daw
02-19-2004, 01:20 AM
for complete article:
http://www.medscape.com/viewarticle/463423
Barrett's Esophagus: Diagnosis and Treatment
Prateek Sharma, MD
Highlights:
Although the incidence of esophageal adenocarcinoma has significantly increased in recent years, it is not clear if this has been paralleled by a similar increase in the incidence of BE. Moreover, the number of upper endoscopies being performed is also increasing and the detection of more BE cases may represent increased detection of this lesion.
-----------
Helicobacter pylori is a documented gastric carcinogen, but its role in the etiology of BE is unknown. Previously, small studies have suggested a "protective effect" of H pylori against BE and esophageal adenocarcinoma.
-------------------
Management of patients with high-grade dysplasia (HGD) in BE remains controversial due to unsuspected cancers detected at esophagectomy and the variable rates of progression to cancer in these patients. Preliminary data have indicated that patients with focal HGD may be less likely to progress to cancer compared with patients with diffuse (multifocal) HGD.
---------------
Another area of intense research in the setting of BE is the study of biomarkers that may predict an increased risk of progression to cancer. 17p (p53) LOH (loss of heterozygosity) predicts progression of BE to cancer.
----------------
Role of acid suppression in progression of BE to dysplasia.
-------------------
It has been reported that patients with BE have continued abnormal esophageal acid exposure while on PPI therapy, but it is unclear whether patients require an increase in PPI dosing during endoscopic ablative therapies.
------------------
Treatment of BE has been explored with multiple ablative modalities, including thermal and photochemical techniques. Cryoablation is a relatively new form of mucosal injury tool that can potentially lead to induction of apoptosis, ischemic injury, and cryonecrosis.
----------------
follow-up results show that the majority of patients (85% in this series) treated with endoscopic ablation with acid-suppression therapy continue to remain free of endoscopic and histologic BE on follow-up. Whether such therapy prevents cancer development is yet unknown, and its role in the treatment of BE remains investigational.
------------------
Photodynamic therapy.
---------------
One of the complications associated with endoscopic ablative therapies is the formation of esophageal stricture, but the precise rates due to different ablative modalities are not known.
---------------------
Endoscopic mucosal resection (EMR) is another exciting and frequently used modality for treating early cancers and dysplasia within BE. Although EMR is able to remove large areas of neoplastic tissue, it is not clear whether it offers a "cure" in all patients.
------------------
Esophagectomy is currently considered by many in the field to be the standard therapy for HGD and early carcinoma in patients with BE.....Endoscopy was performed after esophagectomy in 38 patients, and 7 patients (18%) were documented with recurrent BE and dysplasia/cancer after a "curative resection." This appears to represent the development of metachronous disease after complete resection of BE, raising the possibility that even resection cannot guarantee disease-free survival.
-------------------
Concluding Remarks
New epidemiologic evidence suggests that BE may be increasing in incidence, although this report needs to be validated in population-based studies. The high prevalence of BE in asymptomatic individuals is concerning and forces clinicians to reevaluate screening practices. Acid suppression plays an important role in the treatment of patients with BE, and may have an effect on progression to dysplasia. New forms of endoscopic therapy, such as mucosal resection and cryotherapy, are being evaluated and, although promising, can be associated with complications including stricture formation. Data regarding long-term follow-up are required.
http://www.medscape.com/viewarticle/463423
Barrett's Esophagus: Diagnosis and Treatment
Prateek Sharma, MD
Highlights:
Although the incidence of esophageal adenocarcinoma has significantly increased in recent years, it is not clear if this has been paralleled by a similar increase in the incidence of BE. Moreover, the number of upper endoscopies being performed is also increasing and the detection of more BE cases may represent increased detection of this lesion.
-----------
Helicobacter pylori is a documented gastric carcinogen, but its role in the etiology of BE is unknown. Previously, small studies have suggested a "protective effect" of H pylori against BE and esophageal adenocarcinoma.
-------------------
Management of patients with high-grade dysplasia (HGD) in BE remains controversial due to unsuspected cancers detected at esophagectomy and the variable rates of progression to cancer in these patients. Preliminary data have indicated that patients with focal HGD may be less likely to progress to cancer compared with patients with diffuse (multifocal) HGD.
---------------
Another area of intense research in the setting of BE is the study of biomarkers that may predict an increased risk of progression to cancer. 17p (p53) LOH (loss of heterozygosity) predicts progression of BE to cancer.
----------------
Role of acid suppression in progression of BE to dysplasia.
-------------------
It has been reported that patients with BE have continued abnormal esophageal acid exposure while on PPI therapy, but it is unclear whether patients require an increase in PPI dosing during endoscopic ablative therapies.
------------------
Treatment of BE has been explored with multiple ablative modalities, including thermal and photochemical techniques. Cryoablation is a relatively new form of mucosal injury tool that can potentially lead to induction of apoptosis, ischemic injury, and cryonecrosis.
----------------
follow-up results show that the majority of patients (85% in this series) treated with endoscopic ablation with acid-suppression therapy continue to remain free of endoscopic and histologic BE on follow-up. Whether such therapy prevents cancer development is yet unknown, and its role in the treatment of BE remains investigational.
------------------
Photodynamic therapy.
---------------
One of the complications associated with endoscopic ablative therapies is the formation of esophageal stricture, but the precise rates due to different ablative modalities are not known.
---------------------
Endoscopic mucosal resection (EMR) is another exciting and frequently used modality for treating early cancers and dysplasia within BE. Although EMR is able to remove large areas of neoplastic tissue, it is not clear whether it offers a "cure" in all patients.
------------------
Esophagectomy is currently considered by many in the field to be the standard therapy for HGD and early carcinoma in patients with BE.....Endoscopy was performed after esophagectomy in 38 patients, and 7 patients (18%) were documented with recurrent BE and dysplasia/cancer after a "curative resection." This appears to represent the development of metachronous disease after complete resection of BE, raising the possibility that even resection cannot guarantee disease-free survival.
-------------------
Concluding Remarks
New epidemiologic evidence suggests that BE may be increasing in incidence, although this report needs to be validated in population-based studies. The high prevalence of BE in asymptomatic individuals is concerning and forces clinicians to reevaluate screening practices. Acid suppression plays an important role in the treatment of patients with BE, and may have an effect on progression to dysplasia. New forms of endoscopic therapy, such as mucosal resection and cryotherapy, are being evaluated and, although promising, can be associated with complications including stricture formation. Data regarding long-term follow-up are required.