Treatment of Barrett's with High Grade Dysplasia
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
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
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.