High-Resolution Endoscopy Plus Chromoendoscopy or Narrow-Band Imaging in Barrett’s Esophagus: a Prospective Randomized Crossover Study

Background and study aims: High-resolution endoscopy (HRE) may improve the detection of early neoplasia in Barrett’s esophagus. Indigo carmine chromoendoscopy (ICC) and narrow-band imaging (NBI) may be useful techniques to complement HRE. The aim of this study was to compare HRE-ICC with HRE-NBI for the detection of high-grade dysplasia or early cancer (HGD/EC) in patients with Barrett’s esophagus.
Patients and Methods: Twenty-eight patients with Barrett’s esophagus underwent HRE-ICC and HRE-NBI (separated by 6 - 8 weeks) in a randomized sequence. The two procedures were performed by two different endoscopists, who were blinded to the findings of the other examination. Targeted biopsies were taken from all detected lesions, followed by four-quadrant biopsies at 2-cm intervals. Biopsy evaluation was supervised by a single expert pathologist, who was blinded to the imaging technique used.
Results: Fourteen patients were diagnosed with HGD/EC. The sensitivity for HGD/EC was 93 % and 86 % for HRE-ICC and HRE-NBI, respectively. Targeted biopsies had a sensitivity of 79 % with HRE alone. HGD was diagnosed from random biopsies alone in only one patient. ICC and NBI detected a limited number of additional lesions occult to HRE, but these lesions did not alter the sensitivity for identifying patients with HGD/EC.
Conclusions: In most patients with high-grade dysplasia or early cancer in Barrett’s esophagus, subtle lesions can be identified with high-resolution endoscopy. Indigo carmine chromoendoscopy and narrow-band imaging are comparable as adjuncts to high-resolution endoscopy.

References

• 1 Paull A, Trier J S, Dalton M D. et al . The histologic spectrum of Barrett’s esophagus.  N Engl J Med. 1976;  295 476-480
• 2 Haggitt R C, Tryzelaar J, Ellis F H. et al . Adenocarcinoma complicating columnar epithelium-lined (Barrett’s) esophagus.  Am J Clin Pathol. 1978;  70 1-5
• 3 Sampliner R E. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett’s esophagus.  Am J Gastroenterol. 2002;  97 1888-1895
• 4 Canto M I, Setrakian S, Willis J. et al . Methylene blue-directed biopsies improve detection of intestinal metaplasia and dysplasia in Barrett’s esophagus.  Gastrointest Endosc. 2000;  51 560-568
• 5 Dave U, Shousha S, Westaby D. Methylene blue staining: is it really useful in Barrett’s esophagus?.  Gastrointest Endosc. 2001;  53 333-335
• 6 Egger K, Werner M, Meining A. et al . Biopsy surveillance is still necessary in patients with Barrett’s oesophagus despite new endoscopic imaging techniques.  Gut. 2003;  52 18-23
• 7 Olliver J R, Wild C P, Sahay P. et al . Chromoendoscopy with methylene blue and associated DNA damage in Barrett’s oesophagus.  Lancet. 2003;  362 373-374
• 8 Sharma P, Weston A P, Topalovski M. et al . Magnification chromoendoscopy for the detection of intestinal metaplasia and dysplasia in Barrett’s oesophagus.  Gut. 2003;  52 24-27
• 9 Hamamoto Y, Endo T, Nosho K. et al . Usefulness of narrow-band imaging endoscopy for diagnosis of Barrett’s esophagus.  J Gastroenterol. 2004;  39 14-20
• 10 Sharma P, McGregor D, Cherian R. et al . Use of narrow band imaging, a novel imaging technique, to detect intestinal metaplasia and high-grade dysplasia in patients with Barrett’s esophagus [abstract].  Gastrointest Endosc. 2003;  57 AB77
• 11 Kara M A, Ennahachi M, Fockens P. et al . Narrow-band imaging (NBI) in Barrett’s esophagus (BE): what features are relevant for the detection of high-grade dysplasia (HGD) and early cancer (EC)? [abstract].  Gastroenterology. 2004;  126 A50
• 12 Kara M A, Smits M E, Rosmolen W D. et al . A randomized cross-over study comparing light-induced fluorescence endoscopy with standard video endoscopy for the detection of early neoplasia in Barrett’s esophagus.  Gastrointest Endosc. 2005;  61 671-678
• 13 Schlemper R J, Hirata I, Dixon M F. The macroscopic classification of early neoplasia of the digestive tract.  Endoscopy. 2002;  34 163-168
• 14 Reid B J, Weinstein W M, Lewin K J. et al . Endoscopic biopsy can detect high-grade dysplasia or early adenocarcinoma in Barrett’s esophagus without grossly recognizable neoplastic lesions.  Gastroenterology. 1988;  94 81-90
• 15 Robert M E. Defining dysplasia in Barrett esophagus.  J Clin Gastroenterol. 2003;  36(5 Suppl) S19-S25
• 16 Dixon M F. Gastrointestinal epithelial neoplasia: Vienna revisited.  Gut. 2002;  51 130-131
• 17 Hoffman J I. The incorrect use of chi-square analysis for paired data.  Clin Exp Immunol. 1976;  24 227-229
• 18 Guelrud M, Herrera I, Essenfeld H. et al . Enhanced magnification endoscopy: a new technique to identify specialized intestinal metaplasia in Barrett’s esophagus.  Gastrointest Endosc. 2001;  53 559-565
• 19 Endo T, Awakawa T, Takahashi H. et al . Classification of Barrett’s epithelium by magnifying endoscopy.  Gastrointest Endosc. 2002;  55 641-647
• 20 Gono K, Obi T, Yamaguchi M. et al . Appearance of enhanced tissue features in narrow-band endoscopic imaging.  J Biomed Opt. 2004;  9 568-577
• 21 Machida H, Sano Y, Hamamoto Y. et al . Narrow-band imaging in the diagnosis of colorectal mucosal lesions: a pilot study.  Endoscopy. 2004;  36 1094-1098
• 22 Nakayoshi T, Tajiri H, Matsuda K. et al . Magnifying endoscopy combined with narrow band imaging system for early gastric cancer: correlation of vascular pattern with histopathology (including video).  Endoscopy. 2004;  36 1080-1084
• 23 Shibuya K, Hoshino H, Chiyo M. et al . High magnification bronchovideoscopy combined with narrow band imaging could detect capillary loops of angiogenic squamous dysplasia in heavy smokers at high risk for lung cancer.  Thorax. 2003;  58 989-995
• 24 Yoshida T, Inoue H, Usui S. et al . Narrow-band imaging system with magnifying endoscopy for superficial esophageal lesions.  Gastrointest Endosc. 2004;  59 288-295
• 25 Montgomery E, Bronner M P, Goldblum J R. et al . Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation.  Hum Pathol. 2001;  32 368-378
• 26 Kara M A, Peters F P, Fockens P. et al . Video autofluorescence imaging (AFI) followed by narrow band imaging (NBI) for detection of high grade dysplasia (HGD) and early cancer (EC) in Barrett’s esophagus (BE) [abstract].  Endoscopy. 2004;  36 (Suppl I) A7
• 27 Ishiyama A, Fujisaki J, Hosaka H. et al . NBI enables accurate endoscopic diagnosis of early gastric cancer [abstract].  Gut. 2004;  53 (Suppl VI) A7
• 28 Stevens P D, Lightdale C J, Green P H. et al . Combined magnification endoscopy with chromoendoscopy for the evaluation of Barrett’s esophagus.  Gastrointest Endosc. 1994;  40 747-749
• 29 Meining A, Rösch T, Kiesslich R. et al . Inter- and intra-observer variability of magnification chromoendoscopy for detecting specialized intestinal metaplasia at the gastroesophageal junction.  Endoscopy. 2004;  36 160-164
• 30 Kara M A, Bergman J J, Tytgat G N. Follow-up for high-grade dysplasia in Barrett’s esophagus.  Gastrointest Endosc Clin N Am. 2003;  13 513-533, viii