Background: The management of dysplasia arising in Barrett's esophagus is controversial.
Study design: Twenty patients (group 1, prompt attitude) underwent operation as soon as high-grade dysplasia (HGD) was discovered (n = 8) or just after either the presence of HGD was confirmed (n = 9) or invasive carcinoma (IC) was found (n = 3) in a second set of biopsy samples taken soon after HGD had been discovered. In contrast, esophagectomy in 13 patients (group 2, expectant attitude) was performed only because HGD persisted (n = 4) or turned into IC (n = 4) at endoscopic followup (7 to 23 months) (subgroup 2a, n = 8) or because HGD (n = 2) or low-grade dysplasia (LGD) (n = 3) was disregarded until dysphagia and IC developed (12 to 70 months) (subgroup 2b, n = 5). Skeletonizing en-bloc esophagectomy was performed in 29 patients and four patients (three with HGD and one with mucosal IC in the resected specimen) underwent vagus-sparing esophagectomy.
Results: Invasive carcinoma was found in 11 of 24 patients (45.8%) supposed to have only HGD (in repeat biopsies in 3 patients from group 1 and in the resected specimen in eight of 21 patients (38%) operated on for HGD. Metastatic lymph nodes were found in the resected specimen of seven patients (group 1: one of 20 or 5%, versus subgroup 2a: two of eight or 25%, versus subgroup 2b: four of five or 80%; p = 0.001). Unlike none of the 26 patients (0%) with an intramural process, five of the seven patients (71.4%) with an extramural process (one had had disregarded LGD) developed neoplastic recurrence at followup (p < 0.0001). Cancer-related survival in the long term was 100% in group 1 versus 52.5% in group 2 (p = 0.0094).
Conclusions: Invasive carcinoma is present in almost one half of patients with HGD within a Barrett's area. Promptness in the decision regarding an esophageal resection as soon as HGD is found is much safer than expectant observation. Not enrolling a patient with LGD in an endoscopic surveillance program can lead to the development of extramural IC with poor outcomes.