Barrett`s Esophagus:Screening and Surveillance

Florian SchreiberInternal Department, Medical University of Graz

Division of Gastroenterology and Hepatology

Barrett`s Esophagus

Norman Rupert Barrett

* Adelaide, May, 16th, 1903• Education at Eton, Cambridge• Rockefeller Scholar at Mayo Clinic 1935• Trainee for thoracic surgery at

St. Thomas Hospital, London• President of Thoracic Surgeons of England and Ireland 1962

• Founder Editor of Thorax 1946 - 1971

† London, 1979

1957 firstly described „ The lower esophagus lined by columnar epithelium “,what he later called „ endobrachyesophagus “. *

leads to 21 900 000 hits in a searching machine ( 04/ 2009 ) in 0.4 sec

leads to ~ 5500 publications 1973 – 2008

Barrett´s Esophagus to date is a „ topic of main interest “

* Barrett N; Surgery 1957; 41( 6 ): 881 - 94

Barrett`s Esophagus

• Epidemiology

• Definition

• Classification

• Diagnosis

• Screening

• Surveillance

Barrett`s EsophagusEpidemiology I

• 10 – 20% of caucasian patients with chronic GERD endoscopically are found with Barrett`s ( 1 )

• : only patients with symptomatic GERD develop Barrett`s -25% of asymptomatic male veterans older than 50 had BE ( 4 )

• in autopsy studies 1:60 – 1:80 is found to have Barrett`s ( 2 )

• gender specific distribution ♂ : ♀ = 5.9 : 1

since african – americans do not seem to be protected from developing GERD, they are largely protected from developing Barrett`s Esophagus and esophageal adenocarcinoma ( 3 )

1) Lieberman DA et al; A J Gastroenterol 1997; 92: 1293 – 972) Cameron AJ et al; GE 1990, 99: 918 – 223) Phillips RW et al; GE Clin NA 1991, 20: 791 - 8164) Gerson LB et al; GE 2002, 123: 461 - 67

Barrett`s EsophagusEpidemiology II

1997 2002

endoscopic diagnosis

Barrett`s

( in 1000 endoscopies )

19.8 40. 5

histologic diagnosis

Barrett`s

( in 1000 endoscopies )

9.3 22

histologic diagnosis

of Barrett`s carcinoma

( in 1000 endoscopies )

1.7 6.0

Bergmann JJ et al, Endos 2004

Barrett`s Esophagusetiology/ risk factors

• long standing GERD ( > 1y ) ( 2 )

• presence of Hp ( 6 )

• white/ hispanic people >

coloured/ asian people ( 1 )

• BMI > 30 ( 1. 5 – 2 fold ) ( 4, 5 )

• bile acids, Bilirubin ( 3 )

1) Phillips RW et al, GE Gastro N Am 1991, 20: 791 – 8162) Lieberman DA et al, Am J Gastro 1997, 92: 1293 - 12973) Haggitt RC et al, Hum Patol 1998, 24: 982 - 934) El Serag HB, AM J GE 2005; 100: 2152 – 56.5) Lagergren J et al; Ann Int Med 1999, 130: 883 - 906) Genta RM, Graham DY; Hum Pathol 1994; 25: 915 - 19

Barrett`s Esophagusrisk factors for Barrett`s Carcinoma

• LSBE ( 1 )

• intraepithelial neoplasia ( 2 )

• mucosal “ irregularity “ ( 3 )

• erosion/ ulcer ( 4 )

• insufficient acid suppression ( 5 )

• insufficient Nissen`s

1) Weston AP et al, Am J Gastro 1999, 94: 3413 – 34192) Sampliner RE, Am J Gastro 1998, 93: 1028 – 10323) Buttar NS et al, GE 2001; 120: 1630 – 394) Van der Burgh et al, Gut 1996; 39: 5 – 85) Buttar NS, GE 2004; 123: 1630 - 9

Barrett`s EsophagusDefinition

Barrett´s esophagus should be defined as a change in the esophageallining of ANY LENGTH that can be recognized at upper endoscopy andis confirmed to have intestinal metaplasia by biopsy.

The American College of Gastroenterology 2005

macroscopic/ endoscopic definition

…“ a displacement of the squamocolumnar junction proximal of the gastro –esophageal junction...which is called the columnar lined esophagus ( CLE ) with the presence of intestinal metaplasia … “

Barrett`s Esophagus Chicago Workgroup, 2003

Barrett`s EsophagusChicago Classification

• long segment Barrett`s - LSBE ( 8. 5% )

columnar epithelium > 3 cm

• short segment Barrett`s - SSBE ( 4. 8% )

columnar epithelium < 3 cm

• ultra short Barrett`s - USSBE ( ? )

colummnar epithelium < 1 cm

Barrett`s Esophagusendoscopic classification

LSBE SSBE

Barrett`s EsophagusDiagnosis

• The three steps to the diagnosis of Barrett`s:

• Endoscopic recognition of Barrett`s( white light/ chromo/ zoom/ NBI/ CE/ microendoscopy ---- )

• Endoscopic classification of Barrett`s( Chicago w ussBE, ssBE, lsBE/ Z – Line appearance/ Prague C and M )

• Histologic diagnosis of Barrett`s

( the Goblet cell as conditio sine qua non for the presence of intestinal metaplasia )

Barrett`s EsophagusScreening/ Chromoscopy

Barrett`s EsophagusScreening/ Magnification

Barrett`s EsophagusScreening/ narrow band imaging NBI/ FICE

Barrett`s EsophagusScreening/ confocal laser – spectroscopy/ „ micro – endoscopy “

Esophagitis/ Barrett`s EsophagusScreening

Who is to be set on routine screening

or

decisions have to be made on indecisive data ( SJ Spechler 2007 )

• longstanding ( > 1 year ) GERD

• Patients w erosive esophagitis as incidental finding during EGD ( ? )

Barrett`s Esophagusscreening, which method

method sensitivity specificity

quadrant biopsies/ unguided

biopsies

79% ( 1 ) 57% ( 1 )

chromoscopy + zoom

acetic acid + zoom

86% ( 1 )

100% ( 2 )

59% ( 1 )

66% ( 2 )

NBI 93% ( 1 ) 91% ( 1 )

OCT 68% ( 3 ) 82% ( 3 )

autofluorescence 42% ( 4 ) 92% ( 4 )

microendoscopy 98% 93% ( 5 )

BE NPL

94% 98% ( 5 )

BE NPL

1) Bergman JJ et al, Endos 37; 2005: 929 – 362) Kieslich R et al; GI Endos 64; 2006: 1 – 83) Isenberg G er al; GI Endos 62; 2005: 825 - 31

4) Borovicka et al; Endos 38; 2006: 867 - 725) Kiesslich R et al; Clin Gastro Hepatol 4; 2006: 979-87

Barrett`s Esophagussurveillance for all or for whom ?

pro con

earlier detection of cancer by

endoscopic/ bioptic surveillance ( * )

( retrospective design )

NNT: 400/ 1 cancer diagnosis per year

( 1 )

24 700 $ / saved life in USA ( 2 ),

increased detection rates of curable

cancers ( ** )

( retrospective design )

patients with BE don`t die with

Barrett`s cancer ( 3 )

risk to develop cancer is

overestimated ( 4 )

i. e. 0.5% / year

1) Spechler SJ BMJ 2003; 326: 892 – 42) Soni A et al; AM J Gastro 2000; 95: 2086 – 20933) Eckhardt VF et al; Am J Med 2001; 111: 33 -7 4) Shaheen N et al; GE 2000; 119: 333 - 8

**) Corley DA et al; GE 2002; 122: 633 – 40**) Fitzgerald RC et al; Dif Dis Sci 2001; 46: 1892 - 98

Barrett`s Esophagussurveillance rationale

no evidence of IEN LGIEN HGIEN

progression into cancer

within 3. 4 – 10y ( * )

3%

progression into cancer

within 1. 5 – 4. 3y

progression within

0. 2 – 4. 3y ( * )

18%

34%

Overall lifetime risk to

develop cancer ( ** ) 0. 5%

*Sampliner RE, Am J Gastro 1998; 93: 1028 – 32 ** Shaheen NJ, et al; GE 2000; 19: 333 - 8

Barrett`s EsophagusSurveillance, which technique ?

method sensitivity specificity

quadrant biopsies/ guided

biopsies

79% 57%

chromoscopy + zoom

acetic acid + zoom

86%

100%

59%

66%

NBI 93% 91%

OCT 68% 82%

autofluorescence 42% 92%

video capsule endoscopy

PilCam Eso ®

60% ** 100% **

microendoscopy 98% 93%

BE NPL

94% 98%

BE NPL

** Coron et al; DDW 2007

Barrett`s Esophagussurveillance algorithm

Patients w GERD and two consecutive

endoscopies without dysplasia

EGD 3 years each

If dysplasia is noted, the finding should be

verified by another expert pathologist

LGIEN: EGD w extensive sampling

biopsie each year

HGIEN: another EGD w extensive

sampling biopsies

If HGIEN is verified,

endoscopical ablative Tx

If ( multifocal ) malignancy is

verified, surgical TxSpechler SJ, BMJ 2005; 326: 892 894

Barrett`s EsophagusConclusion

• Longstanding GERD is the main etiologic factor for Barrett`s

• The Barrett`s incidence thus the Barrett`s carcinoma incidence is rising more rapidly than any other form of GI cancer with a nearly six – fold increase from 1997 – 2002

• Even the individual risk to develop Barrett`s carcinoma is as low as 0.5%

• For the screening procedure little is known whom, when, how. A benefit is shown in detecting more early stages of carcinoma

• For the surveillance procedure a stringent algorithm should be followed