Überwachung von Patienten mit Barrett-Ösophagus - eine Übersicht

Zusammenfassung

Der Barrett-Ösophagus stellt eine schwer wiegende Komplikation des gastroösophagealen Refluxes dar und ist mit einem 30- bis 125fach erhöhten Karzinomrisiko assoziiert. Dabei hat die Zunahme der Inzidenz des Adenokarzinoms den Barrett-Ösophagus in den Blickpunkt des Interesses gestellt. Nach anfänglichen Unstimmigkeiten in der Definition des Barrett-Ösophagus werden heute Barrett-Segmente, d. h. histologischer Nachweis von spezialisiertem intestinalisierten Zylinderepithel, von mehr als 3 cm Länge allgemein als Long-Segment-Barrett-Ösophagus (LBS) und solche mit weniger als 3 cm Ausdehnung als Short-Segment-Barrett-Ösophagus (SBS) bezeichnet. Histologischer Nachweis von intestinalem Epithel ohne entsprechende endoskopische Veränderungen wird als mikroskopischer Barrett- oder Ultra-Short-Barrett-Ösophagus definiert.

Der Nachweis dysplastischer Veränderungen gilt als der wichtigste Risikofaktor für die Entstehung eines Adenokarzinoms. Die Überwachungsempfehlungen orientieren sich am Vorhandensein bzw. Fehlen von Dysplasien unterschiedlichen Schweregrades. Zahlreiche neue Methoden (Färbeverfahren, Fluoreszenzdiagnostik, optische Kohärenztomographie) werden in der Diagnostik des Barrett-Ösophagus und der Früherkennung maligner und prämaligner Läsionen evaluiert. Dennoch sind zum jetzigen Zeitpunkt 4 Quadrantenbiopsien in Abständen von 1-2 cm für den LBS empfehlenswert, die Zeitintervalle werden dabei vom Nachweis dysplastischer Areale bestimmt. Ob Patienten mit SBS ähnlich wie Patienten mit LBS zu überwachen sind, ist noch unklar und bedarf weiterer Studien.

Surveillance of patients with Barrett’s esophagus

Barrett’s esophagus is a major complication of gastroesophageal reflux disease and is associated with 30-125 fold increased risk of developing carcinoma. Because of the rising incidence of esophageal adenocarcinoma the malignant potential of Barrett’s esophagus has been generally recognized. The definition of Barrett’s esophagus has evolved over the last decades. It is now accepted that “Long-Barrett-Segment” (LBS) is used when intestinal-type epithelium, characterized by the presence of goblet cells, is detected in the distal esophagus > 3 cm in length. The term “Short-Barrett-Segment” (SBS) is defined by intestinal metaplasia detection < 3 cm in length in the distal esophagus. Recently, there has been focus on microscopic Barrett’s esophagus, so called “Ultra-Short-Barrett’s esophagus”, with histological evidence of intestinal metaplasia without endoscopic appearance.

The most significant predictor of the risk of malignancy in patients with Barrett’s esophagus is the presence of dysplasia. Guidelines for surveillance are based on the diagnosis of dysplastic lesions. New methods (e. g. Methylene blue staining, endoscopic fluorescence detection, OCT) to improve the recognition of Barrett’s esophagus and especially enhance the detection of premaligant and malignant lesions are under evaluation. So far, the standard biopsy protocol for patients with LBS includes biopsies in the 4 quadrants every 1-2 cm, whereas the appropriate surveillance intervals are dependent on the grade of dysplasia. Whether surveillance in patients with SBS has to be similar to that in patients with LBS is unclear and needs further evaluation.

Schlüsselwörter

Barrett-Ösophagus - Überwachung - 5-Aminolävulinsäure - endoskopische Fluoreszenzdiagnostik - Dysplasie - Adenokarzinom - Färbeverfahren

Key words

Barrett’s Esophagus - Surveillance - 5-aminolevulinic Acid - Endoscopic Fluorescence Detection - Dysplasia - Adenocarcinoma - Methylene Blue Staining

Literatur

• 1 Adrian A, Ter H, Cassidy M. et al . High-resolution endoluminal sonography is a sensitive modality for the identification of Barrett’s esophagus.  Gastrointest Endosc. 1997;  46 147-151
• 2 Brand S, Ponero J, Bouma B. et al . Optical coherence tomography in the gastrointestinal tract.  Endoscopy. 2000;  32 796-803
• 3 Bytzer P, Christensen P, Damkier P, Vinding K, Seersholm N. Adenocarcinoma of the esophagus and Barrett’s esophagus: A population-based study.  Am J Gastroenterol. 1999;  94 86-91
• 4 Cameron A, Carpenter H. Barrett’s esophagus, high-grade dysplasia and early adenocarcinoma.  Am J Gastroenterol. 1997;  92 586-591
• 5 Cameron A, Ott B, Payne W. The incidence of adenocarcinoma in columnar-lined (Barrett’s) esophagus.  N Engl J Med. 1985;  313 857-859
• 6 Canto M, Setrakian S, Willis J. et al . Methylene blue-directed biopsies improve detection of intestinal metaplasia and dysplasia in Barrett’s esophagus.  Gastrointest Endosc. 2000;  51 560-568
• 7 Caygill C, Reed P, Johnston B. et al . A Single center’s 20 years’ experience of columnar-lined (Barrett’s) esophagus diagnosis.  Eur J Gastroenterol Hepatol. 1999;  11 1355-1358
• 8 Clark G, Ireland A, Peters J. et al . Short-segment Barrett’s esophagus: A prevalent complication of gastroesophageal reflux disease with malignant potential.  J Gastrointest Surg. 1997;  1 113-122
• 9 DeMas C, Krämer M, Seifert E, Vieth M, Stolte M. Short Barrett: prevalence and risk factors.  Scand J Gastroenterol. 1999;  11 1065-1070
• 10 Drewitz D, Sampliner R, Garewal H. The incidence of adenocarcinoma in Barrett’s esophagus: A prospective study of 170 patients followed 4.8 years.  Am J Gastroenterol. 1997;  92 212-215
• 11 Ell C, May A, Gossner L. et al . Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus.  Gastroenterology. 2000;  118 670-677
• 12 Endlicher E, Knüchel R, Hauser T. et al . Endoscopic fluorescence detection of low and high grade dysplasia in Barrett’s oesophagus using systemic or local 5-aminolevulinic acid sensitization.  Gut. 2001;  48 314-319
• 13 Falk G. Barrett’s esophagus.  Gastrointest Endosc Clin N Am. 1994;  4 773-789
• 14 Falk G, Catalano M, Sivak M, Rice T, Dam J V. Endosonography in the evaluation of patients with Barrett’s esophagus and high grade dysplasia.  Gastrointest Endosc. 1994;  40 207-212
• 15 Falk G, Ours T, Richter J. Practice pattern for surveillance of Barrett’s esophagus in the United States.  Gastrointest Endosc. 2000;  52 197-203
• 16 Falk G, Rice T, Goldblum J, Richter J. Jumbo biopsy forceps protocol still misses unsuspected cancer in Barrett’s esophagus with high-grade dysplasia.  Gastrointest Endosc. 1999;  49 170-176
• 17 Gangarossa L, Halter S, Mertz H. Methylene blue staining and endoscopic ultrasound evaluation of Barrett’s esophagus with low-grade dysplasia.  Dig Dis Sci. 2000;  45 225-229
• 18 Gleeson C, McDougall N, Russell S. et al . Microsatellite analysis provides evidence of neoplastic transformation in long-segment, but not in short-segment, Barrett’s oesophagus.  Int J Cancer. 2000;  85 482-485
• 19 Gossner L, Stolte M, Sroka R. et al . Photodynamic ablation of high-grade dysplasia and early cancer in Barrett’ s esophagus by means of 5-aminolevulinic acid.  Gastroenterology. 1998;  114 448-455
• 20 Gross C, Canto M, Hixson J, Powe N. Management of Barrett’s esophagus: A national study of practice patterns and their cost implications.  Am J Gastroenterol. 1999;  94 3440-3447
• 21 Grunewald M, Vieth M, Kreibich H, Bethke B, Stolte M. Untersuchungen zum Stand der Diagnostik des Barrett-Ösophagus.  Dtsch Med Wochenschr. 1997;  122 427-431
• 22 Hameeteman W, Tytgat G, Houthoff H, van den Tweel J. Barrett’s esophagus: Development of dysplasia and adenocarcinoma.  Gastroenterology. 1989;  96 1249-1256
• 23 Haringsma J, Prawirodirdjo W, Tytgat G. Accuracy of fluorescence imaging of dysplasia in Barrett’s esophagus.  Gastroenterology. 1999;  116 A418
• 24 Iftikhar S, James P, Steele R, Hardcastle J, Atkinson M. Length of Barrett’s esophagus: An important factor in the development of dysplasia and adenocarcinoma.  Gut. 1992;  33 1155-1158
• 25 Jäckle S, Gladkova N, Feldchtein F. et al . In vivo optical coherence tomography of the human gastrointestinal tract-toward optical biopsy.  Endoscopy. 2000;  32 743-749
• 26 Klump B, Hsieh C, Holzmann K. et al . Diagnostic significance of nuclear p53 expression in the surveillance of Barrett’s esophagus - a longitudinal study.  Z Gastroenterol. 1999;  37 1005-1011
• 27 Lagergren J, Bergström R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma.  N Engl J Med. 1999;  340 825-831
• 28 Levine D, Blount P, Rudolph R, Reid B. Saftey of a systematic endoscopic biopsy protocol in patients with Barrett’s esophagus.  Am J Gastroenterol. 2000;  95 1152-1157
• 29 Levine D, Haggitt R, Blount P. et al . An endoscopic biopsy protocol can differentiate high-grade dysplasia from early adenocarcinoma in Barrett’s esophagus.  Gastroenterology. 1993;  105 40-50
• 30 Mann N, Tsai M, Nair P. Barrett’s esophagus in patients with symptomatic reflux esophagitis.  Am J Gastroenterol. 1989;  84 1494-1496
• 31 Marshall R, Anggiansah A, Owen W. Bile in the oesophagus: Clinical relevance and ambulatory detection.  Br J Surg. 1997;  84 21-28
• 32 Messmann H, Knüchel R, Szeimies R. et al . Endoscopic fluorescence detection of dysplasia in patients with Barrett’s oesophagus, ulcerative colitis or adenomatous polyps after 5-amino- laevulinic induced protoporphyrin IX sensitization.  Gastrointest Endosc. 1999;  49 97-101
• 33 Miros M, Kerlin P, Walker N. Only patients with dysplasia progress to adenocarcinoma in Barrett’s esophagus.  Gut. 1991;  32 1441-1446
• 34 Nishimaki T, Hölscher A, Schüler M. et al . Histopathologic characteristics of early adenocarcinoma in Barrett’s esophagus.  Cancer. 1991;  68 1731-1736
• 35 O’Connor J, Falk G, Richter J. The incidence of adenocarcinoma and dysplasia in Barrett’s esophagus: Report on the Cleveland Clinic Barrett’s Esophagus Registry.  Am J Gastroenterol. 1999;  94 2037-2042
• 36 Ormsby A, Vaezi M, Richter J. et al . Cytokeratin immunoreactivity patterns in the diagnosis of short-segment Barrett’s esophagus.  Am J Gastroenterol. 2000;  119 683-690
• 37 Overholt B, Panjehpour M, Haydek J. Photodynamic therapy for Barrett’s esophagus: Follow-up in 100 patients.  Gastrointest Endosc. 1999;  49 1-7
• 38 Pally S, Sampliner R, Garewal H. Management of high-grade dysplasia in Barrett’s esophagus.  J Clin Gastroenenterol. 1989;  11 369-372
• 39 Panjehpour M, Overholt B, Vo-Dinh T. et al . Endoscopic fluorescence detection of high-grade dysplasia in Barrett’s esophagus.  Gastroenterology. 1996;  111 93-101
• 40 Provenzale D, Schmitt C, Wong J. Barrett’s esophagus: A new look at surveillance based on emerging estimates of cancer risk.  Am J Gastroenterol. 1999;  94 2043-2053
• 41 Reid B, Blount P, Rubin C. et al . Flow-cytometric and histological progression to malignancy in Barrett’s esophagus: Prospective endoscopic surveillance of a cohort.  Gastroenterology. 1992;  102 1212-1219
• 42 Reid B, Haggitt R, Rubin C. et al . Observer variation in the diagnosis of dysplasia in Barrett’s esophagus.  Hum Pathol. 1988;  19 166-178
• 43 Reid B, Levine D, Longton G, Blount P, Rabinovitch P. Predictors of progression to cancer in Barrett’s esophagus: Baseline histology and flow cytometry identify low- and high-risk patient subset.  Am J Gastroenterol. 2000;  95 1669-1676
• 44 Robertson C, Mayberry I, Nicholson D, James P, Atkinson M. Value of endoscopic surveillance in the detection of neoplastic change in Barrett’s oesophagus.  Br J Surg. 1988;  75 760-763
• 45 Sampliner R. Practice guidelines on the diagnosis, surveillance and therapy of Barrett’s esophagus. The Practice Parameters Committee of the American College of Gastroenterology.  Am J Gastroenterol. 1998;  93 1028-1032
• 46 Shaheen N, Crosby M, Bozymski E, Sandler R. Is there a publication bias in the reporting of cancer risk in Barrett’s esophagus?.  Gastroenterology. 2000;  119 333-338
• 47 Sharma P, Morales T, Bhattacharyya A, Garewal H, Sampliner R. Dysplasia in short-segment Barrett’s esophagus: A prospective 3-year follow-up.  Am J Gastroenterol. 1997;  92 2012-2016
• 48 Sharma P, Weston A, Morales T. et al . Relative risk of dysplasia for patients with intestinal metaplasia in the distal oesophagus and in the gastric cardia.  Gut. 2000;  46 9-13
• 49 Sjögren R, Johnson L. Barrett’s esophagus: A review.  Am J Med. 1983;  74 313-321
• 50 Soni A, Sampliner R, Sonnenberg A. Screening for high-grade dysplasia in gastroesophageal reflux disease: Is it cost effective?.  Am J Gastroenterol. 2000;  95 2086-2093
• 51 Spechler S, Robbins A, Rubins H. Adenocarinoma and Barrett’s esophagus: An overrated risk?.  Gastroenterology. 1984;  87 927-933
• 52 Srivastava A, Vanagunas A, Kamel P, Cooper R. Endoscopic ultrasound in the evaluation of Barrett’s esophagus: A preliminary report.  Am J Gastroenterol. 1994;  89 2192-2195
• 53 von Stael H olstein C, Nilsson A, Andersson-Engels S. et al . Detection of adenocarcinoma in Barrett’s esophagus by means of laser-induced fluorescence.  Gut. 1996;  39 711-716
• 54 Stein H, Kauer W, Feussner H, Siewert J. Bile reflux in benign and malignant Barrett’s esophagus: Effect of medical acid suppression and Nissen fundoplicatio.  J Gastrointest Surg. 1998;  2 333-341
• 55 Streitz J, Andrews C, Ellis F. Endoscopic surveillance of Barrett’s esophagus.  J Thorac Cardiovasc Surg. 1993;  105 383-388
• 56 Streitz J, Ellis F, Tilden R, Erickson R. Endoscopic surveillance of Barrett’s esophagus: A cost-effectivness comparison with mammographic surveillance for breast cancer.  Am J Gastroenterol. 1998;  93 911-915
• 57 Vaezi M, Falk G, Peek R. et al . CagA-positive strains of Helicobacter pylori may protect against Barrett’s esophagus.  Am J Gastroenterol. 2000;  95 2206-2211
• 58 Vaezi M, Richter J. Bile reflux in columnar-lined esophagus.  Gastroenterol Clin North Am. 1997;  26 565-582
• 59 Van Sandick J, Bartelsman J, van Lanschot J, Tytgat G, Obertop H. Surveillance of Barrett’s esophagus: Physicians’ practices and review of current guidelines.  Eur J Gastroenterol Hepatol. 2000;  12 111-117
• 60 Van Sandick J, van Lanschot J, Kuiken B. et al . Impact of endoscopic biopsy surveillance of Barrett’s esophagus on pathological stage and clinical outcome of Barrett’s carcinoma.  Gut. 1998;  43 216-222
• 61 Vieth M, Stolte M. Barrett’s mucosa, Barrett’s dysplasia and Barrett’s carcinoma: Diagnostic endoscopy without biopsy- taking does not suffice.  Dis Esoph. 2000;  13 23-27
• 62 Wallace M, Perelman L, Backman V. et al . Endoscopic detection of dysplasia in patients with Barrett’s esophagus using light scattering spectroscopy.  Gastroenterology. 2000;  119 677-682
• 63 Weston A, Badr A, Hassanein R. Prospective multivariate analysis of clinical, endoscopic, and histological factors predictive of the development of Barrett’s multifocal high-grade dysplasia or adenocarcinoma.  Am J Gastroenterol. 1999;  94 3413-3419
• 64 Weston A, Badr A, Topalovski M. et al . Prospective evaluation of the prevalence of gastric Helicobacter pylori infection in patients with GERD, Barrett’s esophagus, Barrett’s dysplasia, and Barrett’s adenocarcinoma.  Am J Gastroenterol. 2000;  95 387-394
• 65 Weston A, Krmpotich P, Cherian R, Dixon A, Topalosvki M. Prospective long-term endoscopic and histological follow-up of short segment Barrett’s esophagus: Comparison with traditional long segment Barrett’s esophagus.  Am J Gastroenterol. 1997;  92 407-413
• 66 Weston A, Sharma P, Topalovski M. et al . Long-term follow-up of Barrett’s high-grade dysplasia.  Am J Gastroenterol. 2000;  95 1888-1893
• 67 Winters C J, Spurling T, Chobanian S. et al . Barrett’s esophagus: A prevalent occult complication of gastroesophageal reflux disease.  Gastroenterology. 1987;  92 118-124
• 68 Wright T. High-grade dysplasia in Barrett’s esophagus.  Br J Surg. 1997;  84 760-766