CA : A Cancer Journal for Clinicians

http://incan-mexico.org/incan/pub/docencia/educacion-medica/articulos/esofago/GUIASBARRETAGA.pdf

Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus.

Improvements in genomic and molecular methods are expanding the range of potential applications for circulating tumour DNA (ctDNA), both in a research setting and as a 'liquid biopsy' for cancer management. Proof-of-principle studies have demonstrated the translational potential of ctDNA for prognostication, molecular profiling and monitoring. The field is now in an exciting transitional period in which ctDNA analysis is beginning to be applied clinically, although there is still much to learn about the biology of cell-free DNA. This is an opportune time to appraise potential approaches to ctDNA analysis, and to consider their applications in personalized oncology and in cancer research.

/pdf/liquid-biopsies-come-of-age-towards-implementation-of-3ovu7jzn3f.pdf

Liquid biopsies come of age: towards implementation of circulating tumour DNA

Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.

Tremendous progress has been made in our understanding of food-based allergic disorders over the past 5 years. Recent epidemiologic studies suggest that nearly 4% of Americans are afflicted with food allergies, a prevalence much higher than appreciated in the past. In addition, the prevalence of peanut allergy was found to have doubled in American children less than 5 years of age in the past 5 years. Many food allergens have been characterized at the molecular level, which has contributed to our increased understanding of the immunopathogenesis of many allergic disorders and might soon lead to novel diagnostic and immunotherapeutic approaches. The management of food allergies continues to consist of educating patients on how to avoid relevant allergens, to recognize early symptoms of an allergic reaction in case of an accidental ingestion, and to initiate the appropriate emergency therapy. However, the recent successful clinical trial of anti-IgE therapy in patients with peanut allergy and the number of immunomodulatory therapies in the pipeline provide real hope that we will soon be able to treat patients with food allergy.

https://www.jacionline.org/article/S0091-6749(04)01145-5/pdf

Update on food allergy

859 Initial Control of Acid Reflux After Laparoscopic Anti-Reflux Surgery (Lars) Compared to Chronic Use of Esomeprazole (ESO) 20-40mg Daily

We have read with great interest the editorial by Dr. Genta—an attempt to reconcile the short turnover time of the oesophageal squamous epithelium with the results of our study, which showed that complete “normalisation” of oesophageal histology takes at least a few years. The results obtained in the LOTUS study demonstrated that progressive improvement of oesophageal histology occurs over the course of 5 years, and the same phenomenon is observed with regard to the degree of epithelial proliferation assessed by Ki67. Actually, the histological results obtained in the LOTUS study were unexpected and were a surprise to the authors. The histological evaluation of LOTUS has been centralised in a single laboratory, jointly performed by two experienced GI pathologists who have applied welldefined histological criteria that have been the subject of standardisation and validation. This approach was intended to minimise interobserver variability. In the interpretation of the results, it must be taken into account that the data on histological normalisation refer to the average of histological scores in both groups of patients (ie, those treated with long-term acid suppression or anti-reflux surgery). Many patients showed severe microscopic changes at enrolment, while the finding of severe lesions became progressively rarer during follow-up. It is also worth noting that: (1) the main reduction in lesion severity occurred in both groups after 1 year, while improvement at 3 and 5 years was less obvious; (2) before enrolment, pharmacologically treated patients underwent a short washout period (1 week), which can partly explain the number of patients with normal histology at baseline. A more accurate picture of the situation for individual patients can be deduced from Table 1. Although both groups of patients had no or mild lesions in more than 90% of cases at 5 years (ie, a finding not significantly different from that of a group of healthy controls), 9% of LARS patients and 6% of ESO patients, still showed severe histological lesions despite the absence of clinical failure. The hypothesis proposed in the editorial by Genta cannot be validated according to the data from our study, although it does sound reasonable. It is possible that, in the long-term, medical and surgical therapy have become progressively better at controlling the disease, resulting in episodes of mucosal damage becoming increasingly rare. The 3and 5year narrow “windows” corresponding to the time of biopsy may not have been likely to catch the moment of recurrent mucosal damage. However, the clinical impact does not change regardless of whether the histological improvement is gradual or the biopsies are less and less able to recognise occasional (increasingly rare) relapses of mucosal damage. In both cases, our findings support the concept that an effective healing process and its stabilisation do indeed take a long time. Finally, it should be emphasised that the aim of our study was mainly to understand the dynamics of the histological “normalisation” process and certainly not to propose follow-up biopsy as a tool for the management of patients with GERD.

Editorial: the diminishing returns of normalisation of the oesophageal mucosa―Authors' reply

Comparison with Other Species The adenocarcinomas induced under the above­ mentioned experimental conditions are morpho­ logically similar to their human counterpart (Webb and Busattil 1978; Gassner 1988). From a comparative standpoint, it seems interesting that the experimental adenocarcinomas were induced only after chronic reflux esophagitis plus subse­ quent exposure to the carcinogen and that in hu­ mans most of the adenocarcinomas of the distal third of the esophagus are associated with longstanding reflux esophagitis, which produces glandular metaplasia (Barrett's esophagus) (Pera et al. 1993b). In humans, the risk of developing glandular metaplasia has been estimated to be between 2 % and 11 % in patients with reflux esophagitis (Thompson et al. 1983). Numerous authors have noted a strong correlation between the presence of glandular metaplasia and the development of adenocarcinoma of the distal esophagus in humans (Pera et al. 1993b,c; Thompson et al. 1983; Winters et al. 1987).

Adenosquamous Carcinoma, Esophagus, Rat

Eosinophilic oesophagitis is now being diagnosed more often, although there continues to be a significant delay in the recognition of the condition in primary care, and among patients presenting with food bolus obstruction to other specialities like Ears, Nose and Throat and Accident & Emergency. The diagnosis requires endoscopy and biopsy, with six biopsies taken from at least two different areas of the oesophagus. The diagnostic threshold is > 15 eosinophils/high power field or 0.3 mm2. Dietary management although effective is often difficult to carry out due to poor adherence by patients and the need for a specialist dietitian and repeated biopsies. Orodispersible budesonide is very effective for inducing remission and maintaining it long term, with fewer biopsies. Newer targeted biological agents are promising in the treatment of patients who have not responded to conventional treatments. Dilatation of strictures in this condition is safe.

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Eosinophilic oesophagitis: improving diagnosis and therapy – reducing the burden of repeated endoscopy

EDITOR—The clinical review article by Leslie et al on chronic dysphagia gives a clear and succinct overview of managing dysphagia in a multidisciplinary team specialising in cricopharyngeal dysfunction and oropharyngeal dysphagia.1

We advocate strongly the use of a multidisciplinary team in investigating and managing chronic dysphagia, but Lewis et al make little mention of a gastroenterological input. …

Stephen Attwood

Papers

859 Initial Control of Acid Reflux After Laparoscopic Anti-Reflux Surgery (Lars) Compared to Chronic Use of Esomeprazole (ESO) 20-40mg Daily

Editorial: the diminishing returns of normalisation of the oesophageal mucosa―Authors' reply

Adenosquamous Carcinoma, Esophagus, Rat

Eosinophilic oesophagitis: improving diagnosis and therapy – reducing the burden of repeated endoscopy

Investigating and managing chronic dysphagia: gastroenterological input should have been included.