Barrett氏食道症與食道腺癌的新指引


  【24drs.com】100名國際專家對於診斷及治療食道癌前病變和初期癌症之最佳方式的共識聲明刊載於8月版Gastroenterology期刊。在最近幾十年,Barrett氏食道症(BE)患者中越來越常發現有食道腺癌(EA),但是EA依舊罕見,如何治療或預防這個致命癌症的協議仍少見。
  
  英國皇后大學的Cathy Bennett等人進行了11,904篇報告的回顧與評估,將聲明草案透過匿名的投票過程發展出獲得共識小組至少80%專家同意的聲明。在有實證基礎的德菲法過程中,91項聲明草案有81項獲得共識,研究者在BE、高度發育異常(HGD)和EA診斷、流行病學、監測、治療、預防獲得最後的20項聲明。
  
  多數聲明聚焦在獲得良好的內視鏡設備、使用內視鏡而非開放式手術、組織取樣的重要性。為了進行BE和EA內視鏡,醫師們插入一條有攝影機和必要器械的細小導管進入喉嚨,而避免胸腔手術。
  
  以下是可直接應用於當今臨床的8項聲明:
  1. 內視鏡切除的樣本比切片更能進行病灶分期;
  2. 重點在仔細定位增生區域的範圍;
  3. 接受消融或手術治療的病患需要內視鏡追蹤;
  4. 需以高解析度內視鏡進行準確診斷;
  5. 對於監控而言,內視鏡治療HGD為首選;
  6. 內視鏡治療HGD優於手術;
  7. 併用內視鏡切除與射頻消融是最有效的治療,且
  8. 內視鏡切除HGD病患的病灶之後,所有BE區域都應被消融。
  
  研究者寫道,對於BE與HGD/初期癌症之評估與處置,這項工作可說是迄今最深遠、最包容性、最詳實的共識過程,多數結果與臨床相關,且多數問題獲得高度共識,表示這些聲明多可立即運用於臨床指引。
  
  研究者也寫道,共識過程發現某些領域迫切需要研究,包括評估基因標記以確認癌症風險,而他們分析的這些已發表的研究,多數為中等或不佳品質。
  
  同期期刊刊載的編輯評論中,英國劍橋Hutchison-MRC研究中心MRC癌細胞小組的Rebecca C. Fitzgerald醫師與密西根大學醫學院胃腸科的Joel H. Rubenstein醫師指出,雖不是明確的全盤指引,共識聲明的最後結果可被視為是由一群當今專家對現有知識的整合詮釋,除非有進行更高品質的研究,這些共識建議足堪稱許為早期癌症性Barrett氏食道症患者處置之現有資料的最佳統整。
  
  研究者寫道,EA是癌症死亡急速上升的原因,BE患者發生EA的機率是無BE者的至少20倍,被定義為取代遠端食道鱗狀黏膜與化生性柱狀上皮,不過,EA案例罕見意味著許多胃腸科醫師很少遇到這類病患,因此更顯出共識指引的重要性。
  
  作者們指出,研究限制包括,未代表某些地區,對專家們的建議未使用標準化格式。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6897&x_classno=0&x_chkdelpoint=Y
  

Barrett's and Esophageal Adenocarcinoma Get New Guidelines

By Larry Hand
Medscape Medical News

July 30, 2012 — An international group of almost 100 experts has developed consensus statements on the best ways to diagnose and treat esophageal precancer and early cancer, with their statements published in the August issue of Gastroenterology. Esophageal adenocarcinoma (EA) has become more common in the last few decades among patients with Barrett's esophagus (BE), yet EA remains rare, and little agreement has been reached on how to treat or prevent the deadly cancer, the researchers write.

Cathy Bennett, from Queens University, Belfast, United Kingdom, and colleagues conducted a review and analysis of 11,904 papers and put draft statements through an anonymous 4-vote process to develop statements strongly agreed or agreed to by at least 80% of experts on the consensus panel. Of 91 draft statements developed during the evidence-based Delphi process, 81 achieved consensus, and the researchers arrived at 20 final statements on diagnosis, epidemiology, surveillance, treatment, and prevention of BE, high-grade dysplasia (HGD), and EA.

Many of the statements focus on having good endoscopy equipment, use of endoscopy rather than open surgery, and the importance of tissue sampling. For BE and EA endoscopy, physicians insert a thin tube with a video camera and necessary instruments into the throat, which avoids the need for chest surgery.

Eight of the statements, summarized below, are directly applicable to the clinic today:

  1. specimens from endoscopic resection are better than biopsies for staging lesions,
  2. it is important to carefully map the size of the dysplastic areas,
  3. patients that receive ablative or surgical therapy require endoscopic follow-up,
  4. high-resolution endoscopy is necessary for accurate diagnosis,
  5. endoscopic therapy for HGD is preferred to surveillance,
  6. endoscopic therapy for HGD is preferred to surgery,
  7. the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and
  8. after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated.

"This work represents the most far-reaching, inclusive, and informative consensus process on evaluation and management of BE with HGD/early cancer published to date," the researchers write. "Most of the findings are clinically relevant and the high degree of consensus achieved for most of the questions indicates that many of the statements are appropriate for immediate use in guiding clinical activity."

The researchers also write that the consensus process revealed some areas in which "urgent research is needed, including evaluation of genetic markers to determine cancer risk," and that much of the published research they analyzed is of moderate or poor quality.

In an editorial published in the same journal issue, Rebecca C. Fitzgerald, MD, from the MRC Cancer Cell Unit, Hutchison-MRC Research Centre in Cambridge, United Kingdom, and Joel H. Rubenstein, MD, from the Division of Gastroenterology at the University of Michigan Medical School in Ann Arbor, note, "Rather than definitive, omniscient guidance, the end result of the consensus document can best be viewed as a synthesis of interpretations of an imperfect knowledge base by a set of experts at a particular point in time. Until higher quality studies are conducted, the consensus recommendations are a commendable effort to summarize the best available data for management of patients with early neoplastic Barrett's esophagus."

The researchers write that EA is the most rapidly growing cause of cancer deaths and that people with BE are at least 20 times more likely to progress to EA than people without BE, which "is defined as the replacement of distal esophageal squamous mucosa with metaplastic columnar epithelium," the researchers write. Still, EA's rarity means that many gastroenterologists may see few or no patients with the disease, which highlights the importance of having consensus guidelines.

Potential limitations of the study include the underrepresentation of some geographical areas and not using a standard template for comments from experts, the authors note.

Funding for the research was provided by the International Society of Diseases of the Esophagus, British Society of Gastroenterology, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Association of Upper Gastrointestinal Surgeons, Fight Oesophageal Reflux Together, German Society of Endoscopy, Netherlands Association of Hepatogastroenterologists, and Oesophageal Cancer Fund of Ireland. Full conflict of interest information is provided on the journal's Web site. The editorialists have disclosed no relevant financial relationships.

Gastroenterology. 2012;143:282-284, 336-346.

    
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