Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies

Abstract

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.

Dysplastic Barrett’s Esophagus: Surveillance, Treatment and Follow-Up Care

“…This is recommended because inflammation can cause the pathologist to confuse regenerative changes with dysplasia itself, leading to misdiagnosis. 13,16,18,22,23 Another consensus among international guidelines is that any visible dysplastic lesion, whether low-grade or high-grade, should be diagnosed by at least two pathologists, one of whom should be a specialist in gastrointestinal pathology and use a highquality endoscopic technique to confirm the diagnosis. 8,9,13,14,18,20,22,23 This recommendation was established in order to minimize the chances of misdiagnosis, since low-grade dysplasia can often be confused with nondysplastic BE even among experienced pathologists.…”

“…13,16,18,22,23 Another consensus among international guidelines is that any visible dysplastic lesion, whether low-grade or high-grade, should be diagnosed by at least two pathologists, one of whom should be a specialist in gastrointestinal pathology and use a highquality endoscopic technique to confirm the diagnosis. 8,9,13,14,18,20,22,23 This recommendation was established in order to minimize the chances of misdiagnosis, since low-grade dysplasia can often be confused with nondysplastic BE even among experienced pathologists. 13,24 Even though, for diagnostic confirmation, the British Society of Gastroenterology (BSG), the European Society of Gastrointestinal Endoscopy (ESGE) and the Australian guideline recommend repeating the same endoscopic evaluation in 6 months.…”

“…As a result, this study showed that ablation reduced the risk of progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) by 25%, while surveillance reduced the risk by only 8.8% in the control arm during a 3-year follow-up period. 14,15,16,17,23 Similarly, the prospective randomized study "AIM DYSPLASIA" demonstrated that ablation was associated with a higher rate of eradication of LGD, as well as a decreased risk of progression from LGD to HGD/EAC. Therefore, the risk of progression was assessed at only 5% for follow-up with ablation and 14% with 12-month surveillance.…”

“…Therefore, the risk of progression was assessed at only 5% for follow-up with ablation and 14% with 12-month surveillance. 17,23 Based on this evidence, the ACG, the British Society of Gastroenterology (BSG), the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society of Gastrointestinal Endoscopy (ASGE) all recommend ablation therapy for confirmed cases of LGD. However, the annual surveillance recommended by the ACG and ASGE and the 6-monthly surveillance recommended by the BSG would only be an alternative management for those patients where the risks may outweigh the benefits.…”

“…8 In these patients, it is considered relevant to provide a new examination every 3 to 6 months with high-definition white light endoscopy and preferably optical chromoendoscopy using the Seattle Protocol in order to rule out the presence of visible lesion that could harbor malignancy and therefore justify that endoscopic resection would be better suited instead of the surveillance. 8,15,23,26 In the event of any visible abnormality found on endoscopic surveillance examination, endoscopic mucosal resection (EMR) should be performed, as this alteration suggests a greater likelihood of neoplastic development. 8,15 A study by Peters et.al.…”