Barrett's Esophagus and Dysplasia

Author: Jason Muesse, MD
Institution: University of Arkansas
Date Reviewed: December 2024
Learning Domain: General Thoracic
Learning Objective: Barrett's Esophagus; Dysplasia
PowerPoint File: Barrett's Esophagus and Dysplasia

 

What is Barrett’s Esophagus?

= Metaplasia

  • Defined as the change from one cell type to another
  • Squamous cell to intestinalized simple columnar cells
  • Normal appearing cells but in the wrong place - Not unregulated growth
  • Due to repetitive injury – cells trying to adapt

IS NOT Dysplasia 

  • Defined as the abnormal growth or development of the cells but have not yet gained the ability to evade the organ

IS NOT carcinoma 

  • Defined as the unregulated growth of a cell type that has gained the ability to evade the parent organ (growth beyond basement membrane)

 

  • Probably about a 10-15 percent chance overall of progression to dysplasia and 1-2 percent lifetime risk of developing esophageal cancer 
    • Still 100 fold increase risk of general population of developing cancer

 

What Else Can you Find on an Esophageal biopsy that has abnormal appearance?

  • Esophagitis (generalized)
  • Candida esophagitis
  • Eosonophilic esophagitis
  • Neutrophilic esophagitis
  • HSV esophagitis
  • melanoma

 

Endoluminal Therapy for Barrett’s Esophagus & Dysplasia

Radiofrequency Ablation

  • Radiofrequency Energy on a probe          
  • Superficial therapy
  • Most commonly used now
  • There is a 360 degree circumferential probe and a side facing probe

Photodynamic therapy 

  • Expensive, requires pretreatment 
  • Have to avoid sunlight for many days before and after
  • High stricture rate, rarely used anymore

Endoscopic Mucosal Resection 

  • Maily used for dysplasia and T1a tumors
  • Produces a nice specimen that can tell depth of invasion 
  • Can result in stricture, so not often used for long segment of Barrett’s

 

  • Always have the potential for “hidden glands” / deeper cancer not seen
    • This is why doing endoscopic ultrasound is critical before using this therapy

 

Endoluminal Therapy for T1a Esophageal Cancer

  • First Line Therapy for T1a tumors or dysplasia (but esophagectomy should be offered)
    • The resected specimen is the ultimate T (depth) staging tool 
    • If deeper than a T1a (invading into or past submucosa in any way), patient is recommended to have esophagectomy
      • b/c incidence of nodal metastasis goes from 7 percent to 21 percent when go from T1a to T1b
  • Must be done with endoscopic ultrasound first  
  • Must still obtain full metastatic workup
  • RFA or PDT for coexisting Barrett’s must be performed as a supplement
  • Must have very aggressive short and long term follow up 

 

So what about our patient? (discuss)

  • Should we perform RFA ablation ?  
  • Should we wait the 3 years currently recommended for surveillance
  • If he is on a PPI and has Barret’s, has he failed medical therapy ?
  • Should he be considered for fundoplication assuming he has normal manometry and a DeMeester score >14?