Division of Gastroenterology, University of Minnesota, Minneapolis, MN, USA.
Department of Internal Medicine, University of Minnesota, Minneapolis, MN, USA.
Dis Esophagus. 2020 Sep 4;33(9). doi: 10.1093/dote/doaa015.
Patients with Barrett's esophagus (BE) are at increased risk of esophageal adenocarcinoma (EAC). The risk is largely based on the degree of dysplasia. Dysplasia cannot always be differentiated from inflammatory changes, and therefore may be classified as indefinite for dysplasia (IND). The risk of progressive dysplasia in patients with IND is unclear. Our aim is to characterize the risk of progression in US veterans with BE-IND. We performed a single-center retrospective cohort study of patients with BE-IND between 2006 and 2016. All IND was diagnosed by consensus conference with an expert gastrointestinal (GI) pathologist or review by an expert GI pathologist and persistence was defined as IND present on subsequent endoscopic biopsy. The primary outcome was the incidence rate of high-grade dysplasia (HGD)/EAC. Secondary outcomes included any progression including incident low-grade dysplasia (LGD), any prevalent dysplasia and risk factors for dysplastic progression, namely persistent IND. Risk factors for progression were assessed using univariate and multivariate analysis with logistic regression. Among 107 patients with BE-IND, there were no incident cases of HGD/EAC. Twenty patients (18.7%) developed incident LGD during a median follow-up of 2.39 years (interquartile range, 1.13-5.17). The annual rate of progression to LGD was 5.95 per 100 patient-years (95% CI, 3.73-9.02). Prevalent dysplasia was common (9.3%). Eight patients had prevalent LGD, one patient had prevalent HGD and one patient had prevalent EAC. Twenty-eight patients (30.1%) were found to have persistent IND. Among those with persistent IND, 10 (36%) patients progressed to LGD (none to HGD/EAC). The progression rate to LGD for patients with persistent IND was 7.86 (95% CI, 3.99-14.02) cases per 100 patient-years versus 4.78 (95% CI, 2.48-8.52) for nonpersistent IND (P = 0.036). The odds ratio for progression to LGD in persistent IND was 3.06 (95% CI, 1.08-8.64). In multivariate analysis adjusting for age, smoking history, presence of hiatal hernia and BMI > 30, persistent IND remained significant (OR 3.23; 95% CI, 1.04-9.98). Regression to nondysplastic BE was very common. Seventy-one (61%) patients developed complete and sustained regression of all dysplastic changes at last follow-up. Persistent IND, present in one-third of patients with IND, is an independent risk factor for progression to LGD. Although no patients in this cohort developed HGD/EAC, prevalent dysplasia was common (9.3%). Taken together, patients with IND should receive close surveillance for both prevalent and incident dysplasia especially if IND is persistent.
巴雷特食管（BE）患者患食管腺癌（EAC）的风险增加。这种风险在很大程度上基于异型增生的程度。异型增生不能总是与炎症改变区分开来，因此可能被归类为异型增生不确定（IND）。患有 IND 的患者进展为异型增生的风险尚不清楚。我们的目的是描述美国退伍军人中 BE-IND 患者的进展风险。我们对 2006 年至 2016 年间患有 BE-IND 的患者进行了单中心回顾性队列研究。所有 IND 均通过共识会议由胃肠道（GI）专家病理学家诊断，或由 GI 专家病理学家进行审查，并定义为后续内镜活检中存在 IND。主要结局是高级别异型增生（HGD）/EAC 的发生率。次要结局包括任何进展，包括新发生的低级别异型增生（LGD）、任何现有的异型增生以及异型增生进展的危险因素，即持续存在 IND。使用逻辑回归的单变量和多变量分析评估进展的危险因素。在 107 例 BE-IND 患者中，无 HGD/EAC 新发病例。在中位随访 2.39 年（四分位距，1.13-5.17）期间，有 20 例（18.7%）患者新发生 LGD。LGD 每年进展率为 5.95/100 患者年（95%CI，3.73-9.02）。现有的异型增生很常见（9.3%）。8 例患者存在现有的 LGD，1 例患者存在现有的 HGD，1 例患者存在现有的 EAC。28 例（30.1%）患者存在持续 IND。在持续存在 IND 的患者中，有 10 例（36%）患者进展为 LGD（无一例进展为 HGD/EAC）。持续存在 IND 的患者进展为 LGD 的比率为每 100 患者年 7.86 例（95%CI，3.99-14.02），而非持续存在 IND 的患者为 4.78 例（95%CI，2.48-8.52）（P=0.036）。持续存在 IND 的患者进展为 LGD 的优势比为 3.06（95%CI，1.08-8.64）。在调整年龄、吸烟史、食管裂孔疝和 BMI>30 的多变量分析中，持续存在 IND 仍然具有显著意义（OR 3.23；95%CI，1.04-9.98）。非异型增生性 BE 的完全和持续消退非常常见。71 例（61%）患者在最后一次随访时完全和持续消退了所有异型增生改变。三分之一的 IND 患者存在持续的 IND，这是进展为 LGD 的独立危险因素。尽管该队列中没有患者发展为 HGD/EAC，但现有的异型增生很常见（9.3%）。综上所述，IND 患者应密切监测现有的和新发生的异型增生，特别是如果 IND 持续存在。
