Department of Internal Medicine, Mayo Clinic in Arizona, Scottsdale, AZ 85259, USA.
Dig Dis Sci. 2010 Jul;55(7):1918-31. doi: 10.1007/s10620-010-1218-1. Epub 2010 Apr 20.
Non-dysplastic mucosa (ND-) in Barrett's esophagus (BE) shows clonal molecular aberrations, loss of cell cycle control, and other features of "neoplasia." These changes occur prior to morphologic expression of neoplasia (dysplasia). Morphologic evaluation of dysplasia is fraught with error, and, as a result, often leads to false-negative and false-positive diagnoses. Early "crypt dysplasia" is difficult to detect, and is often missed in routine biopsy specimens. Some studies show substantial progression rates of low-grade dysplasia (LGD), and crypt dysplasia, to esophageal adenocarcinoma (EAC). Dysplasia, even when fully developed, may, in certain circumstances, be difficult to differentiate from non-dysplastic (regenerating) BE. Radiofrequency ablation (RFA) is a safe and effective method for removing mucosa at risk of cancer. Given the difficulties of dysplasia assessment in mucosal biopsies, and the molecular characteristics of ND-BE, this technique should be considered for treatment of all BE patients, including those with ND or LGD. Post-ablation neo-squamous epithelium reveals no molecular abnormalities, and is biologically stable. Given that prospective randomized controlled trials of ablative therapy for ND-BE aiming at reducing EAC incidence and mortality are unlikely to be completed in the near future, endoscopic ablation is a valid management option. The success of RFA in achieving safe, uniform, reliable, and predictable elimination of BE allows surgeons to combine fundoplication with RFA. Currently, there is no type of treatment for dysplastic or non-dysplastic BE that achieves a complete response in 100% of patients, eliminates all risk of developing cancer, results in zero adverse events, is less expensive in terms of absolute costs than surveillance, is durable for 20+ years, or eliminates the need for surveillance. Regardless, RFA shows established safety, efficacy, durability, and cost-effective profiles that should be considered in the management of patients with non-dysplastic or low-grade dysplastic BE.
巴雷特食管（BE）中的非异型增生黏膜（ND-）表现出克隆分子异常、细胞周期失控和其他“肿瘤性”特征。这些变化发生在形态学表现出肿瘤（异型增生）之前。异型增生的形态学评估存在很大的误差，因此，往往导致假阴性和假阳性诊断。早期的“隐窝异型增生”很难检测，在常规活检标本中经常被遗漏。一些研究显示，低级别异型增生（LGD）和隐窝异型增生向食管腺癌（EAC）的进展率很高。在某些情况下，即使是完全发育的异型增生，也可能难以与非异型增生（再生）的 BE 区分开来。射频消融（RFA）是一种安全有效的去除有癌变风险的黏膜的方法。鉴于黏膜活检中异型增生评估的困难，以及 ND-BE 的分子特征，这种技术应该被考虑用于所有 BE 患者的治疗，包括那些有 ND 或 LGD 的患者。消融后的新生鳞状上皮没有分子异常，具有生物学稳定性。鉴于针对降低 EAC 发病率和死亡率的 ND-BE 消融治疗的前瞻性随机对照试验在近期内不太可能完成，内镜消融是一种有效的治疗选择。RFA 成功地实现了 BE 的安全、均匀、可靠和可预测的消除，使得外科医生能够将胃底折叠术与 RFA 结合使用。目前，对于异型增生或非异型增生的 BE，没有一种治疗方法能在 100%的患者中实现完全缓解，消除所有发生癌症的风险，零不良事件，绝对成本低于监测，持续 20 年以上，或消除监测的需要。无论如何，RFA 显示出已确立的安全性、疗效、持久性和成本效益，应在管理非异型增生或低级别异型增生的 BE 患者时加以考虑。
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