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.
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.