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Diagnosis by endoscopy and advanced imaging

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Abstract

Evaluation of patients with Barrett's oesophagus (BO) using dye-based chromoendoscopy, optical chromoendoscopy, autofluorescence imaging, or confocal laser endomicroscopy does not significantly increase the number of patients with a diagnosis of early neoplasia compared with high-definition white light endoscopy (HD-WLE) with random biopsy analysis. These newer imaging techniques are not more effective in standard surveillance of patients with BO because the prevalence of early neoplasia is low and HD-WLE with random biopsy analysis detects most cases of neoplasia. The evaluation and treatment of patients with BO and early-stage neoplasia should be centralized in tertiary referral centers, where procedures are performed under optimal conditions, by expert endoscopists. Lesions that require resection are almost always detected by HD-WLE, although advanced imaging techniques can detect additional flat lesions. However, these are of limited clinical significance because they are effectively eradicated by ablation therapy. No endoscopic imaging technique can reliably assess submucosal or lymphangio-invasion. Endoscopic resection of early-stage neoplasia in patients with BO is important for staging and management. Optical chromoendoscopy can also be used to evaluate lesions before endoscopic resection and in follow-up after successful ablation therapy.

Introduction

The incidence of oesophageal adenocarcinoma (OAC) in the western world has increased sixfold over the past three decades and has a dismal prognosis when detected at a symptomatic stage [1]. Adenocarcinoma develops through a precursor lesion called Barrett's oesophagus (BO) in a sequence of gradually evolving, histologically recognizable steps: intestinal metaplasia, low-grade dysplasia (LGD), high-grade dysplasia (HGD), intramucosal carcinoma (IMC) and eventually invasive carcinoma. These intermediate grades of dysplasia offer a window of opportunity for curative therapy.

In the last decade, endoscopic therapy has been become the treatment of choice for early Barrett's neoplasia (i.e. HGD and IMC), with an excellent prognosis and safety profile compared to surgical resection [2]. A prerequisite for endoscopic therapy is adequate patient selection; only patients with HGD and IMC have a virtual absent risk of lymph node metastasis and are therefore amendable for endoscopic therapy [3].

In patients with known BO, regular surveillance endoscopy with random biopsies is recommended to detect early neoplastic lesions at a curable stage [4]. However, these lesions are often small, focally distributed and endoscopically poorly visible (Fig. 1). Random four-quadrant biopsies may easily miss early lesions, since only about 5% of the Barrett's segment is sampled [5]. Moreover, this process is laborious and many endoscopists do not adhere to the protocol [6]. In recent years, many advanced imaging techniques have been developed to improve the detection of early Barrett's neoplasia.

In this review we will discuss how to endoscopically diagnose early neoplasia during BO surveillance and how advanced imaging techniques may affect clinical management of BO either by improving the primary detection of early neoplastic lesions, allowing real-time diagnosis and decision making during endoscopy, or guiding the endoscopic work-up and treatment. Parts of this review have been published earlier in specific publications on endoscopic work-up of early Barrett's neoplasia and advanced imaging techniques by our group [7], [8].

Section snippets

Endoscopic diagnosis of early neoplasia in Barrett's oesophagus

The goal of endoscopic surveillance of patients with Barrett's oesophagus is the detection of early neoplastic lesions. To ensure the detection of early neoplastic lesions there are three rules that should be followed. These rules relate to the endoscopic equipment used, the ‘detecting eye’ of the endoscopist, and a systematic, meticulous approach.

Detection of early neoplasia

For primary detection of early neoplastic lesions in BO, wide-field imaging techniques are required that allow detection of lesions in overview: to ‘red flag’ areas of interest. As stated in current guidelines, advanced imaging techniques should be superimposed on high-resolution white light endoscopy (WLE) using high-definition (HD) systems [8], [21], [22].

Endoscopic surveillance

Most surveillance endoscopies are performed in community hospitals. In this setting, the prevalence of early neoplasia is low (i.e. <5%) and therefore endoscopists are generally not familiar with the endoscopic appearance of early Barrett's neoplasia [61], [62].

In surveillance settings, detection of early neoplasia can be significantly improved by the use of HD-WLE and implementation of the three rules for detection of early neoplastic lesions as abovementioned.

In our opinion, advanced imaging

Future perspectives

Detection of early neoplasia can be improved by optimizing the endoscopists' recognition of ‘the face of Barrett's neoplasia’ but there are few tools to aid this [8], [21]. The international workgroup for the classification of oesophagitis [71], [72] is working on a training program for ‘Barrett's oesophagus related neoplasia’ (BORN-project) that will be dispersed to the gastroenterology community.

In the near future, molecular markers may enable us to predict which patients will develop

Conflict of interest statement

None.

Practice points

  • The use of advanced imaging techniques does not significantly increase the diagnostic yield of early neoplasia compared with high-definition white light endoscopy (HD-WLE) with random biopsy analysis.

  • For the detection of subtle abnormalities in the oesophagus, a careful and thorough inspection following a systematic approach is imperative.

  • For primary detection of early neoplastic lesions in BO advanced imaging techniques should be superimposed on WLE.

  • Lesions that require

Acknowledgements

Prof. Bergman receives research support from Olympus Endoscopy, Cook Medical, Boston Scientific, GI Solutions Covidien, Erbe and Ninepoint Medical. Dr. Swager and Dr. Curvers have nothing to disclose.

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