously classified into five epithelial types[Ⅰ(small round),Ⅱ(straight),Ⅲ(long oval),Ⅳ(tubular),Ⅴ(villous)]by Endo’s classification.Then,a 0.5%solution of methylene blue(MB)was sprayed over columnar mucosa.The patterns of the magnified image and MB staining were analyzed.Biopsies were obtained from the regions previously observed by magnifying endoscopy and MB chromoendoscopy.RESULTS:Three of five patients with a typeⅤ(villous)epithelial pattern had SIM,whereas 21 patients with a non-typeⅤepithelial patterns did not have SIM.The sensitivity,specificity,accuracy,positive predictive value,and negative predictive value of pit-patterns in detecting SIM were 100%,91.3%,92.3%,60%and100%,respectively(P=0.004).Three of the 12 patients with positive MB staining had SIM,whereas 14patients with negative MB staining did not have SIM.The sensitivity,specificity,accuracy,positive predictive value,and negative predictive value of MB staining in detecting SIM were 100%,60.9%,65.4%,25%and100%,respectively(P=0.085).The specificity and accuracy of pit-pattern evaluation were significantly superior compared with MB staining for detecting SIM by comparison with the exact McNemar’s test(P=0.0391).CONCLUSION:The magnified observation of a shortsegment BE according to the mucosal pattern and its classification can be predictive of SIM.     

Role of chemoprophylaxis with either NSAIDs or statins in patients with Barrett’s esophagus简

The incidence of esophageal adenocarcinoma, a poor prognosis neoplasia, has risen dramatically in recent decades. Barrett’s esophagus represents the best-known risk factor for esophageal adenocarcinoma development. Non-steroidal anti-inflammatory drugs through cyclooxygenase-2 inhibition and prostaglandin metabolism regulation could control cell proliferation, increase cell apoptosis and regulate the expression of growth and angiogenic factors. Statins can achieve equivalent effects through prenylation and subsequently control of cellular signaling cascades. At present, epidemiological studies are small and underpowered. Their data could not justify either medication as a chemo-preventive agent. Population based studies have shown a 43% reduction of the odds of developing an esophageal adenocarcinoma, leaving out or stating a 25% reduction in patients consuming non-aspirin nonsteroidal anti-inflammatory drugs and a 50% reduction in those patients consuming aspirin. They have also stated a 19% reduction of esophageal cancer incidence when statins have been used. Observational studies have shown that non-steroidal anti-inflammatory drugs could reduce the adenocarcinoma incidence in patients with Barrett’s esophagus by 41%, while statins could reduce the risk by 43%. The cancer preventive effect has been enhanced in those patients taking a combination of non-steroidal anti-inflammatory drugs and statins (a 74% decrease). Observational data are equivocal concerning the efficacy of non-steroidal anti-inflammatory drug subclasses. Non-steroidal anti-inflammatory drugs clearly have substantial potential for toxicity, while statins are rather safe drugs. In conclusion, both non-steroidal anti-inflammatory drugs and statins are promising chemopreventive agents and deserve further exploration with interventional studies. In the meanwhile, their use is justified only in patients with cardiovascular disease.     

Psychosocial factors and their association with reflux oesophagitis,Barrett’s oesophagus and oesophageal adenocarcinoma

AIM:To investigate the role of psychological characteristics as risk factors for oesophageal adenocarcinoma(OAC),as well as the reflux-mediated precursor pathway.METHODS:An all-Ireland population-based case-control study recruited 230 reflux oesophagitis(RO),224 Barrett’s oesophagus(BO) and 227 OAC patients and 260 controls.Each case/control group completed measures of stress,depression,self-efficacy,self-esteem,repression and social support.A comparative analysis was undertaken using polytomous logistic regression adjusted for potential confounders.RESULTS:Compared to controls,OAC patients were almost half as likely to report high stress levels over their lifetime(P = 0.010,OR 0.51;95%CI:0.29-0.90)and 36% less likely to report having experienced depression(OR 0.64;95%CI:0.42-0.98).RO patients reported significantly higher stress than controls particularly during middle-and senior-years(P for trends < 0.001).RO patients were 37% less likely to report having been highly emotionally repressed(OR 0.63;95%CI:0.41-0.95).All case groups(OAC,RO and BO) were more likely than controls to report having had substantial amounts of social support(OR 2.84;95%CI:1.63-4.97;OR 1.97;95%CI:1.13-3.44 and OR 1.83;95%CI:1.03-3.24,respectively).CONCLUSION:The improved psychological profile of OAC patients may be explained by response shift.The role of psychological factors in the development of OAC requires further investigation.     

胆管支架联合光动力和（或）射频消融治疗在肝外胆管癌中的应用

为探讨内镜下胆管支架置入后行光动力治疗（photodynamic therapy,PDT）和（或）射频消融术（radiofrequency ablation,RFA）在不可切除肝外胆管癌（extrahepatic cholangiocarcinoma,EHCC）姑息治疗中的应用,回顾性分析了2017年1月至2023年1月在青岛大学附属医院消化内科治疗的5例EHCC患者的临床资料。5例患者均先接受胆管支架置入治疗,支架置入后6个月内接受PDT和（或）RFA。5例患者手术均成功。治疗后,5例患者血清胆红素水平均明显下降,术后恢复良好,1~3 d即好转出院。1例患者出现感染性并发症,其余均未发生不良事件。胆管支架治疗先于PDT和（或）RFA对EHCC进行姑息治疗,为后续PDT和（或）RFA顺利进行创造良好条件,可明显提高手术成功率,快速有效解除管腔梗阻,减少术后不良事件的发生,缩短术后恢复时间。