Kariv Revital, Plesec Thomas P, Goldblum John R, Bronner Mary, Oldenburgh Mary, Rice Thomas W, Falk Gary W
Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Clin Gastroenterol Hepatol. 2009 Jun;7(6):653-8; quiz 606. doi: 10.1016/j.cgh.2008.11.024. Epub 2008 Dec 13.
BACKGROUND & AIMS: The optimal management of high-grade dysplasia in Barrett's esophagus remains controversial. A biopsy protocol consisting of 4 quadrant jumbo biopsies (every 1 cm) with biopsies of mucosal abnormalities (the Seattle protocol) is considered to be the optimal method for detecting early cancers in patients with high-grade dysplasia, although it has never been validated. This study aimed to determine the frequency of unsuspected carcinoma at esophagectomy in Barrett's esophagus patients with high-grade dysplasia who underwent the Seattle protocol and to compare the findings with those of a less rigorous biopsy protocol.
Thirty-three patients with high-grade dysplasia underwent esophagectomy. None had obvious mass lesions at preoperative endoscopy. Patients were divided into group 1 (preoperative surveillance biopsies according to Seattle protocol) and group 2 (4 quadrant biopsies every 2 cm). Preoperative and postoperative diagnoses were confirmed by 2 expert gastrointestinal pathologists.
Unsuspected intramucosal cancer was found in 8 of 20 (40%) patients in group 1 versus 4 of 13 (30%) in group 2 (P = .6). Preoperative mucosal nodularity was observed in 4 of 8 (50%) postoperative intramucosal cancers from group 1 versus 3 of 4 (75%) from group 2. Multifocal high-grade dysplasia was seen preoperatively in 7 of 8 (87.5%) postoperative intramucosal cancers in group 1 versus 2 of 4 (50%) in group 2. No patient had submucosal cancer or lymph node metastases at surgery.
Intense preoperative biopsy sampling by the Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol. This calls into question the concept that extensive sampling with the Seattle protocol consistently detects early cancers arising in Barrett's esophagus patients with high-grade dysplasia.
巴雷特食管高级别异型增生的最佳管理方案仍存在争议。尽管从未得到验证，但由4象限大活检（每1厘米）及黏膜异常活检组成的活检方案（西雅图方案）被认为是检测高级别异型增生患者早期癌症的最佳方法。本研究旨在确定接受西雅图方案的巴雷特食管高级别异型增生患者在食管切除术中意外癌的发生率，并将结果与活检方案不那么严格的情况进行比较。
33例高级别异型增生患者接受了食管切除术。术前内镜检查均未发现明显肿块病变。患者分为第1组（根据西雅图方案进行术前监测活检）和第2组（每2厘米进行4象限活检）。术前和术后诊断由2名专家胃肠病理学家确认。
第1组20例患者中有8例（40%）发现意外黏膜内癌，而第2组13例中有4例（30%）（P = 0.6）。第1组术后8例黏膜内癌中有4例（50%）术前观察到黏膜结节，第2组4例中有3例（75%）。第1组术后8例黏膜内癌中有7例（87.5%）术前发现多灶性高级别异型增生，第2组4例中有2例（50%）。手术时无患者发生黏膜下癌或淋巴结转移。
与监测方案不那么密集的情况相比，采用西雅图方案进行强化术前活检采样并不能更可靠地预测食管切除术时癌症的检出情况。这使人们对西雅图方案广泛采样能持续检测出巴雷特食管高级别异型增生患者早期癌症的概念产生质疑。
