Barrett's esophagus (BE) is the most important identifiable risk factor for the progression to esophageal adenocarcinoma.
Methods
This article reviews the current endoscopic therapies for BE with high-grade dysplasia and intramucosal cancer and briefly discusses the endoscopic palliation of advanced esophageal cancer.
Results
The diagnosis of low-grade or high-grade dysplasia (HGD) is based on several cytologic criteria that suggest neoplastic transformation of the columnar epithelium. HGD and carcinoma in situ are regarded as equivalent. The presence of dysplasia, particularly HGD, is also a risk factor for synchronous and metachronous adenocarcinoma. Dysplasia is a marker of adenocarcinoma and also has been shown to be the preinvasive lesion. Esophagectomy has been the conventional treatment for T1 esophageal cancer and, although debated, is an appropriate option in some patients with HGD due to the presence of occult cancer in over one-third of patients.
Conclusions
Endoscopic ablative modalities (eg, photodynamic therapy and cryoablation) and endoscopic resection techniques (eg, endoscopic mucosal resection) have demonstrated promising results. The significant morbidity and mortality of esophagectomy makes endoscopic treatment an attractive potential option.
BlotW.J.. Esophageal cancer trends and risk factors.Semin Oncol.1994; 21(4): 403–410.
5.
Solaymani-DodaranM., LoganR.F., WestJ.. Risk of esophageal cancer in Barrett's oesophagus and gastro-oesophageal reflux.Gut.2004; 53(8): 1070–1074.
6.
IftikharS.Y., JamesP.D., SteeleR.J.. Length of Barrett's oesophagus: an important factor in the development of dysplasia and adenocarcinoma.Gut.1992; 33(9): 1155–1158.
7.
SamplinerR.E.. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus.Am J Gastroenterol.2002; 97(8): 1888–1895.
8.
HameetemanW., TytgatG.N., HouthoffH.J.. Barrett's esophagus: development of dysplasia and adenocarcinoma.Gastroenterology.1989; 96(5 Pt 1): 1249–1256.
9.
ReidB.J., BlountP.L., RubinC.E.. Flow-cytometric and histological progression to malignancy in Barrett's esophagus: prospective endoscopic surveillance of a cohort.Gastroenterology.1992; 102(4 Pt 1): 1212–1219.
10.
SkacelM., PetrasR.E., GramlichT.L.. The diagnosis of low-grade dysplasia in Barrett's esophagus and its implications for disease progression.Am J Gastroenterol.2000; 95(12): 3383–3387.
11.
MontgomeryE., BronnerM.P., GoldblumJ.R.. Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation.Hum Pathol.2001; 32(4): 368–378.
12.
SharmaP., MoralesT.G., SamplinerR.E.. Short segment Barrett's esophagus–the need for standardization of the definition and of endoscopic criteria.Am J Gastroenterol.1998; 93(7): 1033–1036.
13.
WestonA.P., KrmpotichP., MakdisiW.F.. Short segment Barrett's esophagus: clinical and histological features, associated endoscopic findings, and association with gastric intestinal metaplasia.Am J Gastroenterol.1996; 91(5): 981–986.
14.
PechO., BehrensA., MayA.. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus.Gut.2008; 57(9): 1200–1206.
15.
SharmaP., DentJ., ArmstrongD.. The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria.Gastroenterology.2006; 131(5): 1392–1399.
16.
KondaV.J., RossA.S., FergusonM.K.. Is the risk of concomitant invasive esophageal cancer in high-grade dysplasia in Barrett's esophagus overestimated?Clin Gastroenterol Hepatol.2008; 6(2): 159–164.
17.
NigroJ.J., HagenJ.A., DeMeesterT.R.. Occult esophageal adenocarcinoma: extent of disease and implications for effective therapy.Ann Surg.1999; 230(3): 433–440.
18.
TharavejC., HagenJ.A., PetersJ.H.. Predictive factors of coexisting cancer in Barrett's high-grade dysplasia.Surg Endosc.2006; 20(3): 439–443.
19.
PetersF.P., BrakenhoffK.P., CurversW.L.. Histologic evaluation of resection specimens obtained at 293 endoscopic resections in Barrett's esophagus.Gastrointest Endosc.2008; 67(4): 604–609.
20.
ReidB.J., WeinsteinW.M., LewinK.J.. Endoscopic biopsy can detect high-grade dysplasia or early adenocarcinoma in Barrett's esophagus without grossly recognizable neoplastic lesions.Gastroenterology.1988; 94(1): 81–90.
21.
SchmidtH.G., RiddellR.H., WaltherB.. Dysplasia in Barrett's esophagus.J Cancer Res Clin Oncol.1985; 110(2): 145–152.
22.
SmithR.R., HamiltonS.R., BoitnottJ.K.. The spectrum of carcinoma arising in Barrett's esophagus. A clinicopathologic study of 26 patients.Am J Surg Pathol.1984; 8(8): 563–573.
23.
American Joint Committee on Cancer Staging Manual.7th ed.EdgeS.B., ByrdD.R., ComptonC.C., eds. Springer: New York, NY; 2010.
24.
AnconaE., RampadoS., CassaroM.. Prediction of lymph node status in superficial esophageal carcinoma.Ann Surg Oncol.2008; 15(11): 3278–3288.
25.
EguchiT., NakanishiY., ShimodaT.. Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer: analysis of 464 surgically resected cases.Mod Pathol.2006; 19(3): 475–480.
26.
BergmanJ.J., FockensP.. Endoscopic ultrasonography in patients with gastro-esophageal cancer.Eur J Ultrasound.1999; 10(2-3): 127–138.
27.
PouwR.E., HeldoornN., HerreroL.A.. Do we still need EUS in the workup of patients with early esophageal neoplasia? A retrospective analysis of 131 cases.Gastrointest Endosc.2011; 73(4): 662–668.
28.
ShamiV.M., VillaverdeA., StearnsL.. Clinical impact of conventional endosonography and endoscopic ultrasound-guided fine-needle aspiration in the assessment of patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma who have been referred for endoscopic ablation therapy.Endoscopy.2006; 38(2): 157–161.
29.
MayA, GünterE, RothF. Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high resolution endosonography: a comparative, prospective, and blinded trial.Gut.2004; 53(5): 634–640.
30.
WangV.S., HornickJ.L., SepulvedaJ.A.. Low prevalence of submucosal invasive carcinoma at esophagectomy for high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus: a 20-year experience.Gastrointest Endosc.2009; 69(4): 777–783.
31.
EdwardsM.J., GableD.R., LentschA.B.. The rationale for esophagectomy as the optimal therapy for Barrett's esophagus with high-grade dysplasia.Ann Surg.1996; 223(5): 585–591.
32.
RiceT.W., FalkG.W., AchkarE.. Surgical management of high-grade dysplasia in Barrett's esophagus.Am J Gastroenterol.1993; 88(11): 1832–1836.
33.
FergusonM.K., NaunheimK.S.. Resection for Barrett's mucosa with high-grade dysplasia: implications for prophylactic photodynamic therapy.J Thorac Cardiovasc Surg.1997; 114(5): 824–829.
34.
ChennatJ., KondaV.J., RossA.S.. Complete Barrett's eradication endoscopic mucosal resection: an effective treatment modality for high-grade dysplasia and intramucosal carcinoma–an American single-center experience.Am J Gastroenterol.2009; 104(11): 2684–2692.
35.
FinksJ.F., OsborneN.H., BirkmeyerJ.D.. Trends in hospital volume and operative mortality for high-risk surgery.N Engl J Med.364(22): 2128–2137.
36.
BirkmeyerJ.D., SiewersA.E., FinlaysonE.V.. Hospital volume and surgical mortality in the United States.N Engl J Med.2002; 346(15): 1128–1137.
37.
PouwR.E., van VilsterenF.G., PetersF.P.. Randomized trial on endoscopic resection-cap versus multiband mucosectomy for piecemeal endoscopic resection of early Barrett's neoplasia.Gastrointest Endosc.2011; 74(1): 35–43.
38.
MossA., BourkeM.J., HouriganL.F.. Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit.Am J Gastroenterol.2010; 105(6): 1276–1283.
39.
PrasadG.A., ButtarN.S., WongkeesongL.M.. Significance of neoplastic involvement of margins obtained by endoscopic mucosal resection in Barrett's esophagus.Am J Gastroenterol.2007; 102(11): 2380–2386.
40.
EllC., MayA., PechO.. Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer).Gastrointest Endosc.2007; 65(1): 3–10.
41.
ViethM., EllC., GossnerL.. Histological analysis of endoscopic resection specimens from 326 patients with Barrett's esophagus and early neoplasia.Endoscopy.2004; 36(9): 776–781.
42.
MayA., GossnerL., BehrensA.. A prospective randomized trial of two different endoscopic resection techniques for early stage cancer of the esophagus.Gastrointest Endosc.2003; 58(2): 167–175.
43.
NigroJ.J., HagenJ.A., DeMeesterT.R.. Prevalence and location of nodal metastases in distal esophageal adenocarcinoma confined to the wall: implications for therapy.J Thorac Cardiovasc Surg.1999; 117(1): 16–25.
44.
NigroJ.J., DeMeesterS.R., HagenJ.A.. Node status in transmural esophageal adenocarcinoma and outcome after en bloc esophagectomy.J Thorac Cardiovasc Surg.1999; 117(5): 960–968.
45.
HolscherA.H., BollschweilerE., SchneiderP.M.. Early adenocarcinoma in Barrett's oesophagus.Br J Surg.1997; 84(10): 1470–1473.
46.
ParafF., FlejouJ.F., PignonJ.P.. Surgical pathology of adenocarcinoma arising in Barrett's esophagus. Analysis of 67 cases.Am J Surg Pathol.1995; 19(2): 183–191.
47.
WaniS., MathurS.C., CurversW.L.. Greater interobserver agreement by endoscopic mucosal resection than biopsy samples in Barrett's dysplasia.Clin Gastroenterol Hepatol.2010; 8(9): 783–788.
48.
Mino-KenudsonM., HullM.J., BrownI.. EMR for Barrett's esophagus-related superficial neoplasms offers better diagnostic reproducibility than mucosal biopsy.Gastrointest Endosc.2007; 66(4): 660–666.
49.
MaishM.S., DeMeesterS.R.. Endoscopic mucosal resection as a staging technique to determine the depth of invasion of esophageal adenocarcinoma.Ann Thorac Surg.2004; 78(5): 1777–1782.
50.
HullM.J., Mino-KenudsonM., NishiokaN.S.. Endoscopic mucosal resection: an improved diagnostic procedure for early gastroesophageal epithelial neoplasms.Am J Surg Pathol.2006; 30(1): 114–118.
51.
Alvarez HerreroL., PouwR.E., van VilsterenF.G.. Safety and efficacy of multiband mucosectomy in 1060 resections in Barrett's esophagus.Endoscopy.2011; 43(3): 177–83.
52.
MannerH., MayA., PechO.. Early Barrett's carcinoma with “low-risk” submucosal invasion: long-term results of endoscopic resection with a curative intent.Am J Gastroenterol.2008; 103(10): 2589–2597.
53.
EllC., MayA., GossnerL.. Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus.Gastroenterology.2000; 118(4): 670–677.
54.
EsakiM., MatsumotoT., HirakawaK.. Risk factors for local recurrence of superficial esophageal cancer after treatment by endoscopic mucosal resection.Endoscopy.2007; 39(1): 41–45.
55.
BuskensC.J., WesterterpM., LagardeS.M.. Prediction of appropriateness of local endoscopic treatment for high-grade dysplasia and early adenocarcinoma by EUS and histopathologic features.Gastrointest Endosc.2004; 60(5): 703–710.
56.
MiyamotoS., MutoM., HamamotoY.. A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms.Gastrointest Endosc.2002; 55(4): 576–581.
57.
HirasawaK., KokawaA., OkaH.. Superficial adenocarcinoma of the esophagogastric junction: long-term results of endoscopic submucosal dissection.Gastrointest Endosc.72(5): 960–966.
58.
LewisJ.J., RubensteinJ.H., SingalA.G.. Factors associated with esophageal stricture formation after endoscopic mucosal resection for neoplastic Barrett's esophagus.Gastrointest Endosc.2011; 74(4): 753–760.
59.
GerkeH., SiddiquiJ., NasrI.. Efficacy and safety of EMR to completely remove Barrett's esophagus: experience in 41 patients.Gastrointest Endosc.2011; 74(4): 761–771.
60.
KatadaC., MutoM., ManabeT.. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions.Gastrointest Endosc.2003; 57(2): 165–169.
61.
ShaheenN.J., SharmaP., OverholtB.F.. Radiofrequency ablation in Barrett's esophagus with dysplasia.N Engl J Med.2009; 360(22): 2277–2288.
62.
GanzR.A., UtleyD.S., SternR.A.. Complete ablation of esophageal epithelium with a balloon-based bipolar electrode: a phased evaluation in the porcine and in the human esophagus.Gastrointest Endosc.2004; 60(6): 1002–1010.
63.
DunkinB.J., MartinezJ., BejaranoP.A.. Thin-layer ablation of human esophageal epithelium using a bipolar radiofrequency balloon device.Surg Endosc.2006; 20(1): 125–130.
64.
SharmaV.K., KimH.J., DasA.. A prospective pilot trial of ablation of Barrett's esophagus with low-grade dysplasia using stepwise circumferential and focal ablation (HALO system).Endoscopy.2008; 40(5): 380–387.
65.
GanzR.A., OverholtB.F., SharmaV.K.. Circumferential ablation of Barrett's esophagus that contains high-grade dysplasia: a U.S. Multicenter Registry.Gastrointest Endosc.2008; 68(1): 35–40.
66.
SemlitschT., JeitlerK., SchoeflR.. A systematic review of the evidence for radiofrequency ablation for Barrett's esophagus.Surg Endosc.2010; 24(12): 2935–2943.
67.
ShaheenN.J., SpechlerS.J.. Total endoscopic eradication of Barrett's esophagus: study methodology, candidate selection, and clinical outcomes.Endoscopy.2008; 40(12): 994–999.
68.
DunnJ.M., BanksM.R., OukrifD.. Radiofrequency ablation is effective for the treatment of high-grade dysplasia in Barrett's esophagus after failed photodynamic therapy.Endoscopy.2011; 43(7): 627–630.
69.
OverholtB.F., LightdaleC.J., WangK.K.. Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded, randomized phase III trial.Gastrointest Endosc.2005; 62(4): 488–498.
70.
OverholtB.F., WangK.K., BurdickJ.S.. Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett's high-grade dysplasia.Gastrointest Endosc.2007; 66(3): 460–468.
71.
LovatL.B., JamiesonN.F., NovelliM.R.. Photodynamic therapy with m-tetrahydroxyphenyl chlorin for high-grade dysplasia and early cancer in Barrett's columnar lined esophagus.Gastrointest Endosc.2005; 62(4): 617–623.
72.
MackenzieG.D., JamiesonN.F., NovelliM.R.. How light dosimetry influences the efficacy of photodynamic therapy with 5-aminolaevulinic acid for ablation of high-grade dysplasia in Barrett's esophagus.Lasers Med Sci.2008; 23(2): 203–210.
73.
GreenwaldB.D., DumotJ.A., AbramsJ.A.. Endoscopic spray cryotherapy for esophageal cancer: safety and efficacy.Gastrointest Endosc.2010; 71(4): 686–693.
74.
ShaheenN.J., GreenwaldB.D., PeeryA.F.. Safety and efficacy of endoscopic spray cryotherapy for Barrett's esophagus with high-grade dysplasia.Gastrointest Endosc.2010; 71(4): 680–685.
75.
GreenwaldB.D., DumotJ.A., HorwhatJ.D.. Safety, tolerability, and efficacy of endoscopic low-pressure liquid nitrogen spray cryotherapy in the esophagus.Dis Esophagus.2010; 23(1): 13–19.
76.
JohnstonM.H., EastoneJ.A., HorwhatJ.D.. Cryoablation of Barrett's esophagus: a pilot study.Gastrointest Endosc.2005; 62(6): 842–848.
77.
DumotJ.A., VargoJ.J.2nd, FalkG.W.. An open-label, prospective trial of cryospray ablation for Barrett's esophagus high-grade dysplasia and early esophageal cancer in high-risk patients.Gastrointest Endosc.2009; 70(4): 635–44.
78.
BarthelJ.S., KuceraS., HarrisC.. Cryoablation of persistent Barrett's epithelium after definitive chemoradiation therapy for esophageal adenocarcinoma.Gastrointest Endosc.2011; 74(1): 51–57.
79.
ChenA.M., PasrichaP.J.. Cryotherapy for Barrett's esophagus: who, how, and why?Gastrointest Endosc Clin North Am.2011; 21(1): 111–118.
80.
LightdaleC.J., HeierS.K., MarconN.E.. Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd: YAG laser for palliation of esophageal cancer: a multicenter randomized trial.Gastrointest Endosc.1995; 42(6): 507–512.
81.
CashB.D., JohnstonL.R., JohnstonM.H.. Cryospray ablation (CSA) in the palliative treatment of squamous cell carcinoma of the esophagus.World J Surg Oncol.2007; 5: 34.
82.
SharmaP., KozarekR.. Role of esophageal stents in benign and malignant diseases.Am J Gastroenterol.2010; 105(2): 258–273.
83.
BrownR.E., AbbasA.E., EllisS.. A prospective phase II evaluation of esophageal stenting for neoadjuvant therapy for esophageal cancer: optimal performance and surgical safety.J Am Coll Surg.2011; 212(4): 582–589.
84.
AcunasB., RozanesI., AkpinarS.. Palliation of malignant esophageal strictures with self-expanding nitinol stents: drawbacks and complications.Radiology.1996; 199(3): 648–652.
85.
SaxonR.R., MorrisonK.E., LakinP.C.. Malignant esophageal obstruction and esophagorespiratory fistula: palliation with a polyethylene-covered Z-stent.Radiology.1997; 202(2): 349–354.
86.
RozanesI., PoyanliA., AcunasB.. Palliative treatment of inoperable malignant esophageal strictures with metal stents: one center's experience with four different stents.Eur J Radiol.2002; 43(3): 196–203.
87.
RaijmanI., SiddiqueI., AjaniJ.. Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients.Gastrointest Endosc.1998; 48(2): 172–179.
88.
VerschuurE.M., KuipersE.J., SiersemaP.D.. Esophageal stents for malignant strictures close to the upper esophageal sphincter.Gastrointest Endosc.2007; 66(6): 1082–1090.
89.
SreedharanA., HarrisK., CrellinA.. Interventions for dysphagia in oesophageal cancer.Cochrane Database Syst Rev.2009; (4): CD005048.
90.
RamirezF.C., DennertB., ZiererS.T.. Esophageal self-expandable metallic stents–indications, practice, techniques, and complications: results of a national survey.Gastrointest Endosc.1997; 45(5): 360–364.
