Barrett's Esophagus (cont.)
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How is high grade dysplasia managed?
The most common standard by which treatments for cancer or related disorders, such as dysplasia, are measured is by the 5-year outcome. For example, we just mentioned the 80% five year survival rate for esophageal cancers that were found by surveillance in Barrett's and then treated by esophagectomy (surgical removal of the esophagus).
The finding of high grade dysplasia in Barrett's may mean that cancer already is present. For this reason, when high grade dysplasia is found, the next step is to repeat the endoscopy and take more biopsies. For this purpose, the recommendation is to take four biopsies (one from each quadrant) every one centimeter rather than every two centimeters. If the biopsy findings again reveal just high grade dysplasia, there are a number of management options, including esophagectomy, continued biopsy surveillance, and experimental approaches.
Endoscopic ultrasound
Endoscopic ultrasound is invaluable in the staging of early
cancers to determine the depth of their penetration into surrounding tissue. It
also can be used to determine if dysplastic tissue has invaded the surrounding
tissue, that is, has become cancerous. This technique uses endoscopes as
dedicated ultrasound devices. In other words, these endoscopes are used only for
doing endoscopic ultrasound. These instruments can literally see through the
wall of the esophagus with much greater accuracy than, for example, a computerized tomographic (CT)
scan. Endoscopic ultrasound is available in most centers that specialize in Barrett's esophagus and/or esophageal cancer.
Esophagectomy
The gold standard for the management of high grade dysplasia is esophagectomy. Esophagectomy involves total removal of the esophagus except for a very short cuff of esophagus at its upper end. The esophagus is replaced with a segment of colon, or stomach is brought up under the breastbone and attached to the remaining cuff of the esophagus.
Patients with Barrett's awaiting an esophagectomy should seek an experienced surgeon with a good track record. They should interview the surgeon about his/her results. There is no validated or magic annual number of operations that provides enough surgical experience, but some surgeons believe it should be at least 20 per year. What's important is not just the experience with the actual surgery, but also the experience of the team involved in the pre and post operative care.
The operative death rate (mortality) associated with esophagectomy for high grade dysplasia and early cancer is near 0%. However, in the postoperative period, a host of complications (operative morbidity) may occur, most of which are transient (self-limited). These complications may include delayed gastric emptying of food, temporary hoarseness, and strictures of the esophagus (narrowed areas caused by scarring).
Follow-up biopsy surveillance, and esophagectomy ONLY if cancer is found
Some patients with high grade dysplasia opt to have a
close follow-up. In these individuals, endoscopic biopsy surveillance is done
initially every three months for at least a year and then less often (for exmple,
every four to six months). The understanding is that surgery (esophagectomy)
will be done if carcinoma were found during the course of the follow-up. This
has not been a universally popular approach except at a few centers. It requires
a commitment on the part of the endoscopist to do meticulous surveillance
biopsies frequently. It also requires that the patient be reconciled with the
frequent follow-up procedures and with the attendant uncertainty for what the future holds.
Next: How is low grade dysplasia managed? »
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