I have defined the Barrett’s pattern somewhat to that end, but here is my current definition of Barrett’s: A long-segment Barrett’s would be more than 3 cm of columnar epithelium in the esophagus with intestinal metaplasia. A short-segment Barrett’s would be when you can definitely see a segment less than 3 cm of red mucosa in the lower esophagus and again find intestinal metaplasia. The problem is the finding of intestinal metaplasia of the cardia. If you take biopsies on consecutive patients having endoscopy, as was shown by Speckler first, you will find that about 20% of everyone has intestinal metaplasia, even when you don’t see any Barrett’s endoscopically. If you take biopsies from there that show intestinal metaplasia and there is no visible Barrett’s, I would prefer to say that patient has intestinal metaplasia. If this affects one-fifth of the older population, the cancer risk for the individual has to be very low, and I am very doubtful that any surveillance is required or going to actually be helpful for a person with that situation.

Cancers can arise in short-segment Barrett’s. This was an example where, if you look carefully, you will see three red tongues – here, here and here; the middle one is easier to see. There is a 1.5-cm length of intestinal metaplasia and it is difficult to see, but there is a small adenocarcinoma here, so this was adenocarcinoma of the cardia, arising in a short-segment Barrett’s. So, what recommendations can be made?

Surveillance – these are current suggestions; they are arbitrary, but they are what we are doing, based on the best review of the literature and personal experience. If there is a long or a visible short Barrett’s which is seen on endoscopy and there is intestinal metaplasia on biopsy, then if there is no dysplasia, we have asked the patients to come back after one year, just in case we missed something the first time. We were unhappy about telling them to go away for a long time. If there is still no dysplasia after one year, we ask them to come back for further endoscopy and biopsy every two or three years. If your HMO is strapped for cash, realistically, if that was five years, it would probably be a reasonable cost benefit ratio.

If there is low-grade dysplasia, which we have found in about a third of our Barrett’s patients, we ask them to come back at six months and the if it is still low grade, come back every year.

If there is high-grade dysplasia we recommend surgical resection for the healthy patients who can stand it. If there is no surgery, endoscopic mucosal ablation is done, or we follow every three to six months.

Surveillance is not generally recommended if you have a biopsy showing intestinal metaplasia but you didn’t see any Barrett’s, or you thought there was a Barrett’s on endoscopy and you take enough biopsies, but the pathologist says there isn’t any intestinal metaplasia; it probably isn’t a Barrett’s and the patient would be unfit for surgery. We seem to see patients getting on our list sometimes who are 80 years old, have Alzheimer’s or congestive failure, and really, I don’t think there is any need to continue surveillance on those, because you are not going to do a major operation, whatever you find.

This is data from Brien, Reed and Levine, et al, in Seattle. There is relatively little data, but they did follow high-grade dysplasia for about two to three years. What happened was that patients with high-grade dysplasia initially, 26%, about one quarter went on to get a cancer within two or three years. About half, 47%, still had high-grade dysplasia on the last biopsy done and surprisingly, about a quarter again, 27%, had high-grade dysplasia when first diagnosed, but subsequent biopsies failed to show high-grade dysplasia. They had not done any active treatment; they had done many biopsies and may have removed some of the mucosa, but it is in no way inevitable that patients with high-grade dysplasia will go get cancer, at least in the next two or three years.

Our usual recommendation for treatment of high-grade dysplasia in patients who are otherwise healthy is to do an esophagectomy. This is the resection of the shaded area with the pulling up of the stomach to anastomose to the high thoracic esophagus with a pyloromyotomy, because you’ve cut the vagus nerve.

What do we see if we look microscopically at the resected specimen? Yellow is low grade and this one had four small areas of high-grade in red and a tiny cancer here. This patient had a 2.5-cm long Barrett’s with one tiny area of high-grade dysplasia here. This one had a little low grade, high grade and a very early cancer there. Now, some of the patients had larger areas of high-grade dysplasia. This is to show that you really need to take systematic biopsy samples of the whole esophagus when you are doing endoscopy if you are going to find that and even then, it was perhaps only luck that this was found.

Cancer treatment