Info

Length of follow-up before cancer development in each patient (yr)

5.3 and 8

6 and 10

3.5 and 4.3

Incidence of esophageal cancer (cases/person-years)

1/175

1/441

1/81

Estimated increased risk above that in general population

40-fold

30-fold

Not available

*From Spechler, S.J., and Goyal, R.K.: Barrett's esophagus. N. Engl. J. Med., 315:362, 1986, by permission of the New England Journal of Medicine. tFrom Spechler, S.J., Robbins, A.H., Rubins, H.B., et al.: Adenocarcinoma and Barrett's esophagus: An overrated risk? Gastroenterology, 87:927, 1984. XFrom Cameron, A.J., Ott, B.J., and Payne, W.S.: The incidence of adenocarcinoma in columnar-lined (Barrett's) esophagus. N. Engl. J. Med., 313:857, 1985. §From Sprung, D.J., Ellis, F.H., Jr., and Gibb, S.P.: Incidence of adenocarcinoma in Barrett's esophagus (Abstract). Am. J. Gastroenterol., 79:817, 1984.

*From Spechler, S.J., and Goyal, R.K.: Barrett's esophagus. N. Engl. J. Med., 315:362, 1986, by permission of the New England Journal of Medicine. tFrom Spechler, S.J., Robbins, A.H., Rubins, H.B., et al.: Adenocarcinoma and Barrett's esophagus: An overrated risk? Gastroenterology, 87:927, 1984. XFrom Cameron, A.J., Ott, B.J., and Payne, W.S.: The incidence of adenocarcinoma in columnar-lined (Barrett's) esophagus. N. Engl. J. Med., 313:857, 1985. §From Sprung, D.J., Ellis, F.H., Jr., and Gibb, S.P.: Incidence of adenocarcinoma in Barrett's esophagus (Abstract). Am. J. Gastroenterol., 79:817, 1984.

gastric-fundic type with chief and parietal cells.1 ' Currently, specialized intestinal metaplasia is the only form at risk for progression to dysplasia and subsequent adenocarcinoma.1 ' Biopsy proof of this form is required to confirm the diagnosis of Barrett's esophagus, whether it is of the long-segment (> 3 cm) or the short-segment (< 3 cm) variety. 1 ' BARRETT'S ESOPHAGUS: A PREMALIGNANT CONDITION? [21]

In 1952, Morson and Belcher1 ' were the first to call attention to the development of adenocarcinoma in the columnar epithelium-lined lower esophagus of Barrett. As both Barrett's esophagus and its association with cancer have become more widely recognized, the prevalence of both conditions, either singly or in combination, has increased.

Making this increase even more striking is the finding that there appears to be a marked underestimation of the true prevalence of Barrett's esophagus in the general population. A clinical autopsy review by Cameron and associates demonstrated that the estimated age- and sex-specific prevalence of Barrett's esophagus based on autopsy findings was 376 in a population of 100,000, approximately 16 times more than what had been clinically diagnosed in the same geographic area. The incidence of the development of Barrett's esophagus in patients with gastroesophageal reflux is not well documented. Lomboy and colleagues [ ] reported seven patients with reflux esophagitis who developed Barrett's metaplasia over a mean interval of 1.6 years. Also, Schnell and coworkers[ ] followed 725 patients whose initial biopsy showed no evidence of Barrett's esophagus; 8% later developed Barrett's metaplasia.

The reported prevalence of adenocarcinoma in the columnar epithelium-lined lower esophagus has varied widely, from 6.6% to 46%. Although such data have alerted us to a propensity for the development of malignant disease in Barrett's esophagus, such data cannot be used to assess the risk of cancer developing later in a patient with benign Barrett's esophagus.

The report of Hawe and coworkers[ ] in 1973 was the first study that attempted to address this problem. Among 85 patients diagnosed in a 20-year period as having benign Barrett's esophagus, retrospective follow-up showed that cancer of Barrett's esophagus developed in only two. More stringent incidence studies were provided by three subsequent reports ( Table 15-1 ).[ ] [ ] [ ] Along with this is the finding

that the incidence of adenocarcinoma of the esophagus and esophagogastric junction seems to be rising not only in the United States but also in western Europe1 ' ( Fig. 15-2 ). Obviously, all of these studies have shortcomings, because it is not known how long patients had had Barrett's esophagus before diagnosis and entry into the study, nor is it certain that the diagnostic criteria for entry were not overly selective. In any event, longer-term follow-up of larger numbers of patients is required to place this problem in better perspective. For the present, at least, it is reassuring to note that the survival of patients with benign Barrett's esophagus is roughly similar to that of an age- and sex-adjusted general population ( Fig. 15-3 ).

BARRETT'S ESOPHAGUS WITH CANCER

At the Mayo Clinic between 1970 and 1985, 62 patients underwent resection for invasive adenocarcinoma of the

Figure 15-2 Incidence of squamous carcinoma, esophageal adenocarcinoma, and adenocarcinoma of the esophagogastric junction during three discrete periods.

Figure 15-3 Comparison of age- and sex-adjusted survival rates for 104 patients with Barrett's esophagus and a control population. The numbers in parentheses indicate patients still at risk. (From Cameron, A. J., Ott, B.J., and Payne, W.S.: The incidence of adenocarcinoma in columnar-lined [Barrett's] esophagus. N. Engl. J. Med., 313:857, 1985. Reprinted by permission of the New England Journal of Medicine.)

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