The epidemiology, diagnosis, and treatment of Barrett's carcinoma

Abstract

Background: Roughly 3000 new cases of Barrett's carcinoma arise in Germany each year. In view of recent advances in the epidemiology, diagnosis, and treatment of this disease, an update of the clinical recommendations is in order.

Methods: This review is based on selected relevant publications, including current reviews, meta-analyses, and guidelines.

Results: The risk of progression of Barrett's esophagus to carcinoma lies between 0.10% and 0.15% per year. Risk factors for progression include male sex, age over 50 years, obesity, longstanding and frequent reflux symptoms, smoking, length of the Barrett's esophagus, and intraepithelial neoplasia. Well-differentiated carcinomas that are confined to the esophageal mucosa can be resected endoscopically with a cure rate above 90%. For more advanced, but still locally confined tumors, surgical resection is the treatment of choice. In stages cT3/4, the prognosis can be improved with neo-adjuvant chemo - therapy or combined radiotherapy and chemotherapy. Metastatic Barrett's carcinoma can be treated by endoscopic, chemotherapeutic, radiotherapeutic, and palliative methods.

Conclusion: Early carcinoma can often be cured by endoscopic resection. Locally advanced carcinoma calls for multimodal treatment. Current research focuses on means of preventing the progression of Barrett's esophagus, the scope of applicability of endoscopic techniques, and the optimization of multimodal treatment strategies for advanced disease.

Figures

Figure 1

From gastroesophageal reflux disease (GERD) to Barrett’s carcinoma: risk of progression (according to 7, 8). About 40% of carcinomas occur without clinical signs of pre-existing reflux disease. LG-IEN, low-grade intraepithelial neoplasia; HG-IEN, high-grade intraepithelial neoplasia

Figure 2

Endoscopic images of Barrett’s esophagus made by a high-definition endoscope with acetic acid for contrast enhancement and with electronic image processing (iScan) a+b) Red columnar epithelial metaplasia surrounded by pale squamous epithelium c+d) After electronic image processing

Figure 3

TNM (2010) classification of early carcinomas—left) subclassification of early carcinomas pT1a and pT1b in m1–3 (blue) and right) sm1–3 (green), according to the Japanese classification. HG-IEN, high-grade intraepithelial neoplasia; Cis, carcinoma in situ; HGD, high-grade dysplasia

Figure 4

Endoscopic appearance of an early-stage Barrett’s carcinoma a) high-definition video endoscopy; b) clearer contours after spraying with acetic acid; c) site after endoscopic resection

Figure 5

Algorithm for diagnosis and treatment of Barrett’s carcinoma (follow-up after endoscopic resection after 3 months, then every 6 months for 2 years, then once a year). Carcinoma restricted to the mucosa is treated endoscopically. In some cases where there is superficial submucosal invasion (T1b–sm1), endoscopic resection may suffice. Stage cT2 carcinomas should, and stage cT3/cT4a carcinomas must, be referred for neoadjuvant therapy (chemo- or radiochemotherapy) followed by esophageal resection. CTX, chemotherapy; R-CTX, radiochemotherapy