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Honorary Senior Clinical Lecturer, University of Sheffield
Consultant Gastroenterologist
Barnsley Hospital NHS Foundation Trust, UK
[email protected]©4th SSG conference, Jan 2014
©4th SSG conference, Jan 2014, SAID EM
Definition
Surveillance
Non-dysplastic BO
Dysplastic BO
Early oesophageal cancer
Summary
©4th SSG conference, Jan 2014, SAID EM
Br J Surg. 1950-1951;38:175-182.
Norman R. Barrett 1903-1979
©4th SSG conference, Jan 2014, SAID EM
“I submit that most of these cases are in truth examples of : congenital short oesophagus in which a part of the stomach extends upwards into the mediastinum.”
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• Change in the type of cells within the epithelial layer of the lower oesophagus.
• The leading theory is response to chronic GORD [positive adaptation] as columnar epithelium is better able to withstand acidity.
• Oesophageal intestinal metaplasia or columnar lined oesophagus without metaplasia.
What is Barrett’s oesophagus?
©4th SSG conference, Jan 2014, SAID EM
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• "an endoscopically apparent area above the esophago-gastric junction that is suggestive of Barrett’s esophagus (salmon-colored mucosa) which is supported by the finding of columnar lined esophagus on histology”
• “displacement of the squamo-columnar junction proximal to the gastro-esophageal junction with histological evidence of specialized intestinal metaplasia on biopsy specimens.”
Definition
©4th SSG conference, Jan 2014, SAID EM
Wang, K. K. & Sampliner, R. E. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus. Am. J. Gastroenterol. 103, 788-797 (2008).
Playford, R. J. New British Society of Gastroenterology (BSG) guidelines for the diagnosis and management of Barrett's oesophagus. Gut 55, 442 (2006).
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“Barrett’s oesophagus is defined as an oesophagus in which any portion of the normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium, which is clearly visible endoscopically (≥1 cm) above the GOJ and confirmed histopathologically from oesophageal biopsies”
BSG guidelines 2013(Recommendation grade C)
Definition
©4th SSG conference, Jan 2014, SAID EM
©4th SSG conference, Jan 2014, SAID EM
• To detect patients at greater risk of progressing to OAC at early & curative stage.
Aim of Barrett’s Surveillance
©4th SSG conference, Jan 2014, SAID EM 1-Van der Veen AH et al, GUT, 1989
• Although the risk of developing OC increased at least 30-fold above the general population, the absolute risk of developing cancer is low1
.
• Surveillance is based upon the assumptions that BO adversely influences survival & that surveillance can reduce mortality.
• Survival benefit in patients undergoing surveillance has not been demonstrated in randomized prospective trials.
• Current evidences base are from comparative studies and epidemiological retrospective cohort studies, grade III.
Controversies of Surveillance
©4th SSG conference, Jan 2014, SAID EM
• AspECT trial Aspirin and esomeprazole chemoprevention in Barrett's metaplasia.
• BEST trial Barretts Oesophagus Screening Trial
• BOSS trial Barrett’s Oesophagus Surveillance Study.
• SURF Trial Surveillance with Radio-Frequency Ablation of Barrett’s
osophagus with Low-Grade Dysplasia
Controversies of Surveillance
©4th SSG conference, Jan 2014, SAID EM
• Provide up to date practical and evidence base recourses for management of Barrett’s oesophagus and related early neoplasia, based on systemic review of literature up until Dec 2012.
BSG guidelines 2013
©4th SSG conference, Jan 2014, SAID EM
Barrett’s oesophagus in Sudan
• Data suggest that BO is rare in all regions of sub-Saharan Africa
• A study from Egypt examining 1000 patients with chronic GORD symptoms found the presence of BO in 7.3%.
• heartburn
105
• Reflux oesophagitis
47• Barrett’
oesophagus
5
©4th SSG conference, Jan 2014, SAID EM
Non-dysplastic Barrett’s
Oesophagus
Low grade dysplasia
LGD
High grade dysplasia
HGD
T1M oesophageal
adeno-carcinoma
0.5%
10%40%
©4th SSG conference, Jan 2014, SAID EM
Non-dysplastic Barrett’s
oesophagus
Non-dysplastic BO
©4th SSG conference, Jan 2014, SAID EM 1-Bhat S et al, J Natl Cancer Inst, 2011
Frequency of surveillance:BO without IM <3 cm: DischargeBO with IM <3 cm: 3-5 yrsBO of 3 or more cm: 2-3 yrs
Short segment of columnar epithelium with no IM have an extremely low risk of malignancy
(~0.05% per annum)1.
Non-dysplastic Barrett’s
oesophagus
Non-dysplastic BO
Seattle Protocol Multiple samples, High cost
©4th SSG conference, Jan 2014, SAID EM
Biopsy protocol:Quadrantic 2cm Biopsy protocol Sampling of any visible lesion.
Non-dysplastic BO surveillance flow chart BSG guideline 2013©4th SSG conference, Jan 2014, SAID EM
Low Grade
Dysplasia LGD
Low grade dysplasia LGD
©4th SSG conference, Jan 2014, SAID EM
The diagnosis should be confirmed by two pathologists
Category 1 Negative for neoplasia/ dysplasia
Category 2 Indefinite for dysplasia
Category 3 Low grade dysplasia
Category 4 High grade dysplasia/ Carcinoma in situ
Category 5 Invasive neoplasia
©4th SSG conference, Jan 2014, SAID EM
Revised Vienna classification1
1-Schlemper RJ et al, Gut 2000
Low Grade
Dysplasia LGD
Low grade dysplasia LGD
©4th SSG conference, Jan 2014, SAID EM
The diagnosis should be confirmed by two pathologists
Frequency of surveillance: every 6 months
Endoscopic therapy?
• LGD correlate with higher risk of progression to cancer.
• Unclear whether this warrant endoscopic intervention.
• Clinicians may choose to treat some patients with ablationwhen dysplasia is persistent or multifocal on individual basis.
Low Grade
Dysplasia LGD
Low grade dysplasia LGD
©4th SSG conference, Jan 2014, SAID EM
RFA
• Overall outcome: a lower risk of disease progression in all patients treated with RFA, but subgroup analysis in LGD patients failed to show a significant advantage from treatment.
• SURF Trial: RFA compared with endoscopic surveillance is awaited.
©4th SSG conference, Jan 2014, SAID EM
Radio Frequency Ablation RFA
Shaheen NJ, N Eng J Med, 2009
Low Grade
Dysplasia LGD
Low grade dysplasia LGD
©4th SSG conference, Jan 2014, SAID EM
The diagnosis should be confirmed by two pathologists
Frequency of surveillance: every 6 months
Based on current evidence, ablation therapy cannot be
recommended routinely until data from RCT are available.
Indefinite for
dysplasia
Indefinite for dysplasia
©4th SSG conference, Jan 2014, SAID EM
Pathologists unable to make definite diagnosis of dysplasia
? inflammation
Frequency of surveillance: every 6 months
Treat with high dose PPI
v
High Grade
Dysplasia HGD
High grade dysplasia HGD
©4th SSG conference, Jan 2014, SAID EM
Confirm diagnosis:Expert HRE to detect visible lesion
Second pathologists
• Chromoendoscopy
• Autoflorescence
• Narrow band imaging
• Acetic acid
High Resolution Endoscopy
HRE should be used to maximize dysplasia detection. grade C
©4th SSG conference, Jan 2014, SAID EM
aceticالخل acid chromoendoscopy
©4th SSG conference, Jan 2014, SAID EM
Acetic Acid Spray Is an Effective Tool for the Endoscopic Detection of Neoplasia in Patients With Barrett's Esophagus
v
High Grade
Dysplasia HGD
High grade dysplasia HGD
©4th SSG conference, Jan 2014, SAID EM
Confirm diagnosis:Expert HRE to detect visible lesion
Second pathologists
MDT discussion
Therapeutic intervention?
HGD and early cancer T1a/T1b
©4th SSG conference, Jan 2014, SAID EM
HGD and
early cancer
Imaging for HGD & T1 cancer
©4th SSG conference, Jan 2014, SAID EM
In selected cases, EUS +/- FNA if :1. Endoscopist cannot exclude
advanced stage of nodular lesion.2. Visible lymph nodes in selected
cases of T1b. (Grade C)
Before ER,CT/PET-CT no role in stagingEUS can overstage/ understage. (Grade B), Not recommended
v
HGD and
early cancer
Ablation Therapy
©4th SSG conference, Jan 2014, SAID EM
Flat HGD/intermucosal cancer without visible lesion should be managed with ablation therapy.
1-BSG guideline 2013
RFA has better safety, side effect profile and comparable efficacy1.
All ablation modalities improve eradication compared with surveillance for HGD (grade Ib)
Radio Frequency Ablation RFA
v
HGD and
early cancer
Endoscopic Resection
©4th SSG conference, Jan 2014, SAID EM
Cap & snare with submucosal injBand ligation without submuc inj
Equally effective.2
Patient at high surgical risk, ER can be offered as an alternative.
Therapy of choice for dysplasia + visible lesion and T1a OAC.1
1-Canio M,World J Gastroentrol, 20052-Pouw RE,Gastrointest Endosc,2011
vEndoscopic Resection
©4th SSG conference, Jan 2014, SAID EM
v
High Grade
Dysplasia HGD
Surgery
©4th SSG conference, Jan 2014, SAID EM
Treatment of choice for T1b due to significant risk of LN metastasis.
Oesophagectomy should be performed in high volume specialized centers to reduce mortality.
No sufficient data to recommend surveillance following oesophagectomy.
v
High Grade
Dysplasia HGD
HGD and early cancer T1a/T1b
©4th SSG conference, Jan 2014, SAID EM
Confirm diagnosis:Expert HRE to detect visible lesion
Second pathologists
MDT discussion
Flat lesion-RFAVisible lesion-ER
HGD/T1a cancer:RFA after resectionT1b cancer: surgery
©4th SSG conference, Jan 2014, SAID EM
MDT discussion
©4th SSG conference, Jan 2014, SAID EM
Flow chart for the management of Barrett’s oesophagus.
BSG guideline 2013
HGD
v
• IM is not required for the diagnosis of BO, but impact on surveillance.
• Standard dataset in endoscopic and histopthologicalreporting.
• Consensus diagnosis of dysplasia.
• Surveillance for non-dysplastic Barrett’s hinges on IM and length.
• Routine CT & EUS not required in staging of early Barrett’s neoplasia.
• Communication through MDT& with patient essential
Summary of the main changes
©4th SSG conference, Jan 2014, SAID EM
v
• Controversial due to lack of RCT.
• Current retrospective studies indicates survival advantage.
• On going trials.
• BSG guidelines provides up to date practical and evidence base recourses for management of BO and early oesophageal cancer and should be the gold standard.
Conclusion
©4th SSG conference, Jan 2014, SAID EM
©4th SSG conference, Jan 2014, SAID EM
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