Barrett’s Esophagus with High Grade Dysplasia
We’ve had some questions about high grade dysplasia in Barrett’s esophagus, so here’s some information that may be helpful.
The lifetime risk of esophageal cancer from Barrett’s esophagus is low, probably on the order of 5% or less. Surveillance programs with regular upper endoscopy seem to help detect dysplasia before it progresses to cancer.
So what if you do have high grade dysplasia (HGD)? HGD occurs when the Barrett’s esophagus cells accumulate mutations and lose their normal shape and pattern. HGD isn’t cancer, but it is the step before cancer. The risk of developing esophageal cancer from HGD has been looked at in several studies and ranges from 20% to 50%.
With HGD, there are several options for evaluation and treatment
- Have your slides reviewed by an expert GI pathologist – to make sure the biopsies show HGD and not cancer or low grade dysplasia (LGD)
- Have repeat endoscopy with more biopsies to determine if there’s just one area with HGD or multiple areas of HGD (multifocal HGD)
- Some gastroenterologists like to perform an endoscopic ultrasound for any patient diagnosed with BE-HGD. This is done to look for signs of cancer, such as enlarged lymph nodes or invasion of tissue through the wall of the esophagus. However, experts disagree about whether this is necessary. There have been a few studies that EUS isn’t that helpful for HGD. But EUS is important for staging cancers in Barrett’s esophagus.
There are several options for treatment and there’s no one right answer for every patient. Often, patients may need a combination of the therapies below to treat their HGD. Other health issues and patient preferences play a role in choosing the right treatment.
- Continued surveillance – repeating an EGD every 3 months to look for cancer. This is an option for patients who don’t want (or are too unhealthy) for other therapies. Also, continued surveillance is important for anyone treated for HGD with any of the therapies listed below, to make sure new areas of HGD haven’t arisen.
- High dose proton pump inhibitor therapy – generally given twice daily. It doesn’t cure HGD, but can help reduce inflammation and make biopsies easier to interpret. There are some studies that show regression of low grade dysplasia with PPI therapy.
- Esophagectomy – surgical removal of the esophagus. This procedure gets rid of all the BE and dysplasia. The esophagus is removed and the stomach is pulled up into the chest or a piece of large intestine is used to make a new esophagus. This is very effective for getting rid of HGD, but is a major surgery and the complication rate varies. It’s important to choose a surgeon who does many esophagectomy procedures as they tend to have lower complication rates.
- Endoscopic mucosal resection (EMR) – useful for removing small areas of the esophageal mucosa that contain HGD. EMR is often used to remove bumpy areas of HGD.
- Photodynamic therapy – A light-sensitizing medication, porfimer sodium, is injected intravenously. Then a special laser fiber is inserted through the endoscope to the area of BE and dysplasia. The light from the laser causes a photochemical reaction with the porfimer sodium, which destroys the mucosa. Patients who have PDT are photosensitive for several weeks and are advised to avoid the sun.
- Radiofrequency ablation - A special balloon or small paddle attached to the endoscope are used to burn away a thin layer of the esophageal mucosa, getting rid of the HGD in the Barrett’s esophagus. This is one of the newer treatment options for BE HGD.
- Cryotherapy – Freezing liquid nitrogen or carbon dioxide is sprayed onto the esophageal mucosa, freezing the BE and HGD. This is another newer treatment option for BE HGD.
If you have any questions about treatment of HGD, talk with your gastroenterologist about the different options to see which treatment would be best for you.
posted by Kerry Dunbar, MD