Management of Barrett's oesophagus and intramucosal oesophageal cancer: a review of recent development

Abstract

Barrett's oesophagus is the most important and recognizable precursor lesion for oesophageal adenocarcinoma, which is the one of the fastest growing cancers in the Western World. The incidence of oesophageal adenocarcinoma has increased 600% in the United States between 1975 and 2001 and is thought to represent a real increase in burden rather than a result of histologic or anatomical misclassification or overdiagnosis. Thus, the cancer risk in Barrett's oesophagus has to be managed and involves prevention (surveillance endoscopy), treating underlying gastroesophageal reflux disease (medically and or surgically) and endoscopic therapy to remove diseased epithelium in appropriate patient subgroups. In the last decade, new developments in imaging and molecular markers as well as an armamentarium of novel and effective endoscopic eradication therapy has become available to the endoscopist to combat this exponential rise in oesophageal adenocarcinoma. Paradoxically, the cancer risk in Barrett's oesophagus gets progressively downgraded which raises fundamental questions about our understanding of the known and unknown risk factors and molecular aberrations that are involved in the Barrett's metaplasia-dysplasia-carcinoma sequence. Future research has to be directed at these areas to fine tune our screening and surveillance programs to identify more accurately the high-risk group of progressors to oesophageal adenocarcinoma who would benefit most from endoscopic therapy.

Keywords: Ablative therapy; Barrett’s oesophagus; Barrett’s surveillance; GORD; oesophageal cancer.

Figure 1.

Intramucosal Barrett’s adenocarcinoma (T1) subclassification. Lymph node metastases in intramucosal cancer is <1% and that involving the upper third of the submucosa is between 0-8% [Pech, 2009; Liu et al 2005].

Figure 2.

Paris classification of the endoscopic appearance of superficial neoplastic lesions of the digestive tract mucosa.

Figure 3.

Algorithm for the management of Barrett’s oesophagus (adapted from Singh et al. [2011]).