Is Surveillance (Rather Than Esophagectomy) Safe For High-Grade Dysplasia?

At Johns Hopkins, most of our patients elect to have endoscopic treatment such as endoscopic mucosal resection and something else and do not have an esophagectomy.  Drs. Canto and Dunbar very carefully screen people with numerous biopsies (the “Seattle protocol”, so-named because it was first used at the University of Washington).  Occasionally, some people will decide that they would rather have an esophagectomy than continue to deal with their high-grade dysplasia. We found out what happened to these people and the data suggest that the protocol is indeed safe for those who opt for it.  Dr. Jean Wang compiled our data and has reported them as a preliminary report (called an abstract) and has a full report in progress. 

 

No Occult Cancer At Esophagectomy in Patients with Barrett’s Esophagus with High-Grade Dysplasia Who Have Undergone Surveillance with the Seattle Biopsy Protocol

 

Jean S. Wang, Hilary Cosby, Lisa Hicks, Elizabeth A. Montgomery, Malcolm Brock, Marcia I. Canto. Gastroenterology 2007; 132(4): A64. Digestive Disease Week, Washington, DC; May 2007.

 

Introduction: Historical studies in the surgical literature have reported the prevalence of occult cancer in patients undergoing prophylactic esophagectomy for Barrett’s esophagus with high grade dysplasia to be as high as 30-43%. However, it is unclear what type of endoscopic surveillance biopsy protocol was performed in these patients prior to surgery.

 

Aim: To determine whether use of the Seattle endoscopic biopsy protocol in patients with high grade dysplasia significantly reduces the prevalence of occult cancer at the time of esophagectomy.

 

Methods: We reviewed medical records of patients who underwent prophylactic esophagectomy for Barrett’s esophagus with high-grade dysplasia at Johns Hopkins Hospital from 1994-2006. Clinical records were examined to determine whether the Seattle endoscopic biopsy protocol was followed during endoscopy performed prior to surgery. Pathology reports were examined to determine whether occult adenocarcinoma was detected during surgery.

 

Results: A total of 39 patients underwent prophylactic esophagectomy for Barrett’s esophagus with high grade dysplasia during the study period. Among patients who had undergone endoscopic surveillance with the Seattle biopsy protocol, there were no (0/15) invasive adenocarcinomas detected within their resected surgical specimens. In contrast, among patients who had not undergone endoscopic surveillance with the Seattle biopsy protocol, 33% (8/24) had invasive adenocarcinoma detected in their resected surgical specimens.

 

Conclusions: The prevalence of occult adenocarcinoma in patients with Barrett’s esophagus and high-grade dysplasia is very low if the Seattle biopsy protocol is followed during endoscopic surveillance. Therefore, the standard care of esophagectomy for Barrett’s esophagus with high-grade dysplasia should be reconsidered.

 

 

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