Archive for the ‘basics’ Category

Barrett’s Esophagus with High Grade Dysplasia

Wednesday, November 5th, 2008

We’ve had some questions about high grade dysplasia in Barrett’s esophagus, so here’s some information that may be helpful.

The lifetime risk of esophageal cancer from Barrett’s esophagus is low, probably on the order of 5% or less.  Surveillance programs with regular upper endoscopy seem to help detect dysplasia before it progresses to cancer. 

So what if you do have high grade dysplasia (HGD)?  HGD occurs when the Barrett’s esophagus cells accumulate mutations and lose their normal shape and pattern.  HGD isn’t cancer, but it is the step before cancer. The risk of developing esophageal cancer from HGD has been looked at in several studies and ranges from 20% to 50%.  

With HGD, there are several options for evaluation and treatment

 Evaluation

  1. Have your slides reviewed by an expert GI pathologist – to make sure the biopsies show HGD and not cancer or low grade dysplasia (LGD)
  2. Have repeat endoscopy with more biopsies to determine if there’s just one area with HGD or multiple areas of HGD (multifocal HGD)
  3. Some gastroenterologists like to perform an endoscopic ultrasound for any patient diagnosed with BE-HGD.  This is done to look for signs of cancer, such as enlarged lymph nodes or invasion of tissue through the wall of the esophagus.  However, experts disagree about whether this is necessary.  There have been a few studies that EUS isn’t that helpful for HGD.  But EUS is important for staging cancers in Barrett’s esophagus.

Treatment

There are several options for treatment and there’s no one right answer for every patient.  Often, patients may need a combination of the therapies below to treat their HGD.  Other health issues and patient preferences play a role in choosing the right treatment.

  1. Continued surveillance – repeating an EGD every 3 months to look for cancer.  This is an option for patients who don’t want (or are too unhealthy) for other therapies.  Also, continued surveillance is important for anyone treated for HGD with any of the therapies listed below, to make sure new areas of HGD haven’t arisen. 
  2. High dose proton pump inhibitor therapy – generally given twice daily.  It doesn’t cure HGD, but can help reduce inflammation and make biopsies easier to interpret.  There are some studies that show regression of low grade dysplasia with PPI therapy.
  3. Esophagectomy – surgical removal of the esophagus.  This procedure gets rid of all the BE and dysplasia.  The esophagus is removed and the stomach is pulled up into the chest or a piece of large intestine is used to make a new esophagus. This is very effective for getting rid of HGD, but is a major surgery and the complication rate varies.  It’s important to choose a surgeon who does many esophagectomy procedures as they tend to have lower complication rates.
  4. Endoscopic mucosal resection (EMR) – useful for removing small areas of the esophageal mucosa that contain HGD.  EMR is often used to remove bumpy areas of HGD. 
  5. Photodynamic therapy – A light-sensitizing medication, porfimer sodium, is injected intravenously.  Then a special laser fiber is inserted through the endoscope to the area of BE and dysplasia. The light from the laser causes a photochemical reaction with the porfimer sodium, which destroys the mucosa.  Patients who have PDT are photosensitive for several weeks and are advised to avoid the sun. 
  6. Radiofrequency ablation –  A special balloon or small paddle attached to the endoscope are used to burn away a thin layer of the esophageal mucosa, getting rid of the HGD in the Barrett’s esophagus.  This is one of the newer treatment options for BE HGD.
  7. Cryotherapy – Freezing liquid nitrogen or carbon dioxide is sprayed onto the esophageal mucosa, freezing the BE and HGD.  This is another newer treatment option for BE HGD.

If you have any questions about treatment of HGD, talk with your gastroenterologist about the different options to see which treatment would be best for you. 

posted by Kerry Dunbar, MD

Guidelines for Surveillance of Barrett’s Esophagus

Thursday, October 30th, 2008

One of our blog visitors had a question about how often endoscopy should be performed in patients with Barrett’s esophagus.

With Barrett’s esophagus, studies have shown that surveillance endoscopy (EGD) for dysplasia improves survival by detecting small esophageal cancers earlier in their course. Because of this, several national gastroenterology societies have published guidelines for the surveillance of Barrett’s esophagus. Most recently, the American College of Gastroenterology updated their Barrett’s esophagus guidelines. The guidelines were created using the available published research on BE and dysplasia about the risk of progression to cancer and surveillance of BE.

Here are the 2008 ACG BE Surveillance Guidelines:

For BE with no dysplasia

  • a second EGD with biopsies within a year to confirm there is no dysplasia
  • If both EGDs with biopsies show no dysplasia, then repeat EGD with biopsy is recommended every 3 years

For BE with low grade dysplasia (LGD)

  • Have the pathology slides showing LGD read by an expert pathologist (to make sure no high grade dysplasia (HGD) is present
  • Repeat EGD with biopsies within 6 months to reassess for dysplasia
  • If no dysplasia is present on repeat EGD, then yearly EGD with biopsy is recommended until two years worth of EGDs show no dysplasia

For BE with high grade dysplasia (HGD)

  • Have the pathology slides showing HGD read by an expert pathologist to confirm the diagnosis
  • If the HGD is found in a mucosal irregularity (i.e. and ulcer, a nodule, a bumpy area of the esophagus), then endoscopic mucosal resection (EMR) is recommended to remove it
  • EGD with biopsies should be repeated within 3 months to look for HGD and tiny cancers. Intervention should be performed based on the biopsy results and tailored to the patient.
  • Possible interventions for HGD include – esophagectomy, endoscopic mucosal resection, photodynamic therapy, radiofrequency ablation, ablation using cryotherapy

These are the newest guidelines and they’re widely used, but some gastroenterologists do screen more frequently, so talk with your gastroenterologist to see what he/she recommends.

The reference for the ACG Guidelines is:

Wang, KK and Sampliner, RE. Updated guidelines 2008 for the diagnosis, surveillance, and therapy of Barrett’s esophagus. American Journal of Gastroenterology 2008, volume 103, pages 788-797.

posted by Kerry Dunbar, MD

Gastroenterology and Barrett’s Esophagus

Friday, October 24th, 2008

Welcome again to the Johns Hopkins Barrett’s esophagus blog! I’m Kerry Dunbar, MD and will also be posting new information about Barrett’s esophagus on the blog. I’m a gastroenterologist at Johns Hopkins and have a clinical and research interest in Barrett’s esophagus and Barrett’s-associated dysplasia.

I graduated from the University of Texas Southwestern Medical School in 2000 and have been at Johns Hopkins ever since. I completed my internal medicine residency in 2003 and spent a year as an assistant chief of service for the medicine residency program, which was a great opportunity to teach residents and medical students. Next came gastroenterology fellowship at Johns Hopkins, which included specialized training in clinical research and endoscopic techniques like confocal endomicroscopy, narrow band imaging, chromoendoscopy, endoscopic mucosal resection, cryotherapy, and endoscopic ultrasound. I joined the faculty in July and in addition to seeing patients with Barrett’s esophagus, also take care of patients with GERD, eosinophilic esophagitis, and other esophageal disorders.

There are two other faculty members at Hopkins who have a special interest in Barrett’s esophagus – Marcia Canto, MD, MHS and Jean Wang, MD. If you’re interested in finding out more about the gastroenterology division at Johns Hopkins, you can go here for more information: www.hopkins-gi.org.