Barrett’s surveillance

1. Honorary Senior Clinical Lecturer, University of Sheffield
Consultant Gastroenterologist
Barnsley Hospital NHS Foundation Trust, UK
elmuhtady.said@nhs.net©4th SSG conference, Jan 2014

2. ©4th SSG conference, Jan 2014, SAID EM

3. Definition
Surveillance
Non-dysplastic BO
Dysplastic BO
Early oesophageal cancer
Summary
©4th SSG conference, Jan 2014, SAID EM

4. 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.”

5. =
• 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

6. =
• "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).

7. =
“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distal squamous epithelial lining has been
replaced by metaplastic columnar epithelium,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

8. ©4th SSG conference, Jan 2014, SAID EM

9. • 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.

10. • 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

11. • 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

12. • 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

13. 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

14. 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

15. 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: Discharge
BO with IM <3 cm: 3-5 yrs
BO 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.

16. 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.

17. Non-dysplastic BO surveillance flow chart BSG guideline 2013©4th SSG conference, Jan 2014, SAID EM

18. Low
Grade
Dysplasia
LGD
Low grade dysplasia LGD
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The diagnosis should be confirmed
by two pathologists

19. 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

20. 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?

21. • LGD correlate with higher risk of
progression to cancer.
• Unclear whether this warrant
endoscopic intervention.
• Clinicians may choose to treat
some patients with ablation
when dysplasia is persistent or
multifocal on individual basis.
Low
Grade
Dysplasia
LGD
Low grade dysplasia LGD
©4th SSG conference, Jan 2014, SAID EM

22. 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

23. 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.

24. 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

25. 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

26. • 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

27. ‫الخل‬acetic 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

28. 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?

29. HGD and early cancer T1a/T1b
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30. HGD
and
early
cancer
Imaging for HGD & T1 cancer
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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 staging
EUS can overstage/ understage.
(Grade B), Not recommended

31. 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)

32. Radio Frequency Ablation RFA

33. v
HGD
and
early
cancer
Endoscopic Resection
©4th SSG conference, Jan 2014, SAID EM
Cap & snare with submucosal inj
Band 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, 2005
2-Pouw RE,Gastrointest Endosc,2011

34. vEndoscopic Resection
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35. 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.

36. 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-RFA
Visible lesion-ER
HGD/T1a cancer:RFA after resection
T1b cancer: surgery

37. ©4th SSG conference, Jan 2014, SAID EM

38. MDT discussion
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Flow chart for the management of
Barrett’s oesophagus.
BSG guideline 2013
HGD


39. v
• IM is not required for the diagnosis of BO, but impact
on surveillance.
• Standard dataset in endoscopic and histopthological
reporting.
• 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

40. 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

41. ©4th SSG conference, Jan 2014, SAID EM

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