Barrett’s Esophagus

DIAGNOSIS AND DEFINITION

Barrett’s esophagus is a chronic condition of the lower esophagus in which the lining (mucosal layer) changes from the normal squamous epithelium to columnar epithelium as a result of chronic acid and bile reflux. The columnar epithelium appears as a salmon pink colored lining in the tubular esophagus.

Barrett’s esophagus is a relatively common condition that can affect both men and women but is more frequently seen in Caucasians and in males 50 years of age or older. Other risk factors for Barrett’s esophagus include chronic gastroesophageal reflux disease (GERD) and obesity.

Individuals with Barrett’s esophagus are at increased risk for a particular type of esophageal cancer called adenocarcinoma. The annual risk is estimated at 0.12 percent or 1.2 cases per 1000 person-years.1 An intermediate step between Barrett’s esophagus and the development of esophageal cancer is called dysplasia.

Patients with Barrett’s esophagus should have periodic repeat examinations to detect dysplasia if their general health is satisfactory. Surveillance for dysplasia usually involves repeat examinations every three to five years if no dysplasia is detected when biopsies of the Barrett’s mucosa are taken and examined. Patients receiving endoscopic therapy for dysplasia will require repeated procedures for treatment and will undergo follow-up surveillance at more frequent intervals.

PROGRESSION FROM BARRETT’S ESOPHAGUS TO CANCER

Barrett's Esophagus with Lesion
Click Image to Enlarge

Some patients with Barrett’s esophagus will progress to esophageal cancer over time. Although the reasons for this are unknown, tobacco use is a strong risk factor. Patients at high risk for progression to cancer can be identified by microscopic changes in cells with an abnormal appearance. Biopsy specimens are reviewed for abnormal cell shapes and the formation of cell clusters, which define dysplasia. The severity of the changes in the epithelial cells’ shape and size can distinguish low-grade dysplasia from high-grade dysplasia:

Low-grade dysplasia – The nuclei of the cells have increased in size and take on variable shapes.

High-grade dysplasia – The criteria for high-grade dysplasia includes atypical changes in multiple cells with an abnormal growth pattern.

The progression from no dysplasia to high-grade dysplasia can occur over time or abruptly. Surveillance is recommended to identify areas of dysplasia due to the associated risk for progression to cancer. Accurate pathologic diagnosis is crucial when diagnosing Barrett’s Esophagus. Expert confirmation regarding the grade of dysplasia with review of the biopsy slides is advised. 

ENDOSCOPIC TREATMENT

The goal of endoscopic treatment is to remove or eradicate all Barrett’s mucosa and any associated lesions followed by healing with normal squamous epithelium. The healing process is promoted by the aggressive treatment of acid reflux disease. Patients receiving endoscopic therapy require intense, life-long surveillance.

Treatments include endoscopic tissue removal (mucosal resection or submucosal dissection), ablation with intense energy (radiofrequency energy or cryotherapy) and surgical removal of the esophagus (esophagectomy). Occasionally methods are changed during treatment to address changes that can occur during the healing process or progression of lesions during the treatment period.

Endoscopic treatment is recommended for confirmed low- and high-grade dysplasia, as well as early or superficial cancers limited to the mucosal layer (stage T1a) above the submucosal layer (see Esophageal Cancer Staging diagram). Occasionally, patients are candidates for endoscopic therapy when the lesion invades the submucosa and pathologic grading is favorable or the patient is considered to be at high risk for esophagectomy. Endoscopic ultrasound (EUS) is helpful in determining the depth of tumor invasion and lymph node involvement.

TREATMENT METHODS

  1. Endoscopic Mucosal Resection (EMR) – A lesion or elevated nodular areas of dysplasia and early cancers is removed from the inner lining of the esophagus. This procedure is considered lower risk than surgery. EMR can be performed once during a session or repeated in steps to remove a wider area. EMR specimens average slightly larger than one centimeter in size and contain both mucosal and submucosal layers.
    Endoscopic Mucosal Resection

  2. Endoscopic submucosal dissection (ESD) – ESD is similar to EMR with complete removal of the lesion for pathologic evaluation in larger lesions. ESD is more complicated because the lesion is removed in its entirety as one specimen compared to the piecemeal approach of EMR. ESD specimens range from one to five centimeters.
    Endoscopic submucosal dissection

    The top two images show an elevated cancer with a depression at the four o’clock position. The lower left image shows the area immediately after ESD. The lower left image shows the esophagus during a follow up session using radiofrequency ablation.

    Advantages of EMR and ESD:

    • Removal of the tissue provides complete pathologic staging for depth of tumor invasion, grade and involvement of lymph and vascular channels

    • Ideal for nodular (uneven) or elevated (thick) lesions

    • Minimal discomfort for patients

    Limitations and Complications of EMR and ESD:

    • Difficult to perform in areas of narrowing or scarring caused by acid reflux, ulcers or prior treatments

    • Bleeding during or after the procedure may require blood transfusion or repeated procedures to control the bleeding

    • Stricture (narrowing) of the lumen during the healing process may require endoscopic dilation especially when a wide area is removed

    • Perforation (deep injury to the wall) could require hospitalization with further procedures or surgery

  3. Radiofrequency Ablation (RFA) – RFA is a process by which high temperature thermal energy is delivered over a wide area to destroy the Barrett’s mucosa and any areas of dysplasia. RFA is typically delivered with a balloon catheter on the initial session followed by subsequent sessions using an electrode attached to the endoscope tip to remove any residual Barrett’s mucosa. On average, three sessions spaced at eight weeks apart are required to complete the treatment.

    Advantages of RFA:

    • RFA can treat wide areas of flat Barrett’s mucosa in a single session

    Limitations and complications of RFA:

    • Difficult to perform in areas of narrowing or scarring caused by acid reflux, ulcers or prior treatments

    • Ineffective for nodular or elevated lesions due to the limited depth of treatment

    • Bleeding, stricture and perforation are uncommon complications of RFA

  4. Cryotherapy Ablation – Cryotherapy is a process by which super cooled liquid nitrogen or compressed nitrous oxide is used to freeze the Barrett’s mucosa. The extreme temperature change in the treated tissues causes cell death. On average, three sessions spaced at eight weeks apart are required to complete the treatment.

    Advantages of Cryotherapy:

    • Cryotherapy can treat wide areas of Barrett’s mucosa in a single session

    • Ideal for both flat or nodular (uneven) epithelium with elevated (thick) lesions especially with higher doses

    • Capable of treating Barrett’s mucosa on irregular wall shapes and areas when RFA fails

    Limitations and Complications of Cryotherapy:

    • Difficult to perform in areas of narrowing or scarring caused by acid reflux, ulcers or prior treatments

    • Bleeding, stricture and perforation are uncommon complications of cryotherapy

  5. Argon Plasma Coagulator (APC) – APC is a noncontact thermal energy method used to treat small areas of Barrett’s mucosa with ionized argon gas to destroy tissue near the probe tip.

  6. Surgery – Surgical resection of the esophagus is called esophagectomy. Esophagectomy is a very complex surgical procedure to remove cancerous lesions in the esophagus. This life-saving intervention has the best results when performed early before the cancer has involved the lymph nodes.

    Surgical repair of a hiatal hernia with an anti-reflux fundoplication are used to treat severe gastroesophageal reflux disease (GERD). Anti-reflux surgery is the best procedure to control symptoms of regurgitation of gastric contents. Surgical intervention of the esophagus requires proper planning with testing and consultation by an experienced team.

In conclusion, there are many treatments available for Barrett’s esophagus with dysplasia. A well trained physician can determine and perform the treatments best suited for their patients. Patients with Barrett’s esophagus and dysplasia will require intense, life-long surveillance.

Jensen FH, Pederson L, Drewes AM, et al. Incidence of adenocarcinoma among patients with Barrett’s esophagus. N Engl J Med 2011;365:1375-83.

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