Directional distribution of neoplasia in Barrett's esophagus is not influenced by distance from the gastroesophageal junction

doi:10.1016/j.gie.2013.01.026

Gastrointestinal Endoscopy

Volume 77, Issue 6, June 2013, Pages 877-882

https://doi.org/10.1016/j.gie.2013.01.026 Get rights and content

Background

Accurate endoscopic detection and staging are critical for appropriate management of Barrett's esophagus (BE)–associated neoplasia. Prior investigation has demonstrated that the distribution of endoscopically detectable early neoplasia is not uniform but instead favors specific directional distributions within a short BE segment; however, it is unknown whether the directional distribution of neoplasia differs with increasing distance from the gastroesophageal junction, including in patients with long-segment BE.

Objective

To identify whether directional distribution of BE-associated neoplasia is influenced by distance from the gastroesophageal junction.

Design

Retrospective cohort study.

Setting

Tertiary-care referral center.

Patients

Patients with either short-segment or long-segment BE undergoing EMR.

Intervention

EMR.

Main Outcome Measurements

Directional distribution of BE-associated neoplasia stratified by distance from gastroesophageal junction.

Results

EMR was performed on 60 lesions meeting study criteria during the specified time period. Pathology demonstrated low-grade dysplasia in 22% (13/60), high-grade dysplasia in 38% (23/60), intramucosal (T1a) adenocarcinoma in 23% (14/60), and invasive (≥T1b) adenocarcinoma in 17% (10/60). Directional distribution of lesions was not uniform (P < .001), with 62% of lesions (37/60) located between the 1 o'clock and 5 o'clock positions. When circular statistics methodology was used, there was no difference in the directional distribution of neoplastic lesions located within 3 cm of the gastroesophageal junction compared with ≥3 cm from the gastroesophageal junction.

Limitations

Single-center study may limit external validity.

Conclusion

The directional distribution of neoplastic foci within a BE segment is not influenced by distance of the lesion from the gastroesophageal junction. Mucosa between the 1 o'clock and 5 o'clock locations merits careful attention and endoscopic inspection in individuals with both short-segment BE and long-segment BE.

Section snippets

Methods

Approval to conduct this retrospective study was granted by the Vanderbilt University Institutional Review Board. The cohort consists of patients with BE who had been referred to the Vanderbilt Barrett's Esophagus Endoscopic Treatment Program (V-BEET) and who had undergone EMR between September 2009 and August 2012. Demographic, clinical, and endoscopic data were obtained from review of the electronic medical record. Study data were collected and managed by using REDCap electronic data capture

Results

Sixty-five lesions from a total of 48 patients were resected during the specified study time period. The EMR specimen in 5 patients revealed intestinal metaplasia without dysplasia, and these patients were excluded from further analysis. Resected pathology for the remaining lesions included LGD in 23% (13/60), HGD in 38% (23/60), T1a adenocarcinoma in 23% (14/60), and invasive adenocarcinoma (T1b or greater) in 17% (10/60). Morphologically, 13% of lesions (8/60) were <5 mm in size, 42% (25/60)

Discussion

This study supports the findings of prior research demonstrating a directional preference of the distribution of neoplasia within BE.12, 13 In our study, nearly two-thirds (62%) of all lesions were located within a 1 o'clock to 5 o'clock distribution. The novel finding of our study is that the directional distribution of endoscopically detected neoplasia is not influenced by distance from the gastroesophageal junction. The analysis was stratified not by overall BE length but instead by location

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Cited by (21)

Barrett's esophagus: diagnosis and management
2017, Gastrointestinal Endoscopy
Citation Excerpt :
Longer mucosal inspection time has been associated with increased detection of HGD and/or EAC.59 In addition, highly dysplastic lesions in BE are more often found in the right side of the esophagus, so particular attention to this area maybe beneficial.60-63 A standardized biopsy protocol for surveillance includes random 4-quadrant biopsies every 2 cm in nondysplastic BE and every 1 cm in dysplastic BE,64 in addition to targeted sampling of focal mucosal abnormalities.
Predictors of Progression to High-Grade Dysplasia or Adenocarcinoma in Barrett's Esophagus
2015, Gastroenterology Clinics of North America
Citation Excerpt :
Overall, it seems that mucosal abnormalities are associated with an increased risk of neoplastic progression in patients with Barrett’s esophagus. Early adenocarcinoma and high-grade dysplasia seem to have a predilection to develop in the right hemisphere of the esophagus.19–22 The author's group found that 85% of patients with adenocarcinoma or high-grade dysplasia referred for endoscopic management had these abnormalities located in the right hemisphere of the esophagus, predominantly in the area between 12-o'clock and 3-o'clock positions.20
Recurrent intestinal metaplasia after radiofrequency ablation for Barrett's esophagus: Endoscopic findings and anatomic location
2015, Gastrointestinal Endoscopy
Radiofrequency ablation (RFA) is a safe and effective treatment for Barrett’s esophagus (BE) that results in high rates of complete eradication of intestinal metaplasia (CEIM). However, recurrence is common after CEIM, and surveillance endoscopy is recommended. Neither the anatomic location nor the endoscopic appearance of these recurrences is well-described.
Describe the location of histologic specimens positive for recurrence after CEIM and the testing performance of endoscopic findings for the histopathologic detection of recurrence.
Retrospective cohort.
Single referral center.
A total of 198 patients with BE with at least 2 surveillance endoscopies after CEIM.
RFA, EMR, surveillance endoscopy.
The anatomic location and histologic grade of recurrence.
In a mean 3.0 years of follow-up, 32 (16.2%; 95% confidence interval [CI], 11.0%-22.0%) patients had recurrence of disease, 5 (2.5%; 95% CI, 0.3%-4.7%) of whom progressed beyond their worst before-treatment histology. Recurrence was most common at or near the gastroesophageal junction (GEJ). Recurrence >1 cm proximal to the GEJ always was accompanied by endoscopic findings, and random biopsies in these areas detected no additional cases. The sensitivity of any esophageal sign under high-definition white light or narrow-band imaging for recurrence was 59.4% (42.4%, 76.4%), and the specificity was 80.6% (77.2%, 84.0%).
Single-center study.
Recurrent intestinal metaplasia often is not visible to the endoscopist and is most common near the GEJ. Random biopsies >1 cm above the GEJ had no yield for recurrence. In addition to biopsy of prior EMR sites and of suspicious lesions, random biopsies oversampling the GEJ are recommended.
Barrett's oesophagus: Frequency and prediction of dysplasia and cancer
2015, Best Practice and Research: Clinical Gastroenterology
Citation Excerpt :
Subsequently, an Australian series of 75 patients with visible lesions who underwent EMR in Barrett's segments ≤5 cm demonstrated that 55% of lesions with high-grade dysplasia or adenocarcinoma were found in the area between 2 and 4 o'clock [15]. Work from Vanderbilt identified dysplasia or adenocarcinoma in 60 EMR specimens of which 62% were found in the 1 to 5 o'clock regions [16]. Finally, Enestvedt et al found advanced histology (high-grade dysplasia or adenocarcinoma) in the right hemisphere extending from 12 to 6 o'clock in 85% of patients, with the majority of abnormalities located between 12 and 3 o'clock [17].
The incidence of oesophageal adenocarcinoma is continuing to increase at an alarming rate in the Western world today. Barrett's oesophagus is a clearly recognized risk factor for the development of oesophageal adenocarcinoma, but the overwhelming majority of patients with Barrett's oesophagus will never develop oesophageal cancer. A number of endoscopic, histologic and epidemiologic risk factors identify Barrett's oesophagus patients at increased risk for progression to high-grade dysplasia and oesophageal adenocarcinoma. Endoscopic factors include segment length, mucosal abnormalities as seemingly trivial as oesophagitis and the 12 to 6 o'clock hemisphere of the oesophagus. Both intestinal metaplasia and low grade dysplasia, the latter only if confirmed by a pathologist with expertise in Barrett's oesophagus pathologic interpretation are the histologic risk factors for progression. Epidemiologic risk factors include ageing, male gender, obesity, and smoking. Factors that may protect against the development of adenocarcinoma include a diet rich in fruits and vegetables, and the use of proton pump inhibitors, aspirin/NSAIDs and statins.
Gastroesophageal acid reflux mainly occurs on the right side of the esophagus
2014, Gastrointestinal Endoscopy
Current status of quality control in screening esophagogastroduodenoscopy and the emerging role of artificial intelligence
2024, Digestive Endoscopy

View all citing articles on Scopus

: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr Yachimski at [email protected].

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Original articleClinical endoscopyDirectional distribution of neoplasia in Barrett's esophagus is not influenced by distance from the gastroesophageal junction

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Methods

Results

Discussion

Gastroenterology

Ann Thorac Surg

J Thorac Cardiovasc Surg

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

J Biomed Inform

Clin Gastroenterol Hepatol

Surgical management of high-grade dysplasia in Barrett's esophagus

Am J Gastroenterol

The rationale for esophagectomy as the optimal therapy for Barrett's esophagus with high-grade dysplasia

Ann Surg

Barrett's esophagus with high-grade dysplasia: an indication for prophylactic esophagectomy

Ann Surg

Original article
Clinical endoscopy
Directional distribution of neoplasia in Barrett's esophagus is not influenced by distance from the gastroesophageal junction