Location and appearance of dysplastic Barrett's esophagus recurrence after endoscopic eradication therapy: no additional yield from random biopsy sampling neosquamous mucosa

Tony He; Vijaya Sundararajan; Nicholas J Clark; John Slavin; Edward H Tsoi; Alexander J Thompson; Bronte A Holt; Paul V Desmond; Andrew C F Taylor

doi:10.1016/j.gie.2023.06.002

Location and appearance of dysplastic Barrett's esophagus recurrence after endoscopic eradication therapy: no additional yield from random biopsy sampling neosquamous mucosa

Gastrointest Endosc. 2023 Nov;98(5):722-732. doi: 10.1016/j.gie.2023.06.002. Epub 2023 Jun 8.

Authors

Tony He¹, Vijaya Sundararajan², Nicholas J Clark¹, John Slavin³, Edward H Tsoi¹, Alexander J Thompson¹, Bronte A Holt¹, Paul V Desmond¹, Andrew C F Taylor¹

Affiliations

¹ Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia.
² University of Melbourne, Melbourne, Victoria, Australia.
³ Department of Pathology, St Vincent's Hospital, Melbourne, Victoria, Australia.

PMID: 37301519
DOI: 10.1016/j.gie.2023.06.002

Abstract

Background and aims: Surveillance after complete remission of intestinal metaplasia (CRIM) is essential. Current recommendations are to sample visible lesions first, followed by random 4-quadrant biopsy sampling of the original Barrett's esophagus (BE) length. To inform post-CRIM surveillance protocols, we aimed to identify the anatomic location, appearance, and histology of BE recurrences.

Methods: We performed an analysis of 216 patients who achieved CRIM after endoscopic eradication therapy for dysplastic BE at a Barrett's Referral Unit between 2008 and 2021. The anatomic location, recurrence histology, and endoscopic appearance of dysplastic recurrences were evaluated.

Results: After a median of 5.5 years (interquartile range, 2.9-7.2) of follow-up after CRIM, 57 patients (26.4%) developed nondysplastic BE (NDBE) recurrence and 18 patients (8.3%) developed dysplastic recurrence. From 8158 routine surveillance biopsy samplings of normal-appearing tubular esophageal neosquamous epithelium, the yield for recurrent NDBE or dysplasia was 0%. One hundred percent of dysplastic tubular esophageal recurrences were visible and in BE islands, whereas 77.8% of gastroesophageal junction dysplastic recurrences were nonvisible. Four distinct endoscopic features suspicious for recurrent advanced dysplasia or neoplasia were identified: buried or subsquamous BE, irregular mucosal pattern, loss of vascular pattern, and nodularity or depression.

Conclusions: The yield of routine surveillance biopsy sampling of normal-appearing tubular esophageal neosquamous epithelium was zero. BE islands with indistinct mucosal or loss of vascular pattern, nodularity or depression, and/or signs of buried BE should raise clinician suspicion for advanced dysplasia or neoplasia recurrence. We suggest a new surveillance biopsy sampling protocol with a focus on meticulous inspection, followed by targeted biopsy sampling of visible lesions and random 4-quadrant biopsy sampling of the gastroesophageal junction.