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This article is compiled and compiled by Yimaitong, please do not reprint without authorization.
Core information: 1.
It is recommended to perform Barrett for people who have long-term reflux symptoms (>5 years) or who have one or more risk factors (including male sex, age over 50, white, central obesity, and smoking history).
Esophageal screening.
2.
For Barrett's esophagus without dysplasia, endoscopy is recommended every 3-5 years to monitor whether there is atypical hyperplasia and early esophageal adenocarcinoma.
3.
The recommended treatment for atypical hyperplasia of Barrett's esophagus is to perform endoscopic monitoring after endoscopic eradication.
Barrett's esophagus and esophageal cancer According to the American Cancer Society, in 2018, there were 17,290 new cases of esophageal cancer in the United States, of which 15,850 died.
And Barrett's esophagus is the precancerous lesion of esophageal cancer.
It is not clear how Barrett's esophageal cancer evolves into atypical hyperplasia, cancer, but the process is gradual.
From no atypical hyperplasia to low-grade atypical hyperplasia, to high-grade atypical hyperplasia and cancer, the risk of esophageal cancer depends on the grade of atypical hyperplasia: if there is no atypical hyperplasia, the risk of esophageal cancer within one year is 0.
33%; if there is low-grade SARS Type hyperplasia, the risk of developing esophageal cancer within one year is 0.
54%; if there is high-grade atypical hyperplasia, the risk of developing esophageal cancer within one year is 7%.
Although all esophageal adenocarcinomas originate in Barrett's esophagus, more than 90% of patients with esophageal adenocarcinoma are unaware of the Barrett's esophagus when they are diagnosed with esophageal adenocarcinoma.
Therefore, people with risk factors have a huge demand for Barrett's esophagus screening, which is not met.
Gastroesophageal reflux disease is a risk factor for esophageal cancer.
The purpose of Barrett's esophageal screening is to reduce the mortality of high-risk groups developing adenocarcinoma through early diagnosis and early intervention of Barrett's esophagus.
Chronic gastroesophageal reflux is a high risk factor for esophageal adenocarcinoma (OR 7.
7, 95%CI 5.
3-11.
4).
If symptoms persist for a long time (> 20 years), severe symptoms, or at least once a day, the risk of esophageal cancer is further increased (OR 43.
5, 95% CI 18.
3-103.
5).
Gastroesophageal reflux symptoms are scored as follows: ➤ Heartburn only, 1 point ➤ Reflux only 1 point ➤ Heartburn with reflux, 1.
5 points ➤ Nocturnal symptoms (yes 2 points, no 0 points) ➤ Symptoms 1 time/week, 0 points; 2-6 times/week, 1 point; 7-15 times/week, 2 points; more than 15 times/week, 3 points; if the score exceeds 4.
5 points or higher, it indicates severe reflux disease.
However, it is worth noting that the annual incidence of esophageal adenocarcinoma is less than 0.
001% in patients with long-term gastroesophageal reflux.
Risk factors for BARRETT's esophagus Male gender Barrett's esophagus is more common in men than women, with a ratio of 2:1 for men to women, but in people younger than 50 years old, the ratio of men to women is 4:1.
When Barrett's esophagus is diagnosed over the age of 50, the patient's age is usually around 60 or 70 years old.
In just 30 years from the age of 30 to 60, the prevalence of Barrett's esophagus rose from 2.
1% to 9.
3%.
White Barrett's esophagus is more common among whites than blacks (5.
0% vs 1.
5%, P<0.
0001).
Central obesity Waist circumference is an independent risk factor.
For every 5 cm increase, OR increased by 1.
14 times (95% CI 1.
03-1.
27, P = 0.
02).
Smoking history Smoking history increases the risk of Barrett's esophagus (OR 1.
42; 95% CI 1.
15-1.
76). Family history Family history of Barrett's esophagus or family history of esophageal adenocarcinoma is a very strong risk factor (OR 12, 95% CI 3.
3-44.
8).
A study found that the risk of first- and second-degree relatives of patients with Barrett's esophagus is as high as 24%, while this percentage is only 5% in the general population (P<0.
005).
Low-grade atypical hyperplasia: After the recommended treatment is carefully examined by a pathologist, most (73%) of patients who are diagnosed with low-grade atypical hyperplasia for the first time may be diagnosed with Barrett's esophagus without atypical hyperplasia, or an indeterminate atypia Hyperplasia.
However, patients who continue to be diagnosed with low-grade dysplasia are more likely to have disease progression.
Once the low-grade atypical hyperplasia is confirmed by a second gastroenterological pathologist, the patient should undergo endoscopic ablation.
A study led by Shaheen et al.
showed that compared with sham surgery, radiofrequency ablation was able to cure atypical hyperplasia (radiofrequency ablation: 90.
5% vs sham operation: 22.
7%) and completely eradicate intestinal metaplasia (radiofrequency ablation: 77.
4% vs.
Sham operation: 2.
3%) has obvious advantages.
The results of another trial of 136 patients with low-grade atypical hyperplasia completed by Phoa et al.
with a follow-up period of up to 3 years showed that compared with endoscopic monitoring, radiofrequency ablation can progress to high-grade atypical hyperplasia The risk of hyperplasia is reduced by 25%, and the risk of adenocarcinoma is reduced by 7.
4%.
Patients who are diagnosed with low-grade atypical hyperplasia and have not received eradication therapy should undergo endoscopic surveillance every 6-12 months, as shown in the following (note: all guidelines recommend careful identification of whether the lesion is atypical hyperplasia): AGA, ACG, ASGE’s Barrett’s Esophageal Monitoring Guidelines No dysplasia Barrett’s esophagus AGA, ACG and ASGE are recommended to be monitored every 3-5 years.
Uncertain dysplasia AGA: No recommendation ACG: 3-6 months of proton pump inhibitor (PPI) ) After the treatment, recheck the esophagus gastroduodenoscopy (EGD).
If the recheck results still show uncertain dysplasia, monitor it every 12 months. ASGE: Check the pathological results again, increase the dose of PPI, recheck EGD plus biopsy.
Low-grade atypical hyperplasia AGA: review every 6-12 months.
ACG: If the patient has no serious comorbidities affecting life expectancy, patients with confirmed low-grade atypical hyperplasia should undergo endoscopic eradication therapy or be reviewed every 12 months.
ASGE: EGD is reviewed within 6 months to confirm low-grade dysplasia, and then monitored annually, and eradication therapy is performed in designated patients.
High-grade atypical hyperplasia AGA: eradication treatment or monitoring every 3 months ACG: If the patient has no serious comorbidities that affect life span, eradicate the diagnosed high-grade atypical hyperplasia.
ASGE: Eradication treatment or monitoring of high-grade dysplasia every 3 months: The recommended treatment is the same as low-grade dysplasia.
The diagnosis of high-grade dysplasia also needs to be confirmed by a second pathologist.
In the past, the treatment for high-grade atypical hyperplasia was esophagectomy, but due to the low incidence of esophageal cancer, and the effect of esophagectomy is similar to radiofrequency ablation, the current treatment is to perform endoscopic mucosal resection on raised lesions.
Then radiofrequency ablation was performed on the entire affected esophageal segment.
In the study by Shaheen et al.
, 42 patients with high-grade dysplasia were randomly assigned to the radiofrequency ablation group, 21 patients were randomly assigned to the sham operation group, and 81% of the patients in the radiofrequency ablation group had reached SARS Type hyperplasia was completely cured, and only 19% of patients in the sham operation group achieved a complete cure.
77% of patients undergoing radiofrequency ablation achieved eradication of intestinal metaplasia, and only 2% of patients in the sham operation group achieved eradication of intestinal metaplasia.
Follow-up after 3 years showed that 98% of patients in the radiofrequency ablation group had no recurrence of atypical hyperplasia, and 91% of patients had no recurrence of intestinal metaplasia.
Therefore, it is recommended that all patients with Barrett's esophagus and high-grade atypical hyperplasia, but without complications that affect their life, undergo endoscopic eradication.
If the patient is unwilling to receive eradication therapy, it can also be monitored every 3 months.
However, radiofrequency ablation is more cost-effective than esophagectomy or endoscopic monitoring after the development of adenocarcinoma.
Early-stage esophageal adenocarcinoma: The recommended treatment is that there is no lymph node involvement and the adenocarcinoma confined to the mucosa can be removed by endoscopy.
For patients with local cancer, mucosal resection is not only for treatment, but also for better staging.
The ideal treatment is multidisciplinary, including the combined treatment of gastroenterologists, thoracic surgeons, and oncologists.
If the lesion invades the submucosa, the diameter of the lesion is greater than 1.
5cm, or it is difficult to separate the submucosa from the mucosa, then mucosal dissection is recommended, followed by radiofrequency ablation of the remaining Barrett's esophagus.
Treatment after ablation After ablation, because atypical proliferation is at the risk of recurrence, it is recommended to use long-term PPI for the patient and do a good job of monitoring.
The length of the monitoring interval depends on the preoperative grade of dysplasia.
For low-grade atypical hyperplasia, it is recommended to monitor every 6 months within the first year after ablation.
If there is no recurrence of atypical hyperplasia, it must be monitored annually from the second year.
For high-grade atypical hyperplasia or intramucosal adenocarcinoma, it is recommended to monitor every 3 months in the first year, every 6 months from the second year, and once a year from the third year.
Yimaitong compiled and compiled from: Singh T, Sanghi V, Thota PN.
Current management of Barrett esophagus and esophageal adenocarcinoma.
Cleveland Clinic journal of medicine.
2019, 86 (11 ): 724-732.
Core information: 1.
It is recommended to perform Barrett for people who have long-term reflux symptoms (>5 years) or who have one or more risk factors (including male sex, age over 50, white, central obesity, and smoking history).
Esophageal screening.
2.
For Barrett's esophagus without dysplasia, endoscopy is recommended every 3-5 years to monitor whether there is atypical hyperplasia and early esophageal adenocarcinoma.
3.
The recommended treatment for atypical hyperplasia of Barrett's esophagus is to perform endoscopic monitoring after endoscopic eradication.
Barrett's esophagus and esophageal cancer According to the American Cancer Society, in 2018, there were 17,290 new cases of esophageal cancer in the United States, of which 15,850 died.
And Barrett's esophagus is the precancerous lesion of esophageal cancer.
It is not clear how Barrett's esophageal cancer evolves into atypical hyperplasia, cancer, but the process is gradual.
From no atypical hyperplasia to low-grade atypical hyperplasia, to high-grade atypical hyperplasia and cancer, the risk of esophageal cancer depends on the grade of atypical hyperplasia: if there is no atypical hyperplasia, the risk of esophageal cancer within one year is 0.
33%; if there is low-grade SARS Type hyperplasia, the risk of developing esophageal cancer within one year is 0.
54%; if there is high-grade atypical hyperplasia, the risk of developing esophageal cancer within one year is 7%.
Although all esophageal adenocarcinomas originate in Barrett's esophagus, more than 90% of patients with esophageal adenocarcinoma are unaware of the Barrett's esophagus when they are diagnosed with esophageal adenocarcinoma.
Therefore, people with risk factors have a huge demand for Barrett's esophagus screening, which is not met.
Gastroesophageal reflux disease is a risk factor for esophageal cancer.
The purpose of Barrett's esophageal screening is to reduce the mortality of high-risk groups developing adenocarcinoma through early diagnosis and early intervention of Barrett's esophagus.
Chronic gastroesophageal reflux is a high risk factor for esophageal adenocarcinoma (OR 7.
7, 95%CI 5.
3-11.
4).
If symptoms persist for a long time (> 20 years), severe symptoms, or at least once a day, the risk of esophageal cancer is further increased (OR 43.
5, 95% CI 18.
3-103.
5).
Gastroesophageal reflux symptoms are scored as follows: ➤ Heartburn only, 1 point ➤ Reflux only 1 point ➤ Heartburn with reflux, 1.
5 points ➤ Nocturnal symptoms (yes 2 points, no 0 points) ➤ Symptoms 1 time/week, 0 points; 2-6 times/week, 1 point; 7-15 times/week, 2 points; more than 15 times/week, 3 points; if the score exceeds 4.
5 points or higher, it indicates severe reflux disease.
However, it is worth noting that the annual incidence of esophageal adenocarcinoma is less than 0.
001% in patients with long-term gastroesophageal reflux.
Risk factors for BARRETT's esophagus Male gender Barrett's esophagus is more common in men than women, with a ratio of 2:1 for men to women, but in people younger than 50 years old, the ratio of men to women is 4:1.
When Barrett's esophagus is diagnosed over the age of 50, the patient's age is usually around 60 or 70 years old.
In just 30 years from the age of 30 to 60, the prevalence of Barrett's esophagus rose from 2.
1% to 9.
3%.
White Barrett's esophagus is more common among whites than blacks (5.
0% vs 1.
5%, P<0.
0001).
Central obesity Waist circumference is an independent risk factor.
For every 5 cm increase, OR increased by 1.
14 times (95% CI 1.
03-1.
27, P = 0.
02).
Smoking history Smoking history increases the risk of Barrett's esophagus (OR 1.
42; 95% CI 1.
15-1.
76). Family history Family history of Barrett's esophagus or family history of esophageal adenocarcinoma is a very strong risk factor (OR 12, 95% CI 3.
3-44.
8).
A study found that the risk of first- and second-degree relatives of patients with Barrett's esophagus is as high as 24%, while this percentage is only 5% in the general population (P<0.
005).
Low-grade atypical hyperplasia: After the recommended treatment is carefully examined by a pathologist, most (73%) of patients who are diagnosed with low-grade atypical hyperplasia for the first time may be diagnosed with Barrett's esophagus without atypical hyperplasia, or an indeterminate atypia Hyperplasia.
However, patients who continue to be diagnosed with low-grade dysplasia are more likely to have disease progression.
Once the low-grade atypical hyperplasia is confirmed by a second gastroenterological pathologist, the patient should undergo endoscopic ablation.
A study led by Shaheen et al.
showed that compared with sham surgery, radiofrequency ablation was able to cure atypical hyperplasia (radiofrequency ablation: 90.
5% vs sham operation: 22.
7%) and completely eradicate intestinal metaplasia (radiofrequency ablation: 77.
4% vs.
Sham operation: 2.
3%) has obvious advantages.
The results of another trial of 136 patients with low-grade atypical hyperplasia completed by Phoa et al.
with a follow-up period of up to 3 years showed that compared with endoscopic monitoring, radiofrequency ablation can progress to high-grade atypical hyperplasia The risk of hyperplasia is reduced by 25%, and the risk of adenocarcinoma is reduced by 7.
4%.
Patients who are diagnosed with low-grade atypical hyperplasia and have not received eradication therapy should undergo endoscopic surveillance every 6-12 months, as shown in the following (note: all guidelines recommend careful identification of whether the lesion is atypical hyperplasia): AGA, ACG, ASGE’s Barrett’s Esophageal Monitoring Guidelines No dysplasia Barrett’s esophagus AGA, ACG and ASGE are recommended to be monitored every 3-5 years.
Uncertain dysplasia AGA: No recommendation ACG: 3-6 months of proton pump inhibitor (PPI) ) After the treatment, recheck the esophagus gastroduodenoscopy (EGD).
If the recheck results still show uncertain dysplasia, monitor it every 12 months. ASGE: Check the pathological results again, increase the dose of PPI, recheck EGD plus biopsy.
Low-grade atypical hyperplasia AGA: review every 6-12 months.
ACG: If the patient has no serious comorbidities affecting life expectancy, patients with confirmed low-grade atypical hyperplasia should undergo endoscopic eradication therapy or be reviewed every 12 months.
ASGE: EGD is reviewed within 6 months to confirm low-grade dysplasia, and then monitored annually, and eradication therapy is performed in designated patients.
High-grade atypical hyperplasia AGA: eradication treatment or monitoring every 3 months ACG: If the patient has no serious comorbidities that affect life span, eradicate the diagnosed high-grade atypical hyperplasia.
ASGE: Eradication treatment or monitoring of high-grade dysplasia every 3 months: The recommended treatment is the same as low-grade dysplasia.
The diagnosis of high-grade dysplasia also needs to be confirmed by a second pathologist.
In the past, the treatment for high-grade atypical hyperplasia was esophagectomy, but due to the low incidence of esophageal cancer, and the effect of esophagectomy is similar to radiofrequency ablation, the current treatment is to perform endoscopic mucosal resection on raised lesions.
Then radiofrequency ablation was performed on the entire affected esophageal segment.
In the study by Shaheen et al.
, 42 patients with high-grade dysplasia were randomly assigned to the radiofrequency ablation group, 21 patients were randomly assigned to the sham operation group, and 81% of the patients in the radiofrequency ablation group had reached SARS Type hyperplasia was completely cured, and only 19% of patients in the sham operation group achieved a complete cure.
77% of patients undergoing radiofrequency ablation achieved eradication of intestinal metaplasia, and only 2% of patients in the sham operation group achieved eradication of intestinal metaplasia.
Follow-up after 3 years showed that 98% of patients in the radiofrequency ablation group had no recurrence of atypical hyperplasia, and 91% of patients had no recurrence of intestinal metaplasia.
Therefore, it is recommended that all patients with Barrett's esophagus and high-grade atypical hyperplasia, but without complications that affect their life, undergo endoscopic eradication.
If the patient is unwilling to receive eradication therapy, it can also be monitored every 3 months.
However, radiofrequency ablation is more cost-effective than esophagectomy or endoscopic monitoring after the development of adenocarcinoma.
Early-stage esophageal adenocarcinoma: The recommended treatment is that there is no lymph node involvement and the adenocarcinoma confined to the mucosa can be removed by endoscopy.
For patients with local cancer, mucosal resection is not only for treatment, but also for better staging.
The ideal treatment is multidisciplinary, including the combined treatment of gastroenterologists, thoracic surgeons, and oncologists.
If the lesion invades the submucosa, the diameter of the lesion is greater than 1.
5cm, or it is difficult to separate the submucosa from the mucosa, then mucosal dissection is recommended, followed by radiofrequency ablation of the remaining Barrett's esophagus.
Treatment after ablation After ablation, because atypical proliferation is at the risk of recurrence, it is recommended to use long-term PPI for the patient and do a good job of monitoring.
The length of the monitoring interval depends on the preoperative grade of dysplasia.
For low-grade atypical hyperplasia, it is recommended to monitor every 6 months within the first year after ablation.
If there is no recurrence of atypical hyperplasia, it must be monitored annually from the second year.
For high-grade atypical hyperplasia or intramucosal adenocarcinoma, it is recommended to monitor every 3 months in the first year, every 6 months from the second year, and once a year from the third year.
Yimaitong compiled and compiled from: Singh T, Sanghi V, Thota PN.
Current management of Barrett esophagus and esophageal adenocarcinoma.
Cleveland Clinic journal of medicine.
2019, 86 (11 ): 724-732.
