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

Published online: 2019-12-10 Original article Diffuse endoscopically visible, predominantly low grade dysplasia in Barrett’s esophagus (with video) Authors Edward H. Tsoi1, 2, Sasha Fehily1, Richard Williams3, Paul Desmond1, 2, Andrew Taylor1, 2 Institutions 1 St. Vincent’s Hospital, Department of Gastroenterology, Fitzroy, Victoria, Australia 2 University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Victoria, Australia 3 St. Vincent’s Hospital, Department of Pathology, Fitzroy, Victoria, Australia submitted 14.6.2019 accepted after revision 11.9.2019 Bibliography DOI https://doi.org/10.1055/a-1031-9327 | Endoscopy International Open 2019; 07: E1742–E1747 © Georg Thieme Verlag KG Stuttgart · New York eISSN 2196-9736 Corresponding author Dr. Edward H. Tsoi, MBBS MPH FRACP, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia Fax: +61-3-86486318 ABSTR AC T Background Low grade dysplasia (LGD) in Barrett’s esophagus (BE) has generally been considered as undetectable endoscopically. Introduction There has been significant technological advancement in endoscopic imaging over the last decade [1]. This has led to a reliable detection of high grade dysplasia (HGD) and early esophageal adenocarcinomas (EAC) in Barrett’s esophagus [2, 3]. However, low grade dysplasia (LGD) is generally considered to be undetectable endoscopically, despite our best imaging modalities [3, 4]. The progression rate of LGD varies significantly in the literature from 0.4 % to 13.4 % [5, 6]. This is in part due to the large interobserver variability among pathologists in diagnosing LGD [7, 8]. Many studies have described risk factors for E1742 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. progression from LGD to EAC, and these include: a confirmed diagnosis of LGD by expert pathologists, multifocal dysplasia, persistent LGD, and use of biomarkers; however, the natural history of progression of LGD is still unpredictable [9–12]. We have recognized a small subgroup of patients with an area of subtle endoscopic features within their Barrett’s segment; the histology from the resection specimens within this area contains widespread LGD and often harbors more advanced dysplasia or even EAC. Tsoi Edward H et al. Diffuse endoscopically visible … Endoscopy International Open 2019; 07: E1742–E1747 ▶ Fig. 1 Well demarcated diffuse subtle nodularity or variation in mucosal pattern from each patient. a Patient 2. b Patient 3. c Patient 4. d Patient 5. e Patient 6. f Patient 7. Aim Equipment and referral center We aim to describe a case series of a specific phenotype of Barrett’s esophagus that we have termed Diffuse Endoscopically Visible predominantly Low-Grade Dysplasia in Barrett’s (DEVLB), with features that are defined below and that can be identified on endoscopic examination with high definition white light (HDWL) and narrow-band imaging (NBI). Our hospital is a tertiary teaching hospital and a major referral center for management of dysplastic Barrett’s esophagus. All patients had their assessment endoscopy performed with an Olympus HQ180 or HQ190 gastroscope by a single expert endoscopist (AT) with extensive experience in assessment of dysplastic Barrett’s esophagus. Prospectively collected Barrett’s database Methods This observational study was performed at a tertiary referral expert center for management of dysplastic Barrett’s esophagus. Definition of DEVLB and identification of study patients We have defined DEVLB as consisting of a large area (cutoff for this study defined arbitrarily as at least 6 cm 2) with: 1) diffusely abnormal mucosa with either: a) patchy loss of or variation in mucosal pattern, and/or b) widespread, subtle nodularity; 2) a clear demarcation from normal looking smooth Barrett’s mucosa, and 3) histology showing predominantly multifocal LGD though sometimes with areas of more advanced dysplasia. Patients who fitted the criteria for DEVLB on their initial assessment endoscopy were identified by manual review of endoscopic and histological data collected prospectively on our Barrett’s database from all patients referred with dysplastic Barrett’s esophagus for assessment and management. A prospective database was established in 2009 documenting all patients referred with dysplastic Barrett’s esophagus. Information such as patient demographics, medical history, endoscopy results, histology results, and multidisciplinary meeting outcomes are all recorded. To date, there are a total of 419 patients referred with dysplastic Barrett’s esophagus. 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 seven patients (1.7 %) who satisfied the definition of DEVLB, identified on their initial assessment endoscopy (▶ Fig. 1). All were male with a median age of 70 years (IQR:61–72). The median maximum length of Barrett’s segment was 9 cm [IQR: 7–12]. Four patients (57 %) had DEVLB predominantly on the right wall of the esophagus only (12–6 o’clock position) and three patients (43 %) had Tsoi Edward H et al. Diffuse endoscopically visible … Endoscopy International Open 2019; 07: E1742–E1747 E1743 Original article ▶ Fig. 2 Distribution of dysplasia within Barrett’s esophagus for patients 2 – 7. DEVLB on both the left wall (6–12 o’clock position) and the right wall of the esophagus. Patients were treated initially with (...truncated)