Esophageal cancer accounts for a jaw-dropping amount of cancer-related deaths, and is now classified as the 6th-highest cause of death in this group. In this installment of the study guide series, I will discuss Barrett Esophagus (I learned this entity as Barrett Metaplasia) and esophageal cancer (neoplasia).
Barrett Metaplasia
- Metaplasia: columnar epithelium replaces the physiologic squamous epithelium in the distal portion of the food pipe.
- PRE-MALIGNANT CONDITION
- Cancer risk of 0.5% per year in those who have Barrett Esophagus.
- Usual pathway (if progresses to ca): intestinal metaplasia –> low-grade dysplasia –> high-grade dysplasia.
- NO evidence that routine screening for BE based on GERD symptoms is helpful.
- Clinically:
- Think of this in an older obese white male with chronic reflux and a history of chain-smoking.
- Protective = average wine consumption, fruits/veggies.
- Barrett Esophagus occurs in the presence or absence of reflux!
- Diagnosis:
- Upper endoscopy showing typical intestinal metaplasia of distal esophagus.
- “Salmon-colored mucosa“
- Further classifications: Short segment (< 3cm) or long segment (> 3cm)
- Upper endoscopy showing typical intestinal metaplasia of distal esophagus.
- Treatment:
- PPI are useful for reflux symptom improvement, not preventing progression to dysplasia.
- HIGH-grade dysplasia = destroy bad tissue with radiofrequency ablation or other resection.
- Surveillance
- EGD is primary modality.
- Based on dysplasia grade:
- none = repeat EGD 3-5 years.
- low-grade = repeat EGD 6-12 months
- high-grade = look for focal lesions, which may harbor more progressive disease; repeat EGD q3 months with resection/surgery.
Esophageal Carcinoma
- Adenocarcinoma is most common type (#1) in US; SCC is also very common.
- Typically presents in males, aged 50-60’s.
- 5-year survival rate 15-25%, depending on stage at presentation.
- Risk factors:
- Adenocarcinoma = GERD, Barrett metaplasia, tobacco, radiation, male, old age, poor diet.
- SCC = tobacco and alcohol, direct toxic injury, Zn and selenium deficiency, prior radiation to region, poor population, poor oral hygiene, HPV, nitrosamine exposure (occupational hazards), nonepidermolytic palmoplantar keratoderma.
- Diagnosis:
- #1 symptom = SOLID-food dysphagia
- Weight loss, low appetite, low hemoglobin/hematocrit.
- EGD is best way to diagnose.
- Squamous Cell Carcinoma is proximal
- Adenocarcinoma is distal
- CT scan is useful to evaluate for metastatic disease; PET used for questionable lesions.
- Treatment
- Refer to Oncology, resection versus chemotherapy is stage dependent at time of diagnosis.
Bibliography
- ACP MKSAP 17: Gastroenterology and Hepatology, pgs. 9-12
- Image source: https://en.wikipedia.org/wiki/Barrett’s_esophagus
- Intestinal metaplasia consistent with Barrett esophagus (left side of main image) and normal stratified squamous epithelium (right side), Alcian blue stain.