Pathophysiology of Barrett's Esophagus-Associated Neoplasia: Circumferential Spatial Predilection

Ishimura, Norihisa; Okada, Minoru; Mikami, Haruo; Okimoto, Eiko; Fukuda, N.; Uno, Goichi; Aimi, Masahito; Oshima, Naoki; Ishihara, Shunji; Kinoshita, Yoshikazu

doi:10.1159/000365123

Cited by 8 publications

(12 citation statements)

References 45 publications

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“…Esophageal mucosal breaks were mostly found on the right anterior wall (2 o’clock) of the esophagus in RE patients with LA grade of A or B, while those were often seen on the posterior wall of the esophagus in patients with high-grade RE (grade C). Potential pathophysiologic explanations underlying the circumferential distribution of mucosal breaks in RE include the functional structure of the lower esophageal sphincter and nonuniform asymmetric distribution of esophageal acid exposure 26 27 28. Interestingly, circumferential intraesophageal pressure at the LES has been reported to be asymmetrical 29, while a recent study that used 3-dimensional high-resolution manometric imaging revealed decreased competency within the right-side portion of the LES pressure zone as compared to the left side 30.…”

Section: Discussionmentioning

confidence: 99%

Mucosal breaks show same circumferential distribution in majority of patients with recurrent reflux esophagitis

et al. 2017

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Background and study aims Esophageal mucosal breaks in patients with reflux esophagitis (RE) have a unique circumferential distribution. However, the specific location of mucosal breaks during recurrence of RE remains unclear. We investigated the circumferential distribution of mucosal breaks in patients with recurrent RE and compared their location to that noted at the initial diagnosis. Patients and methods We retrospectively enrolled patients with recurrent RE with Los Angeles (LA) grade A-C who were treated at our University Hospital between July 1996 and June 2014. The circumferential distribution of esophageal mucosal breaks was evaluated at the time of the initial diagnosis and again at the time of recurrence. Information regarding clinical parameters, including proton pump inhibitor administration, presence of hiatal hernia, and mucosal atrophy, was also reviewed. Results A total of 114 patients with recurrent RE were examined during the study period, with a mean duration to recurrence after initial diagnosis of 39.4 months. The majority (72.8 %) had the same LA grade at recurrence. In addition, recurrent mucosal breaks in 96 (84.2 %) patients were observed to have occurred in the same circumferential location as at the initial diagnosis, while those in 18 (15.8 %) were observed in a different location. When recurrent lesions had a different location, the LA grade also tended to be different (P = 0.02). Conclusions We found that most patients with recurrent RE developed lesions in the same circumferential location as noted for the initial lesions. Those in different locations at recurrence were associated with a change in LA grade.

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Section: Discussionmentioning

confidence: 99%

Mucosal breaks show same circumferential distribution in majority of patients with recurrent reflux esophagitis

et al. 2017

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“…Previous studies, except for one 5 , reported that when the circumferential distribution of small lower esophageal lesions was represented on a clock face (Fig. 1), most low-grade mucosal breaks and neoplasms arising in short-segment Barrett's esophagus [1][2][3][4][6][7][8] were located between the 12 and 3 o'clock positions. These findings have been attracting attention because if this circumferential distribution is observed in early Barrett's adenocarcinoma or dysplasia, it may be useful for the early detection of Barrett's esophagus-associated neoplasia and surveillance of Barrett's esophagus 8,[11][12][13][14] .…”

Section: Discussionmentioning

confidence: 99%

“…In addition, further clarification of the reason for the occurrence of mild mucosal breaks in limited areas will provide insights into their pathogenic mechanism. However, in previous evaluations of the circumferential distribution of lesions, "the 3 o'clock position was shown to be aligned with the lesser curvature of the stomach" 1,[5][6][7][8] , whereas other studies reported that "the 12 o'clock position corresponds to the gastric lesser curvature and the right lateral wall of the esophagus" 2,4 . Due to this difference in the reference point, caution is needed in comparisons.…”

Section: Discussionmentioning

confidence: 99%

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Defining the Position of the Right Wall of the Esophageal Hiatus to Identify the Circumferential Distribution of Small Lesions of the Lower Esophagus

et al. 2021

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Background: The reliability of methods to identify the circumferential position of small lower esophageal lesions remains unknown. We prospectively investigated a new method for distinctively presenting lesion positions as times on a clock face. Methods: Eighty-seven patients were consecutively examined by endoscopy. After observing the esophagus, an endoscope was inserted into the stomach and fixed, setting the greater curvature folds at the upper gastric corpus horizontal on the endoscope monitor display. The scope was retrogressed into the lower esophagus. At this point, the right wall at the hiatus may be at the 3 o'clock position (R-line). The scope was then retrogressed from the gastric angle to the cardia along the center of the lesser curvature in the retroflexed view to obtain the LC-line (the center of the lesser curvature at the cardia). The LC-line in the esophageal hiatus in the frontal view was then identified. The angle between the R-and LC-lines (R-LC) was measured. Results: Seventy-seven patients were examined after excluding 7 with >2-cm hernias and 3 with esophageal stenosis. R-LC angles ranged between −38° and +35°. The mean R-LC angle was −0.3° ± 15.9° and its 95% confidence interval was [−4.0°, 3.3°] within [−15°, + 15°]. When indicating lesion locations as times on a clock face, there may be an error of ±30 min (±15°); therefore, R-and LC-lines were demonstrated to be identical using an equivalence test. Conclusions: Using this method, the circumferential position of small lower esophageal lesions may be reliably represented as a clock face.

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“…Cotton et al 22 have observed that dysplasia is also preferentially present in the proximal half of segments. There are a number of studies that find Barrett's related dysplasia and early adenocarcinoma are more prevalent in the right hemisphere of the esophagus on a circumferential axis, [23][24][25] but no studies describing the circumferential distribution of goblet cells have been identified.…”

Section: Discussionmentioning

confidence: 99%

Early Barrett esophagus-related neoplasia in segments 1 cm or longer is always associated with intestinal metaplasia

et al. 2017

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The assumption that intestinal metaplasia is a prerequisite for intraepithelial neoplasia/dysplasia and adenocarcinoma in the distal esophagus has been challenged by observations of adenocarcinoma without associated intestinal metaplasia. This study describes our experience of intestinal metaplasia in association with early Barrett neoplasia in distal esophagus and gastroesophageal junction. We reviewed the first endoscopic mucosal resection of 139 patients with biopsy-proven neoplasia. In index endoscopic mucosal resection, 110/139 (79%) cases showed intestinal metaplasia. Seven had intestinal metaplasia on prior biopsy specimens and three had intestinal metaplasia in subsequent specimens, totaling 120/139 (86%) patients showing intestinal metaplasia at some point supporting the theory of sampling error for absence of intestinal metaplasia in some cases. Those without intestinal metaplasia (13%) were enriched for higher stage disease (T1a Stolte m2 or above) supporting the assertion of obliteration of intestinal metaplasia by the advancing carcinoma. All cases of intraepithelial neoplasia and T1a Stolte m1 carcinomas had intestinal metaplasia (42/42). The average density of columnar-lined mucosa showing goblet cells was significantly less in shorter segments compared to those ≥3 cm (0.31 vs 0.51, P=0.0304). Cases where segments measured less than 1 cm were seen in a higher proportion of females and also tended to lack intestinal metaplasia. We conclude that early Barrett neoplasia is always associated with intestinal metaplasia; absence of intestinal metaplasia is attributable to sampling error or obliteration of residual intestinal metaplasia by neoplasia and those with segments less than 1 cm show atypical features for Barrett-related disease (absent intestinal metaplasia and female gender), supporting that gastroesophageal junction adenocarcinomas are heterogeneous.

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Pathophysiology of Barrett's Esophagus-Associated Neoplasia: Circumferential Spatial Predilection

Cited by 8 publications

References 45 publications

Mucosal breaks show same circumferential distribution in majority of patients with recurrent reflux esophagitis

Mucosal breaks show same circumferential distribution in majority of patients with recurrent reflux esophagitis

Defining the Position of the Right Wall of the Esophageal Hiatus to Identify the Circumferential Distribution of Small Lesions of the Lower Esophagus

Early Barrett esophagus-related neoplasia in segments 1 cm or longer is always associated with intestinal metaplasia

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