Progression Common in Low-Grade Dysplasia of Barrett's Esophagus
Last Updated: 2010-05-11 17:04:39 -0400 (Reuters Health)
NEW YORK (Reuters Health) - Patients with "true" low-grade dysplasia of Barrett's esophagus have neoplastic progression rates as high as 13% per year, so strict follow-up or endoscopic ablation therapy is necessary, Dutch researchers advise.
According to senior author Dr. Jacques J.G.H.M. Bergman and colleagues, low-grade dysplasia of Barrett's esophagus is "overdiagnosed and underestimated." In other words, because the condition is overdiagnosed, progression may seem less likely than it really is.
Dr. Bergman, from Amsterdam's Academic Medical Center, and his team studied the natural history of low-grade dysplasia in 1198 Barrett's esophagus patients who had surveillance endoscopies at six non-university hospitals. Clinicians diagnosed low-grade dysplasia in 147 patients (12%) between 2000 and 2006.
Two gastrointestinal pathologists with extensive experience in Barrett's esophagus reviewed pathology slides from all 147 cases, confirming the diagnosis of low-grade dysplasia in only 22 (15.0%). They diagnosed high grade dysplasia in patient (0.7%), indefinite for dysplasia in 14 (9.5%), and non-dysplastic Barrett's esophagus in 100 (74.8%).
Thus, in general practice, a diagnosis of low grade dysplasia probably overestimates the reactive changes in a patient with nondysplastic Barrett's esophagus, the authors say.
During mean follow-up of 51 months, among 19 patients diagnosed with low-grade dysplasia with follow-up endoscopy data, 8 (42%) progressed to either carcinoma or high grade dysplasia. That's in contrast to 2 of 92 (2.2%) who were downstaged to non-dysplastic Barrett's esophagus.
Corresponding incidence rates of high grade dysplasia or carcinoma were 13.4% and 0.49% per patient per year of follow-up, respectively. Patients with a consensus diagnosis of low grade dysplasia had a cumulative risk of progression of 85.0% over 9 years, versus 4.6% among those with non-dysplastic Barrett's esophagus (p < 0.0001).
The authors comment that low-grade dysplasia in biopsies may be a marker for synchronous high-grade dysplasia or carcinoma that was missed endoscopically and by random biopsies.
For all 10 patients with progression, the mean interval since diagnosis of low grade dysplasia was 40 months, during which time they underwent an average of 2.3 follow-up endoscopies. Eight underwent endoscopic resection and/or radiofrequency ablation with disease eradication; one with submucosal invasion underwent esophagectomy, and one with extensive comorbidity underwent radiation therapy.
Dr. Bergman's team suggests that in cases of potential low-grade dysplasia of Barrett's esophagus, having pathology specimens re-evaluated by an expert gastrointestinal pathologist may be a cost-effective alternative to standard surveillance endoscopy every 6-12 months.
If cases are confirmed, then endoscopic ablation may be justified even if there are no visible abnormalities, the researchers say. On the other hand, patients with visible abnormalities in Barrett's esophagus should undergo endoscopic resection before ablative therapy.
Am J Gastroenterol 2010.
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