Does Multifocal Dysplasia in Barrett's Esophagus Increase the Risk of Progression to Esophageal Adenocarcinoma?

• Published in: The American journal of gastroenterology Vol. 113; p. S187
• Main Authors: Peng, Frederick B, Elden, Andrew C, Shinn, Brianna, Spataro, Joseph, Kastenberg, David M, Tofani, Christina, Infantolino, Anthony
• Format: Journal Article
• Language: English
• Published: New York Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins 01-10-2018
• Subjects: Cancer; Esophageal cancer; Esophagus; Gastroenterology
• ISSN: 0002-9270; 1572-0241

Introduction: Barrett's Esophagus (BE), is thought to be secondary to gastroesophageal reflux disease and progresses to esophageal adenocarcinoma (EAC) in a stepwise manner. Current guidelines utilize dysplasia to guide management, but there is conflicting evidence on the extent of dysplasia for risk stratification. Here, we evaluated the effect of multifocal dysplasia on the risk for EAC and hypothesized that multifocality in low-grade dysplasia (LGD) and high-grade dysplasia (HGD) are risk factors for progression to EAC. Methods: This was a retrospective study of BE patients with, or with suspected, dysplasia presenting to an academic medical center for evaluation from 2006 to 2016. Information collected include: patient demographics; BE length; histology, including grade and presence of multifocal dysplasia; disease progression; PPI use; need for esophagectomy; and length of follow-up. All pathology specimens were read by expert GI pathologists as: no dysplasia (ND), indefinite for dysplasia (IND), LGD, or HGD. LGD or HGD was further categorized as unifocal or multifocal. Results: Of 305 BE patients with, or with suspected, dysplasia, 51 were excluded (33 ND, 18 IND). 254 BE patients were included in the final analysis: 112 LGD (unifocal=90, multifocal=22) and 142 HGD (unifocal=108, multifocal=34). In total, twenty-five patients with dysplastic BE (13 unifocal, 12 multifocal) developed EAC; all were diagnosed with intramucosal adenocarcinoma with either T1a or T1b lesions. Multifocality significantly increased the risk for progression to EAC (Table 2: RR 3.26, p=0.004), with the effect most pronounced in the subgroup with multifocal LGD as compared to those with unifocal LGD (RR 8.18, p=0.013). In patients with HGD, multifocality did not increase the risk for subsequent EAC (RR 2.31, p=0.079). Lastly, multifocal dysplasia associated with long segment BE (LSBE) significantly increased the risk for EAC (Table 3: RR 3.09, p=0.011), and HGD patients with LSBE were more at-risk for progression to EAC than that of LGD patients (RR 4.33, p=0.007). Conclusion: Multifocal dysplasia significantly increases the risk of progressing from BE to EAC and is especially important in BE patients with LGD. Identification of the extent of dysplasia is also essential in patients with LSBE, particularly those diagnosed with HGD. If confirmed, incorporating dysplasia multifocality into the BE management algorithm should be considered.