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The surgeon's perspective on oesophageal disease, and what it means to pathologists
  1. Christina L Greene,
  2. P Michael McFadden
  1. Department of Surgery, Division of Thoracic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
  1. Correspondence to Dr Christina L Greene, Department of Surgery, Division of Thoracic Surgery, Keck School of Medicine of the University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033, USA; Christina.Greene{at}med.usc.edu

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Introduction

Gastro-oesophageal reflux disease (GERD) has become the most important oesophageal issue of the 21st century. It is defined by the Montreal International Consensus as a ‘condition which develops when the reflux of stomach contents causes troublesome symptoms and or complications.’1 To surgeons, its importance lies not only in its prevalence but, more importantly, in its potential to lead to adenocarcinoma of the oesophagus. GERD affects between 18% and 28% of the US population, and approximately 8%–15% of these patients will go on to develop the premalignant condition of Barrett's oesophagus.2–5 The two most prevalent types of oesophageal carcinoma are squamous cell and adenocarcinoma. Squamous cell carcinoma used to be the most prevalent oesophageal cancer in the Western world, but it has been surpassed by oesophageal adenocarcinoma in the last 40 years.6 Oesophageal adenocarcinoma primarily affects white men with GERD, while squamous cell carcinoma is more commonly associated with tobacco and alcohol use.6

Oesophageal adenocarcinoma is an extremely lethal form of cancer with a five-year survival rate of 15%–20% despite best available therapy. The five-year mortality rate in early stage disease has been reported to be as high as 63%.3 ,7–10 GERD is a prevalent disease affecting nearly one-quarter of Americans and Barrett's oesophagus is a known complication of GERD.2 For clarity, Barrett's oesophagus is defined as specialised intestinal metaplasia of the metaplastic columnar epithelium.11 Of those with Barrett's oesophagus, approximately 0.12%–0.38% per year will progress to oesophageal adenocarcinoma.11 ,12 We know that chronic GERD leads to Barrett's oesophagus, which is a precursor to oesophageal adenocarcinoma. Since we have effective treatment for Barrett's oesophagus, why then does the incidence of oesophageal cancer continue to rise in the USA?10

Since the 1970s, there has been a nearly 400% increase in the incidence …

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