Endoscopic features of low-grade dysplastic Barrett's

Abstract

Background and study aims Barrett's esophagus (BE) with low-grade dysplasia (LGD) is considered usually endoscopically invisible and the endoscopic features are not well described. This study aimed to: 1) evaluate the frequency of visible BE-LGD; 2) compare rates of BE-LGD detection in the community versus a Barrett's referral unit (BRU); and 3) evaluate the endoscopic features of BE-LGD. Patients and methods This was a retrospective analysis of a prospectively observed cohort of 497 patients referred to a BRU with dysplastic BE between 2008 and 2022. BE-LGD was defined as confirmation of LGD by expert gastrointestinal pathologist(s). Endoscopy reports, images and histology reports were reviewed to evaluate the frequency of endoscopically identifiable BE-LGD and their endoscopic features. Results A total of 135 patients (27.2%) had confirmed BE-LGD, of whom 15 (11.1%) had visible LGD identified in the community. After BRU assessment, visible LGD was detected in 68 patients (50.4%). Three phenotypes were observed: (A) Non-visible LGD; (B) Elevated (Paris 0-IIa) lesions; and (C) Flat (Paris 0-IIb) lesions with abnormal mucosal and/or vascular patterns with clear demarcation from regular flat BE. The majority (64.7%) of visible LGD was flat lesions with abnormal mucosal and vascular patterns. Endoscopic detection of BE-LGD increased over time (38.7% (2009-2012) vs. 54.3% (2018-2022)). Conclusions In this cohort, 50.4% of true BE-LGD was endoscopically visible, with increased recognition endoscopically over time and a higher rate of visible LGD detected at a BRU when compared with the community. BRU assessment of BE-LGD remains crucial; however, improving endoscopy surveillance quality in the community is equally important.

Keywords: Barrett's and adenocarcinoma; Diagnosis and imaging (inc chromoendoscopy, NBI, iSCAN, FICE, CLE); Endoscopic resection (ESD, EMRc, ...); Endoscopy Upper GI Tract; Image and data processing, documentatiton; Quality and logistical aspects.

Fig. 1

Fig. 1a C0M1 flat, regular Barrett’s examined on high-definition white light examination. b Barrett’s tongue with regular mucosal pattern examined using narrow band imaging. c Seattle protocol biopsy: <1 mm, single focus of LGD.

Fig. 2

Fig. 2 Low-grade dysplastic Barrett’s with irregular vascular pattern (yellow arrow) and loss of mucosal pattern (blue arrow) on NBI.

Fig. 3

Fig. 3 Study algorithm.

Fig. 4

Fig. 4 Frequency of endoscopic features suspicious for dysplasia among cases of histologically confirmed Barrett’s with LGD.

Fig. 5

Fig. 5 Endoscopically visible versus non-visible BE with LGD over time.

Fig. 6

Fig. 6a 14-mm Paris 0-IIa lesion with regular mucosal pattern examined using narrow band imaging. b Edges of the Paris 0-IIa lesion being marked using soft tip coagulation. c , d Paris 0-IIa lesion removed by endoscopic resection.

Fig. 7

Fig. 7a 12-mm Paris 0-IIa lesion with prominent villous pattern, seen using narrow band imaging. b Paris 0-IIa lesion removed by endoscopic resection. ( c,d ) EMR specimen: multiple foci of LGD within the Paris 0-IIa lesion (arrows).

Fig. 8

Fig. 8a 8-mm Paris 0-IIa lesion with indistinct mucosal pattern, seen using narrow band imaging. b 15-mm Paris 0-IIa lesion central indistinct mucosal and vascular pattern, visualized using narrow band imaging. c,d de novo 4-mm Barrett’s island with a raised rim of dark brown squamous mucosa with narrow band imaging, suggestive of sub-squamous Barrett’s.

Fig. 9

Fig. 9a 8-mm Paris 0-IIb lesion with loss of regular mucosal pattern, detected using narrow band imaging. b Endoscopic mucosal resection of visible BE-LGD lesion.

Fig. 10

Fig. 10a Diffusely abnormal mucosal pattern and a slightly raised lesion, seen using narrow band imaging, with edges marked with soft tip coagulation. b Indistinct mucosal and vascular pattern, visualized using narrow band imaging. c Endoscopic resection of abnormal Barrett’s mucosa. d EMR specimen: multiple foci of LGD (blue and red arrows) with depth of dysplasia seen up to 1.2 mm from squamous epithelium (red arrow).