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Journal ArticleDOI

Risk Factors for Progression of Low-Grade Dysplasia in Patients With Barrett's Esophagus

TL;DR: Overall, patients with BE and LGD have a low annual incidence of EAC, similar to nondysplastic BE, and there is significant interobserver variation in diagnosis, even among expert pathologists.
About: This article is published in Gastroenterology.The article was published on 2011-10-01. It has received 243 citations till now.
Citations
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Journal ArticleDOI
01 Jan 2014-Gut
TL;DR: These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia and suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria for the first time.
Abstract: These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.

1,083 citations

Journal ArticleDOI
26 Mar 2014-JAMA
TL;DR: Radiofrequency ablation resulted in a reduced risk of neoplastic progression over 3 years of follow-up and the data and safety monitoring board recommended early termination of the trial due to superiority of ablation for the primary outcome and the potential for patient safety issues if the trial continued.
Abstract: RESULTS Sixty-eight patients were randomized to receive ablation and 68 to receive control. Ablation reduced the risk of progression to high-grade dysplasia or adenocarcinoma by 25.0% (1.5% for ablation vs 26.5% for control; 95% CI, 14.1%-35.9%; P < .001) and the risk of progression to adenocarcinoma by 7.4% (1.5% for ablation vs 8.8% for control; 95% CI, 0%-14.7%; P = .03). Among patients in the ablation group, complete eradication occurred in 92.6% for dysplasia and 88.2% for intestinal metaplasia compared with 27.9% for dysplasia and 0.0% for intestinal metaplasia among patients in the control group (P < .001). Treatment-related adverse events occurred in 19.1% of patients receiving ablation (P < .001). The most common adverse event was stricture, occurring in 8 patients receiving ablation (11.8%), all resolved by endoscopic dilation (median, 1 session). The data and safety monitoring board recommended early termination of the trial due to superiority of ablation for the primary outcome and the potential for patient safety issues if the trial continued.

547 citations

Journal ArticleDOI
Cathy Bennett1, Nimish Vakil2, Jacques J. Bergman3, Rebecca Harrison4, Robert D. Odze5, Michael Vieth, Scott Sanders6, Oliver Pech, Gaius Longcroft-Wheaton7, Yvonne Romero8, John M. Inadomi9, Jan Tack10, Douglas A. Corley11, Hendrik Manner, Susi Green7, David Al Dulaimi, Haythem Ali12, Bill Allum13, Mark R Anderson, Howard Curtis14, Gary W. Falk15, M. Brian Fennerty16, Grant Fullarton17, Kausilia K. Krishnadath3, Stephen J. Meltzer18, David Armstrong19, Robert A. Ganz, Gianpaolo Cengia20, James J. Going17, John R. Goldblum21, Charles Gordon22, Heike I. Grabsch23, Chris Haigh, Michio Hongo24, David Johnston25, Ricky Forbes-Young26, Elaine Kay27, Philip Kaye28, Toni Lerut10, Laurence Lovat29, Lars Lundell30, Philip Mairs31, Tadakuza Shimoda32, Stuart J. Spechler33, Stephen J. Sontag34, Peter Malfertheiner35, Iain A. Murray, Manoj Nanji14, David N. Poller7, Krish Ragunath28, Jaroslaw Regula36, Renzo Cestari20, Neil A. Shepherd37, Rajvinder Singh38, Hubert J. Stein, Nicholas J. Talley39, Jean Paul Galmiche40, Tony C.K. Tham41, Peter Watson1, Lisa Yerian21, Massimo Rugge42, Thomas W. Rice21, John Hart43, Stuart Gittens, David Hewin37, Juergen Hochberger, Peter J. Kahrilas44, Sean L. Preston45, Richard E. Sampliner46, Prateek Sharma47, Robert C. Stuart, Kenneth K. Wang8, Irving Waxman43, Chris Abley4, Duncan Loft, Ian D. Penman26, Nicholas J. Shaheen48, Amitabh Chak49, Gareth Davies50, L. J. Dunn51, Yngve Falck-Ytter, John deCaestecker4, Pradeep Bhandari7, Christian Ell, S. Michael Griffin51, Stephen Attwood52, Hugh Barr37, John J.B. Allen53, Mark K. Ferguson43, Paul Moayyedi19, Janusz Jankowski54, Janusz Jankowski4, Janusz Jankowski14 
Queen's University Belfast1, University of Wisconsin-Madison2, University of Amsterdam3, University Hospitals of Leicester NHS Trust4, Harvard University5, University of Warwick6, Queen Alexandra Hospital7, Mayo Clinic8, University of Washington9, Katholieke Universiteit Leuven10, Kaiser Permanente11, Maidstone and Tunbridge Wells NHS Trust12, The Royal Marsden NHS Foundation Trust13, Queen Mary University of London14, University of Pennsylvania15, Oregon Health & Science University16, Glasgow Royal Infirmary17, Johns Hopkins University18, McMaster University19, University of Brescia20, Cleveland Clinic21, Christchurch Hospital22, University of Leeds23, Tohoku University24, Ninewells Hospital25, University of Edinburgh26, Trinity College, Dublin27, Nottingham University Hospitals NHS Trust28, University College London29, Karolinska Institutet30, Valley Hospital31, National Cancer Research Institute32, University of Dallas33, Veterans Health Administration34, Otto-von-Guericke University Magdeburg35, Curie Institute36, Gloucestershire Hospitals NHS Foundation Trust37, University of Adelaide38, University of Newcastle39, University of Nantes40, Ulster Hospital41, University of Padua42, University of Chicago43, Northwestern University44, Barts Health NHS Trust45, University of Arizona46, University of Kansas47, University of North Carolina at Chapel Hill48, Case Western Reserve University49, Harrogate and District NHS Foundation Trust50, Royal Victoria Infirmary51, Durham University52, University of Minnesota53, University of Oxford54
TL;DR: An international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with Barrett's esophagus and dysplasia or early-stage EA and developed a data-sifting platform and used the Delphi process to create evidence- based consensus statements.

359 citations

Journal ArticleDOI
TL;DR: In this paper, the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared a series of statements discussing the use of GI endoscopy in common clinical situations.

313 citations

Journal ArticleDOI
01 May 2015-Gut
TL;DR: Confirmed LGD in BO has a markedly increased risk of malignant progression, however, the vast majority of patients with community LGD will be downstaged after expert review and have a low progression risk.
Abstract: Objective Reported malignant progression rates for low-grade dysplasia (LGD) in Barrett9s oesophagus (BO) vary widely. Expert histological review of LGD is advised, but limited data are available on its clinical value. This retrospective cohort study aimed to determine the value of an expert pathology panel organised in the Dutch Barrett9s Advisory Committee (BAC) by investigating the incidence rates of high-grade dysplasia (HGD) and oesophageal adenocarcinoma (OAC) after expert histological review of LGD. Design We included all BO cases referred to the BAC for histological review of LGD diagnosed between 2000 and 2011. The diagnosis of the expert panel was related to the histological outcome during endoscopic follow-up. Primary endpoint was development of HGD or OAC. Results 293 LGD patients (76% men; mean 63 years±11.9) were included. Following histological review, 73% was downstaged to non-dysplastic BO (NDBO) or indefinite for dysplasia (IND). In 27% the initial LGD diagnosis was confirmed. Endoscopic follow-up was performed in 264 patients (90%) with a median follow-up of 39 months (IQR 16–72). For confirmed LGD, the risk of HGD/OAC was 9.1% per patient-year. Patients downstaged to NDBO or IND had a malignant progression risk of 0.6% and 0.9% per patient-year, respectively. Conclusions Confirmed LGD in BO has a markedly increased risk of malignant progression. However, the vast majority of patients with community LGD will be downstaged after expert review and have a low progression risk. Therefore, all BO patients with LGD should undergo expert histological review of the diagnosis for adequate risk stratification.

240 citations

References
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Journal ArticleDOI
TL;DR: The guidelines for the diagnosis, surveillance and therapy of Barrett’s esophagus were originally published by the American College of Gastroenterology in 1998 and updated in 2002 and once again reviewed using the National Library of Medicine database.

2,044 citations


"Risk Factors for Progression of Low..." refers background or methods in this paper

  • ...7,15–18,24 In a large multicenter cohort of patients with BE, this study aimed to (1) define the incidence rates of HGD, EAC, and HGD/EAC in patients with BE who have LGD and (2) compare progression rates of LGD to HGD and EAC between prevalent and incident LGD and between multifocal and unifocal LGD and in patients with a consensus diagnosis of LGD among expert pathologists versus no consensus diagnosis....

    [...]

  • ...The inclusion criteria for this study were as follows: (1) patients who met the standardized definition of BE, that is, presence of columnar-lined mucosa in the distal esophagus of any length at endoscopy and presence of LGD on histology1,25 and (2) follow-up of at least 1 year from the time of initial diagnosis....

    [...]

Journal ArticleDOI
01 Aug 2000-Gut
TL;DR: The differences between Western and Japanese pathologists in the diagnostic classification of gastrointestinal epithelial neoplastic lesions can be resolved largely by adopting the proposed terminology, which is based on cytological and architectural severity and invasion status.
Abstract: Background—Use of the conventional Western and Japanese classification systems of gastrointestinal epithelial neoplasia results in large diVerences among pathologists in the diagnosis of oesophageal, gastric, and colorectal neoplastic lesions. Aim—To develop common worldwide terminology for gastrointestinal epithelial neoplasia. Methods—Thirty one pathologists from 12 countries reviewed 35 gastric, 20 colorectal, and 21 oesophageal biopsy and resection specimens. The extent of diagnostic agreement between those with Western and Japanese viewpoints was assessed by kappa statistics. The pathologists met in Vienna to discuss the results and to develop a new consensus terminology. Results—The large diVerences between the conventional Western and Japanese diagnoses were confirmed (percentage of specimens for which there was agreement and kappa values: 37% and 0.16 for gastric; 45% and 0.27 for colorectal; and 14% and 0.01 for oesophageal lesions). There was much better agreement among pathologists (71% and 0.55 for gastric; 65% and 0.47 for colorectal; and 62% and 0.31 for oesophageal lesions) when the original assessments of the specimens were regrouped into the categories of the proposed Vienna classification of gastrointestinal epithelial neoplasia: (1) negative for neoplasia/dysplasia, (2) indefinite for neoplasia/dysplasia, (3) non-invasive low grade neoplasia (low grade adenoma/ dysplasia), (4) non-invasive high grade neoplasia (high grade adenoma/ dysplasia, non-invasive carcinoma and suspicion of invasive carcinoma), and (5) invasive neoplasia (intramucosal carcinoma, submucosal carcinoma or beyond). Conclusion—The diVerences between Western and Japanese pathologists in the diagnostic classification of gastrointestinal epithelial neoplastic lesions can be resolved largely by adopting the proposed terminology, which is based on cytological and architectural severity and invasion status. (Gut 2000;47:251‐255)

1,940 citations

Journal ArticleDOI
TL;DR: A classification system for the epithelial changes that occur in ulcerative colitis was developed, which should be applicable to other forms of inflammatory bowel disease as well and makes use of standardized terminology, addresses specific problem areas, and offers practical solutions.

1,730 citations

Journal ArticleDOI
TL;DR: In patients with dysplastic Barrett's esophagus, radiofrequency ablation was associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia, and a reduced risk of disease progression.
Abstract: Background Barrett’s esophagus, a condition of intestinal metaplasia of the esophagus, is associated with an increased risk of esophageal adenocarcinoma. We assessed whether endoscopic radiofrequency ablation could eradicate dysplastic Barrett’s esophagus and decrease the rate of neoplastic progression. Methods In a multicenter, sham-controlled trial, we randomly assigned 127 patients with dysplastic Barrett’s esophagus in a 2:1 ratio to receive either radiofrequency ablation (ablation group) or a sham procedure (control group). Randomization was stratified according to the grade of dysplasia and the length of Barrett’s esophagus. Primary outcomes at 12 months included the complete eradication of dysplasia and intestinal metaplasia. Results In the intention-to-treat analyses, among patients with low-grade dysplasia, complete eradication of dysplasia occurred in 90.5% of those in the ablation group, as compared with 22.7% of those in the control group (P<0.001). Among patients with highgrade dysplasia, complete eradication occurred in 81.0% of those in the ablation group, as compared with 19.0% of those in the control group (P<0.001). Overall, 77.4% of patients in the ablation group had complete eradication of intestinal metaplasia, as compared with 2.3% of those in the control group (P<0.001). Patients in the ablation group had less disease progression (3.6% vs. 16.3%, P = 0.03) and fewer cancers (1.2% vs. 9.3%, P = 0.045). Patients reported having more chest pain after the ablation procedure than after the sham procedure. In the ablation group, one patient had upper gastrointestinal hemorrhage, and five patients (6.0%) had esophageal stricture. Conclusions In patients with dysplastic Barrett’s esophagus, radiofrequency ablation was associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia and a reduced risk of disease progression. (ClinicalTrials.gov number, NCT00282672.)

1,231 citations

Journal ArticleDOI
TL;DR: The rising incidence of esophageal adenocarcinoma represents a real increase in disease burden and overdiagnosis can be excluded as an explanation for the rise in incidence.
Abstract: Background The incidence of esophageal adenocarcinoma is rising dramatically. This increase may reflect increased disease burden, reclassification of related cancers, or overdiagnosis resulting from increased diagnostic intensity, particularly upper endoscopy for patients with gastroesophageal reflux disease or Barrett esophagus. Methods We used the National Cancer Institute's Surveillance, Epidemiology, and End Results database to extract information on incidence, stage distribution, and disease-specific mortality for esophageal adenocarcinoma as well as information on related cancers. Results From 1975 to 2001, the incidence of esophageal adenocarcinoma rose approximately sixfold in the United States (from 4 to 23 cases per million), a relative increase greater than that for melanoma, breast, or prostate cancer. Reclassification of squamous cell carcinoma is an unlikely explanation for the rise in incidence, because the anatomic distribution of esophageal cancer in general has changed. The only location with increased incidence is the lower third of the esophagus-the site where adenocarcinoma typically arises. Reclassification of adjacent gastric cancer is also unlikely because its incidence has also increased. Because there has been little change in the proportion of patients found with in situ or localized disease at diagnosis since 1975 (from 25% to 31%) and because esophageal adenocarcinoma mortality has increased more than sevenfold (from 2 to 15 deaths per million), overdiagnosis can be excluded as an explanation for the rise in incidence. Conclusion The rising incidence of esophageal adenocarcinoma represents a real increase in disease burden.

1,219 citations


"Risk Factors for Progression of Low..." refers background or methods in this paper

  • ...7,15–18,24 In a large multicenter cohort of patients with BE, this study aimed to (1) define the incidence rates of HGD, EAC, and HGD/EAC in patients with BE who have LGD and (2) compare progression rates of LGD to HGD and EAC between prevalent and incident LGD and between multifocal and unifocal LGD and in patients with a consensus diagnosis of LGD among expert pathologists versus no consensus diagnosis....

    [...]

  • ...The inclusion criteria for this study were as follows: (1) patients who met the standardized definition of BE, that is, presence of columnar-lined mucosa in the distal esophagus of any length at endoscopy and presence of LGD on histology1,25 and (2) follow-up of at least 1 year from the time of initial diagnosis....

    [...]

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