Biopsy surveillance is still necessary in patients with Barrett's oesophagus despite new endoscopic imaging techniques

Abstract

Background and aims: Endoscopic surveillance including stepwise four quadrant biopsies (4QB) is still regarded as the standard approach in patients with Barrett's oesophagus (BO). Several methods such as dye staining with methylene blue (MB) and tissue autofluorescence (AF) have been advocated to reduce the number of biopsies. We assessed their sensitivity and specificity compared with the standard approach-that is, endoscopy with 4QB-in the surveillance of a mixed BO population. Patients and methods: Thirty five consecutive BO patients (mean age 64.9 years; 30 men, five women) were included in the study. AF endoscopy was followed by high resolution video endoscopy (VE) plus tissue staining with 0.5% MB. Biopsies were taken from any suspicious area found on any of the above tests, in addition to 4QB every 2 cm. The results were classified as either positive or negative for the various tests used. Histopathological results were used as the reference standard. Results: In the 35 study patients, a total of 345 biopsies showed low grade dysplasia (LGD) in 88 biopsies, high grade dysplasia (HGD) in 19 biopsies, and carcinoma in 12 biopsies. The sensitivity and specificity rates for AF and MB for the diagnosis of cancer or dysplasia versus BO mucosa without dysplasia were 21%/91% and 37%/91%, respectively. 4QB revealed five cancer/HGD areas and 76 LGD areas not detected by AF, MB, or VE. The additional yield of MB and AF over VE with 4QB concerned only one HGD area (in the vicinity of a cancer) and seven LGD areas. Conclusions: Due to their low sensitivity, AF and MB are not suitable techniques for reducing the high numbers of routine biopsies needed for finding additional foci of HGD or cancer. Careful endoscopic observation and stepwise four quadrant biopsy therefore still represent the gold standard for surveillance of Barrett's oesophagus.

Detection and staging of esophageal cancers

“…However, the clinical impact of finding these short segments of Barrett esophagus is debatable given the low incidence of cancer in these patients unless dysplasia is found. Unfortunately, despite initial encouraging results, the most recent studies seem to indicate that the sensitivity of methylene blue for high-grade dysplasia was only 37% in a group of 35 patients who were screened [7].…”

Diagnosis of Neoplasia in Barrett’s Esophagus using Vital-dye Enhanced Fluorescence Imaging

“…With standard endoscopic surveillance, neoplasia in BE is often missed 8 because benign metaplasia can be indistinguishable from highgrade dysplasia and adenocarcinoma. As a tool that would better enable gastroenterologists to remedy this currently unavoidable error, vitaldye enhanced fluorescence imaging highlights a tissue's glandular morphology thereby providing a distinct feature to differentiate the tissue types.…”

Detection of dysplasia in Barrett’s oesophagus: Are there impending optical and spectroscopic solutions?

“…Different wavelengths penetrate and effectively interrogate the tissue to different depths, resulting in an image which provides clues as to the tissue topography and vasculature [46]. Studies using a variety of systems have had confounding results with some improving detection of dysplasia [47], and others being no better than traditional white light endoscopy [24,48]. A combined video endoscope system with both white light and autofluorescence did improve the detection of new areas of dysplasia [49], but was hampered by the inability to accurately distinguish inflamed tissue with that of dysplasia.…”