Background and study aims: The reference surveillance method in patients with Barrett’s esophagus is careful endoscopic observation, with targeted as well as random four-quadrant biopsies. Autofluorescence endoscopy (AFE) may make it easier to locate neoplasia. The aim of this study was to elucidate the diagnostic accuracy of surveillance with AFE-guided plus four-quadrant biopsies in comparison with the conventional approach.
Patients and methods: A total of 187 of 200 consecutive Barrett’s esophagus patients who were initially enrolled (73 % male, mean age 67 years, mean Barrett’s segment length 4.6 cm), who underwent endoscopy for Barrett’s esophagus in four study centers, were randomly assigned to undergo either AFE-targeted biopsy followed by four-quadrant biopsies or conventional endoscopic surveillance, also including four-quadrant biopsies (study phase 1). After exclusion of patients with early cancer or high-grade dysplasia, who underwent endoscopic or surgical treatment, as well as those who declined to participate in phase 2 of the study, 130 patients remained. These patients were examined again with the alternative method after a mean of 10 weeks, using the same methods described. The main study parameter was the detection of early cancer/adenocarcinoma or high-grade dysplasia (HGD), comparing both approaches in study phase 1; the secondary study aim in phase 2 was to assess the additional value of the AFE-guided approach after conventional surveillance, and vice versa. Test accuracy measures were derived from study phase 1.
Results: In study phase 1, the AFE and conventional approaches yielded adenocarcinoma/HGD rates of 12 % and 5.3 %, respectively, on a per-patient basis. With AFE, four previously unrecognized adenocarcinoma/HGD lesions were identified (4.3 % of the patients); with the conventional approach, one new lesion (1.1 %) was identified. Of the 19 adenocarcinoma/HGD lesions detected during AFE endoscopy in study phase 1, eight were visualized, while 11 were only detected using untargeted four-quadrant biopsies (sensitivity 42 %). Of the 766 biopsies classified at histology as being nonneoplastic, 58 appeared suspicious (specificity 92 %, positive predictive value 12 %, negative predictive value 98.5 %). In study phase 2, AFE detected two further lesions in addition to the initial alternative approach in 3.2 % of cases, in comparison with one lesion with conventional endoscopy (1.7 %).
Conclusions: In this referral Barrett’s esophagus population with a higher prevalence of neoplastic lesions, the AFE-guided approach improved the diagnostic yield for neoplasia in comparison with the conventional approach using four-quadrant biopsies. However, AFE alone was not suitable for replacing the standard four-quadrant biopsy protocol.
References
1
Corley D A, Levin T R, Habel L A. et al .
Surveillance and survival in Barrett’s adenocarcinomas: a population-based study.
Gastroenterology.
2002;
122
633-640
2
Spechler S J, Goyal R K.
The columnar-lined esophagus, intestinal metaplasia, and Norman Barrett.
Gastroenterology.
1996;
110
614-621
3
Streitz J M, Ellis F H, Tilden R L. et al .
Endoscopic surveillance of Barrett’s esophagus: a cost-effectiveness comparison with mammographic surveillance for breast cancer.
Am J Gastroenterol.
1998;
93
911-915
4
Hurschler D, Borovicka J, Neuweiler J. et al .
Increased detection rates for Barrett’s oesophagus without rise in incidence of oesophageal adenocarcinoma - a ten-year survey in Eastern Switzerland.
Swiss Med Wkly.
2003;
133
507-514
5
Drewitz D J, Sampliner R E, Garewal H S.
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
6
Reid B J, Blount P L, Rubin C E. et al .
Flow-cytometric and histological progression to malignancy in Barrett’s esophagus: prospective endoscopic surveillance of a cohort.
Gastroenterology.
1992;
102
1212-1219
7
Weston A P, Badr A S, Hassanein R S.
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
8
Levine D S.
Management of dysplasia in the columnar-lined esophagus.
Gastroenterol Clin North Am.
1997;
26
613-634
9
Stepp H, Sroka R, Baumgartner R.
Fluorescence endoscopy of gastrointestinal diseases: basic principles, techniques, and clinical experience.
Endoscopy.
1998;
30
379-386
10
Arens C, Dreyer T, Glanz H. et al .
Indirect autofluorescence laryngoscopy in the diagnosis of laryngeal cancer and its precursor lesions.
Eur Arch Otorhinolaryngol.
2004;
261
71-76
11
Stepinac T, Felley C, Jornod P. et al .
Endoscopic fluorescence detection of intraepithelial neoplasia in Barrett’s esophagus after oral administration of aminolevulinic acid.
Endoscopy.
2003;
35
663-668
12
Vo-Dinh T, Panjehpour M, Overholt B F.
Laser-induced fluorescence for esophageal cancer and dysplasia diagnosis.
Adv Opt Biopsy Opt Mammogr.
1998;
838
116-22
13
Egger K, Werner M, Meining A. et al .
Biopsy surveillance is still necessary in patients with Barrett’s oesophagus despite new endoscopic imaging techniques.
Gut.
2003;
52
18-23
14
Niepsuj K, Niepsuj G, Cebula W. et al .
Autofluorescence endoscopy for detection of high-grade dysplasia in short-segment Barrett’s esophagus.
Gastrointest Endosc.
2003;
58
715-719
15
Mayinger B, Horner P, Jordan M. et al .
Light-induced autofluorescence spectroscopy for the endoscopic detection of esophageal cancer.
Gastrointest Endosc.
2001;
54
195-201
16
Haggitt R C.
Barrett’s esophagus, dysplasia, and adenocarcinoma.
Hum Pathol.
1994;
25
982-993
17
Kara M A, Smits M E, Rosmolen W D. et al .
A randomized crossover study comparing light-induced fluorescence endoscopy with standard videoendoscopy for the detection of early neoplasia in Barrett’s esophagus.
Gastrointest Endosc.
2005;
61
671-678
18
Kara M A, Peters F P, ten Kate F J. et al .
Endoscopic video autofluorescence imaging may improve the detection of early neoplasia in patients with Barrett’s esophagus.
Gastrointest Endosc.
2005;
61
679-685
19
Herth F JF, Ernst A, Becker H D.
Autofluorescence bronchoscopy: a comparison of two systems (LIFE and D-light).
Respiration.
2003;
70
395-398
20
Buttar N S, Wang K K, Sebo T J. et al .
Extent of high-grade dysplasia in Barrett’s esophagus correlates with risk of adenocarcinoma.
Gastroenterology.
2001;
120
1630-1639
J. Borovicka, M. D.
Division of Gastroenterology/Hepatology · Dept. of Internal Medicine · Cantonal Hospital
9007 St. Gallen · Switzerland
Fax: +41-71-494-2862
Email: jan.borovicka@kssg.ch