Barrett’s Registry Collaboration of academic centers in Ireland reveals high progression rate of low-grade dysplasia and low risk from nondysplastic Barrett’s esophagus: report of the RIBBON network

Abstract

Summary Barrett’s esophagus (BE) is the main pathological precursor of esophageal adenocarcinoma (EAC). Progression to high-grade dysplasia (HGD) or EAC from nondysplastic BE (NDBE), low-grade dysplasia (LGD) and indefinite for dysplasia (IND) varies widely between population-based studies and specialized centers for many reasons, principally the rigor of the biopsy protocol and the accuracy of pathologic definition. In the Republic of Ireland, a multicenter prospective registry and bioresource (RIBBON) was established in 2011 involving six academic medical centers, and this paper represents the first report from this network. A detailed clinical, endoscopic and pathologic database registered 3,557 patients. BE was defined strictly by both endoscopic evidence of Barrett’s epithelium and the presence of specialized intestinal metaplasia (SIM). A prospective web-based database was used to gather information with initial and follow-up data abstracted by a data manager at each site. A total of 2,244 patients, 1,925 with no dysplasia, were included with complete follow-up. The median age at diagnosis was 60.5 with a 2.1:1 male to female ratio and a median follow-up time of 2.7 years (IQR 1.19–4.04), and 6609.25 person years. In this time period, 125 (5.57%) progressed to HGD/EAC, with 74 (3.3%) after 1 year of follow-up and 38 (1.69%) developed EAC, with 20 (0.89%) beyond 1 year. The overall incidence of HGD/EAC was 1.89% per year; 1.16% if the first year is excluded. The risk of progression to EAC alone overall was 0.57% per year, 0.31% excluding the first year, and 0.21% in the 1,925 patients who had SIM alone at diagnosis. Low-grade dysplasia (LGD) progressed to HGD/EAC in 31% of patients, a progression rate of 12.96% per year, 6.71% with the first year excluded. In a national collaboration of academic centers in Ireland, the progression rate for NDBE was similar to recent population studies. Almost one in two who progressed was evident within 1 year. Crucially, LGD diagnosed and confirmed by specialist gastrointestinal pathologists represents truly high-risk disease, highlighting the importance of expertise in diagnosis and management, and providing indirect support for ablative therapies in this context.

Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline

“…A systematic review and meta-analysis of 8 studies found that while the summary overall weighted annual incidence for progression to HGD/EAC was 4.6/100 patient-years (95% CI 2.0 -7.2), the rate was higher,at 8.8/100 patients, in the first year after diagnosis (181). Others have found a similar increase in risk in the first year after diagnosis, thereby emphasizing the importance of a careful repeat examination (182). Finally, there is considerable evidence that a diagnosis of confirmed LGD that persists on a second examination increases the risk for progression still further (34,183).…”

The natural history of low‐grade dysplasia in Barrett's esophagus and risk factors for progression

“…Approximately 15–40% of all patients with BE are diagnosed with LGD at some point during their lifetime. LGD has been suggested to be a risk factor for progression to HGD/EAC 3,4 . Therefore, a clear management strategy for LGD is important.…”

“…LGD has been suggested to be a risk factor for progression to HGD/EAC. 3 , 4 Therefore, a clear management strategy for LGD is important. The management of LGD in BE is controversial due to various factors including variability in the natural history of LGD among different populations and interobserver variability among pathologist in its diagnosis.…”

Low-grade dysplasia in Barrett’s esophagus: More than meets the eye?

“…examination as outlined below. 8 Finally, there is considerable evidence that a diagnosis of confirmed lowgrade dysplasia that persists on a second examination increases the risk for progression still further. 9 The issue of prevalent higher-level lesions is addressed in this issue of Gastrointestinal Endoscopy in the study by Tsoi et al, 10 who examined what happens to patients with diagnoses of Barrett's esophagus and low-grade dysplasia in the community setting when they were referred to any of 6 designated Barrett's expert tertiary care centers in Australia.…”