Challenges to diagnostic standardization of Barrett's esophagus in Asia

Abstract

Barrett's esophagus (BE), a premalignant condition of the lower esophagus, is increasingly prevalent in Asia. However, endoscopic and histopathological criteria vary widely between studies across Asia, making it challenging to assess comparability between geographical regions. Furthermore, guidelines from various societies worldwide provide differing viewpoints and definitions, leading to diagnostic challenges that affect prognostication of the condition. In this review, the authors discuss the controversies surrounding the diagnosis of BE, particularly in Asia. Differences between guidelines worldwide are summarized with further discussion regarding various classifications of BE used, different definitions of gastroesophageal junction used across geographical regions and the clinical implications of intestinal metaplasia in the setting of BE. Although many guidelines recommend the Seattle protocol as the preferred approach regarding dysplasia surveillance in BE, some limitations exist, leading to poor adherence. Newer technologies, such as acetic acid‐enhanced magnification endoscopy, narrow band imaging, Raman spectroscopy, molecular approaches and the use of artificial intelligence appear promising in addressing these problems, but further studies are required before implementation into routine clinical practice. The Asian Barrett's Consortium also outlines its ongoing plans to tackle the challenge of standardizing the diagnosis of BE in Asia.

Is Malignant Potential of Barrett’s Esophagus Predictable by Endoscopy Findings?

“…Patients with EAC have been gradually increasing in Asian countries, and those with BE are known to share similar risk factors for neoplastic progression as demonstrated in Western populations [ 118 , 119 ]. In Japan, EAC has not been well known in clinical practice, different from esophageal squamous cell carcinoma, though EAC cases have been steadily increasing in association with increases of erosive esophagitis and BE [ 120 ]. According to the annual report of the Japanese Association for Thoracic Surgery, the ratio of EAC to squamous cell carcinoma cases had increased to 9.4:100 in 2017 [ 121 ].…”

Prevalence, clinical characteristics, and risk factors of Barrett esophagus in Vietnamese patients with upper gastrointestinal symptoms

“…Currently, the most challenging barrier for further investigations of BE in Asia is diagnostic standardization. [ 5 ] Endoscopic criteria, biopsy protocols and histologic criteria have been used significantly different across Asian studies. Consequently, there is substantially variability in the reported BE prevalence in the region and the true risk factors might not be correctly identified.…”

“…Consequently, there is substantially variability in the reported BE prevalence in the region and the true risk factors might not be correctly identified. [ 5 , 6 ] At present, the updated Asia-Pacific consensus defines BE as the replacement of the normal distal squamous epithelial lining by columnar epithelium, which must be clearly visible endoscopically ≥1 cm above the gastroesophageal junction, and be confirmed by histology. In addition, the Prague C and M classification is recommended for documenting BE in clinical practice.…”

Endoscopic submucosal dissection is associated with less pathologic uncertainty than endoscopic mucosal resection in diagnosing and staging Barrett's‐related neoplasia

“…Despite this, treatment outcomes remain poor, as approximately half of all patients newly diagnosed with esophageal adenocarcinoma die within a year of diagnosis, and fewer than 20% survive 5 years . Secondary to this, a concerted effort to identify those at risk for esophageal adenocarcinoma by screening for its precursor lesion, Barrett's associated neoplasia (BN), has been suggested by multiple societal guidelines …”

“…3 Secondary to this, a concerted effort to identify those at risk for esophageal adenocarcinoma by screening for its precursor lesion, Barrett's associated neoplasia (BN), has been suggested by multiple societal guidelines. [4][5][6][7][8][9][10][11][12] In patients with BN, endoscopic resection is the preferred therapeutic approach. 4,5 While both endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have demonstrated similar efficacy in removal of neoplastic lesions in the esophagus, significant controversy exists over the preferred resection technique and there is a paucity of direct comparisons between the two for the treatment of BN.…”