Dysplasia

Norman Barrett first described Barrett’s oesophagus in 1950. It is caused by long-term exposure to stomach acid, bile acids and pancreatic enzymes. Since the vast majority of patients with Barrett’s oesophagus do not get oesophageal cancer, the usual practice in the United Kingdom is not to attempt to remove the Barrett’s cells. Treatment is usually only offered if the cells look as though they are starting to change and the risk of getting cancer starts to rise. Although in theory exposure to acid and bile may make cells more likely to turn cancerous, there is no clear evidence that aggressive suppression of acid reflux does actually reduce the risk of cancer. Decisions about treatments should generally be made on the basis of symptoms, not on the likelihood of preventing cancer.

Over time, Barrett’s cells can sometimes change in structure, becoming more disordered, a condition called dysplasia. This word is derived from the Greek meaning roughly "bad formation.” Dysplasia is the earliest form of a pre-cancerous change that can be recognised and may be classified as either low grade or high grade, the latter representing a more advanced progression towards cancer. It can be a difficult diagnosis for the pathologist to make and therefore it is recommended that if dysplasia is suspected that this is confirmed by an independent, expert pathologist and discussed at the multi-disciplinary meeting to decide whether treatment is recommended.

If a patient has an upper GI endoscopy (a camera test to view the inside of the oesophagus and stomach) and high-grade dysplasia is found, or low-grade dysplasia is present on two endoscopies, 6 months apart, doctors will consider using endoscopic therapies to remove all of the Barrett’s segment to prevent progression to cancer.

Treatment for dysplasia

The precise treatment offered will depend on your fitness, your preference for treatment over monitoring and the expertise available at your hospital. Endoscopic treatment is now recommended, provided that there is no cancer present and invading into the deeper layers of the oesophageal wall. More than one type of treatment may be required and this may include removing pieces of tissue (endoscopic resection) or a treatment aiming to remove the entire Barrett's tissue (ablationtherapy).

Endoscopic Mucosal Resection or EMR

Some patients with high grade dysplasia have a visible nodule in their oesophagus. It is relatively straightforward to remove the nodule during endoscopy. If you have this procedure you will be given a sedative to make you slightly sleepy. The procedure takes around 30-45 minutes and you can usually go home the same day. Most people can eat and drink normally afterwards. In about one in ten people there may be minor bleeding, and more serious bleeding in one in 100 people, which can be stopped by treatment at endoscopy. If severe, a blood transfusion may occasionally be required. The EMR procedure can be repeated a number of times if there are several nodules, but it cannot remove large sections of affected oesophagus without causing scarring and difficulty in swallowing. This treatment does not aim to remove the Barrett’s oesophagus cells completely. EMR can successfully remove small, localised cancerous lesions and will be considered in expert centres for highly selected cases.

Endoscopic mucosal resection is a particularly useful technique if the diagnosis is not clear because the removed nodule can be sent to the laboratory to be checked by the pathologist. In this situation, it serves as both a diagnostic test and a treatment.

Radio Frequency Ablation (RFA)

RFA is performed by a gastroenterologist or surgeon within an outpatient setting under sedation. It is an endoscopic procedure using an endoscope which is thin and flexible with a special electrode attached which produces heat directly to the area of Barrett’s oesophagus. The doctor will choose one of three different sizes of electrodes depending on the length or amount of Barrett’s to be treated. Over a period of time the Barrett’s tissue is replaced by normal squamous lining. This procedure is in general used for high and low grade dysplasia and had been approved by NICE.

The outcomes of this treatment for dysplasia look very promising. Approximately 85% of patients have reversal of the dysplasia at the end of the course of treatment, which usually takes a few months to complete. It is still a relatively new treatment and we are not yet certain about how long the benefits last. For this reason, in the long term all patients having the treatment will need to have follow up endoscopies to ensure that they remain well.

Surgery

A small proportion of patients with high grade dysplasia will also be found to have cancer cells. For these patients surgery may be recommended in order to completely remove the cancer cells and the Barrett’s cells. Some patients with high grade dysplasia and no definite cancer elect to undergo surgery so that they can be certain that the high grade dysplasia has been removed. These decisions are difficult and should be made only after discussion with the team of specialists conducting your treatment.

Research is going on all the time into new ways to treat Barrett’s oesophagus. New studies are being published regularly. Please speak to your specialist about the current state of knowledge regarding the treatments available. You may also wish to discuss with a specialist the possibility of taking part in a research study.

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