Endoscopic resection (ER) is safe and effective for Barrett’s esophagus (BE) containing high-grade dysplasia (HGD) or mucosal adenocarcinoma (T1A). The risk of metachronous neoplasia is reduced by ablation of residual BE by using radiofrequency ablation (RFA) or argon plasma coagulation (APC). These have not been compared directly. We aimed to recruit up to 100 patients with BE and HGD or T1A confirmed by ER over 1 year in 6 centers in a randomized pilot study.
Randomization was 1:1 to RFA or APC (4 treatments allowed at 2-month intervals). Recruitment, retention, dysplasia clearance, clearance of benign BE, adverse events, healthcare costs, and quality of life by using EQ-5D, EORTC QLQ-C30, or OES18 were assessed up to the end of the trial at 12 months.
Of 171 patients screened, 76 were randomized to RFA (n = 36) or APC (n = 40). The mean age was 69.7 years, and 82% were male. BE was <5 cm (n = 27), 5 to 10 cm (n = 45), and >10 cm (n = 4). Sixty-five patients completed the trial. At 12 months, dysplasia clearance was RFA 79.4% and APC 83.8% (odds ratio [OR] 0.7; 95% confidence interval [CI], 0.2-2.6); BE clearance was RFA 55.8%, and APC 48.3% (OR 1.4; 95% CI, 0.5-3.6). A total of 6.1% (RFA) and 13.3% (APC) had buried BE glands. Adverse events (including stricture rate after starting RFA 3/36 [8.3%] and APC 3/37 [8.1%]) and quality of life scores were similar, but RFA cost $27491 more per case than APC.
This pilot study suggests similar efficacy and safety but a cost difference favoring APC. A fully powered non-inferiority trial is appropriate to confirm these findings. (Clinical trial registration number: NCT01733719.)
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
In this chapter the fundamentals of esophagogastroduodenoscopy (EGD) will be explained with an emphasis on the assessment of patients with gastroesophageal reflux disease (GERD). It includes the fundamentals of endoscopic ultrasound (EUS) in the assessment of esophageal cancer. Numerous color photographs demonstrate different findings of interest on EGD through the spectrum of GERD, from erosive esophagitis to cancer. Photographs of EUS images will help demonstrate findings of interest in cancer patients.
Cancer prevention is the most cost-effective, long-term strategy for the control of cancer.1, 2 It is now well established that approximately one-third to one-half of all adult cancers occurring in Western populations can be prevented through the adoption of “healthy lifestyles.” A comprehensive view of a healthy lifestyle includes adherence to published cancer prevention recommendations that seek to eliminate or minimize exposure to lifestyle risk factors, and the use of screening and early detection tests as well as molecular preventive agents (e.g., aspirin, tamoxifen, human papillomavirus [HPV] vaccine) when warranted. This chapter focuses on the epidemiology of lifestyle risk factors and their associated interventions, as well as on the use of molecular preventive agents. Screening and early detection are addressed in another chapter.
Barrett's metaplasia is the only known morphological precursor to oesophageal adenocarcinoma and is characterized by replacement of stratified squamous epithelium by columnar epithelium. The cell of origin is uncertain and the molecular mechanisms responsible for the change in cellular phenotype are poorly understood. We therefore explored the role of two transcription factors, Cdx2 and HNF4α in the conversion using primary organ cultures. Biopsy samples from cases of human Barrett's metaplasia were analysed for the presence of CDX2 and HNF4α. A new organ culture system for adult murine oesophagus is described. Using this, Cdx2 and HNF4α were ectopically expressed by adenoviral infection. The phenotype following infection was determined by a combination of PCR, immunohistochemical and morphological analyses. We demonstrate the expression of CDX2 and HNF4α in human biopsy samples. Our oesophageal organ culture system expressed markers characteristic of the normal SSQE: p63, K14, K4 and loricrin. Ectopic expression of HNF4α, but not of Cdx2 induced expression of Tff3, villin, K8 and E-cadherin. HNF4α is sufficient to induce a columnar-like phenotype in adult mouse oesophageal epithelium and is present in the human condition. These data suggest that induction of HNF4α is a key early step in the formation of Barrett's metaplasia and are consistent with an origin of Barrett's metaplasia from the oesophageal epithelium.