Yield of Repeat Endoscopy in Barrett’s Esophagus with No Dysplasia and Low-Grade Dysplasia: A Population-Based Study

Visrodia, Kavel; Iyer, Prasad G.; Schleck, Cathy D.; Zinsmeister, Alan R.; Katzka, David A.

doi:10.1007/s10620-015-3697-6

Cited by 28 publications

(25 citation statements)

References 28 publications

(37 reference statements)

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“…8,9 Furthermore, as most cancer screening tools have a miss rate, one can speculate that there might be cancers that are missed at the index endoscopy during which an initial BE diagnosis is made. Indeed, in recent large population-based studies with long-term follow-up, 58%–66% of EACs detected were diagnosed within 1 year of index endoscopy.…”

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confidence: 99%

“…2,3 Using data from the Olmsted County population-based cohort of BE patients, we observed that 2% of patients might have missed HGD or EAC and 10% have missed dysplasia when endoscopy is repeated in 1–2 years. 9 As a result, one has to question whether the missed EAC group is an important BE population to target for detection of dysplasia via methods, such as a 1-year follow-up endoscopy, which currently is not recommended by any of the 3 major gastroenterologic societies. 10–12 …”

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Magnitude of Missed Esophageal Adenocarcinoma After Barrett’s Esophagus Diagnosis: A Systematic Review and Meta-analysis

et al. 2016

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Background & Aims A proportion of patients with Barrett's esophagus (BE) are diagnosed with esophageal adenocarcinoma (EAC) within 1 year of an endoscopic examination that produced negative findings. These cases of missed cancers have not been well studied, despite current surveillance strategies for BE. We performed a systematic review and meta-analysis to determine the magnitude of missed EAC in cohorts of patients with BE. Methods We searched MEDLINE, EMBASE, and Web of Science from their inception to May 31, 2015 to identify cohort studies of adults with BE (baseline nondysplastic BE ± BE with low-grade dysplasia) and at least a 3-year follow-up period, providing data on missed and incident EACs (diagnosed within 1 year and diagnosed more than 1 year after the initial endoscopy in which BE was diagnosed, respectively). The main outcome measure was pooled proportion of missed and incident EACs (of all EACs detected after initial endoscopy) among BE cohorts, using a random effects model. Results In a metaanalysis of 24 studies reporting on 820 missed and incident EACs, 25.3% were classified as missed (95% confidence interval: 16.4%–36.8%) and 74.7% as incident EACs (95% CI: 63.2%–83.6%), although there was substantial heterogeneity among studies (I2 = 74%). When the analysis was restricted to nondysplastic BE cohorts (15 studies), 23.9% of EACs were classified as missed (95% confidence interval: 15.3%–35.4%; I2 = 0%). In a meta-analysis of 10 studies with follow-up periods of ≥5 years (a total of 239 EACs), 22.0% were classified as missed (95% confidence interval: 8.7%–45.5%), with substantial heterogeneity (I2 = 68%). Conclusions Among adults with nondysplastic BE (or BE with low-grade dysplasia) at their index endoscopy and at least a 3-year follow-up period, 25% of EACs are diagnosed within 1 year after the index endoscopy. Additional resources should be allocated to detect missed EAC.

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Magnitude of Missed Esophageal Adenocarcinoma After Barrett’s Esophagus Diagnosis: A Systematic Review and Meta-analysis

et al. 2016

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“…Th e rate can decrease if, over time, there is a decrease in environmental insult (such as acid refl ux) and/or if metaplastic mutations tend to stabilize over time. In addition, multiple negative endoscopies may improve the negative predictive value of endoscopy and hence identify a low risk group (missed rate of dysplasia at index endoscopy=9.5%) ( 34 ). On the contrary, the rate can increase if environmental noxious stimuli continue unabated or due to increase in probability of mutations by sheer number of mitotic cycles over time.…”

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Editorial: Best Practices in Surveillance of Barrett's Esophagus

Wani

Gaddam

2017

American Journal of Gastroenterology

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Endoscopic surveillance in Barrett's esophagus (BE) has numerous limitations and thus provides several opportunities for improving the effectiveness of our current surveillance strategies. Several risk stratifi cation and prediction tools have been investigated to identify patients at highest risk for progression to esophageal adenocarcinoma (EAC). Persistence of non-dysplastic BE (NDBE) has been proposed as an indicator of lower risk of progression to EAC. This editorial highlights the variable results and methodologies in studies evaluating persistence of NDBE as a risk stratifi cation tool in the surveillance of BE patients and provides guidance for optimizing outcomes in BE patients enrolled in surveillance programs. Am J Gastroenterol 2017; 112:1056-1060 doi: 10.1038/ajg.2017 RATIONALE AND CURRENT STATUS OF SURVEILLANCEAs survival in esophageal adenocarcinoma (EAC) is stage dependent, studies suggest that survival may be enhanced by endoscopic surveillance of Barrett's esophagus (BE), the only identifi able premalignant condition for this lethal cancer that continues to increase in incidence and is associated with a dismal 5-year survival rate. Current practice guidelines recommend endoscopic surveillance of patients with BE in an attempt to detect cancer at an early and potentially curable stage ( 1-3 ). Observational studies suggest that patients with BE in whom EAC was detected in a surveillance program have their cancers detected at an earlier stage with markedly improved 5-year survival compared with similar patients not undergoing routine surveillance ( 4-8 ).Variable results regarding the impact of surveillance in BE patients have been reported from four recent population-based studies. A large Northern Ireland population-based study and a large Dutch population-based study showed that in patients with EAC and a prior diagnosis of BE, survival was improved, and tumor stage and grade was lower compared with patients without a prior diagnosis of BE ( 9,10 ). Similarly, a cohort study of patients with BE diagnosed in the National Veterans Aff airs hospitals showed that surveillance endoscopy was associated with an early stage diagnosis of EAC, longer survival, and decreased overall and cancer-related mortality ( 11 ). On the other hand, a case-control study from the Northern California Kaiser Permanente population found no evidence that endoscopic surveillance improved survival from EAC ( 12 ). Despite these variable results and the lack of data from randomized controlled trials comparing surveillance vs. no surveillance (not likely to be performed in the future), surveillance of BE patients will continue to be recommended in clinical practice.Surveillance intervals are currently determined by the presence and grade of dysplasia. Several contemporary studies have demonstrated a low rate of progression to EAC in patients with non-dysplastic BE and this estimate ranges from 0.1-0.3% per year (13)(14)(15). Also, most patients with BE are likely to die of other causes, the commonest cause of deat...

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“…No randomized, controlled trials have supported decreased mortality as a result of these programs, but given evidence from cohort and retrospective studies combined with the rapidly rising incidence of esophageal adenocarcinoma (EAC), some GI societies have weakly recommended screening and surveillance endoscopy for BE patients [1]. The goal of the initial endoscopy is to detect BE and, if detected, to grade and evaluate for the presence of dysplasia and EAC.In this issue of Digestive Diseases and Sciences, Visrodia et al [2] report the proportion of cases of ''missed dysplasia'' diagnosed at repeat endoscopy in comparison with the index endoscopy findings. In this retrospective study, patients who underwent initial endoscopy from 1976 to 2011, with diagnosed BE of length 1 cm or greater, i.e., columnar mucosa with intestinal metaplasia, and who had undergone repeat endoscopy within 24 months of the index examination, were included in the analysis.…”

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“…In this issue of Digestive Diseases and Sciences, Visrodia et al [2] report the proportion of cases of ''missed dysplasia'' diagnosed at repeat endoscopy in comparison with the index endoscopy findings. In this retrospective study, patients who underwent initial endoscopy from 1976 to 2011, with diagnosed BE of length 1 cm or greater, i.e., columnar mucosa with intestinal metaplasia, and who had undergone repeat endoscopy within 24 months of the index examination, were included in the analysis.…”

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From Prague to Seattle: Improved Endoscopic Technique and Reporting Improves Outcomes in Patients with Barrett’s Esophagus

Brown

2015

Dig Dis Sci

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Endoscopic screening and surveillance practices in patients with Barrett's esophagus (BE) remain controversial. No randomized, controlled trials have supported decreased mortality as a result of these programs, but given evidence from cohort and retrospective studies combined with the rapidly rising incidence of esophageal adenocarcinoma (EAC), some GI societies have weakly recommended screening and surveillance endoscopy for BE patients [1]. The goal of the initial endoscopy is to detect BE and, if detected, to grade and evaluate for the presence of dysplasia and EAC.In this issue of Digestive Diseases and Sciences, Visrodia et al. [2] report the proportion of cases of ''missed dysplasia'' diagnosed at repeat endoscopy in comparison with the index endoscopy findings. In this retrospective study, patients who underwent initial endoscopy from 1976 to 2011, with diagnosed BE of length 1 cm or greater, i.e., columnar mucosa with intestinal metaplasia, and who had undergone repeat endoscopy within 24 months of the index examination, were included in the analysis. Notably, the rate of missed high-grade dysplasia and EAC was 1.9 %, whereas the overall rate of missed dysplasia of any grade and/or EAC was 9.5 %. While the study has limitations, including its retrospective nature, questionable adherence to guidelines, adequate number of biopsies, and the types of endoscopes used, it does highlight an important issuethe importance of meticulous endoscopy and biopsy at the time of index endoscopy in BE patients.If during index endoscopy BE is confirmed or suspected, the extent of BE should be carefully documented using the Prague C&M criteria. As part of this exercise, the landmarks that should be evaluated include the squamocolumnar junction, the gastroesophageal junction, and the extent of BE. Since this classification describes the circumferential (C) columnar lining and the maximum length (M) of BE, excluding islands [1], in this fashion it provides a standardized description of BE, useful for comparison with subsequent endoscopic evaluations. It also facilitates communication among gastroenterologists when patients are referred to tertiary centers for treatment. Despite the benefits of the Prague classification, a recent study reported that a surprising 78 % of gastroenterologists across varying practice settings did not use the Prague classification [3].Other considerations during index endoscopy that increase the value of the examination are careful inspection of the BE mucosa, the time spent in its evaluation, and the choice of imaging modalities. For instance, longer inspection times during endoscopic evaluation are associated with higher detection rates for HGD. A recent study reported that when endoscopists spent *1 min/cm extent of BE, the detection rate for neoplastic lesions improved [4]. Regarding the choice of imaging modality, high-definition imaging is superior to standard-definition imaging for BE. For example, narrowband imaging (NBI) enables evaluation of the mucosal patterns superior to that of conven...

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Yield of Repeat Endoscopy in Barrett’s Esophagus with No Dysplasia and Low-Grade Dysplasia: A Population-Based Study

Cited by 28 publications

References 28 publications

Magnitude of Missed Esophageal Adenocarcinoma After Barrett’s Esophagus Diagnosis: A Systematic Review and Meta-analysis

Magnitude of Missed Esophageal Adenocarcinoma After Barrett’s Esophagus Diagnosis: A Systematic Review and Meta-analysis

Editorial: Best Practices in Surveillance of Barrett's Esophagus

From Prague to Seattle: Improved Endoscopic Technique and Reporting Improves Outcomes in Patients with Barrett’s Esophagus

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