This same patient had a preoperative barium esophogram suggestive of an esophageal stricture. Two other patients had preoperative findings suggestive of invasive disease. The patient with a 1.6 cm tumor staged as T1b had esophageal thickening up to 7 mm noted on a preoperative learn more computed tomography scan and on preoperative endoscopy multiple

esophageal nodules were noted. The patient with T1b staging and a 1.5 cm Inhibitors,research,lifescience,medical tumor had nodular, ulcerated lesions on endoscopy and a preoperative endoscopic ultrasound was suggestive of submucosal involvement (Table 2). None of the other patients with invasive cancer or intramucosal carcinoma had radiologic or endoscopic evidence suggestive of cancer on preoperative testing. Table 2 Preoperative testing of patients with invasive adenocarcinoma Despite a preoperative diagnosis of HGD 2 patients staged as T3 had radiologic and endoscopic evidence to suggest invasive cancer. Two patients with subsequent T1b staging postoperatively also had preoperative suspicion for malignancy. Thus, 4 patients with preoperative HGD had occult carcinoma detected postoperatively, for an occult Inhibitors,research,lifescience,medical incidence rate of 5.9% (4/68). We performed a time based analysis, based

on date of surgical resection to see if the rate of adenocarcinoma in association with HGD decreased over time. We divided patients to 2 groups: those who Inhibitors,research,lifescience,medical underwent surgery between 1993 and 2000, and those between 2000 and 2007. Three of 20 patients (15%) were found to have adenocarcinoma

in first group, while 9 of 48 (18.8%) were found to have adenocarcinoma Inhibitors,research,lifescience,medical in second group (P=0.77). Even when the groups were analyzed from 1993 to 2003 and 2004 to 2007, no significant difference was found (8/40 and 4/28 respectively, P=0.379). Discussion In this large surgical series examining adenocarcinoma in Barrett’s esophagus with a preoperative diagnosis of high grade dysplasia, we report an overall prevalence of adenocarcinoma of 17.6% with Inhibitors,research,lifescience,medical 11.7% invasive and 5.9% occult. This is in contrast to previous early surgical reports where a much higher rate of adenocarcinoma was observed. In the meta analysis of 23 studies involving 441 patients undergoing surgery for HGD, the pooled rate of adenocarcinoma was 39.9% (12). However, in 14 studies within the meta analysis where a distinction between intramucosal and invasive carcinoma was possible and the intramucosal cancers were excluded, the rate of invasive adenocarcinoma fell to 12.7%, consistent with our observation. In another recent surgical series, the rate of invasive adenocarcinoma those at surgery for HGD was 6.7% (4/60) (14). Several predictors of invasive carcinoma in the setting of HGD have been recognized. Nodular lesions in HGD have been shown to be at a higher risk for adenocarcinoma (15). A recent study analyzed pooled data from multiple studies, and showed that visible lesions at endoscopy are associated with a higher risk of submucosal invasion, although statistical significance was not reached (12).