Non-biopsy detection of intestinal metaplasia and dysplasia in Barrett’s esophagus: a prospective multicenter study

Background and study aims: There have been no multicenter studies investigating the use of magnification chromoendoscopy (MCE) for the detection of intestinal metaplasia and dysplasia/cancer in Barrett’s esophagus. Our aims were to assess the ability of MCE to predict the histological diagnosis (non-biopsy detection), to compare the yield of MCE-targeted versus random biopsies for dysplasia, and to compare procedure times.
Patients and methods: In this prospective multicenter study, patients with known or suspected Barrett’s esophagus underwent MCE with indigo carmine dye staining. Three mucosal patterns (ridge/villous, circular, and irregular/distorted) were standardized, based on past experience. Mucosal patterns were noted and target biopsies were obtained only if irregular/distorted patterns were identified. Otherwise, random four-quadrant biopsies were obtained.
Results: A total of 56 patients (mean age 64 years, mean length of Barrett’s esophagus 2.7cm) were prospectively evaluated: 38 patients (67.8 %) had ridge/villous patterns, four patients (7.1 %) had circular patterns, four patients (7.1 %) had irregular/distorted patterns, and ten patients (17.8 %) had a combination of patterns. Histologically, intestinal metaplasia was not shown in eight patients (14.2 %), nondysplastic Barrett’s esophagus was diagnosed in 30 patients (53.5 %), low-grade dysplasia was detected in 12 patients (21.4 %), and high-grade dysplasia was detected in six patients (10.7 %). An irregular/distorted pattern either throughout the entire segment of Barrett’s esophagus or in combination with a ridge/villous or circular pattern had a sensitivity or 83 %, a specificity of 88 %, a positive predictive value of 45 %, and a negative predictive value of 98 % for high-grade dysplasia. The yield of high-grade dysplasia was similar for the two techniques but the time taken to perform MCE was less than the time taken to perform random biopsies.
Conclusion: An irregular/distorted pattern is specific for high-grade dysplasia and so it may not be necessary to perform biopsies in patients with ridge/villous or circular mucosal patterns.

References

• 1 Sampliner R E. Practice parameters committee of the ACG. Updated guidelines for the diagnosis, surveillance and therapy of Barrett’s esophagus.  Am J Gastroenterol. 2002;  97 1888-1895
• 2 Fitzgerald R C, Triadafilopoulus G. Recent developments in the molecular characterization of Barrett’s esophagus.  Dig Dis Sci. 1998;  16 63-80
• 3 Hamilton S R, Smith R, Cameron J L. Prevalence and characteristics of Barrett’s esophagus in patients with adenocarcinoma of the esophagus or esophagogastric junction.  Hum Pathol. 1988;  19 942-948
• 4 Sharma P, McQuaid K, Dent J. et al . A critical review of the diagnosis and management of Barrett’s esophagus. The AGA Chicago Workshop.  Gastroenterology. 2004;  127 310-330
• 5 Blot W J, McLaughlin J K. The changing epidemiology of esophageal cancer.  Semin Oncol. 1999;  26 2-8
• 6 Brown L M, Devesa S S. Epidemiologic trends in esophageal and gastric cancer in the United States.  Surg Oncol Clin N Am. 2002;  11 235-256
• 7 Eloubeidi M A, Mason A C, Desmond R A, El-Serag H B. Temporal trends (1973-1997) in survival of patients with esophageal adenocarcinoma in the United States: a glimmer of hope?.  Am J Gastroenterol. 2003;  98 1627-1633
• 8 Eloubeidi M A, Provenzale D. Does this patient have Barrett’s esophagus? The utility of predicting Barrett’s esophagus at the index endoscopy.  Am J Gastroenterol. 1999;  94 937-943
• 9 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
• 10 Stevens P D, Lightdale C J, Green P HR. et al . Combined magnification endoscopy with chromoendoscopy for the evaluation of Barrett’s esophagus.  Gastrointest Endosc. 1994;  40 747-749
• 11 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
• 12 Kudo S, Tamura S, Nakajima T. et al . Diagnosis of colorectal tumorous lesions by magnifying endoscopy.  Gastrointest Endosc. 1996;  44 8-14
• 13 Fujiya M, Saitoh Y, Nomura M. et al . Minute findings by magnifying colonoscopy are useful for the evaluation of ulcerative colitis.  Gastrointest Endosc. 2002;  56 535-542
• 14 Connor M J, Sharma P. Chromoendoscopy and magnification endoscopy in Barrett’s esophagus.  Gastrointest Endosc Clin N Am. 2003;  13 269-277
• 15 Endo T, Awakawa T, Takahashi H. et al . Classification of Barrett’s epithelium by magnifying endoscopy.  Gastrointest Endosc. 2002;  55 641-647
• 16 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;  51 560-567
• 17 Sharma P, Topalovski M, Mayo M. et al . Methylene blue chromoendoscopy for detection of short-segment Barrett’s esophagus.  Gastrointest Endosc. 2001;  54 289-293
• 18 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
• 19 Kara M A, Peters F P, Rosmolen W D. et al . High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in Barrett’s esophagus: a prospective randomized crossover study.  Endoscopy. 2005;  37 929-936
• 20 Sharma P, Falk G, Weston A P. et al . Natural history of LGD, an infrequent finding which usually regresses: preliminary results from the Barrett’s esophagus study.  Gastroenterology. 2002;  122 156
• 21 Skacel M, Petras R E, Gramlich T L. et al . The diagnosis of low-grade dysplasia in Barrett’s esophagus and its implications for disease progression.  Am J Gastroenterol. 2000;  95 3383-3387
• 22 Sharma P. Low-grade dysplasia in Barrett’s esophagus.  Gastroenterology. 2004;  127 1233-1238
• 23 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
• 24 Mayinger B, Oezturk Y, Stolte M. et al . Evaluation of sensitivity and inter- and intra-observer variability in the detection of intestinal metaplasia and dysplasia in Barrett’s esophagus with enhanced magnification endoscopy.  Scand J Gastroenterol. 2006;  41 349-356
• 25 Sharma P, Bansal A, Mathur S. et al . The utility of a narrow band imaging endoscopy system in patients with Barrett’s esophagus.  Gastrointest Endosc. 2006;  64 167-175