Photodynamic therapy and endoscopic mucosal resection for Barrett's dysplasia and early esophageal adenocarcinoma

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas. MATERIALS AND METHODS: All patients with Barrett's esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT. RESULTS: In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia. CONCLUSIONS: The use of EMR resection in Barrett's high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett's mucosal adenocarcinoma. EMR should be strongly considered for Barrett's dysplasia patients being evaluated for endoscopic ablation therapy.     

Poor results of 5-aminolevulinic acid-photodynamic therapy for residual high-grade dysplasia and early cancer in barrett esophagus after endoscopic resection

BACKGROUND AND STUDY AIMS: The aim of the study was to evaluate the efficacy of photodynamic therapy (PDT) in the treatment of residual high-grade dysplasia or early cancer (HGD/EC) after endoscopic resection in Barrett esophagus. PATIENTS AND METHODS: Study patients were separated into group A, with proven residual HGD/EC, and group B with possible HGD/EC (positive lateral margins in the endoscopic resection specimen, without HGD/EC in the remaining Barrett esophagus). PDT treatment consisted of 5-aminolevulinic (5-ALA) photosensitization (40 mg/kg) followed by illumination of the Barrett esophagus with a total light dose of 100 J/cm (2). Complete remission was defined as the absence of HGD/EC in biopsies taken in two consecutive follow-up endoscopies. The percentage regression of Barrett esophagus, as well as the recurrence rate of HGD/EC, was calculated. RESULTS: 20 patients underwent PDT (group A, 11; group B, 9). Mild complications were seen in 4/26 procedures. The overall success rate was 15/20 (75 %). There was a significant difference in success rate between group A (55 %) and group B (100 %); P = 0.03. All patients had residual Barrett esophagus after PDT; the median regression percentage was 50 % (IQR 25 - 70 %). Recurrence of HGD/EC occurred in four patients (two each in groups A and B) after a median follow up of 30 months. CONCLUSIONS: In this selected group of patients, the addition of 5-ALA-PDT after endoscopic resection for HGD/EC had a disappointing success rate in patients who had residual HGD/EC after endoscopic resection. Most patients undergoing 5-ALA-PDT have residual Barrett mucosa after PDT and 5-ALA-PDT does not seem to prevent recurrences during follow-up.     

Is topical delta-aminolevulinic acid adequate for photodynamic therapy in Barrett's esophagus? A pilot study

BACKGROUND AND STUDY AIMS: The methods of endoscopic ablation of metaplastic and dysplastic areas in Barrett's esophagus so far described, are not satisfactory with respect to efficacy and safety. Therefore we investigated whether photodynamic therapy (PDT) with topical delta-aminolevulinic acid (delta-ALA) leads to ablation of specialized columnar epithelium and eradication of low-grade dysplasia while not producing phototoxicity and systemic side effects. PATIENTS AND METHODS: 14 patients with histologically proven Barrett's esophagus, seven of whom had evidence of low-grade dysplasia, underwent endoscopic treatment with topical delta-ALA. Photoactivation (wavelength, 632 nm) was performed at 1.5 - 2 hours after drug administration using an argon dye laser. Patients received omeprazole 80 mg daily for 2 months; thereafter; maintenance therapy depended on reflux symptoms. Patients were endoscopically re-evaluated after 7 days, and subsequently at 3, 6, 12 and up to 48 months (mean follow up 33 months). Re-treatment with high-dose topical delta-ALA was offered to the 11 patients with remaining metaplasia and was carried out in five of them. RESULTS: Low-grade dysplasia was eradicated in all patients. One patient with no dysplasia before PDT developed a high-grade dysplasia after PDT. Complete ablation of Barrett's metaplasia was observed in 21 % of the patients after the first treatment session and in 20 % after the second treatment session. The mean reduction in the length of Barrett's metaplasia was 1.54 +/- 1.29 cm after the first PDT session and 1.02 +/- 0.80 cm after the second PDT session. Post-endoscopic pain and photosensitivity reactions were less frequent with low-dose delta-ALA PDT than with high-dose PDT (pain 15 %, 100 %, respectively; P = 0.001 by Fisher's exact test; phototoxicity, 0 %, 50 %, respectively; P = 0.021 by Fisher's exact test). CONCLUSION: Low-dose topical administration of delta-ALA provides ablation of low-grade dysplasia in the range obtained with oral delta-ALA. In addition, it is safe and well tolerated. Since, however, topical administration of delta-ALA is not able to consistently eradicate Barrett's esophagus, alternative methods will have to be developed.     

A new long-range through-the-scope balloon applicator for photodynamic therapy in the esophagus and cardia.

BACKGROUND AND STUDY AIMS: Photodynamic therapy (PDT) is a new local, endoscopically controlled therapeutic technique based on the sensitization of malignant and precancerous lesions prior to light-induced tissue destruction. PDT of Barrett's esophagus with severe dysplasia, or of mucosal carcinomas and superficial squamous-cell cancer of the esophagus, requires light application devices allowing homogeneous illumination of the tissue surface in spite of esophageal motility and respiratory movement. On the basis of a commercially available through-the-scope balloon system, we developed a long-range light applicator for homogeneous and circumferential irradiation during PDT, and describe here the initial clinical experience with the device. PATIENTS AND METHODS: The new balloon applicator consists of a flexible cylindrical diffuser fiber with a length of up to 10 cm, depending on the lesion to be illuminated, and an inflatable balloon based on the type of balloon used for esophageal dilation. The balloon is made of a transparent polyurethane membrane with negligible absorption (<5%) at lambda = 600-700 nm, and it can be positioned through the biopsy channel of a conventional endoscope, with direct endoscopic visualization of the targeted lesion. The light intensity distribution perpendicular to the optical axes of the diffuser was measured for red laser light (lambda = 632.8 nm) and for green laser light (lambda = 542 nm). The study of photodynamic treatment included two women and four men (aged 48-79 years) with histologically proved high-grade dysplasia (n = 2) or mucosal cancer in Barrett's esophagus (n = 2) and superficial squamous-cell cancer (SCC) (n = 2), who had undergone EUS staging showing uT0 or uT1N0. Laser light irradiation was conducted after oral ingestion of 5-aminolevulinic acid (5-ALA) or intravenous administration of meta-(tetrahydroxyphenyl)chlorin (mTHPC). RESULTS: Both in vitro and in vivo, precise positioning of the new application system at the targeted tissue and homogeneous illumination were feasible, safe and effective. The total efficiency of transmitted light at wavelengths of lambda = 632.8 nm and lambda = 542 nm was 85-90%. A high degree of homogeneity was measured with applicator lengths of between 15 mm and 95 mm, and the maximum deviation from the mean intensity extended over a range of 40% over the total length of 80 mm. High-grade dysplasia was eradicated in all patients, and in addition mucosal cancer was successfully destroyed in three-quarters of them, requiring an average of 1.3 treatment sessions, with a mean follow-up of 12 months (range 10-15 months). CONCLUSIONS: This centering balloon system may in the future be capable of improving light application techniques during esophageal photodynamic therapy, making PDT a more reliable alternative modality for minimally invasive treatment of high-grade dysplasia and early Barrett's esophagus or squamous-cell carcinoma, as compared with esophagectomy.     

Clinical impact of conventional endosonography and endoscopic ultrasound-guided fine-needle aspiration in the assessment of patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma who have been referred for endoscopic ablation therapy

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett's esophagus and high-grade dysplasia or intramucosal adenocarcinoma. However, there is lack of uniformity regarding which staging method should be used prior to therapy, and some investigators even question whether staging is required prior to ablation. We report our experience with a protocol of conventional endoscopic ultrasound staging prior to endoscopic therapy. PATIENTS AND METHODS: A total of 25 consecutive patients with a diagnosis of high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus who had been referred to the University of Chicago for staging in preparation for endoscopic therapy between March 2002 and November 2004 were included in the study. All 25 patients underwent repeat diagnostic endoscopy and conventional endosonography with a radial echo endoscope. Any suspicious lymph nodes that were detected were sampled using endoscopic ultrasound-guided fine-needle aspiration. RESULTS: Baseline pathology in the 25 patients (mean age 70, range 49-85) revealed high-grade dysplasia in 12 patients and intramucosal carcinoma in 13 patients. Five patients were found to have submucosal invasion on conventional endosonography. Seven patients had suspicious adenopathy, six regional (N1) and one metastatic to the celiac axis (M1a). Fine-needle aspiration confirmed malignancy in five of these seven patients. Based on these results, five patients (20%) were deemed to be unsuitable candidates for endoscopic therapy. CONCLUSIONS: By detecting unsuspected malignant lymphadenopathy, conventional endosonography and endoscopic ultrasound with fine-needle aspiration dramatically changed the course of management in 20% of patients referred for endoscopic therapy of Barrett's esophagus with high-grade dysplasia or intramucosal carcinoma. Based on our results, we believe that conventional endosonography and endoscopic ultrasound with fine-needle aspiration when nodal disease is present should be performed routinely in all patients referred for endoscopic therapy in this setting.     

Argon plasma coagulation in the treatment of Barrett's high-grade dysplasia and in situ adenocarcinoma

BACKGROUND AND STUDY AIMS: Endoscopic therapy of high-grade dysplasia (HGD) and superficial adenocarcinoma associated with Barrett's esophagus (BE), using Nd:YAG laser, KTP laser, or photodynamic therapy (PDT), has been reported to be effective in a curative role. Argon plasma coagulation (APC) appears to be effective in the eradication of nondysplastic Barrett's mucosa, but no results are available in the management of early neoplasms complicating BE. We report our initial experience in the application of APC in this indication. PATIENTS AND METHODS: Ten patients (mean age 74.2) with histologically proven HGD (n = 7) or in situ adenocarcinoma (n = 3) associated with BE (mean length 6 cm) and unfit for surgery were treated using APC and high-dose omeprazole (40 mg daily) until squamous re-epithelialization or complete eradication of the initially apparent lesions. Endoscopic follow-up was maintained at every 3 months. RESULTS: Complete eradication of HGD and in situ adenocarcinoma was achieved after a mean number of 3.3+/-1.5 APC sessions in 8/10 patients (80%). The eight patients with complete clearance of the neoplastic areas did not show any evidence of local recurrence during a median follow-up of 24 months (range 12-36 months). One patient with initial HGD had persistence of HGD 30 months after initial diagnosis, and one patient progressed to invasive adenocarcinoma after failure of APC and PDT. CONCLUSIONS: APC is safe and effective in the management of HGD and in situ adenocarcinoma associated with BE, and might represent an interesting alternative in selected patients who are not candidates for surgery.     

Circumferential endoscopic mucosal resection in Barrett's esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients

BACKGROUND AND STUDY AIMS: Treatment by endoscopic mucosal resection (EMR) has been established for early lesions in Barrett's esophagus. However, the remaining Barrett's esophagus epithelium remains at risk of developing further lesions. The aim of this study was to evaluate the efficacy of circumferential endoscopic mucosectomy (circumferential EMR)s in removing not only the index lesion (high-grade intraepithelial neoplasia (HGIN) or mucosal cancer), but also the remaining Barrett's esophagus epithelium. PATIENTS AND METHODS: A total of 21 patients were included in the study (11 men, 10 women), who had Barrett's esophagus and either HGIN (n = 12) or mucosal cancer (n = 9). Of the patients, 17/21 were at high surgical risk and five had refused surgery. On the basis of preprocedure endosonography their lesions were classified as T1N0 (n = 19) or T0N0 (n = 2). The lesions and the Barrett's esophagus epithelium were removed by polypectomy after submucosal injection of 10-15 ml of saline; a double-channel endoscope was used in 15/21 cases. Circumferential EMR was performed in two sessions, the lesion and the surrounding half of the circumferential Barrett's esophagus mucosa being removed in the first session. In order to prevent the formation of esophageal stenosis, the second half of the Barrett's esophagus mucosa was resected 1 month later. RESULTS: Complications occurred in 4/21 patients (19 %), consisting of bleeding which was successfully managed by endoscopic hemostasis in all cases. No strictures were observed during follow-up (mean duration 18 months) and endoscopic resection was considered complete in 18/21 patients (86 %). For three patients, histological examination showed incomplete removal of tumor: one of these underwent surgery; two received chemoradiotherapy, and showed no evidence of residual tumor at 18 months' and 24 months' follow-up, respectively. Two patients in whom resection was initially classified as complete later presented with local recurrence and were treated again by EMR. Barrett's esophagus mucosa was completely replaced by squamous cell epithelium in 15/20 patients (75 %). CONCLUSIONS: Circumferential EMR is a noninvasive treatment of Barrett's esophagus with HGIN or mucosal cancer, with a low complication rate and good short-term clinical efficacy. Further studies should focus on long-term results and on technical improvements.     

Esophageal dysmotility in patients undergoing photodynamic therapy

OBJECTIVE: To study the esophageal motility of patients with esophageal adenocarcinoma or Barrett esophagus with high-grade dysplasia before and after photodynamic therapy. PATIENTS AND METHODS: In this prospective study conducted between January 1998 and October 1999, esophageal motility testing of the lower esophageal sphincter and esophageal body was performed with a water-perfused catheter, 2 days before and at least 3 weeks after patients underwent photodynamic therapy for esophageal adenocarcinoma or Barrett esophagus. Results were classified as normal motility, ineffective esophageal motility, or aperistalsis. RESULTS: Twenty-three patients were studied, 13 with carcinoma and 10 with Barrett esophagus. Overall, 11 patients (48%) had normal motility, 6 (26%) had ineffective esophageal motility, and 6 (26%) had aperistalsis. Five patients with aperistalsis had carcinoma. Follow-up tracings after photodynamic therapy found that 6 patients (26%) had normal motility, 7 (30%) had ineffective esophageal motility, and 10 (43%) had aperistalsis. CONCLUSIONS: Esophageal dysmotility is common in patients with esophageal adenocarcinoma or Barrett esophagus. Photodynamic therapy may worsen esophageal motility in some patients. Dysphagia after photodynamic therapy therefore may be related to underlying esophageal dysmotility and may not always be caused by stricture or underlying carcinoma.     

Photodynamic therapy in Barrett's esophagus

Photodynamic therapy (PDT) was one of the earliest ablative techniques applied to Barrett's esophagus. The rationale for this use was the ability to treat large amounts of esophageal mucosa in a single rapid application. Additionally, PDT has the ability to treat early carcinoma and dysplastic tissue. Because a small carcinoma in dysplastic Barrett's esophagus cannot not be excluded, PDT therapy is a reasonable treatment in this setting. The treatment involves the use of a light and drug combination that must be administered with close attention to dosimetry, since tissue effects of the therapy are delayed and cannot be observed at the time of treatment. Drug administration of sodium porfimer should precede photoradiation by 48 hours. Overall results with this treatment have been good. Case series have established a success rate of 88% to 100% in elimination of high-grade dysplasia. The only randomized multi-center prospective trial in the treatment of Barrett's esophagus with high-grade dysplasia has established that the treatment eliminates high-grade dysplasia better than administration of proton pump inhibitors alone. Unfortunately, there are significant adverse events, including cutaneous photosensitivity, odynophagia, stricture formation, and lack of response.     

内镜下Toluidine Blue和Lugol''''s Solution双重染色 在食管早期癌和浅表癌诊断中的意义

目的为评价内镜下甲体胺兰和卢戈氏液双重染色在食管早期癌和浅表癌诊断中的意义。方法对108例食管癌可疑患者进行食管粘膜双重染色，对TB染色区和LS不染色区(以下简称为目标区)进行活检病理诊断，癌组织经手术后病理证实。结果染色后病理诊断结果常规内镜检查发现食管进展期癌10例，有粘膜粗糙感21例，小片状粘膜剥脱7例；染色病理诊断后发现原位癌1例，浅表癌5例，10例食管癌发现跳跃灶2例，异型增生15例，单纯增生和慢性炎37例，放疗后复查发现2例；108例患者(48例有症状，60例无症状)总染色阳性率57.4%，其中早期癌阳性率为5.5%，异型增生的阳性率为13.8%，有症状组总阳性率79.1%高于无症状组40%(P＜0.01)，其中癌的检出率有症状组10.4%高于无症状组1.6%(P＜0.05)，不典型增生检出率有症状组22.9%高于无症状组6.6%(P＜0.05)。结论内镜下双重染色有助于食管早期癌、表浅癌及癌前病变的诊断，并有助于指导食管癌的治疗。     

Staging and neoadjuvant therapy of squamous cell carcinoma of esophagus

Once the diagnosis of esophageal cancer is established, the decision on treatment will depend on the stage of the disease. Since improvement of prognosis can only be expected in patients with complete removal of their tumor, preoperative staging plays a pivotal role in the decision-making process. Preoperative diagnostic procedures should define the tumor in its relation to the tracheal bifurcation (site), determine the depth of tumor invasion (T status), evaluate regional lymph node metastases (N1 disease) and exclude distant metastases (M1 disease). Endosonography represents currently the most accurate imaging technique for detecting the correct T stage over the correct N stage. A higher accuracy rate may be achieved by combining endosonography with other staging modalities such as computed tomography. Chest x-ray, and percutaneous ultrasonography (abdominal, neck) form the diagnostic basis in staging M1 disease. Computed tomography (neck, chest and abdomen) is currently the best method to detect metastases in the liver and in celiac nodes. Staging laparoscopy when combined with laparoscopic ultrasonography shows a higher sensitivity than ultrasonography and computed tomography in the diagnosis of smaller metastases and peritoneal seedings. En bloc esophagectomy together with the regional lymph nodes remains the treatment of choice in medically fit patients with localized esophageal carcinoma (Stage I-IIB, T1-T2/N0-N1/M0). Due to early involvement of mediastinal structures, curative resection is unlikely to be achieved in patients with locally advanced esophageal carcinoma (Stage III, T3-T4/N0-N1/M0). Most available data indicate that neoadjuvant radiochemotherapy leads in a significant number of patients to downstaging of the tumor, increases the rate of R0 resection, improves local tumor control, and prolongs the recurrence free interval. However, neoadjuvant radiochemotherapy resulted in a marked increase of morbidity and postoperative mortality without improvement of survival. At present, neoadjuvant therapy is still experimental and there is no consensus for an optimal treatment regimen. Its use outside of an investigational setting can not be recommended. Future research must focus on more effective and less toxic neoadjuvant modalities (e.g. new chemotherapy agents, hyperthermia).     

Traitement de l’endobrachyoesophage par radiofréquence. Pour qui ? Pour quels résultats ?

The main risk of Barrett’s oesophagus is the development of adenocarcinoma. Therefore, endoscopic surveillance is required to detect pre-neoplastic lesions. Radiofrequency ablation of oesophagus is a new technique used to destroy superficial tumours as an alternative to surgery. In France, radiofrequency ablation indication in Barrett’s oesophagus is due to the presence of high-grade dysplasia without nodular lesion. After several sessions of radiofrequency, complete response on dysplasia and intestinal metaplasia is excellent, and is achieved in more than 90% in majority of published studies. Major complications (perforation and major bleeding) are very rare and minor ones (dorsal pain and fever) are treated conservatively in most cases. Nodular lesions associated with circumferential Barrett’s oesophagus, classified us T1N0 in echoendoscopy, required endoscopic resection (endoscopic mucosal resection or submucosal dissection) to determine invasion depth of the lesion. Residual Barrett’s oesophagus will be treated by radiofrequency in a second session. Long-term follow-up demonstrate the durability of complete response after radiofrequency. However, limited data are available on recurrence risk and endoscopic follow-up must be recommended even for patients with initial complete eradication of Barrett’s oesophagus.     

Endoscopic and histologic diagnosis of Barrett esophagus

Endoscopy plays an important role in the identification, diagnosis, and treatment of Barrett esophagus. Short-segment (<2-3 cm) and traditional long-segment (>2-3 cm) Barrett esophagus are distinguished solely on the length of metaplastic tissue above the esophagogastric junction. The histologic hallmark of intestinal metaplasia is required to confirm diagnosis. Biopsy specimens obtained from tissue of presumed Barrett esophagus or an irregular Z line confirm metaplastic glandular mucosa and permit evaluation of dysplastic or neoplastic changes. In the appropriate clinical setting, the use of adjunctive diagnostic techniques may facilitate the diagnosis of Barrett esophagus and sequelae such as dysplasia. Chromoendoscopy with high-resolution or magnified endoscopy is simple, safe, and desirable for surveillance but requires additional procedural time. The use of light-induced fluorescence endoscopy and light-scattering spectroscopy (i.e., optical biopsy) is appealing for the diagnosis and characterization of suspicious lesions. Adjunctive endoscopic techniques and adherence to a protocol for performing biopsies facilitate the early detection and subsequent surveillance of Barrett esophagus.     

Radiofrequency ablation is effective for the treatment of high-grade dysplasia in Barrett's esophagus after failed photodynamic therapy

Endoscopic radiofrequency ablation (RFA) is an effective treatment for high-grade dysplasia in Barrett's esophagus in ablation-na?ve patients, but no studies have evaluated its use in patients in whom ablative therapy has previously failed. We describe 14 patients with residual high-grade dysplasia following aminolevulinic acid or Photofrin (porfimer sodium) photodynamic therapy (PDT). An overall complete reversal of dysplasia was achieved in 86?% with a combination of RFA and rescue endoscopic mucosal resection. The median total follow-up is 19 months. The rate of strictures was 7?% (1/14) and there was a low rate of buried glands (0.5?% follow-up biopsies). These data suggest RFA is both safe and effective for eradication of high-grade dysplasia in patients in whom PDT has failed.     

黏膜切除治疗Barrett食管疗效及安全性的Meta分析

目的评价黏膜切除(EMR)对于Barrett食管(BE)治疗的有效性、持久性及不良事件发生率。方法计算机检索Embase、PubMed、维普、中国期刊全文数据库、万方数字化期刊全文数据库等。提取各病理类型的BE接受EMR治疗后根除肠上皮化生(CE-IM)、上皮内瘤变(CE-N)的比率,治疗随访期间肠上皮化(IM)或瘤变复发及不良事件发生率,应用R3.1.3软件合并数据进行统计学分析,计算其有效性、持久性及不良事件发生率。结果共纳入4篇研究,总病例130例。EMR治疗异型增生或黏膜内癌的BE患者中,达到CE-N为97%(95%CI:0.91~0.99),达到CE-IM为91%(95%CI:0.83~0.95),在随访过程中瘤变或IM复发率为8%,常见并发症食管狭窄与出血,其发生率分别为39%和6%。结论 EMR作为BE内镜治疗的推荐方式,其在治疗伴异型增生或黏膜内癌的BE上有确切的效果,但其并发症特别是食管狭窄发生率较高。     

An educational tool for photodynamic therapy of Barrett esophagus with high-grade dysplasia: from screening through follow-up.

Photodynamic therapy using a centering balloon was recently approved by the Food and Drug Administration for ablation of Barrett esophagus with high-grade dysplasia. This article is an educational tool for the photodynamic therapy team, addressing four important steps involved with photodynamic therapy: screening for potential patients, patient education, treatment using the centering balloon, and follow-up after treatment. Each step ensures proper care for the patient requiring photodynamic therapy.     

Barrett esophagus: update for radiologists

Barrett esophagus is a well-recognized entity in which there is progressive columnar metaplasia of the lower esophagus due to longstanding gastroesophageal reflux and reflux esophagitis [1]. This condition is important because it is associated with an increased risk of developing esophageal adenocarcinoma by a well-established sequence from dysplasia to carcinoma [2]. During the past decade, however, an explosion of new data has dramatically affected our understanding of Barrett esophagus. Not only have revised histopathologic criteria been developed for this condition, but it is currently believed that patients with Barrett esophagus should be classified as having short-segment or long-segment disease based on the extent of columnar metaplasia in the distal esophagus. This distinction has important implications for the risk of developing esophageal adenocarcinoma and subsequent need for endoscopic surveillance. The purpose of this article is to present these new concepts about Barrett esophagus and provide radiologists with a more current framework for diagnosing this condition.     

Frequency of Barrett's neoplasia after initial negative endoscopy with biopsy: a long-term histopathological follow-up study

BACKGROUND: Barrett's adenocarcinoma is being diagnosed increasingly. We examine possible differences between long segment and short-segment Barrett esophagus (LSBE and SSBE) in long-term follow-up on the basis of our histopathology registry. METHODS AND PATIENTS: All Barrett's esophagus patients diagnosed histologically between 1990 and 1995 (n = 1071) were selected. Long-term follow-up data from endoscopy with biopsy were sought on all patients without neoplasia on initial endoscopic biopsy (n = 1003). A total of 255 individuals (25.4 %) were regarded as drop-outs (201 lost and 54 without further endoscopy). Of the remaining 748 patients with follow up for more than 5 years, 315 had documented LSBE, 246 had SSBE, and 187 had no length of Barrett esophagus recorded (NLBE). RESULTS: In the study cases (male : female ratio 2.1 : 1, mean age +/- SD 60.9 +/- 14.2 years), the biopsy procedure was fully compliant with guidelines in only 32.5 %. Only 5 cases (0.6 %) had visible lesions reported on endoscopy, but all were negative for neoplasia. Over a mean follow-up of 78.2 +/- 35.6 months (range 0-240), 7 new cases of low grade intraepithelial neoplasia (LGIN) and 15 cancer cases developed, accounting for a yearly incidence of 0.2 % (LGIN) or 0.4 % (cancer) after an initial negative endoscopy. When the cases with initial diagnosis of neoplasia were included, this yearly incidence rose to 0.5 % (LGIN), 0.3 % (high grade intraepithelial neoplasia [HGIN]) or 1.7 % (cancer). Differences between SSBE and LSBE were only encountered for cancer incidence. CONCLUSION: The yearly incidence of Barrett esophagus cancer varies between 0.4 % and 1.7 %. Despite the limitations of this retrospective and pathology-based study, the observed risk of developing cancer in Barrett esophagus without neoplasia is comparable to that found in other studies, mainly from the US and the UK, and varies between 0.7 % and 1.0 % of yearly incidence.     

Long-Segment early squamous cell carcinoma of the proximal esophagus: curative treatment and long-term follow-up after 5-aminolevulinic acid (5-ALA)-photodynamic therapy

Photodynamic therapy (PDT) is an established treatment for the ablation of dysplastic Barrett's epithelium and early esophageal carcinoma, but no data have been published on curative 5-aminolevulinic acid (5-ALA)-PDT for long-segment early esophageal cancer with infiltration of the upper sphincter. We describe successful curative treatment of an unusual early long-segment squamous cell carcinoma (uT1a,N0) of the proximal esophagus (18 - 28 cm aborally), with three sessions of 5-ALA-PDT. Endoscopic and endosonographic follow-up macroscopically showed a complete remission of the tumor, proven by biopsy showing total histological ablation. After a follow-up period of 23 months, there has been no indication of tumor recurrence. Early superficial (< 3 mm) squamous cell carcinomas of the esophagus can be ablated completely by 5-ALA-PDT. However, long-term follow-up is required in order to prove the effectiveness of endoscopic ablation therapy for early esophageal cancer.     

套扎辅助内镜下黏膜切除术治疗Barrett食管的前瞻性研究

目的 研究套扎辅助黏膜切除治疗Barrett食管的有效性、安全性。方法 采用前瞻性研究。套扎辅助黏膜切除治疗57例Barrett食管患者。单环或多环套扎器预先吸引病灶形成假息肉,后再通电切除。切除前不予黏膜下注射。术后1个月复查胃镜。结果 57例患者接受套扎辅助黏膜切除,46例为岛型,11例为舌型。舌型组中特殊肠化、异型增生发生率高于岛型组。活检准确率为94.74%。5例术中出血。无狭窄、穿孔发生。结论 套扎辅助黏膜切除用于Barrett食管诊断治疗安全有效。