How to Manage a Barrett's Esophagus Patient With Low-Grade Dysplasia
How to Manage a Barrett's Esophagus Patient With Low-Grade Dysplasia
A 52-year-old Caucasian man with a 12-year history of heartburn requiring daily therapy with proton pump inhibitors undergoes an upper endoscopy for screening of Barrett's esophagus (BE). His symptoms of gastroesophageal reflux disease are well controlled on once-daily proton-pump inhibitor therapy. His physical examination is unremarkable except for mild obesity. Upper endoscopy performed at an outside facility revealed a 5-cm-long segment of BE. In addition, a single small area of mucosal irregularity was reported within this segment. A biopsy specimen obtained from this area was reported as having 'acute and chronic inflammatory changes with atypical cells, cannot rule out high-grade dysplasia (HGD)' whereas the remaining random biopsy specimens revealed intestinal metaplasia without dysplasia. Repeat upper endoscopy revealed a 3-cm hiatal hernia and the squamocolumnar junction was displaced 5 cm above the most proximal extent of the gastric folds (circumferential segment, 3 cm; maximal extent, 5 cm; Prague C3M5). The previously mentioned nodule was identified within the Barrett's segment. The presence and extent of the small area of mucosal irregularity (approximately 7-8 mm) was well defined using narrow band imaging and was removed by endoscopic mucosal resection (EMR). Random surveillance biopsy specimens were obtained from the remaining Barrett's segment. The specimen obtained by EMR revealed low-grade dysplasia (LGD) that was confirmed by an expert pathologist, whereas the random biopsy specimens showed intestinal metaplasia with no dysplasia. How should this patient be managed? How should you counsel this patient with BE and LGD regarding progression to esophageal adenocarcinoma? What is the role of advanced imaging techniques and ablative therapies in the management of patients with BE and LGD?
A 52-year-old Caucasian man with a 12-year history of heartburn requiring daily therapy with proton pump inhibitors undergoes an upper endoscopy for screening of Barrett's esophagus (BE). His symptoms of gastroesophageal reflux disease are well controlled on once-daily proton-pump inhibitor therapy. His physical examination is unremarkable except for mild obesity. Upper endoscopy performed at an outside facility revealed a 5-cm-long segment of BE. In addition, a single small area of mucosal irregularity was reported within this segment. A biopsy specimen obtained from this area was reported as having 'acute and chronic inflammatory changes with atypical cells, cannot rule out high-grade dysplasia (HGD)' whereas the remaining random biopsy specimens revealed intestinal metaplasia without dysplasia. Repeat upper endoscopy revealed a 3-cm hiatal hernia and the squamocolumnar junction was displaced 5 cm above the most proximal extent of the gastric folds (circumferential segment, 3 cm; maximal extent, 5 cm; Prague C3M5). The previously mentioned nodule was identified within the Barrett's segment. The presence and extent of the small area of mucosal irregularity (approximately 7-8 mm) was well defined using narrow band imaging and was removed by endoscopic mucosal resection (EMR). Random surveillance biopsy specimens were obtained from the remaining Barrett's segment. The specimen obtained by EMR revealed low-grade dysplasia (LGD) that was confirmed by an expert pathologist, whereas the random biopsy specimens showed intestinal metaplasia with no dysplasia. How should this patient be managed? How should you counsel this patient with BE and LGD regarding progression to esophageal adenocarcinoma? What is the role of advanced imaging techniques and ablative therapies in the management of patients with BE and LGD?
