This is data from Brien, Reed and Levine, et al, in Seattle. There is relatively little data, but they did follow high-grade dysplasia for about two to three years. What happened was that patients with high-grade dysplasia initially, 26%, about one quarter went on to get a cancer within two or three years. About half, 47%, still had high-grade dysplasia on the last biopsy done and surprisingly, about a quarter again, 27%, had high-grade dysplasia when first diagnosed, but subsequent biopsies failed to show high-grade dysplasia. They had not done any active treatment; they had done many biopsies and may have removed some of the mucosa, but it is in no way inevitable that patients with high-grade dysplasia will go get cancer, at least in the next two or three years.

Our usual recommendation for treatment of high-grade dysplasia in patients who are otherwise healthy is to do an esophagectomy. This is the resection of the shaded area with the pulling up of the stomach to anastomose to the high thoracic esophagus with a pyloromyotomy, because you’ve cut the vagus nerve.

What do we see if we look microscopically at the resected specimen? Yellow is low grade and this one had four small areas of high-grade in red and a tiny cancer here. This patient had a 2.5-cm long Barrett’s with one tiny area of high-grade dysplasia here. This one had a little low grade, high grade and a very early cancer there. Now, some of the patients had larger areas of high-grade dysplasia. This is to show that you really need to take systematic biopsy samples of the whole esophagus when you are doing endoscopy if you are going to find that and even then, it was perhaps only luck that this was found.

Cancer treatment