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Clinical Crossroads |

Barrett Esophagus and Risk of Esophageal Cancer:  A Clinical Review

Stuart Jon Spechler, MD, Discussant1,2
[+] Author Affiliations
1Chief of Gastroenterology, VA North Texas Healthcare System, Dallas, Texas
2Professor of Medicine and Berta M. and Cecil O. Patterson Chair in Gastroenterology, University of Texas Southwestern Medical Center, Dallas
JAMA. 2013;310(6):627-636. doi:10.1001/jama.2013.226450.
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Importance  Barrett esophagus, a complication of gastroesophageal reflux disease (GERD), predisposes patients to esophageal adenocarcinoma, a tumor that has increased in incidence more than 7-fold over the past several decades. Controversy exists regarding the issues of endoscopic screening and surveillance for Barrett esophagus, treatment for the underlying GERD, and the role of endoscopic eradication therapy.

Objectives  To review current concepts on the pathogenesis, diagnosis, and treatment of Barrett esophagus; to discuss the importance of dysplasia and the role of endoscopic eradication therapy for its treatment; and to review current management guidelines.

Evidence Review  MEDLINE and the Cochrane Library were searched from 1984 to April 2013. Additional citations were obtained by reviewing references from selected research and review articles.

Findings  Risk factors for cancer in Barrett esophagus include chronic GERD, hiatal hernia, advanced age, male sex, white race, cigarette smoking, and obesity with an intra-abdominal body fat distribution. The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia. High-quality studies have found no significant differences in cancer incidence for patients with Barrett esophagus whose GERD is treated medically or surgically. Endoscopic eradication therapy with radiofrequency ablation significantly reduces the frequency of progression to cancer for patients with high-grade dysplasia.

Conclusions and Relevance  Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barrett esophagus. For patients with Barrett esophagus without dysplasia, endoscopic surveillance at intervals of 3 to 5 years is recommended, and GERD is treated much as it is for patients without Barrett esophagus. Endoscopic eradication therapy is the treatment of choice for high-grade dysplasia and is an option for low-grade dysplasia. Endoscopic eradication therapy is not recommended for the general population of patients with nondysplastic Barrett esophagus.

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Figure 1.
Endoscopic Image of Barrett Esophagus

Note the contrast between the Barrett columnar mucosa, with its reddish color and velvet-like texture, and the pale, glossy esophageal squamous mucosa. The yellow arrowheads mark the tops of the gastric folds, which identify the level of the gastroesophageal junction.

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Figure 2.
Photomicrograph of Esophageal Biopsy Specimen Showing the Junction Between Stratified Squamous Epithelium and Specialized Intestinal Metaplasia

The yellow arrowheads identify the prominent goblet cells in the intestinal metaplasia of Barrett esophagus. Hematoxylin-eosin stain, original magnification ×20. Debris in the esophageal lumen was removed using Adobe Photoshop. Photomicrograph reproduced with permission from Robert Genta, MD.

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Figure 3.
Schematic of the Esophageal Wall and Grading of Esophageal Neoplasms

Endoscopic eradication therapy cannot cure tumors that have metastasized to lymph nodes. Endoscopic eradication therapy is recommended for patients with mucosal neoplasms (high-grade dysplasia and intramucosal carcinoma), for whom the risk of lymph node metastases is only 1% to 2%. For invasive tumors that breach the muscularis mucosae to enter the submucosa, the risk of lymph node metastases is higher than 10% and endoscopic therapy generally is not recommended.

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