High-grade dysplasia in the columnar-lined esophagus

doi:10.1016/0002-9610(91)90367-M

The American Journal of Surgery

Volume 161, Issue 1, January 1991, Pages 97-100

https://doi.org/10.1016/0002-9610(91)90367-M Get rights and content

Abstract

Abnormal columnar lining of the esophagus is a well-recognized premalignant condition. The management of patients with high-grade dysplasia without evidence of carcinoma remains controversial. Esophagectomy is proposed by some investigators, whereas others favor follow-up endoscopy and biopsy until microinvasive malignancy is documented. We reviewed our experience with nine patients referred with high-grade dysplasia on endoscopic biopsies without evidence of carcinoma. Eight patients had the columnar lining extending orad from the cardia, and one patient had heterotopic columnar epithelium in the cervical esophagus. All were white men ranging in age from 19 to 76 years (median: 47 years). Eight patients underwent esophagectomy with colon interposition. A sleeve resection of the cervical esophagus was done in one patient. Multifocal carcinoma was found in three patients, all of whom had severe dysplastic changes throughout the columnar lining. The patient with heterotopic columnar epithelium had microinvasive carcinoma. All four patients with carcinoma had negative nodes and are long-term survivors. No carcinoma was found in the resected specimens of the remaining five patients. High-grade dysplasia is an important marker of malignancy in patients with a columnar-lined esophagus. Esophagectomy is indicated in suitable candidates since carcinoma was found in 45% of our patients.

References (11)

RH Riddell et al.
Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications
Hum Pathol
(1983)
BC Morson et al.
Adenocarcinoma of the oesophagus and ectopic gastric mucosa
Br J Cancer
(1953)
DB Skinner
The incidence of cancer in Barren's esophagus varies according to series
AJ Cameron et al.
The incidence of adenocarcinoma in columnar-lined (Barrett's) esophagus
N Engl J Med
(1985)
EC Saubier et al.
Adenocarcinoma in columnar-lined Barren's esophagus: analysis of 13 esophagectomies
Am J Surg
(1985)

There are more references available in the full text version of this article.

Cited by (183)

Benign Esophageal Disease
2010, Medical Management of the Thoracic Surgery Patient
Benign Esophageal Disease
2009, Medical Management of the Thoracic Surgery Patient
The Seattle Protocol Does Not More Reliably Predict the Detection of Cancer at the Time of Esophagectomy Than a Less Intensive Surveillance Protocol
2009, Clinical Gastroenterology and Hepatology
The optimal management of high-grade dysplasia in Barrett's esophagus remains controversial. A biopsy protocol consisting of 4 quadrant jumbo biopsies (every 1 cm) with biopsies of mucosal abnormalities (the Seattle protocol) is considered to be the optimal method for detecting early cancers in patients with high-grade dysplasia, although it has never been validated. This study aimed to determine the frequency of unsuspected carcinoma at esophagectomy in Barrett's esophagus patients with high-grade dysplasia who underwent the Seattle protocol and to compare the findings with those of a less rigorous biopsy protocol.
Thirty-three patients with high-grade dysplasia underwent esophagectomy. None had obvious mass lesions at preoperative endoscopy. Patients were divided into group 1 (preoperative surveillance biopsies according to Seattle protocol) and group 2 (4 quadrant biopsies every 2 cm). Preoperative and postoperative diagnoses were confirmed by 2 expert gastrointestinal pathologists.
Unsuspected intramucosal cancer was found in 8 of 20 (40%) patients in group 1 versus 4 of 13 (30%) in group 2 (P = .6). Preoperative mucosal nodularity was observed in 4 of 8 (50%) postoperative intramucosal cancers from group 1 versus 3 of 4 (75%) from group 2. Multifocal high-grade dysplasia was seen preoperatively in 7 of 8 (87.5%) postoperative intramucosal cancers in group 1 versus 2 of 4 (50%) in group 2. No patient had submucosal cancer or lymph node metastases at surgery.
Intense preoperative biopsy sampling by the Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol. This calls into question the concept that extensive sampling with the Seattle protocol consistently detects early cancers arising in Barrett's esophagus patients with high-grade dysplasia.
Low prevalence of submucosal invasive carcinoma at esophagectomy for high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus: a 20-year experience
2009, Gastrointestinal Endoscopy
The rate of occult adenocarcinoma at esophagectomy in patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) has been reported to be approximately 40%. Recently, it has been suggested that this risk may be overestimated.
Our purpose was to determine the rate of submucosal invasive adenocarcinoma in patients undergoing esophagectomy for BE after biopsy diagnosis of HGD or intramucosal carcinoma (IMC). A secondary aim was to identify clinical risk factors for submucosal invasive adenocarcinoma in these patients.
A retrospective study.
Tertiary referral center.
All patients with preoperative BE with HGD or IMC treated with esophagectomy over a 20 year period.
Esophagectomy.
Submucosal invasive adenocarcinoma at esophagectomy.
Sixty patients were included (41 with preoperative HGD, 19 with preoperative IMC). The overall rate of submucosal invasive carcinoma was 6.7% (95% CI, 1.8%-16.2%) (n = 4), with a 5% rate of submucosal invasion in patients with preoperative HGD and 11% for patients with preoperative IMC. All 4 patients with submucosal invasion at esophagectomy had either nodular or ulcerated mucosa on preoperative endoscopy. The 1-year and 5-year all-cause risks of death for the entire cohort were 1.9% and 10.9%, respectively.
Retrospective study.
The rate of submucosal invasive adenocarcinoma at esophagectomy in BE patients with HGD or IMC on biopsy is much lower than 40%. After adequate sampling and staging, patients with BE with HGD and IMC, especially those without endoscopically visible lesions, can potentially be treated by nonsurgical (local) therapies.
EMR for Barrett's esophagus-related superficial neoplasms offers better diagnostic reproducibility than mucosal biopsy{A figure is presented}
2007, Gastrointestinal Endoscopy
EMR of Barrett's esophagus (BE)–related superficial neoplasms represents an efficacious staging modality. It also allows for better pathologic grading compared with mucosal biopsy specimens. However, the interobserver variation in the interpretation of EMR specimens has not been tested.
To evaluate consistency in the diagnosis of BE–related neoplasia on EMR specimens.
Nine pathologists reviewed 25 esophageal EMR specimens and corresponding biopsy specimens independently. Each pathologist classified the cases as either non-neoplastic BE, low-grade dysplasia, high-grade dysplasia, intramucosal adenocarcinoma, or invasive adenocarcinoma. Interobserver concordance for both specimens from EMRs and biopsies was measured by intraclass correlation and Kendall's coefficient of concordance. The proportion of agreement was also calculated for each specimen and compared for EMR and biopsy by using the Wilcoxon signed rank test.
Teaching hospitals.
Twenty-five patients who underwent EMR for BE–related neoplasia.
The intraclass correlation and the Kendall's coefficient for the 25 biopsy specimens was 0.938 (95% CI 0.880-0.965) and 0.677, respectively; for the 25 EMRs, these were significantly improved, at 0.977 (95% CI 0.957-0.987) and 0.831, respectively. In addition, the proportion of agreement for EMR specimens was significantly better compared with biopsy specimens (P = .015).
Interobserver agreement of BE-related neoplasia on EMR specimens is significantly higher compared with biopsy specimens. The results may relate to the larger tissue sampling compared with biopsy specimens and the ability to evaluate mucosal landmarks, such as double muscularis mucosae. Thus, we suggest that EMRs, in addition to being a staging and therapeutic procedure, improve diagnostic consistency.
Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: International, partially blinded, randomized phase III trial
2005, Gastrointestinal Endoscopy
Barrett's esophagus (BE) may lead to high-grade dysplasia (HGD) and adenocarcinoma. The objective was to examine the impact of treating patients with BE and with HGD by using porfimer sodium (POR) and photodynamic therapy (PDT) for ablating HGD and reducing the incidence of esophageal adenocarcinoma.
The design was a multicenter, partially blinded (pathology), randomized clinical trial conducted in patients with BE who have HGD. There were 30 contributing centers. A total of 485 patients were screened, with 208 in the intent-to-treat population and 202 in the safety population. Patients were randomized on a 2:1 basis to compare PDT with POR plus omeprazole (PORPDT) with omeprazole only (OM). The main outcome measurement was complete HGD ablation occurring at any time during the study period.
There was a significant difference (p < 0.0001) in favor of PORPDT (106/138 [77%]) compared with OM (27/70 [39%]) in complete ablation of HGD at any time during the study period. The occurrence of adenocarcinoma in the PORPDT group (13%) (n = 18) was significantly lower (p < 0.006) compared with the OM group (20%) (n = 20). The safety profile showed 94% of patients in the PORPDT group and 13% of patients in the OM group had treatment-related adverse effects. The limitations of the study were that PDT therapy may have had to be applied more than once and that patients spent more time in treatment. The patients and the physicians were not blinded to the treatment.
PORPDT in conjunction with omeprazole is an effective therapy for ablating HGD in patients with BE and in reducing the incidence of esophageal adenocarcinoma.

View all citing articles on Scopus

^☆: Presented at the 31st Annual Meeting of the Society for Surgery of the Alimentary Tract, San Antonio, Texas, May 15–16, 1990.

View full text

Scientific paperHigh-grade dysplasia in the columnar-lined esophagus☆

Abstract

Hum Pathol

Adenocarcinoma of the oesophagus and ectopic gastric mucosa

Br J Cancer

The incidence of cancer in Barren's esophagus varies according to series

The incidence of adenocarcinoma in columnar-lined (Barrett's) esophagus

N Engl J Med

Adenocarcinoma in columnar-lined Barren's esophagus: analysis of 13 esophagectomies

Am J Surg

Scientific paper
High-grade dysplasia in the columnar-lined esophagus☆