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The Case for Endoscopic Treatment of Non-dysplastic and Low-Grade Dysplastic Barrett’s Esophagus

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Abstract

Non-dysplastic mucosa (ND-) in Barrett’s esophagus (BE) shows clonal molecular aberrations, loss of cell cycle control, and other features of “neoplasia.” These changes occur prior to morphologic expression of neoplasia (dysplasia). Morphologic evaluation of dysplasia is fraught with error, and, as a result, often leads to false-negative and false-positive diagnoses. Early “crypt dysplasia” is difficult to detect, and is often missed in routine biopsy specimens. Some studies show substantial progression rates of low-grade dysplasia (LGD), and crypt dysplasia, to esophageal adenocarcinoma (EAC). Dysplasia, even when fully developed, may, in certain circumstances, be difficult to differentiate from non-dysplastic (regenerating) BE. Radiofrequency ablation (RFA) is a safe and effective method for removing mucosa at risk of cancer. Given the difficulties of dysplasia assessment in mucosal biopsies, and the molecular characteristics of ND-BE, this technique should be considered for treatment of all BE patients, including those with ND or LGD. Post-ablation neo-squamous epithelium reveals no molecular abnormalities, and is biologically stable. Given that prospective randomized controlled trials of ablative therapy for ND-BE aiming at reducing EAC incidence and mortality are unlikely to be completed in the near future, endoscopic ablation is a valid management option. The success of RFA in achieving safe, uniform, reliable, and predictable elimination of BE allows surgeons to combine fundoplication with RFA. Currently, there is no type of treatment for dysplastic or non-dysplastic BE that achieves a complete response in 100% of patients, eliminates all risk of developing cancer, results in zero adverse events, is less expensive in terms of absolute costs than surveillance, is durable for 20+ years, or eliminates the need for surveillance. Regardless, RFA shows established safety, efficacy, durability, and cost-effective profiles that should be considered in the management of patients with non-dysplastic or low-grade dysplastic BE.

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Acknowledgments

Grant Support for Work Performed in Conjunction with this Manuscript

None.

Financial disclosure

Some authors have received research grant support from BÂRRX Medical, Inc. for the conduct of clinical trials (DEF, CJL, BFO, KJC, JG, RR, VKS, HW). Some authors have received speaking honoraria from BÂRRX Medical, Inc. (DEF, CJL, BFO, KJC, RR, VKS, GT).

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Mayo Clinic in Arizona, 13400 East Shea Blvd., Scottsdale, AZ, 85259, USA

    David E. Fleischer & Ananya Das

  2. Department of Pathology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, 02115, USA

    Robert Odze

  3. Gastrointestinal Associates, 801 Weisgarber Road Suite 100, Knoxville, TN, 37909, USA

    Bergein F. Overholt

  4. Department of Internal Medicine, Georgetown University, 3800 Reservoir Road, NW 2nd Main Bldg, M2025, Washington, DC, 20007-2197, USA

    John Carroll

  5. University of California Irvine, 101 The City Drive, Building 22C 1st Floor, Orange, CA, 92868, USA

    Kenneth J. Chang

  6. Department of Pathology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    John Goldblum

  7. Department of Surgery, Emory University Medical Center, 1364 Clifton Road NE, Suite H124, Atlanta, GA, 30322, USA

    Daniel Miller

  8. Department of Internal Medicine, Columbia Presbyterian Hospital, 630 W. 168th Street Room HP-712, New York, NY, 10032, USA

    Charles J. Lightdale

  9. Department of Surgery, University of Rochester, 610 Elmwood Avenue, Rochester, NY, 14642, USA

    Jeffrey Peters

  10. Department of Internal Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Rubin Bldg #8888 Hinman 7934, Lebanon, NH, 03756, USA

    Richard Rothstein

  11. Az Center for Digestive Health, 3420 S. Mercy Drive, Suite 215, Gilbert, AZ, 85297, USA

    Virender K. Sharma

  12. Department of Surgery, Mayo Clinic in Florida, 4500 San Pablo Road, Davis 3 North, Jacksonville, FL, 32224, USA

    Daniel Smith

  13. Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd. 7th Floor, Detroit, MI, 48202-2689, USA

    Victor Velanovich

  14. Department of Internal Medicine, Mayo Clinic in Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA

    Herbert Wolfsen

  15. Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, M-211, Stanford, CA, 94305, USA

    George Triadafilopoulos

Authors
  1. David E. Fleischer
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  2. Robert Odze
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  3. Bergein F. Overholt
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  4. John Carroll
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  5. Kenneth J. Chang
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  6. Ananya Das
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  7. John Goldblum
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  8. Daniel Miller
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  9. Charles J. Lightdale
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  10. Jeffrey Peters
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  11. Richard Rothstein
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  12. Virender K. Sharma
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  13. Daniel Smith
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  14. Victor Velanovich
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  15. Herbert Wolfsen
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  16. George Triadafilopoulos
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Corresponding author

Correspondence to George Triadafilopoulos.

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Fleischer, D.E., Odze, R., Overholt, B.F. et al. The Case for Endoscopic Treatment of Non-dysplastic and Low-Grade Dysplastic Barrett’s Esophagus. Dig Dis Sci 55, 1918–1931 (2010). https://doi.org/10.1007/s10620-010-1218-1

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  • DOI: https://doi.org/10.1007/s10620-010-1218-1

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