Purpose of review: This article discusses the various controversies that surround the management of low-grade dysplasia (LGD) in Barrett's esophagus.
Recent findings: Data on the clinical course of LGD patients with regards to rates of progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) are highly variable. Recent data suggest that the rate of progression to EAC may be similar to that of patients with nondysplastic Barrett's esophagus (0.4-0.5% per year). There is significant interobserver variability in the diagnosis of LGD even among expert gastrointestinal pathologists. Data on various endoscopic eradication therapies (EET) specifically in this patient population are limited. Eradication of LGD and intestinal metaplasia can be achieved by radiofrequency ablation as demonstrated in a randomized controlled trial. Although treatment appears to be durable for up to 3 years, progression to HGD and EAC can occur, highlighting the need for close endoscopic surveillance even after EET.
Summary: There is a need to risk stratify Barrett's esophagus patients with LGD to identify patients most likely to progress using a reliable and objective system that incorporates clinical features, advanced imaging techniques and biomarkers. If such a high risk group could be identified, they may benefit from EET, whereas, the majority may be managed conservatively.