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1.
Dig Dis Sci ; 59(7): 1560-6, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24395382

RESUMO

BACKGROUND: The rate and risk factors of recurrent or metachronous adenocarcinoma following endoscopic ablation therapy in patients with Barrett's esophagus (BE) have not been specifically reported. AIM: The aim of this study was to determine the incidence and predictors of adenocarcinoma after ablation therapy for BE high-grade dysplasia (HGD) or intramucosal carcinoma (IMC). METHODS: This is a single center, retrospective review of prospectively collected data on consecutive cases of endoscopic ablation for BE. A total of 223 patients with BE (HGD or IMC) were treated by ablation between 1996 and 2011. Primary outcome measures were recurrence and new development of adenocarcinoma after ablation. Recurrence was defined as the presence of adenocarcinoma following the absence of adenocarcinoma in biopsy samples from two consecutive surveillance endoscopies. Logistic regression analysis was performed to assess predictors of adenocarcinoma after ablation. RESULTS: One hundred and eighty-three patients were included in the final analysis, and 40 patients were excluded: 22 for palliative ablation, eight lost to follow-up, five for residual carcinoma and five for postoperative state. Median follow-up was 39 months. Recurrence or new development of adenocarcinoma was found in 20 patients (11 %) and the median time to recurrence/development of adenocarcinoma was 11.5 months. Independent predictors of recurrent or metachronous adenocarcinoma were hiatal hernia size ≥ 4 cm (odds ratio 3.649, P = 0.0233) and histology (HGD/adenocarcinoma) after first ablation (odds ratio 4.141, P = 0.0065). CONCLUSIONS: Adenocarcinoma after endoscopic therapy for HGD or IMC in BE is associated with large hiatal hernia and histology status after initial ablation therapy.


Assuntos
Adenocarcinoma/cirurgia , Esôfago de Barrett/cirurgia , Ablação por Cateter , Neoplasias Esofágicas/cirurgia , Esofagoscopia , Lesões Pré-Cancerosas/cirurgia , Adenocarcinoma/epidemiologia , Adenocarcinoma/etiologia , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Esôfago de Barrett/patologia , Neoplasias Esofágicas/epidemiologia , Neoplasias Esofágicas/etiologia , Neoplasias Esofágicas/patologia , Feminino , Seguimentos , Hérnia Hiatal/complicações , Humanos , Incidência , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Lesões Pré-Cancerosas/patologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
2.
Gastrointest Endosc ; 71(1): 35-43, 2010 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-19922916

RESUMO

BACKGROUND: Spectrally encoded confocal microscopy (SECM) is a high-speed reflectance confocal microscopy technique that has the potential to be used for acquiring comprehensive images of the entire distal esophagus endoscopically with subcellular resolution. OBJECTIVE: The goal of this study was to demonstrate large-area SECM in upper GI tissues and to determine whether the images contain microstructural information that is useful for pathologic diagnosis. DESIGN: A feasibility study. SETTING: Gastrointestinal Unit, Massachusetts General Hospital. PATIENTS: Fifty biopsy samples from 36 patients undergoing routine EGD were imaged by SECM, in their entirety, immediately after their removal. RESULTS: The microstructure seen in the SECM images was similar to that seen by histopathology. Gastric cardia mucosa was clearly differentiated from squamous mucosa. Gastric fundic/body type mucosa showed more tightly packed glands than gastric cardia mucosa. Fundic gland polyps showed cystically dilated glands lined with cuboidal epithelium. The presence of intraepithelial eosinophils was detected with the cells demonstrating a characteristic bilobed nucleus. Specialized intestinal metaplasia was identified by columnar epithelium and the presence of goblet cells. Barrett's esophagus (BE) with dysplasia was differentiated from specialized intestinal metaplasia by the loss of nuclear polarity and disorganized glandular architecture. LIMITATIONS: Ex vivo, descriptive study. CONCLUSIONS: Large-area SECM images of gastroesophageal biopsy samples enabled the visualization of both subcellular and architectural features of various upper GI mucosal types and were similar to the corresponding histopathologic slides. These results suggest that the development of an endoscopic SECM probe is merited.


Assuntos
Esôfago/patologia , Microscopia Confocal/métodos , Estômago/patologia , Adulto , Idoso , Biópsia , Endoscopia do Sistema Digestório , Junção Esofagogástrica/patologia , Estudos de Viabilidade , Feminino , Mucosa Gástrica/patologia , Humanos , Masculino , Pessoa de Meia-Idade
3.
Gastrointest Endosc ; 69(2): 205-12, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-18950764

RESUMO

BACKGROUND: Photodynamic therapy (PDT) has been used extensively for endoscopic ablation of Barrett's esophagus with high-grade dysplasia (HGD) or intramucosal carcinoma. OBJECTIVE: To identify patient variables that influence the likelihood of response to PDT. DESIGN: A retrospective cohort study. SETTING: Tertiary-referral center. PATIENTS: A total of 116 patients with Barrett's esophagus and with HGD, intramucosal carcinoma, or T1 cancer. INTERVENTIONS: PDT with porfimer sodium. MAIN OUTCOME MEASUREMENTS: (1) Ablation of HGD and/or intramucosal carcinoma and (2) eradication of all Barrett's epithelium. RESULTS: Of the patients, 51% underwent treatment for HGD and 49% of patients had intramucosal carcinoma or T1 cancer. At 12-month follow-up, ablation of HGD and/or cancer was observed in 70% of patients, and ablation of all Barrett's epithelium was observed in 39%. In multivariate analysis, the pretreatment length of Barrett's esophagus was inversely correlated with successful ablation of all Barrett's epithelium. Patients with Barrett's esophagus length more than 3 cm were less likely to experience complete ablation compared with patients with Barrett's esophagus length 3 cm or less (odds ratio [OR] 0.15 [95% CI, 0.04-0.50]). Patients with intramucosal carcinoma were not significantly less likely to experience elimination of HGD and/or cancer (OR 0.77 [95% CI, 0.30-2.00]) or ablation of all Barrett's epithelium (OR 0.82 [95% CI, 0.32-2.07]) compared with patients with HGD alone. LIMITATIONS: Retrospective study, limited sample size without a control group for comparison. CONCLUSIONS: PDT of Barrett's esophagus with HGD, intramucosal carcinoma, or T1 cancer can result in ablation of dysplasia and/or eradication of all Barrett's epithelium. Factors associated with the likelihood of response include length of Barrett's esophagus. The presence of intramucosal carcinoma or T1 cancer was not associated with higher likelihood of treatment failure.


Assuntos
Esôfago de Barrett/tratamento farmacológico , Esôfago de Barrett/patologia , Endoscopia Gastrointestinal , Neoplasias Esofágicas/tratamento farmacológico , Fotoquimioterapia , Idoso , Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/patologia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Resultado do Tratamento
4.
Clin Gastroenterol Hepatol ; 6(3): 302-8, 2008 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-18255349

RESUMO

BACKGROUND & AIMS: The most common significant adverse event after photodynamic therapy (PDT) with porfimer sodium is esophageal stricture formation. This study assessed whether pretreatment variables, including prior endoscopic therapy for Barrett's esophagus, are associated with post-PDT stricturing. METHODS: Data from all patients who had undergone PDT with porfimer sodium for Barrett's esophagus with high-grade dysplasia, intramucosal carcinoma, or T1 cancer at our institution since 1997 were reviewed. RESULTS: One hundred sixteen patients underwent 160 courses of PDT. The incidence of stricture formation after index PDT was 16% (19/116). For all PDT courses, the overall incidence of stricture was 23% (37/160). Stricture rate was significantly higher after a second PDT course compared with index PDT (43% vs 16%, P = .0007). There was no association between post-PDT stricture development and age, gender, body mass index, or prior endoscopic mucosal resection. Patients who developed a stricture had a longer length of Barrett's esophagus before treatment than those who did not develop a stricture (7.7 vs 5.7 cm for index PDT only, P = .025; 7.4 vs 5.7 cm for all PDT courses, P = .007). Length of Barrett's esophagus, multiple PDT courses, and presence of intramucosal carcinoma on pretreatment pathology were independent predictors of post-PDT stricture in a stepwise logistic regression analysis controlling for treatment variables, including treatment length. CONCLUSIONS: An increased risk of stricture development was seen after multiple courses of PDT. An association between post-PDT stricture and length of Barrett's esophagus but not treatment length was also found. Endoscopic mucosal resection did not appear to influence the likelihood of stricture development after porfimer sodium-based PDT.


Assuntos
Éter de Diematoporfirina/efeitos adversos , Estenose Esofágica/etiologia , Fármacos Fotossensibilizantes/efeitos adversos , Fototerapia/efeitos adversos , Idoso , Esôfago de Barrett/patologia , Esôfago de Barrett/terapia , Éter de Diematoporfirina/uso terapêutico , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/terapia , Estenose Esofágica/diagnóstico , Estenose Esofágica/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Estadiamento de Neoplasias , Razão de Chances , Fármacos Fotossensibilizantes/uso terapêutico , Prognóstico , Estudos Retrospectivos
5.
Am J Surg Pathol ; 29(5): 680-6, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15832094

RESUMO

Endoscopic mucosal resection (EMR), a relatively new endoluminal therapeutic technique with low morbidity and no mortality reported to date, is advocated for the treatment of Barrett's esophagus (BE)-related superficial neoplasms. However, recent studies revise its success downward, particularly regarding the ability to achieve complete excision. To evaluate what remains an evolving technique, we analyzed our experience with a series of 27 esophageal EMRs (20 lesions in 18 patients). Our goal was to evaluate the diagnostic, staging, and therapeutic advantages of EMR separately by correlating the initial biopsies and pre-EMR endoscopic ultrasound (EUS) staging with the final histologic diagnoses and stage. Persistence/recurrence of neoplastic tissue was also correlated with the margin status of the resections. The mean size of the neoplasms, which included low-grade dysplasias (n=2), high-grade dysplasias (n=8), intramucosal carcinomas (n=14), and submucosal invasive carcinomas (n=3), was 11 mm. EUS correctly reported an intramucosal or submucosal lesion in 70% of the cases while it overstaged 18% and understaged 12% of the cases. The biopsy diagnosis corresponded to the EMR diagnosis in 63% of the cases. The biopsy underestimated the grade of the lesion in 21% of the cases. EMR revealed a lower histologic grade compared with the biopsy in 16% of the cases. The resection was microscopically complete in only 4% of the cases. No residual/recurrent disease was observed in 10 lesions (9 patients) at 4 to 63 months (mean, 23 months) post-EMR. However, 9 lesions (8 patients) persisted/recurred 28 days to 25 months (mean, 6 months) after treatment; 56% of the cases with positive lateral margin(s) and negative deep margin persisted/recurred. However, 86% of the EMRs with positive deep margin showed residual tumor/recurrence on follow-up biopsies. In conclusion, we observed that EMR offers improved diagnosis and staging as compared with biopsy and EUS. This is a significant advantage since it can modify patients' management. However, frequent incompleteness of resection and high persistence/recurrence are significant pitfalls that dictate continued endoscopic surveillance.


Assuntos
Adenocarcinoma/cirurgia , Esôfago de Barrett/cirurgia , Endoscopia Gastrointestinal/métodos , Endoscopia/métodos , Neoplasias Esofágicas/cirurgia , Adenocarcinoma/patologia , Esôfago de Barrett/patologia , Biópsia , Neoplasias Esofágicas/patologia , Humanos
6.
Virchows Arch ; 459(6): 581-6, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22081106

RESUMO

Cyclooxygenase-2 expression is upregulated in Barrett's esophagus and esophageal adenocarcinoma. Photodynamic therapy using porfimer sodium can result in ablation of dysplasia and intramucosal carcinoma, eradication of Barrett's esophagus, and restitution of squamous epithelium. The aim of this study was to determine the effect of photodynamic therapy on cyclooxygenase-2 expression in esophageal epithelium. Paired pre- and post-photodynamic therapy biopsy samples from the same anatomical levels of 20 individuals who had undergone photodynamic therapy for Barrett's esophagus with high-grade dysplasia and/or intramucosal carcinoma were immunostained using a cyclooxygenase-2 monoclonal antibody. Cyclooxygenase-2 expression was graded in squamous epithelium, Barrett's esophagus, and neoplasia (if present) as follows: grade 0 (no staining), grade 1 (staining in 1-10% of cells), grade 2 (staining in 11-90% of cells), and grade 3 (staining in >90% of cells). Pre-photodynamic therapy median cyclooxygenase-2 expression was grade 2 (range 1-3) in neoplastic foci and grade 1 (range 1-3) in nondysplastic Barrett's esophagus (P=0.0009 for pairwise comparison). With the exception of a few cells staining in the basal epithelial layers, median cyclooxygenase-2 expression was graded as 0 (similar to controls) in both pre-photodynamic therapy squamous epithelium and post-photodynamic therapy neosquamous epithelium. This was significantly lower when compared to either neoplastic foci (P<0.0001) or nondysplastic Barrett's esophagus (P<0.0001) pre-photodynamic therapy. Notably, in four patients with post-photodynamic therapy recurrent neoplasia, cyclooxygenase-2 expression returned to elevated levels. Cyclooxygenase-2 expression is elevated in Barrett's esophagus with high-grade dysplasia or intramucosal carcinoma prior to photodynamic therapy. Following successful photodynamic therapy, cyclooxygenase-2 expression in neosquamous epithelium returns to a low baseline level similar to that observed in native esophageal squamous epithelium. Post-photodynamic therapy neoplastic recurrence is associated with elevated cyclooxygenase-2 expression. Prospective studies should determine whether cyclooxygenase inhibitors have a role as adjuvant therapy to prevent recurrence of Barrett's esophagus following endoscopic therapy.


Assuntos
Esôfago de Barrett/tratamento farmacológico , Ciclo-Oxigenase 2/metabolismo , Esôfago/metabolismo , Esôfago/patologia , Fotoquimioterapia , Idoso , Idoso de 80 Anos ou mais , Esôfago de Barrett/metabolismo , Esôfago de Barrett/patologia , Biópsia , Estudos de Coortes , Éter de Diematoporfirina/uso terapêutico , Epitélio/metabolismo , Epitélio/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fármacos Fotossensibilizantes/uso terapêutico , Estudos Retrospectivos , Resultado do Tratamento
7.
Dig Dis Sci ; 51(10): 1783-90, 2006 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-16967312

RESUMO

To determine if multilayered epithelium (MLE) is a useful prognostic indicator for a benign natural history of Barrett's epithelium, we evaluated endoscopic biopsies from patients with Barrett's epithelium without and with dysplasia and/or adenocarcinoma and from non-Barrett's controls for the presence of MLE. MLE was found in 6% of non-Barrett's controls, 30% of Barrett's patients with no dysplasia, and 14% of Barrett's patients with dysplasia and/or adenocarcinoma. MLE was significantly associated with shorter lengths of Barrett's epithelium in both Barrett's groups. Three of 5 photodynamic therapy patients were noted to develop MLE after therapy. MLE may be found in patients with dysplasia and/or adenocarcinoma and after photodynamic therapy; its presence is not useful as a prognostic indicator for a more benign course of Barrett's. This study confirms that MLE is significantly associated with shorter lengths of Barrett's epithelium.


Assuntos
Adenocarcinoma/patologia , Esôfago de Barrett/patologia , Epitélio/patologia , Neoplasias Esofágicas/patologia , Esôfago/patologia , Adulto , Idoso , Esôfago de Barrett/tratamento farmacológico , Estudos de Casos e Controles , Esofagoscopia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fotoquimioterapia , Índice de Gravidade de Doença
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