Endoscopic work-up of early Barrett’s neoplasia

Introduction

In recent years, endoscopic therapy of early Barrett’s esophagus neoplasia has become a safe and effective alternative to esophagectomy [1] [2] [3] [4]. Only patients with high-grade intraepithelial neoplasia (HGIN) or mucosal cancer are eligible for curative endoscopic treatment. Lesions that invade the submucosa are associated with a significant risk of lymph node metastases and are therefore preferably to be treated surgically. There are two main types of endoscopic therapy: endoscopic resection and endoscopic ablation. An important difference between these two modalities is that endoscopic resection permits histopathological evaluation of the resection specimen, whereas this safeguard is missing with endoscopic ablation therapy. A practical approach is to resect the areas with endoscopically visible lesions by endoscopic resection followed by ablation of residual Barrett’s esophagus [5] [6] [7] [8]. This assumes that if the histopathological evaluation of the most involved areas is favorable, the chances that the residual Barrett’s esophagus harbors more advanced neoplasia elsewhere are small and thus additional ablation therapy without histological correlation is justified. It is, therefore, crucial that the most involved area in the Barrett’s esophagus is indeed identified and resected rather than overlooked and ablated, since this may lead to undertreatment of submucosal lesions.

In this review, we will discuss the endoscopic work-up for diagnosis and staging of early neoplasia in Barrett’s esophagus (i. e., HGIN or mucosal cancer), including the role of advanced imaging techniques and the importance of histopathological evaluation by endoscopic resection.

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