Barrett's esophagus is a condition where the normal squamous epithelium of the esophagus is replaced by columnar epithelium as a result of chronic reflux. It increases the risk of developing esophageal adenocarcinoma significantly. Current management involves endoscopic surveillance for non-dysplastic and low-grade dysplastic Barrett's. For high-grade dysplasia or adenocarcinoma, the standard treatment in the UK is esophagectomy, but endoscopic resection has been used successfully in specialist centers with high remission rates and improved outcomes over surgery.
Barrett's esophagus is a condition in which the tissue lining the esophagus—the muscular tube that connects the mouth to the stomach—is replaced by tissue that is similar to the lining of the intestine. This process is called intestinal metaplasia.
No signs or symptoms are associated with Barrett's esophagus, but it is commonly found in people with gastroesophageal reflux disease (GERD). A small number of people with Barrett's esophagus develop a rare but often deadly type of cancer of the esophagus.
Barrett's esophagus affects about 1 percent1 of adults in the United States. The average age at diagnosis is 50, but determining when the problem started is usually difficult. Men develop Barrett's esophagus twice as often as women, and Caucasian men are affected more frequently than men of other races. Barrett's esophagus is uncommon in children.
The EsophagusThe esophagus carries food and liquids from the mouth to the stomach. The stomach slowly pumps the food and liquids into the intestine, which then absorbs needed nutrients. This process is automatic and people are usually not aware of it. People sometimes feel their esophagus when they swallow something too large, try to eat too quickly, or drink very hot or cold liquids.
Digestive tract.
The muscular layers of the esophagus are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax to allow food or drink to pass from the mouth into the stomach. The muscles then close rapidly to prevent the food or drink from leaking out of the stomach back into the esophagus and mouth.
NIDDK
Barrett's esophagus is a condition in which the tissue lining the esophagus—the muscular tube that connects the mouth to the stomach—is replaced by tissue that is similar to the lining of the intestine. This process is called intestinal metaplasia.
No signs or symptoms are associated with Barrett's esophagus, but it is commonly found in people with gastroesophageal reflux disease (GERD). A small number of people with Barrett's esophagus develop a rare but often deadly type of cancer of the esophagus.
Barrett's esophagus affects about 1 percent1 of adults in the United States. The average age at diagnosis is 50, but determining when the problem started is usually difficult. Men develop Barrett's esophagus twice as often as women, and Caucasian men are affected more frequently than men of other races. Barrett's esophagus is uncommon in children.
The EsophagusThe esophagus carries food and liquids from the mouth to the stomach. The stomach slowly pumps the food and liquids into the intestine, which then absorbs needed nutrients. This process is automatic and people are usually not aware of it. People sometimes feel their esophagus when they swallow something too large, try to eat too quickly, or drink very hot or cold liquids.
Digestive tract.
The muscular layers of the esophagus are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax to allow food or drink to pass from the mouth into the stomach. The muscles then close rapidly to prevent the food or drink from leaking out of the stomach back into the esophagus and mouth.
NIDDK
New Treatments for GERD and Barrett's EsophagusSummit Health
Learn the symptoms of Gastroesophageal Reflux Disease (GERD) and Barrett’s esophagus, and when they may warrant further medical attention. Hear the latest in treatment methods, including radio frequency ablation and endoscopic ultrasound.
Oesophageal surgery- Is there light at the end of the tunnel? Professor Neil ...SMACC Conference
The 105 years since the first successful thoracic oesophagectomy was performed saw initially slow progress in terms of operative mortality, morbidity and oncological outcomes. Even until the late 1990’s, operative mortality figures of 15-20% were commonplace and long term survival was poor, as low as 12%1. The last 20 years has seen a major change in these outcomes both within Australia and overseas. These improvements have been based on the bed rocks of improved surgical techniques, improved peri operative care, changes in the distribution of the pathophysiology of the disease, improved patient selection through better staging, Development of endoscopic techniques for early tumours, development of effective neo adjuvant regimes and the development of “high” volume centres have all contributed to the current figures of 4% preoperative mortality and overall 5 year survivals in the post surgical patient of 40%. Better understanding of the nutritional issues involved has led to an emphasis on better quality of life issues in both the curative and palliative settings. This talk outlines the forces that have brought about the changes including outlining the modern treatment algorithm and discussing the volume effects of surgery in the Australian context
1. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: I. A critical review of surgery. Br J Surg 1980;67: 381-90
Running head ESOPHAGUS ADENOCARCINOMA T2N2M01ESOPHAGUS ADENOCA.docxcharisellington63520
Running head: ESOPHAGUS ADENOCARCINOMA T2N2M0 1
ESOPHAGUS ADENOCARCINOMA T2N2M0 9
Esophagus Adenocarcinoma T2N2M0
Adenocarcinoma is a complication of the gastroesophageal reflux that affects the distal esophagus. Out of an estimated 12,500 cases diagnosed in 2000 there were 12,200 deaths. Therefore, the mortality rate is rather high for this type of cancer. According to the National Center for Biotechnology Information this type of cancer is currently ranking seventh in the list of the most common cancers in the world (Lerut, 2001). The cancer affects those who are in there mid to late adulthood and only 8% of those who are diagnosed with this disease survive. Mostly, the differences in survival are based on racial background, sex, and histological type, which means the kind of cancer that affects an individual.
Anatomy
Esophagus is a thin-walled, hollow tube, measuring at about 25 cm in length. Squamous cell carcinoma for the proximal to mid esophagus and adenocarcinoma for the distal end of the esophagus. The esophagus is roughly from C6 to T11 it is also divided into four regions. These regions are the Cervical, Upper thoracic, Mid thoracic & Lower thoracic. The Lower thoracic is where this patients Cancer is located. The lymphatics in this area are the Lower peri-esophagogastric lymph node below the level of the azygos vein, the diaphragmatic, peri-cardiac, left peri-gastric and celiac nodes.
Epidemiology
Regarding gender, the cancer of the esophageal 2.7 more commonly found in men than women and more lethal. Concerning the issue of age and the incidence of the disease, it peaks most in the 7th decade in patient’s life. With adenocarcinoma white males ranging in the age of 40 to 50 are mostly affected (Zhang, 2013). In fact, 20% of death rates in the United States among men are caused by adenocarcinoma. In 2012, the National Cancer Institute speculated that out of 17,460 persons diagnosed with cancer of the esophagus, 15,070 would die. Based on the fact that the cancer affects men more than women it was estimated that the cancer would affect 13,950 men and 3,510 women that year. However, the United States is not the only country affected by adenocarcinoma. The rates are much higher in China. Chronic alcohol uses, as well as external carcinogens, have been pinpointed as the main causes of adenocarcinoma (Zhang, 2013).
Additionally, there have been instances in which nutrition has been raised as a factor leading to the problem; however, diet does not explain the origin of the cancer well. Specialists claim that if the cancer can be related to diet, then it would be much easier for the disease to be averted by changes in eating patterns. Regarding the issue of race in America, incidences of whites getting the adenocarcinoma is more common than that of blacks (Baquet CR, 2015), due to poor eating habits, diet, status and exposure to alcohol and external carcinogens. Inherently, smokers have an increased risk of getting the esophagus adenoca.
Similar to Barrett's Oesophagus - Treatment and Management (20)
2. Barrett’s Oesophagus
Affects the distal oesophagus
Consequence of chronic pathological reflux of the gastric content
Often asymptomatic, and found as a consequenece of
endoscopic investigation for other conditions.
Risk factor Literature
GORD (Eisen et al., 1997)
Obesity (El-Serag et al.,
2006)
Hiatial hernia (El-Serag et al.,
2006)
Absence of H. pylori
infection
(Goldblum et al.,
1998)
3. Pathophysiology
Chronic exposure to gastric content leads to
intestinal metaplasia
Cellular & DNA damage alters the differentiation
potential of proliferating epithelial cells.
The metaplastic change is macroscopically visible
using an endoscope.
Squamous epithelium Columnar epithelium
(distal oesophagus) (gastric cardia, fundus, upper intestine)
6. Pathophysiology cont.
The intestinal metaplasia may be classified
histologically as:
Non-dysplasic
Low grade dysplasia (LGD)
High grade dysplasia (HGD)
In HGD, dysplastic cells are still confined by the
basement membrane. However, due to the large
numbers of dysplastic cells there is a high chance
of subsequent invasion of the submucosa, and
progression to adenocarcinoma.
8. ...So what?
Individuals with this condition have a 30- to 50-
fold increased risk of developing oesophageal
cancer (adenocarcinoma). (O'Connor et al.,
1999).
The 5 year survival rate with oesophageal cancer
is 9% (Kumar & Clark, 2008).
... This makes oesophageal cancer one of the
commonest causes of cancer related mortality.
9. Why diagnose Barrett’s?
Part of the reason oesophageal cancer has such a high
mortality, is because 70% patients don’t present until the
disease is stage III or higher (TMN classification system)
BO is one of the most important risk factors for
oesophageal cancer
Therefore if BO is diagnosed and treated before it
becomes dysplastic, could the oesophageal carcinoma
associated mortality be reduced?
Staging of oesophageal cancer based on the TNM classification system
Stage of cancer Five year survival
I 80%
II 30%
III 18%
IV 4%
10. Treatment of Barrett’s?
An American study in the 1990s by Cameron et
al. showed the prevalence of Barrett’s to be 0.5%
on autopsy.
A more recent Sweedish study showed a
prevalence of 1.6% in a cohort of 3000.
Prevalence of BO in patients with GORD is
significantly higher- 8-20% in Western countries.
The risk of developing adenocarcinoma from BO
is relatively low, at 0.5% per patient year.
11. Treatment of Barrett’s cont.
Treatment of everyone with the condition would
be unfeasible, and place too greater strain
financially on the NHS.
Treatment is invasive, and isn’t preferable to
patients with asymptomatic Barrett’s.
12. Current management
Non-dysplastic Barrett’s
Endoscopic surveillance every 2-3 years
Low-grade dysplasia
Endoscopic surveillance every 2-3 years
6-28% risk of developing HGD
High-grade dysplasia
Invasive surgical or endoscopic treatment
2.2-11.8% risk of developing adenocarcinoma
Adenocarcinoma
Invasive surgical or endoscopic treatment
13. What is the treatment?
SURGICAL
Total oesophagectomy and lymphadenectomy
20% post-operative mortality
85% 5 year mortality
£25,000- before any post-operative complications
Therefore this treatment is far from ideal...
Could it be more successful if the disease was treated when
less dysplastic?
o A very extreme treatment option for an asymptomatic
patient with LGD and only a 6-28% chance of
developing HGD.
o Financial burden on NHS would increase
14. What is the treatment cont.
ENDOSCOPIC
Ablation
Destroy the affected tissue, allowing it to be replaced with
the normal squamous epithelium of the oesophagus.
However, no sample of the tissue is obtained therefore
infiltration depth of the lesion may be underestimated, and
invasion of lymph nodes and blood vessels may not be
identified
Therefore this shouldn’t be used as a stand-alone treatment
for HGD or adenocarcinoma.
Resection
Remove the mucosa and submucosa, leaving the
muscularis propria exposed.
Confirm that the cancerous tissue has margins within the
resected lesion.
15. Endoscopic resection
This technique has been used with high success rates
Specialist centre in Wiesbaden, Germany involving 144
patients undergoing endoscopic resection for HGD showed
a 99% remission rate in patients, with a 98% 5 year
survival rate. (Pech et al. 2007).
However, this wasn’t an RCT- these patients were selected
as they were considered ‘low-risk’ (ie. The cancer was
limited to the mucosal layer).
Studies involving ‘higher-risk’ patients showed poorer
results.
Reoccurrence is quite frequent, estimated at around 11%
(Peters et al, 2006). However, if patients attend follow-up
appointments, complications from this are minimised.
Is this only treating ‘the tip of the iceberg’? Leaving behind
residual, potentially cancerous tissue? Could this
compromise the long-term prognosis, and chances of
actually ‘curing’ the cancer?
No, if used successfully like in Wiesbaden Germany.
16. Endoscopy vs surgery?
At present, most centres in the UK offer
oesophagectomy as first-line treatment for HGD and
adenocarcinoma.
Endoscopic treatment is considered only if the patient
is considered un-fit for surgery, and as palliative
treatment.
There has yet to be an RCT comparing the two.
However, study using a decision analysis model
carried out based on data from non-RCTs showed:
Endoscopic was more effective and less expensive than
surgical treatment.
The cost of endoscopic resection was $17,000 and 4.88
Quality adjusted life years (QALY), compared with a cost of
$28,000 and 4.59 QALY for oesophagectomy.
(Pohl et al, 2009)
17. In conclusion...
There are two main ways of treating high-grade
dysplasia.
Oesophagectomy
Endoscopic ablation or resection
Oesophagectomy is the treatment of choice in the
UK, but it is expensive and has low success
rates.
Endoscopic resection has been used successfully
in specialist centres, such as Wiesbaden,
Germany with excellent results.
If this technique can be used successfully in other
countries, surely it is only a matter of time before
this technique is used with similar success rates
