3. Appropriateness of Gastroscopy: Barrett\'s Esophagus 1

June 3, 2017 | Autor: Jean-Jacques Gonvers | Categoria: Endoscopy, Humans, Clinical Sciences, Gastroscopy
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3. Appropriateness of Gastroscopy: Barrett’s Esophagus 1 M. Bochud *, J.-J. Gonvers **, J.-P. Vader *, R.W. Dubois ***, B. Burnand *, F. Froehlich ** * Institut Universitaire de Médecine Sociale et Préventive, Lausanne, Switzerland ** Policlinique Médicale Universitaire, Lausanne, Switzerland *** Protocare Sciences, Santa Monica, USA

Introduction

1. Literature Review

Columnar-lined or Barrett’s esophagus is an acquired metaplasia of the distal esophagus that occurs secondary to long-standing gastroesophageal reflux disease (GERD). Patients with Barrett’s esophagus have a well-recognized risk of developing an adenocarcinoma of the esophagus and endoscopy combined with biopsy remains the gold standard for the diagnosis of Barrett’s.

Definition

In November 1998, a multidisciplinary European expert panel convened in Lausanne, Switzerland, to discuss and develop criteria for the appropriate use of gastrointestinal endoscopy, a widely-used procedure, regarded as highly accurate and safe. The RAND appropriateness method was chosen for this purpose, because it allows the development of appropriateness criteria based on published evidence and supplemented by explicit expert opinion. A detailed description of the RAND appropriateness method, including the literature search process [1], and of the whole process, as well as the global results of the panel [2], are published as separate articles in this issue of the Journal. The literature review was based on a systematic search of Medline, Embase and the Cochrane Library conducted up to the end of 1997 and completed with some key articles published in 1998. Updating and revision of the literature review is currently ongoing. This article presents a literature review on Barrett’s esophagus, that was provided to the panelists to study and comment prior to the panel meeting to support their ratings of appropriateness of use of upper gastrointestinal endoscopy. This article furthermore presents an overview of the main panel results related to Barrett’s esophagus and a summary of published evidence and panel-based appropriateness criteria.

Endoscopy 1999; 31 (8): 604 – 610 © Georg Thieme Verlag Stuttgart New York ISSN 0013-726X •

Barrett’s esophagus (BE) is characterized by the presence of a columnar epithelium as opposed to a squamous epithelium in the distal esophagus. BE is one of the esophageal complications of GERD, together with esophagitis and stricture [3]. Others define BE as a circumferential columnar epithelial lining of the distal esophagus extending 3 cm or more above the gastroesophageal junction [4]. The presence of intestinal metaplasia at biopsy is considered as a part of the definition of BE by most experts [5]. The degree of columnar epithelium needed to confirm a diagnosis of BE differs, with most authorities requiring at least 2 – 3 cm of columnar-lined esophagus [6]. Shorter segments may, however, also be lined with specialized (or intestinaltype) epithelium, in which cancer may occur [7]. These definitions presuppose that endoscopic assessments of the length of esophageal columnar lining are valid and reproducible, but inconsistencies in the ability to detect BE endoscopically and histologically have been shown to be frequent [6]. The metaplastic glandular epithelium characteristic of Barrett’s esophagus may develop areas of dysplasia, often simultaneously in multiple sites. There can be considerable inter-observer variations in classifying dysplasia histologically, particularly in the case of the earliest and the most advanced dysplastic changes [4]. Incidence/Prevalence of BE and of Adenocarcinoma In a population-based study, a prevalence of Barrett’s esophagus of 22.6/100,000 (95 % CI: 11.7 – 33.6) was found and 376/100,000 (95 % CI: 95 – 967), in a prospective autopsy series of 733 consecutive patients, thus demonstrating that the majority of cases go unrecognized [8]. 1

The European Panel on Appropriateness of Gastrointestinal Endoscopy (EPAGE, Lausanne, Switzerland)

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mated to be 1/76 (range: 48 – 175) patient-years of surveillance on average [21]. The risk of adenocarcinoma is 30 – 125 times that in an age-matched population [22], as shown in Table 2.

The prevalence rate of histologically verified Barrett’s esophagus in patients undergoing upper endoscopy for various UGI symptoms ranges from 7.4/1,000 to 9.5/1,000 [9, 10]. In the GORGE prospectively completed communitybased database [11], a diagnosis of probable or certain BE could be found in 77/2,641 and 49/2,641 consecutive elective EGDs respectively, and thus in 29/1,000 endoscopies and 19/1,000 endoscopies respectively; a probable or certain BE could be found in 12 % and 7.4 % respectively of patients with GERD symptoms. Symptom duration showed a significant correlation with the prevalence of probable BE (Table 1).

The mean age at diagnosis of BE varies from 55 to 63 years [10, 23, 24]. Blot documented the increase in the incidence in adenocarcinoma, which at 10 % per year is higher than that of any other cancer [25]. Symptoms The frequency of Barrett’s esophagus in patients with reflux symptoms ranges from 4 to 14 % [26].

Winters demonstrated a similar rate (12 %) of BE in patients presenting with reflux symptoms [12]. The prevalence of BE increased with age to reach a plateau in patients in their seventies. Follow-up studies suggest that a fairly rapid evolution of BE to its full length occurs with minimal subsequent changes [10].

In the GOSPE study in Italy, Barrett’s esophagus was 25 times more frequent among patients who complained of heartburn (80.1/1,000) than among others (3.2/1,000) [9]. In a prospective study [14] of 56 patients with BE, 70 % had heartburn, 55 % dysphagia and 52 % acid reflux.

Most patients with BE will not develop dysplasia during their lifetime [4]. The incidence of adenocarcinoma in patients with Barrett’s esophagus (patient-year incidence) ranged from 1/52 to 1/280 in prospective studies [13 – 17] and from 1/150 to 1/441 in retrospective studies [18 – 20]. Prospective endoscopic surveillance programmes provide the most accurate means of measuring the incidence, esti-

Diagnosis/Surveillance Patients with Barrett’s esophagus have a 30 to 125-fold increased risk for development of esophageal adenocarcinoma compared to the normal population [13 – 15, 18]. Symptoms alone are of no assistance in predicting endoscopic

Table 1 Relationship between symptom and prevalence of probable BE [11] Symptom duration (yrs)

N

Esophagitis (%)

probable BE (%)

Odds ratio for BE (Cl95)

10

127 236 81 140

47 53 48 42

4 11 17 21

1.0 3.0 (1.2 – 8.0) 5.1 (1.7 – 14.7) 6.4 (2.4 – 17.1)

Table 2 Incidence of adenocarcinoma in patients with Barrett’s esophagus Retrospective studies

Cameron 1985 [18] Van der Veen 1989 [20]

US NL

Achkar 1988 [46] Ovaska 1989 [16] Spechler 1984 [24]

US FL US

Prospective studies Hameeteman 19891 [13] Robertson 19882 [14] Iftikhar 19923 [28] Drewitz 19984 [17]

NL UK UK US

1 2 3 4

Study design

No. patients

Age

surveillance series of consecutive cases surveillance surveillance series of consecutive cases

104 166

62 (14 – 96)

72 32 1 15

cohort cohort cohort cohort

50 56 102 177

97/69

2 4

Follow-up (patientyears) 882 681

57 (2 – 81) 59.2 (27 – 79) 58 (33 – 87)

55/17 22/10 1 12/3

1 3 2

166 166 350

1/166 1/55 1/175

59.3 (28 – 78) 62 (23 – 84) 63 (18 – 84) 62 (30 – 85)

30/20 31/25 62/40 174/3

5 3 4 4

260 224 462 834

1/52 1/56 1/1 15 1/280

Patient selection filter not described; some cases might have been prevalent cases Some cases might have been prevalent cases Consecutive patients, some cases might have been prevalent cases Well designed study, exclusion of prevalent cases, unselected consecutive patients

M:F

Incidence cases

Incidence/ patient-years follow-up 1/441 1/170

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findings and do not offer any assistance in stratifying the risk of BE [27]. Long-segment as well as short-segment Barrett’s epithelium can lead to cancer [6].

gressive option. Operative mortality rates for esophagectomy range from 2 – 30 % [32]; the overall 5-year actuarial survival rate for adenocarcinoma is 20 % [37].

Most of the cases are diagnosed by random biopsy rather than macroscopically [28]. In the GOSPE study, a high rate of endoscopic false positives (30.4 %) and the low sensitivity of endoscopy (62.2 %) were pointed out [29], to the extent that BE cannot reliably be identified by endoscopy alone. Histology represents the gold standard in the diagnosis of BE [29] and histological grading is currently the most important parameter used to follow up patients with BE [7]. The major diagnostic difficulty is to differentiate between high-grade dysplasia and superficial carcinoma, because therapy regimens and follow-up for the former are not well established, with some authors recommending endoscopic follow-up (as such lesions can be stable for a long time [13, 30]) and others esophagectomy. Areas of high-grade dysplasia and microscopic adenocarcinoma are often small, so that early adenocarcinomas are often missed at endoscopic biopsy [31]. Prospective studies have shown a small risk of missing a carcinoma if systematic biopsies are taken from the Barrett’s esophagus in its entirety [32]. Moreover, pathologists disagree in distinguishing high-grade dysplasia from early invasive adenocarcinoma [7, 31, 33]. Only patients with dysplasia progress to adenocarcinoma in BE, as reported in two prospective studies [30, 34].

Fennerty [27] recommends screening for BE in patients with reflux disease of five years’ or greater duration, but in patients with a negative screening endoscopy, further screening exams are not justified. Endoscopy should be performed every 2 – 3 years in patients with a stable nondysplastic histology of BE, every 6 – 12 months for those with low-grade dysplasia with an increase to every 2 – 3 years if stable on repeat examinations; those with highgrade dysplasia should ideally have surgery and if not, an intensive biopsy programme every 3 – 6 months.

A prospective cohort study [30] in 62 patients with BE without adenocarcinoma found that high-grade dysplasia was always detected before the appearance of carcinoma, confirming Miro’s findings [34], and indefinite/low-grade dysplasia before high-grade-dysplasia. The mean time between indefinite/low-grade dysplasia and high-grade dysplasia was 29 months (ranges: 22 – 43) and between highgrade dysplasia and cancer 14 months (ranges: 5 – 21). Four patients with high-grade dysplasia remained histologically stable after a mean follow-up period of 14 months. Some patients did not, however, progress from indefinite/ low-grade to high-grade dysplasia or cancer during a follow-up period of nearly three years. In this study, all cancers were detected at an early stage with no evidence of invasion of the muscularis propria or of spread to the lymph nodes. The patients were followed by both histological and flow-cytometric evaluation of endoscopic biopsy. The authors recommend endoscopy at 2 – 3-year intervals for patients without dysplasia and with normal cytometry, every 6 – 12 months for those with no or low-grade dysplasia but abnormal cytometry; for patients with high-grade dysplasia, no clear recommendation can be made and each patient must be evaluated individually to decide between surgery or endoscopic surveillance every 3 – 6 months. There is controversy about whether patients with high-grade dysplasia should undergo esophagectomy [35, 36], which is the recommended therapy for adenocarcinoma. In a retrospective series [36] of 30 consecutive patients who underwent esophagectomy for high-grade dysplasia, invasive adenocarcinoma was found in 43 %, thus favouring the most ag-

Some authors suggest annual endoscopy with biopsy in patients with Barrett’s esophagus [14]. The cost of detecting one cancer with annual endoscopies is £14,868 for men and £42,084 for women [21]. The 1990 Barrett’s Esophagus Working Party of the World Congress of Gastroenterology made the following recommendations: 1. Endoscopy with biopsy and brush cytology should be performed every other year. 2. If dysplasia is detected, another expert pathologist should confirm the findings. 3. Healthy patients with multifocal high-grade dysplasia should undergo esophageal resection of the Barrett’s epithelium. In poor surgical candidates, experimental modalities such as photodynamic therapy should be considered. 4. Patients with low-grade dysplasia should undergo intensive anti-reflux therapy with PPIs for eight to 12 weeks followed by repeat endoscopy and multiple biopsies and cytological studies. 5. Patients with histological improvement should undergo endoscopy every six months until two consecutive examinations reveal negative findings. 6. Patients with persistent low-grade dysplasia should undergo continued intensive treatment and surveillance. A decision-analysis [22] for surveillance of BE found that annual surveillance with esophagectomy for high-grade dysplasia prevents the development of cancer and is the preferred strategy, if survival rate only is considered. For those who consider quality of life to be of greater importance, endoscopy every 2 – 3 years will provide the greatest quality-adjusted life expectancy; when costs are considered, endoscopy every 5 years also increases life expectancy and has an incremental cost-effectiveness ratio similar to other common medical procedures. The cumulative incidence of cancer and the quality of life after esophagectomy had the most significant impact on the decision as to surveillance and the optimal surveillance strategy. This study outlines the importance of a valid estimate of the incidence of adenocarcinoma, which can only be obtained by means of a long-term prospective population-based study.

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The efficacy of a surveillance programme in reducing the morbidity and mortality of esophageal cancer remains to be demonstrated [7]. Patients after anti-reflux procedure for BE probably need endoscopic surveillance: the incidence of adenocarcinoma was 1/274 patient years in a retrospective series of 113 patients [38].

2. Panel Results The experts of the European panel on appropriateness of gastrointestinal endoscopy (EPAGE) considered the above literature review as well as their own clinical expertise in evaluating the appropriateness of upper gastrointestinal endoscopy for Barrett’s esophagus. Definitions of terms, clinical variables used, general and specific panel results related to Barrett’s esophagus are presented below.

Certain authors also recommend that the surveillance applied for long-segment Barrett’s esophagus should also be applied for short-segment Barrett’s esophagus [39].

Definition of Terms

Treatment

Definitions used by the European panel on gastrointestinal endoscopy to assess appropriateness of upper gastrointestinal endoscopy in Barrett’s esophagus are shown in Table 3.

Photodynamic therapy has been shown to eliminate Barrett’s mucosal dysplasia and superficial esophageal cancer [40] without cancer recurrence in 36 patients. This therapy seems to represent a good alternative for patients not suitable for esophagectomy. Controversial data on regression of BE with both long-term medical treatment (omeprazole) [41, 42] and anti-reflux surgery [43] have been reported. Studies alleging regression or progression of BE must be regarded with caution given the diagnostic inconsistencies in endoscopic, histological and manometric measurements in BE [6]. Impact of Endoscopy on Outcome We found no randomized controlled trials or prospective studies comparing outcome in patients with BE who underwent endoscopic surveillance to that in patients with known Barrett’s without surveillance. Several retrospective studies offer evidence that patients with Barrett’s who undergo surveillance suggest improved outcome as compared to those patients not undergoing surveillance [44, 45]. Peters [45] found that patients referred from surveillance programmes for BE (n = 17) have a better outcome and that tumours were detected at an earlier stage than unsurveyed patients (n = 35); the retrospective nature of this study, the substantial differences in management and the history of both groups and the small number of patients included render the evidence shown in the study results very weak. Streitz [44] found a significantly higher percentage of stage 0 and 1 disease (58 % vs. 17 %) and better 5-year actuarial survival rates (62 % vs. 20 %) in patients under surveillance prior to the diagnosis of carcinoma. In contrast, Van der Veen [20] retrospectively compared survival rates for patients with Barrett’s esophagus to an age and gendermatched population, and found no significant differences.

Clinical Variables Table 4 shows the clinical variables and their level of details that were used to create and rate patient scenarios to assess the use of upper gastrointestinal endoscopy in patients with Barrett’s esophagus. General Panel Results for Barrett’s Esophagus Indications for Barrett’s esophagus were assessed in 10 scenarios. The results of previous histology were classified into 4 categories: no intestinal metaplasia, intestinal metaplasia but no dysplasia, low-grade dysplasia and highgrade dysplasia. Of the 10 scenarios, the panel rated 4 as inappropriate, 2 as uncertain and 4 as appropriate. The rate of overall agreement was high (70 %). Table 3 Definition of terms. Appropriateness of gastrointestinal endoscopy for Barrett's esophagus Barrett's esophagus: Metaplastic columnar epithelium of various extent, replacing the normal squamous epithelial lining of the lower esophagus. Conventionally, at least 3 cm of histologically confirmed columnar epithelium are required to make the diagnosis of full Barrett’s. Three main histological types of epithelium can be identified in Barrett's esophagus: fundic, junctional and specialized, also described as intestinal type with a villiform surface and intestinal goblet cells. Low-grade dysplasia: Low degree of a combination of architectural and cytological alterations such as gross distortion, hyperchromasia, enlarged nuclei, large nucleoli, loss of cellular polarity confirmed within the basement membrane of the glands in which it arose. High-grade dysplasia: High degree of a combination of architectural and cytological alterations such as gross distortion, hyperchromasia, enlarged nuclei, large nucleoli, loss of cellular polarity confirmed within the basement membrane of the glands in which it arose. Alarm symptoms: One or more of the following: melena, unexplained weight loss, iron-deficiency anemia, hematemesis, esophageal dysphagia. (Alarm symptoms are treated in the article on alarm symptoms [47]).

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Table 4 Clinical variables used to assess appropriateness of upper GI endoscopy in patients with Barrett’s esophagus Variables

Number of categories

Categories

Date of last EGD

3

Result of last EGD (histology)

4

– ≥ 2 years ago – ≥ 12 months and < 2 years ago – ≥ 6 months ago and < 12 months ago – Barrett's esophagus without intestinal metaplasia or dysplasia – intestinal metaplasia but no dysplasia – intestinal metaplasia with low-grade dysplasia – intestinal metaplasia with high-grade dysplasia

Table 5 Description of appropriateness of indications for upper gastrointestinal endoscopy for patients with Barrett’s esophagus (without alarm symptoms) Clinical situation

Specific Clinical Panel Results for Barrett’s Esophagus Main results are expressed as overall statements representing several clinical scenarios. In some cases, the same scenario may apply to more than one statement. Detailed appropriateness and necessity criteria are available in a computerized form accessible by Internet on EPAGE web site (http://www.epage.ch). Description of Appropriateness Appropriateness of upper GI endoscopy in Barrett’s esophagus is described in 4 overall statements in Table 5. Description of Necessity Three out of 10 scenarios (30 %) related to Barrett’s were further judged necessary (Table 6).

In individuals with Barrett's esophagus without intestinal metaplasia at prior endoscopy, indication for gastrointestinal endoscopy is inappropriate, regardless of when the last endoscopy was performed In Barrett's esophagus with intestinal metaplasia but no dysplasia at prior endoscopy, indication for gastrointestinal endoscopy is appropriate if last endoscopy was performed > 2 years previously uncertain if last endoscopy was performed ≥ 12 months but < 2 years previously inappropriate if last endoscopy was performed < 12 months previously In Barrett's esophagus with low-grade dysplasia at prior endoscopy, indication for gastrointestinal endoscopy is appropriate if last endoscopy was performed > 12 months previously uncertain if last endoscopy was performed < 12 months previously In individuals with Barrett's esophagus with high-grade dysplasia at prior endoscopy, indication for gastrointestinal endoscopy is appropriate

Table 6 Description of necessary indications for upper gastrointestinal endoscopy in patients with Barrett’s esophagus Clinical situation In individuals with high-grade dysplasia at the previous endoscopy, indication for gastrointestinal endoscopy is necessary In individuals with low-grade dysplasia at the previous endoscopy, indication for gastrointestinal endoscopy is necessary if the last endoscopy was performed more than one year previously

there is no consensus on the standard of practice for endoscopic surveillance of Barrett’s esophagus.

3. Conclusions The prevalence rate of Barrett’s esophagus in patients undergoing UGE for various upper GI symptoms ranges from 7.4/1,000 to 9.5/1,000. A probable or certain Barrett’s esophagus can be found in 12 % and 7.4 % of patients with gastroesophageal reflux symptoms respectively. The majority of cases of Barrett’s esophagus go unrecognized and most patients with Barrett’s will not develop dysplasia during their lifetime. Nevertheless, the risk of adenocarcinoma is 30 to 125 times that found in an age-matched population. Histology represents the gold standard in the diagnosis of Barrett’s esophagus. Evidence exists for a dysplasia → carcinoma sequence in Barrett’s esophagus. Only specialized (intestinal) columnar epithelium seems to progress to low-grade dysplasia, high-grade dysplasia, and finally invasive carcinoma. Circumstantial evidence suggests that surveillance of Barrett’s esophagus is cost-effective but

The EPAGE panel considered only long-segment Barrett’s esophagus. Type of histology and intervals of surveillance gastroscopy were the main determinants of expert judgement. UGE was judged not only appropriate but necessary when high-grade dysplasia was present histologically for more than 6 months or when low-grade dysplasia was present for more than 12 months. In the absence of intestinal metaplasia at histology, UGE was considered inappropriate. Acknowledgement The authors gratefully acknowledge the selfless commitment and invaluable contribution of the expert panel members, who made this project possible: Marcello Anti (IT), Peter Bytzer (DK), Mark Cottrill (UK), Michael Fried (CH), Roar Johnsen (NO), Gerd Kanzler (DE), Franc¸ois Lacaine (FR), Cornelis Lamers (NL), Roger J. Leicester (UK), Mattijs E. Numans (NL), Javier P. Piqueras (E),

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Jean-Franc¸ois Rey (FR), Giacomo Sturniolo (IT), Robert P. Walt (UK). This work was supported by the EU BIOMED II Programme (BMH4-CT96-1202), the Swiss National Science Foundation (32.40522.94) and the Swiss Federal Office of Education and Science (95.0306-2). References 1

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Corresponding Author Prof. Jean-Jacques Gonvers Policlinique Médicale Universitaire Rue César-Roux 19 CH-1005 Lausanne Switzerland Fax: + 41-21-3452323 E-mail: [email protected]

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