title: Is the risk of concomitant invasive esophageal cancer in high-grade dysplasia in Barrett's esophagus overestimated?
abstract: OBJECTIVE
  Recent studies have claimed long neoplasia-free survival rates with endoscopic mucosal resection of high-grade dysplasia (HGD) in Barrett's esophagus (BE). However, reports have contended that approximately 40% of patients who have esophagectomy for HGD have occult invasive cancer. The aim of this study was to use explicit criteria to determine the true prevalence of invasive adenocarcinoma in reports of patients who had esophagectomy for HGD in BE.
  
  
  METHODS
  Studies reporting rates of esophageal cancer in patients who underwent esophagectomy for HGD in BE were gathered using MEDLINE and PUBMED. We defined invasive esophageal adenocarcinoma (IEAC) as tumor with submucosal invasion or beyond. Intramucosal carcinoma (IMC) was not considered IEAC.
  
  
  RESULTS
  Twenty-three articles were selected for analysis. Most investigators reported rates of invasive cancer in the esophagectomy specimen, and the pooled average was 39.9% among the 441 patients who underwent an esophagectomy for HGD. Reported rates varied from 0% to 73%. A total of 267 patients had American Joint Committee on Cancer stage 0 postoperatively, 132 patients had stage I, 23 patients had stage IIa, 10 patients had stage IIb, and 9 patients had stage III. Fourteen studies provided differentiation between intramucosal and submucosal invasion. Among 213 patients, only 12.7% had IEAC, whereas 87.3% had HGD or IMC. The IEAC rate of 11% among patients with visible lesions is greater than the rate of 3% among patients with no visible lesion.
  
  
  CONCLUSIONS
  By using strict pathologic definitions of invasive disease, the present study indicates the true prevalence of IEAC in BE and HGD may have been overestimated significantly. Separating IMC from IEAC is clinically relevant because endoscopic techniques potentially may treat IMC.
authors: Center for Endoscopic Research and Therapeutics, University of Chicago Medical Center, Chicago, Illinois, USA.
authors: Vani J A
authors: VJ
authors: Konda
authors: Andrew S
authors: AS
authors: Ross
authors: Mark K
authors: MK
authors: Ferguson
authors: John A
authors: JA
authors: Hart
authors: Shang
authors: S
authors: Lin
authors: Keith
authors: K
authors: Naylor
authors: Amy
authors: A
authors: Noffsinger
authors: Mitchell C
authors: MC
authors: Posner
authors: Charles
authors: C
authors: Dye
authors: Barbara
authors: B
authors: Cislo
authors: Lynne
authors: L
authors: Stearns
authors: Irving
authors: I
authors: Waxman
mesh_terms: D000230:Adenocarcinoma / Q000453:epidemiology* / Q000601:surgery; D001471:Barrett Esophagus / Q000150:complications* / Q000473:pathology*; D016099:Endoscopy, Gastrointestinal; D004938:Esophageal Neoplasms / Q000453:epidemiology* / Q000601:surgery; D016629:Esophagectomy; D006801:Humans; D008679:Metaplasia / Q000601:surgery; D015995:Prevalence; D018570:Risk Assessment; D012720:Severity of Illness Index