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

 Evaluation

  1. Have your slides reviewed by an expert GI pathologist – to make sure the biopsies show HGD and not cancer or low grade dysplasia (LGD)
  2. Have repeat endoscopy with more biopsies to determine if there’s just one area with HGD or multiple areas of HGD (multifocal HGD)
  3. 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.

Treatment

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.

  1. 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. 
  2. 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.
  3. 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.
  4. 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. 
  5. 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. 
  6. 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.
  7. 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

18 thoughts to “Barrett’s Esophagus with High Grade Dysplasia”

  1. My colleague Dr. Marcia Canto notes that if all BE is completely eliminated, the long term chance of cancer is reduced significantly. Even if only BE HGD is eliminated, the data suggest that cancer risk is reduced by half but not eliminated. Dr. Canto has yet to introduce herself on the site, but she works closely with Dr. Dunbar and has extensive experience with Barrett’s esophagus.

    Elizabeth Montgomery, MD
    Professor of Pathology and Oncology

  2. I am a fairly healthy 53 yr. woman who has had two endoscopies at my local county hospital, and a endoscopy biopsy mapping done at UCLA. All three of these test have come back the same and I am told that the diagnosis is BE/HGD.

    My question and concern is that UCLA only offers the Radiofrequency abalation or the complete removal of the esophagus. I’ve read enough about Halo 360/90 to know that it is a fairly new treatment and it seems that all of the options (except surgery) do not have much statistical data to help me make an informed decision.

    I debate back and forth whether I want to have scopes done every three months, and then worry if the BE/HGD has come back, or if it would just be better for me to have the surgery and get on with my life.

    I’ve known two people personally who had Barrett’s and then developed esophagus cancer. One is no longer living.

    Any feedback you can provide would be greatly appreciated.

    Thank you so much!

  3. Hi, the Halo 360 and 90 are relatively new, but there’s alot of ongoing research looking at it. If your BE has lesions, like small nodules or bumpy areas, then EMR would be reasonable to remove these areas. The preliminary data for radiofrequency ablation that says it might be 90% effective for BE HGD eradication. There’s a large study being completed looking at Halo treatment in patients with HGD. So talk with your gastroenterologist about what they recommend and remember that it’s ok to get a second opinion.

  4. I have HGD ,if it turns into cancer ( it could be soon ) what would you do and who is the best doctor ?

  5. Dr. Dunbar

    Do you feel that all hospital GI departments are coordinating in an effort to preserve or save all records of patients treated for LGD and HGD, and by all available treatments?

    I guess that I am trying to ask you if this precious data is being collected by any one particular organization, such as the American College of Gastroenterology, or the National Institutes of Health?

    I was diagnosed with BE without dysplasia, around 3 months ago and have read about a lot of research that has one common theme; “small studies”. This is very discouraging for myself, when cancer from BE has been around so long and is increasing.

    There seems to be a lack of funding from the NIH for BE research. Do you agree? I believe that we need a campaign for awareness of BE and it’s potential.

    Also, all of the currently available treatments for HGD, excluding removal of the esophagus, must carry a bias by the treatment specialist, as these treatment centers invest in the different equipment, for different treatments. Do you think that any of the treatment results are skewed, or not properly reported due to rival technologies?

    Thank you very much for your precious time :)

  6. I have been diagnosed with Barrett’s (a few 2 cm islands just above the 38 cm-located gastric folds) with HGD found at 37 cm (with no HGD at 36 cm). The rest of the esophagus and stomach appeared normal according to the endoscopist. This is my forth endoscopy over the past 8 years where the diagnosis has evolved from BE to LGD to (last month) HGD. The recommendation is that I go directly to a Barrx procedure. Would you recommend an additional endoscopic exam with biopsies or is this not necessary? I also want to consider Cryoablation. I’m told there is more data and a longer track record on Barrx but the Cryoablation also seems to report well with maybe less invasiveness and risk. Which of the two procedures is indicated for the described (mild to moderate) case of BE with HGD?

    Thanks, Mike

  7. Jan 27th
    I do not wish to create some more confusion about the best way to get treated. It happens that I am involved in this therapy through my professional activities. To-day, according to my knowledge there is no long term data available for the treatment of HGD with BarrX. The only data available at 5 year is a PDT study run by Dr Overolt in the US showing an eradication rate of 77% of HGD using PDT. It is difficult to chose to-day because some confusion arises from doctors who think, as often, that a new technique is “the” solution. PDT, which gets rid of ill tissue on 6 mm is sometimes leaving untreated zones which cause reccurence. What is the garantee that Halo 360, treating only 1 mm, will eradicate your HGD ?
    Drugs needed more than 10 years to get approval for such treatments and I am very surprised that an equipment can be used as alternative treatment without an equivalent long term study ?

  8. Mike Letsky – Thanks for your questions. From your description it sounds like you have a small amount of BE, but now have HGD. It would be reasonable to have your slides reviewed by an expert GI pathologist to make sure you have HGD. If your GI physician did 4 quadrant biopsies during your last EGD (or if you just have a few islands, biopsied them all) then you’ve had good sampling of your BE. If there was just one small area of HGD , EMR could be considered. With multiple areas, ablation may be more effective. There aren’t any head to head studies comparing RFA and cryo, so it’s hard to say which is better. At this point, there’s more published data with RFA. There aren’t any clear guidelines about which treatment would be best, so it’s a discussion to have with your GI doctor. You can always get a second opinion from another gastroenterologist. There are a few posts on this site with more detailed information on RFA and cryo.

  9. Diagnosed BE(HGD) – Your decision is not an easy one. You could think about a second opinion. Esophagectomy is definitive treatment, but is a big surgery. The results for RFA so far have been good, but you will need to have continued endoscopy. There’s more info to discuss on the subject of RFA and surgery, so I’ll put them in longer posts.

  10. Boucher – Thanks for your comment. PDT is an effective treatment for BE with HGD and early cancer. It seems to be used less frequently in the US now due to the advent of RFA. There are several good long term studies worth discussing, and I’ve posted some information about PDT in a separate post.

  11. Jeff Combs – The answer to your question is long, so you may want to look at the post about BE with high grade dysplasia as a starting point. As far as picking the best doctor… There are lots of good gastroenterologists. GI doctors who work at academic medical centers (usually ones with a medical school or affiliated with a university) often specialize in some aspect of GI. If there’s an academic center near where you live, check and see if they have a GI doctor who specializes in Barrett’s esophagus.

  12. Jack – Thanks for your interest. You have great questions and my answers are too long to fit in a reply. I’ll try to address them in an upcoming blog post (or two).

  13. My husband was diagnosed with HGD in multi spots and has had halo 360 and then spot removal the 2nd procedure. It’s 6mos into treatment and his intensive biopse showed 2 spots. We are due for consult. Surgery or more treatments. Can anyone help with like results or diagnosis? Where to go from here is the question

  14. My husband has HGD which is multi-focal. BE is between 6-8 cm. long.Both RFA and Surgery have been recommended by two differnt doctors. Anyone have any ideas???

  15. Ablation can be effective for flat HGD, even if it is multifocal. Most of the ablative therapies can also be repeated if the BE comes back. Barrett’s with nodules or lumps may need endoscopic mucosal resection and then ablation. Surgery is also an option (and needs its own post) for HGD.

  16. My husband is scheduled to have two-thirds of his esophagus removed on Wednesday. we are still not sure that this is the right thing to do. We have had several GIs tell us that this is the right thing to do, because he has multi-focal hgd that is circular (goes around the esophagus) However, does anyone know is there is a safe and reliable alternative??? PLEASE HELP

  17. I was diagnosed with Barrett’s Esophagus a few years ago, and have had Upper GI’s performed every two years since first diagnosis. All pathology reports have shown no dysplasia until this year. My most recent Upper GI (performed two weeks ago) showed low-grade dysplasia (LGD) in one area only. Therefore, my gastroenterologist has scheduled another Upper GI to be performed six months from now. He has discussed radio-frequency ablasion with me, but has not scheduled it as of now. Is it relatively safe for me to wait for six more months and undergo yet another Upper GI (which is scheduled for December 2010) with a diagnosis of Barrett’s with LGD, or would it be more prudent to pursue radio-frequency ablasion as soon as possible? I am of course frightened by the aspect of this developing into cancer. Please advise me, and thank you.

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