Gastroenterology

Gastroenterology

Volume 120, Issue 7, June 2001, Pages 1630-1639
Gastroenterology

Alimentary Tract
Extent of high-grade dysplasia in Barrett's esophagus correlates with risk of adenocarcinoma*,**

https://doi.org/10.1053/gast.2001.25111Get rights and content

Abstract

Background & Aims: The identification of any high-grade dysplasia (HGD) in Barrett's esophagus has been considered to be an indication for esophagectomy because of the increased risk of cancer. The aim of this study was to determine if a limited extent of HGD has the same potential for cancer as diffuse HGD. Methods: A retrospective cohort study was performed to assess the risk of developing adenocarcinoma in relationship to the extent of HGD found on endoscopic surveillance. The extent of HGD was defined as focal if cytologic and/or architectural changes of HGD were limited to a single focus of 5 or fewer crypts and diffuse if more than 5 crypts were involved in a single biopsy specimen or if HGD involved more than one biopsy fragment. The relative risk of cancer was assessed using a Cox proportional hazard model, and cancer-free survival was determined using survival curves. Results: Sixty-seven patients with diffuse HGD and 33 with focal HGD satisfied selection criteria. Cancer-free survival rates at 1 and 3 years were 93% and 86% for focal HGD compared with 62% and 44% for diffuse HGD (P < 0.001). On univariate analysis, extent of HGD (relative risk, 5.36; 95% confidence interval, 1.84–15.56), nodularity on endoscopy (relative risk, 3.98; 95% confidence interval, 1.97–8.04), and lack of acid suppression (relative risk, 2.48; 95% confidence interval, 1.16–5.28) were associated with an increased risk of esophageal adenocarcinoma. Diffuse HGD had a 3.7-fold increase in the risk of esophageal cancer compared with focal HGD (P = 0.02) on multivariate analysis. Conclusions: Patients with focal HGD are less likely to have cancer during the first year after diagnosis or on subsequent follow-up compared with diffuse HGD.

GASTROENTEROLOGY 2001;120:1630-1639

Section snippets

Study design

Patients with Barrett's esophagus and HGD who were followed up with a uniform surveillance program as part of the Mayo Clinic Barrett's Esophagus project were assessed in this retrospective cohort study. Patients were classified into focal or diffuse HGD based on the extent of HGD on endoscopic biopsy specimens for Barrett's esophagus. In a prospective fashion, follow-up information was collected to determine their cancer-free survival rate from the date of first endoscopic biopsy at the Mayo

Results

During the study period, 134 patients were diagnosed with Barrett's esophagus and HGD on endoscopic biopsy. Thirty-four patients were excluded from the analysis (Figure 2) for the following reasons: 8 patients had a mass lesion on endoscopy and the biopsy specimen was suspicious for adenocarcinoma, and 4 patients had no obvious mass lesion but there was suspicion for adenocarcinoma. These 12 patients were only excluded after confirmation of adenocarcinoma by the study pathologist. Ten patients

Discussion

Barrett's esophagus is a premalignant condition in which the normal squamous epithelium of the lower esophagus is replaced by specialized columnar intestinal epithelium.1, 3, 4 The association of a columnar-lined esophagus with adenocarcinoma was first described by Adler in the early 1950s.20 Morson later noted that dysplasia could be shown on biopsy, which may identify patients who are likely to have or develop cancer.21 Studies subsequently have showed that HGD in Barrett's esophagus was

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    *

    Address requests for reprints to: Kenneth K. Wang, M.D., Main Alfred Gastroenterology Unit, St. Mary's Hospital, 1216 Second Street S.W., Rochester, Minnesota 55905. e-mail: [email protected].

    **

    Supported by grants CA85992-01 and CA78870-01 from the National Institutes of Health and by the Mayo Foundation.

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