Progression of high grade dysplasia to cancer may take several years and may occur in some patients. At this time it is difficult to predict with some degree of certainty which patients and how many years. Furthermore to find high grade dysplasia and cancer in a flat Barrett’s mucosa is like looking for a “needle in a haystack”. Mayo study of resected esophageal specimens finds that in an average of 37 cm2 Barrett’s mucosa only 1.3 cm was HGD and 1.1 cm was cancer pointing to difficulty in finding them during surveillance and the need for multiple biopsy samples.

My own practice is to confirm presence of high-grade dysplasia by repeating endoscopy, obtain more biopsy samples and make sure that at least two pathologists, one experienced in Barrett’s and dysplasia agree with diagnosis. If confirmed and the patient is a good surgical candidate, or if I believe the patient will be lost in follow-up, I’ll refer the patient for surgery and resection to centers with high volume esophagectomy. Surgical mortality is 3-20% depending on the institution and reported morbidity is 20-50%. However, this rate may be significantly less in specialized centers.

Studies have shown that close to a third of these patients have carcinomas on the resected specimen. Loss of p53 gene on biopsy specimens also indicates a 16 folds increase in progression to cancer compared to those who have not lost their p53 gene. If p53 staining is available, such patients should be strongly considered for surgery as well. In patients who are poor surgical risks, or if they refuse surgery, then extensive medical therapy with PPIs, NSAID and, every three months, endoscopy surveillance is another option. Surveillance problem is sampling error and patient compliance.

In recent years different modalities are developed for ablation of High grade dysplasia by applying heat, Photochemicals or mechanical resection.

Thermal techniques are: Multipolar Electrocoagulation (MPEC), Argon Plasma Coagulation (APC), LASERS (Nd-YAG, Argon, KTP), and Heater Probe.

Photodynamic Therapy (PDT) using combination of porfimer sodium injection and fibers emitting red light.

Mechanical ablation includes: Endoscopic Mucosal Resection (EMR), and removing the area by biopsying it.

In centers with experienced endoscopists and endosonographers (EUS), with raised or nodular lesions, EMR appears to be a reasonable option to esophagectomy in patients with high grade dysplasia or adenocarcinoma limited to the mucosal especially in patients who are poor surgical risk. It appears logical to start the evaluation of a person with Barrett’s esophagus with a suspicious lesion (polyp, nodule, erosion and so on) or an already diagnosed adenocarcinoma with endoscopic ultrasound (EUS). This can help better define the target lesion and confirm that malignancy is limited to the mucosa. The next step would be to remove the target lesion by EMR (strip or suck methods).

After EMR has eliminated the area of invasive cancer, the remainder of the dysplastic mucosa can be managed by less invasive ablative techniques like photodynamic therapy (PDT), argon plasma coagulation (APC) or multipolar electrocoagulation (MPEC).

It must be noted that in one study 13% of patients with HGD who had ablation by PDT developed carcinoma during follow up.

March 12, 2013: Barrett's treatment with endoscopic radio frequency ablation (RFA) of Barrett's mucosa with dysplasia or endoscopic mucosal resection (EMR) for treatment of high grade dysphasia and early cancer may be preferred to esophagectomy in selected group of patients.