Surveillance history of endoscopically treated patients with early Barrett's neoplasia: nonadherence to the Seattle biopsy protocol leads to sampling error

Abstract

The study's aim was to retrospectively evaluate the surveillance history of Barrett's esophagus (BE) patients with endoscopically treated early neoplasia. All BE patients endoscopically treated for early cancer (EC) or high-grade intraepithelial neoplasia (HGIN) in a lesion or mass between 1998 and 2005 were included. Endoscopy and histology records were reviewed. Ninety-four patients (78 males, mean age 67 years, 24 HGIN, 70 EC) were included. In 36 (38%) patients, HGIN/EC was diagnosed at (or within 6 months after) initial endoscopy. The remaining 58 (62%) patients had a surveillance history (median duration 7 years, mean 6.7 endoscopies). Seventy-nine percent of these had low-grade intraepithelial neoplasia (LGIN) diagnosed at least once during their surveillance period with a median of seven endoscopies and a median number of biopsies that was 50% of what should have been taken according to the Seattle protocol. Patients without any dysplasia during earlier surveillance (n = 12, 21%) had undergone significantly less endoscopies (median four endoscopies, P = 0.02) and had a median biopsy percentage that was 23% of the Seattle protocol (P < 0.001 versus 50% in LGIN). In this selected cohort of patients with early Barrett's neoplasia, 38% of patients were diagnosed at initial endoscopy. Of the patients with a surveillance history, 79% had shown LGIN prior to HGIN/EC diagnosis. Only 21% of patients had a surveillance history without any dysplasia, which in general encompassed endoscopies with an insufficient number of biopsies, suggesting sampling error. This underlines the importance of obtaining an adequate number of biopsies during surveillance endoscopies.

Endocytoscopic visualization of squamous cell islands within Barrett’s epithelium

“…Long-term endoscopic surveillance with multiple and repeated sets of biopsies are the standard recommended practice in Barrett's esophagus in an attempt to detect dysplasia or carcinoma at an early and potentially curable stage [26][27][28][29] . The Seattle multiple biopsy protocol (4 quadrant jumbo biopsies every 1 cm with additional biopsies of mucosal abnormalities), is considered to be the optimal method for surveillance of Barrett's esophagus, although it has never been validated [27,30] . However, even the most intensive biopsy protocols are associated with significant sampling errors [31,32] .…”

Evaluation of Difluoromethylornithine for the Chemoprevention of Barrett's Esophagus and Mucosal Dysplasia

“…An expert GI pathologist reviewed pre-and postintervention biopsies for consistency of interpretation. Recognizing the potential for sampling error, we used the more rigorous biopsy technique referred to as the "Seattle" protocol, which utilizes larger forceps and requires biopsies at 1-cm intervals throughout the Barrett's segment (15). This biopsy protocol is generally reserved for endoscopic surveillance of BE and HGD (51).…”

“…Endoscopic biopsies from Barrett's appearing mucosa were conducted at 1-cm intervals and in 4 quadrants with jumbo biopsy forceps, using the "Seattle" protocol at all time points (15). Biopsies were directed by the endoscopist to be away from areas of obvious scarring related to prior biopsies.…”

Endoscopy and Histopathology

“…[29] Non-adherence to a protocol during surveillance leads to under-diagnosis or missed diagnosis because of sampling error. [30] However, problems with inter-observer agreement, particularly for low-grade dysplasia, on biopsy specimens have raised concern about the ability of pathologists to provide a consistent and accurate diagnosis upon which management decisions can be based. [31,32] In order to reduce sampling errors, guidelines for the surveillance have been established by national and international societies.…”