Diffuse endoscopically visible, predominantly low grade dysplasia in Barrett’s esophagus (with video)

Abstract

Background Low grade dysplasia (LGD) in Barrett’s esophagus (BE) has generally been considered as undetectable endoscopically. Aim To describe a phenotype which consists of diffuse, endoscopically visible, predominantly low grade dysplasia in Barrett’s esophagus (DEVLB), with often subtle but visible endoscopic changes seen with high definition white light (HDWL) and narrow-band imaging (NBI). Method A systematic search of a prospectively collected database for patients satisfying predefined criteria for DEVLB and a review of endoscopic and histological features of biopsies and endoscopic mucosal resection (EMR) specimens. Results Out of a total of 419 patients referred to our expert center for assessment of dysplastic Barrett’s esophagus during the period January 2009 to March 2018, there were 7 patients (1.7 %) who satisfied the criteria defined for DEVLB, identified on their initial assessment endoscopy. All patients were treated by EMR of visible abnormal mucosa during their assessment endoscopy at our tertiary referral center. There was a total of 47 EMR specimens obtained, with a median of 6 (IQR 5–9) EMR resection pieces per patient, of which 36 (77 %) contained LGD, 8 (17 %) high grade dysplasia (HGD), 2 (4 %) non-dysplastic Barrett’s esophagus (NDBE), and 1 (2 %) contained early esophageal adenocarcinoma (EAC). Conclusion DEVLB is a distinct phenotype seen in a small but significant proportion of individuals with dysplastic Barrett’s esophagus. Patients with DEVLB have widespread LGD, with many having areas of focal HGD or early cancer within this area. We believe these patients are best treated with extensive EMR of the visibly abnormal area.

Endoscopic features of low-grade dysplastic Barrett’s

“…This was considerably lower than the 50.4% of visible LGD lesions identified at BRU assessment (in the same cohort). Our high proportion of visible lesions was also significantly more than the current reported rates from other expert Barrett's centres (6.4 -18.7%) [7,8,9,10,19,20].…”

“…The majority of non-visible lesions detected on protocol biopsies had a single, <1mm focus of LGD, whilst visible LGD lesions often had multiple foci or a larger, continuous area of LGD within the biopsy or resection specimen. Furthermore, our patients with the DEVLB phenotype [10] frequently had LGD that was deeper than 1mm (see Figure 9) and interestingly did not respond to RFA therapy (the reported controlled treatment depth of RFA is 0.5-1mm [23]).…”

“…A key strength of a single-center analysis is that the data are homogeneous: endoscopic assessment, location and biopsy reporting, visible lesion description, biopsy sampling techniques, and forceps sizes were all consistent, and surveillance protocols were followed diligently, leading to lower detection bias and decreased sampling error. Importantly also, our definition of true BE-LGD was the same as prior studies and all histology samples were reviewed by expert gastrointestinal pathologists, allowing for generalizability to the real world 22 55 66 77 88 99 1010 1111 1212 .…”

“…Furthermore, Hussein et al recently identified that nodular BE-LGD at index endoscopy was associated with progression to neoplasia 99 . Separately, Tsoi et al described a subset of BE-LGD patients with a diffusely nodular, multifocal LGD phenotype (DEVLB) that also appeared to be associated with an increased risk of progression to HGD or cancer 1010 . Current guidelines recommend endoscopic resection for all visible dysplastic BE lesions and this may be equally relevant in patients with visible BE-LGD 1111 1212 .…”

Low-grade dysplasia on Barrett’s esophagus: visible or not ?

“…The 50% rate of visible LGD reported by He et al is much higher than the 6% to 19% reported in other Barrett's expert centers. It can be explained by the systematic use of a cap to analyze the Barrett's segment, the specific expertise of the group in analyzing the Barrett's mucosa, demonstrated by the description in 2019 of the diffuse endoscopically visible LGD in BE or DEVLB [4], and the performances in diagnostic endoscopy of the community centers involved. However, the fact that LGD is endoscopically invisible in half of the cases, even to experts specifically seeking it, reminds us that random biopsies following the Seattle protocol are still needed in 2023.…”