A 60-year-old male with a history of coronary artery disease and Barrett disease completes a surveillance upper endoscopy. A 1-cm flat plaque is identified with pathology confirming low-grade dysplasia (LGD). Endoscopic ultrasound shows no lymphadenopathy and the tumor is confined to the mucosa.
What is an appropriate next step in treatment?A. Photodynamic therapy
Correct Answer: D
BE is a premalignant condition with an increased risk of developing EA. Dysplasia continues to be the best clinically available marker of malignancy risk in patients with BE. In fact, the risk of progression for patients with nondysplasia is 0.2% to 0.5% per year but increases to 0.7% for patients afflicted with LGD and 7% in high-grade dysplasia. Definitive diagnosis of dysplasia can be challenging with slight variations in the interpretation of “indefinite for dysplasia” and LGD and thus requiring verification from a second pathologist with expertise in BE for confirmation of dysplasia. Patients with LGD should receive aggressive antisecretory therapy for reflux disease with a proton pump inhibitor to decrease changes associated with inflammation.
Current guidelines for management of LGD recommend annual surveillance with a protocol of four-quadrant biopsies at 1 cm intervals until two examinations in a row are negative for dysplasia, after which time surveillance intervals for nondysplastic BE can be followed. Six-month interval surveillance is advised for those with a diagnosis of “indefinite for dysplasia” who require further confirmation.
All other therapies are reserved for a locally advanced symptomatic disease rather than a tumor confined to the mucosa (Tis, N0, M0).