Elsevier

Gastrointestinal Endoscopy

Volume 49, Issue 2, February 1999, Pages 170-176
Gastrointestinal Endoscopy

Jumbo biopsy forceps protocol still misses unsuspected cancer in Barrett's esophagus with high-grade dysplasia,☆☆

Presented at the Annual Meeting of the American Society of Gastrointestinal Endoscopy, Washington, DC, May 11-14, 1997.
https://doi.org/10.1016/S0016-5107(99)70482-7Get rights and content

Abstract

Background: The optimal management of high-grade dysplasia in patients with Barrett's esophagus is controversial. The aim of this study was to assess the prevalence of unsuspected carcinoma at esophagectomy in patients with Barrett's esophagus with high-grade dysplasia after endoscopic surveillance with jumbo biopsy forceps compared with standard biopsy forceps. Methods: Twelve patients with high-grade dysplasia in Barrett's esophagus without gross or microscopic evidence of carcinoma underwent esophagectomy after preoperative endoscopy with 4-quadrant jumbo biopsies at 2-cm intervals. The findings in this group were compared with those in a group of patients with Barrett's esophagus who underwent esophagectomy for high-grade dysplasia after biopsies obtained at 2-cm intervals with standard biopsy forceps. Results: Unsuspected cancer was found in 4 of 12 (33%) patients in the jumbo biopsy group compared with 6 of 16 (38%) in the standard biopsy group (p = NS). All 6 cancers in the standard biopsy group were intramucosal, whereas 2 were intramucosal and 2 were submucosal in the jumbo biopsy group. No patients in either group had lymph node metastases. Conclusions: Unsuspected cancer is found frequently in patients with Barrett's esophagus who are undergoing esophagectomy for high-grade dysplasia despite the use of a rigorous jumbo biopsy protocol. Esophageal resection is still indicated in appropriately selected patients with high-grade dysplasia until better markers of cancer risk are available. (Gastrointest Endosc 1999;49:170-6)

Section snippets

Patients and Methods

We studied 2 groups of patients with Barrett's esophagus who were undergoing extensive evaluation for high-grade dysplasia prior to undergoing esophagectomy. The patients in the first group, identified between 1986 and 1991 and evaluated with a standard endoscopic biopsy forceps protocol, have been reported on elsewhere.3 The patients in the second group, identified between 1993 and 1997, were evaluated by using jumbo biopsy forceps and a more rigorous biopsy protocol (see below). All

RESULTS

Demographics of the study population are shown in Table 1.

. Patient characteristics

ParameterStandard biopsyJumbo biopsy
Empty Cellprotocolprotocol
Number of patients1612
Male/female16/012/0
Mean age (range)63 yr (36-79 yr)57 yr (50-65 yr)
Mean length of Barrett's7.5 cm (2-13 cm)8.9 cm (5-15 cm)
 segment (range)
A total of 28 white male patients underwent surgery for high-grade dysplasia, 16 in the standard biopsy group and 12 in the jumbo biopsy group. There were no differences in patient age or length of

DISCUSSION

The best approach to the patient with Barrett's esophagus and high-grade dysplasia is uncertain. Esophagectomy is recommended by many authorities to eliminate the risk of carcinoma or to detect and treat cancer at an early curable stage. Others argue that the risk of esophagectomy is too high and that the natural history of high-grade dysplasia is too variable to justify such invasive surgery without a preoperative diagnosis of at least intramucosal carcinoma. Thus, the major controversies

Acknowledgements

We thank Michael Vaezi, MD, for his helpful comments and suggestions in reviewing the manuscript, and Kirk Easley, for his statistical assistance.

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  • Cited by (0)

    Reprint requests: Gary W. Falk, MD, Department of Gastroenterology, Desk S-40, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.

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