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October 10th, 2012

Barrett esophagus with high-grade dysplasia: How should it be staged?

I am amazed at the variation I have seen in the use of endoscopic ultrasound (EUS) in staging Barrett esophagus (BE). Some of us use EUS universally, and others (myself included) never use it to stage intramucosal carcinoma or high-grade dysplasia.

So, let me propose a case and ask what you would do: The patient is a healthy 58-year-old man with 3 cm of BE with a 0.5 cm nodule in the distal segment. There is no ulceration or other surface irregularity found upon inspection with high-definition white-light and narrow-band imaging.

Would you:
1) Stage with EUS and resect the nodule?
2) Resect the nodule and stage with EUS only if intramucosal carcinoma or greater neoplasia is seen?
3) Resect the nodule and stage with EUS for invasive adenocarcinoma only?
4) Perform radiofrequency ablation (RFA) of the nodule after staging EUS?
5) Perform RFA of the nodule without staging EUS?

I look forward to your comments.

8 Responses to “Barrett esophagus with high-grade dysplasia: How should it be staged?”

  1. Ihab Beblawi says:

    I perform EUS and would feel much safer staging with EUS first then performing EMR.

  2. K.Venkataraman says:

    perfom RF abalation of nodule after EUS

  3. VALLADARES says:

    I WILL RESECT THE NODULE AND STAGE WITH EUS ONLY IF INTRAMUCOSAL CARCINOMA OR GREATER NEOPLASIA IS SEEN

  4. Felix says:

    Option 3

  5. Resect with EMR, and then only EUS if you are staging an invasive cancer. EUS often over- or under-stages mucosal lesions.

  6. Stephan Hollerbach says:

    Dear Dr. Fennerty,

    we perform EUS prior to resection only if a higher degree of invasive carcinoma is suspected. If not, I would rather go ahead with your second option to resect the nodule endoscopically and apply EUS later on only if a submucosal carcinoma or greater neoplasia is seen.

    Best regards.
    Stephan

  7. Alireza Ghamkhar says:

    Resect the nodule and stage with EUS only if intramucosal carcinoma or greater neoplasia is seen

  8. I had exactly the patient you described 1 yea ago.
    patient with barret’s of 2-3 cm. that was on surveillance for years. a nodule of 0,5 cm. appeared that was adenocarcinoma: I send him for EUS–> resection of the nodule–> and RFA OF THE BARRETT’S. until now he is o’kay. his age about 60 and very fat: high operation risk.

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Gastroenterology Research: Author M. Brian Fennerty, M.D.

M. Brian Fennerty, MD

Editor-in-Chief

NEJM Journal Watch Gastroenterology

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