Barretts Esophagus and Dysplasia: Diagnosis and Management Prateek - - PowerPoint PPT Presentation

Barrett’s Esophagus and Dysplasia: Diagnosis and Management

Prateek Sharma, MD Kansas City

Barrett’s associated adenocarcinoma

squamous

Barrett’s

Rising Incidence of Esophageal Adenocarcinoma

Rate per 1,000,000 1975 2000 1980 1985 1990 1995 Pohl H et al, J Natl Cancer Inst 2005 5 10 15 20 25 30 35 Adenocarcinoma Squamous Cell Carcinoma Not otherwise specified

Intestinal Metaplasia

Barrett’s Esophagus

Columnar lined esophagus

Endoscopic recognition of the columnar lined esophagus

Long Barrett’s Short Barrett’s Ultra short Barrett’s Microscopic Barrett’s Invisible Barrett’s Terminology Issues

Prague C & M Criteria

• Based on –

Circumference and Maximum extent

• Patient with 5 cm long

Barrett’s, distal 2 cm circumferential and proximal 3 cm in form

• f a tongue

Barrett’s: C2M5

C2 M5

Sharma P, Dent J, Armstrong D et al, Gastroenterology 2006

Progression of Barrett’s Esophagus

Dysplasia and cancer in BE patients: absolute risk

6.7 3 7.3 0.5 0.9 4.3 1 2 3 4 5 6 7 8 Cancers HGD LGD %

Prevalence

(n=1376)

Incidence

(n=618) Sharma et al, Clin Gastro Hepatol 2006

Endoscopic Therapy for Esophageal Neoplasia

Early Detection Accurate Staging Effective Treatment

Narrow Band Imaging (NBI)

Conventional imaging NBI

Field of view: 500x500µm Range: 0-250µm Lateral resolution: <1µm

Technique of Endomicroscopy

Endoscopic Therapy for Esophageal Neoplasia

Early Detection Accurate Staging Effective Treatment

EMR versus EUS

Baseline Diagnosis EMR Diagnosis

• 48 patients underwent EUS
• Invasion confirmed in 8 (7 at surgery)

Overall accuracy of EUS for staging 85% 1 over-staged, 6 under-staged

Larghi A et al, Gastrointest Endosc 2005

HGD (n=25) EUS: no cancer Cancers (n=15) EUS: intra mucosal 24% invasive cancer 40% invasive cancer

Endoscopic Therapy for Esophageal Neoplasia

Early Detection Accurate Staging Effective Treatment

PDT: 5 Year Follow Up

• 208 HGD patients
• PDT (138), observation (70)

Patients (%)

Overholt B et al, Gastrointest Endosc 2007 *p = 0.02

Progression to cancer

Observation

PDT 28% 13%* 29%

15%*

5 10 15 20 25 30 35 2 years 5 years

EMR for BE Cancer

• 1.47 resection/patient
• Follow up: 3 years
• 100 patients with cancer
• Low risk

– types I, IIa, IIb, IIc – lesion < 2 cm; mucosal – grades: G1, G2

Ell C et al, Gastrointest Endosc 2007

Complete local remission 99% Complications 11% Minor bleeding, no perforation All treated endoscopically Recurrent lesions 11% 5 yr survival 98%

20 40 60 80 100

Patient %

A Randomized, Multicenter, Sham Controlled Trial of RF Ablation

• 128 patients with BE and dysplasia (LGD/HGD)
• Mean BE length 5 cm; 12 month follow up

IM Eradication (n=127) LGD Eradication (n=64) HGD Eradication (n=63)

2% 23% 19% 77%* 90%* 81%*

Patients %

10 20 30 40 50 60 70 80 90 100 SHAM RFA

p<0.001

Shaheen N et al. DDW 2008

Endoscopic therapy

• HGD: uni/multi-focal; flat/nodular
• Intra-mucosal adenocarcinoma
• Careful endoscopic grading and staging
• f the BE segment
• Diagnostic EMR a must

Continued Challenges with Endoscopic Therapy

• All intestinal metaplasia cannot be eliminated (70-80%)
• Strictures, bleeding, perforation
• Non uniform ablation
• Persistence of sub-squamous intestinal metaplasia
• Persistence of genetic abnormalities

Conclusions

• Clear identification of endoscopic landmarks is

the basis for an endoscopic diagnosis of BE

• The reliability of using the Prague C&M criteria

for the endoscopy grading of BE is excellent

• Dysplasia remains the best marker for risk

stratification of BE patients; higher the grade of dysplasia greater the risk

• Endoscopic therapies should be limited to

patients with HGD and intra-mucosal adenocarcinoma; should be performed in expert centres for optimal results

Management of Barrett’s Neoplasia

Diagnosis of dysplasia Diagnostic/staging EMR Enhanced endoscopic imaging LGD HGD/early cancer

• Consider enrollment in trials
• Chemoprevention
• Ablation
• Continued surveillance

LGD HGD/ early cancer Invasive cancer Combination therapy: EMR + ablation (RFA, PDT, Cryo) Therapeutic EMR (If length: Prague C0, M<3) Surgery