When it comes to the diagnosis and treatment of precancerous and cancerous conditions of the esophagus, the most important factors for clinicians are to have good endoscopic equipment, to keep in mind that endoscopic surgery can be a better choice than the riskier open surgery, and to obtain more and larger tissue samples for pathology to ensure that no early cancers are missed.
These are the key messages to emerge from a review focusing on the care and treatment of the precancerous conditions of Barrett esophagus and Barrett dysplasia, as well as early-stage esophageal adenocarcinoma, as relayed by Janusz Jankowski of the Blizard Institute of Cell and Molecular Science at Queen Mary, University of London (United Kingdom), in a statement issued by the university.
“At present, there are no reliable biomarkers that can replace good equipment, a well-trained endoscopist, and a methodical pathologist,” Jankowski affirmed.
Jankowski led a multinational team of researchers in a review of nearly 12,000 papers on Barrett esophagus and dysplasia and early-stage esophageal adenocarcinoma to make evidence-based consensus statements for the management of patients with these conditions. Despite generally low quality of evidence, the reviewers achieved consensus (80% or more of the reviewers strongly agreed or agreed with reservation on a statement) for 81 of 91 statements, including eight clinical statements:
- Specimens from endoscopic resection are better than biopsies for staging lesions.
- The size of the dysplastic areas must be carefully mapped.
- Patients who undergo ablative or surgical therapy require endoscopic follow-up.
- High-resolution endoscopy is necessary for accurate diagnosis.
- Endoscopic therapy for high-grade dysplasia is preferable to surveillance.
- Endoscopic therapy for high-grade dysplasia is preferable to surgery.
- The combination of endoscopic resection and radiofrequency ablation is the most effective therapy.
- After endoscopic removal of lesions from patients with high-grade dysplasia, all areas of Barrett esophagus should be ablated.
A detailed accounting of the recommendations appears in the journal Gastroenterology (2012;143:336-346).