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Barrett's esophagus and cancer

The first slide to give you a typical history is a patient I saw about a year ago, a man of 61, who came with a complaint of three months of increasing dysphagia for solid foods, which were sticking at the chest level Barrett's esophagus, cancer. When asked, he also had a 30-year history of heartburn and sour reflux, for which he had never sought other treatment except taking antacids.

This is actually very frequent as shown by Dr. Lock. In the population, there are many people with heartburn who have not had it investigated. A barium x-ray was done at his home hospital and this showed an esophageal ulcer with what was called edema. However, they recognized that it wasn't just edema and did an endoscopy at his home hospital, which showed an adenocarcinoma and a Barrett's esophagus which had not been recognized previously. He was referred to the Mayo Rochester 

We started with an endoscopic ultrasound, which is our standard staging procedure now, and this showed a mass as shown on endoscopy in the lower esophagus and a 2-cm lymph node near to the esophageal wall. If we had seen enlarged nodes in the celiac area, for example, now we would use the endoscopic ultrasound to take a needle-directed biopsy, but it was not necessary for one that was right next to the esophagus. He had a CT scan of the chest and abdomen, which showed no evidence of distant metastasis to liver, lung or abdomen, so he proceeded to have an esophagogastrectomy. The pathologist reported on the resected specimen that the nodes were positive for cancer. This is the endoscopic photograph of this patient to show squamous pale mucosa here in the mid esophagus. Further down, you can clearly see the junction to the darker red mucosa of the Barrett's esophagus. In the distance, this kind of nodular ring here extends upwards on the left side; that was the adenocarcinoma which had arisen in the Barrett's esophagus.

The results of treatment of patients of this type are unfortunately not very good. This shows the results of surgical resection in seven fairly large series. Here are the numbers of patients who had resection for adenocarcinoma of the esophagus and here is

Combination treatments.

It has been shown that postoperative radiation and chemotherapy do not increase survival in adenocarcinoma. Preoperative chemotherapy alone is not helpful, although there is a recent paper in the New England Journal of a large multi-center study confirming that again. Presently, preoperative, so-called neoadjuvant, chemotherapy plus radiotherapy looks somewhat more promising,. with radiation being given to improve control over local disease, and sometimes by the time the operation is done

I'm afraid that for many patients, possibly half of all patients with adenocarcinoma of the esophagus presenting with symptoms, an operation is not possible because of distant metastases, because of age or other medical conditions, and sometimes all that can be done is the endoscopic placement of a metal spring stent to enable them to be swallow, as is being done here, but

Let's go back to Barrett's esophagus, the place where most adenocarcinomas of the esophagus begin. Normally, all of your esophagus is lined with pale pink squamous mucosa and the Z line, the junction, should be at the lower end of the esophagus. In Barrett's esophagus, a variable length of lower esophagus is lined with red columnar epithelium, easily seen at endoscopy. Barrett's esophagus is an acquired condition and is associated with severe gastroesophageal reflux. Most patients will have a weak lower esophageal sphincter and over 90% of patients will also have a sliding hiatal hernia. These are at least two of the factors that probably cause reflux to occur, reflux then damaging the normal squamous lining here, which becomes replaced later by columnar. This is an acquired condition and this is an interesting and unusual patient, but we are showing a typical finding, a patient with reflux symptoms. On the left here, biopsy from the lower esophagus shows squamous epithelium with changes of esophagitis, elongated papillae and a thickened basal cell here.

The same patient, approximately one year later, had another endoscopy and he had developed a Barrett's esophagus in the meantime. Here on the right is the typical epithelium found in a Barrett's esophagus - glandular; note the goblet cells. You can see the little sort of oval holes in the cells here. This is intestinal metaplasia; this is not the normal type of epithelium found at

Here are some endoscopic pictures; we are looking down in about the mid esophagus here at an untreated patient with Barrett's esophagus. You will see these erosions, these triangular, pale-centered, bright-red margined lesions in the squamous mucosa. This is typical reflux esophagitis. If you look further down here, however, you will see red mucosa which covers a long segment