The American Gastroenterological Association (AGA) defines Barrett's esophagus as the condition in which any extent of metaplastic columnar epithelium that predisposes to cancer development replaces the squamous epithelium that normally lines the distal esophagus. Although cardiac mucosa may be metaplastic, its malignant predisposition is not clear, and the AGA still requires the demonstration of intestinal metaplasia (with goblet cells) for a diagnosis of Barrett's esophagus. The AGA generally recommends endoscopic eradication therapy for patients with high-grade dysplasia, who otherwise develop esophageal adenocarcinoma at the rate of 6% per year. Endoscopic therapy is often curative for mucosal neoplasms in Barrett's esophagus because the risk of lymph node metastases is only 1-2%. American gastroenterologists generally do not recommend endoscopic therapy for patients whose neoplasms involve any portion of the submucosa because of the high rate of lymph node metastases that has been described in these cases. The management of low-grade dysplasia is disputed because of poor agreement among pathologists on the diagnosis and because of contradictory data on the natural history, but the AGA recommends that radiofrequency ablation (RFA) should be a therapeutic option for patients with confirmed low-grade dysplasia in Barrett's esophagus. Arguments for using RFA to treat nondysplastic Barrett's metaplasia are based on the premise that RFA decreases cancer risk, but no study has established that premise. In the absence of definitive data, concerns about the frequency and importance of buried metaplastic glands and recurrent metaplasia should temper enthusiasm for treating nondysplastic Barrett's esophagus with RFA.

Keywords:
Barrett’s esophagus, Gastroesophageal reflux disease , Endoscopic therapy, Metaplasia, Esophageal adenocarcinoma
1.
American Gastroenterological Association, Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ: American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology 2011;140:1084-1091.
2.
Paull A, Trier JS, Dalton MD, Camp RC, Loeb P, Goyal RK: The histologic spectrum of Barrett's esophagus. N Engl J Med 1976;295:476-480.
3.
Spechler SJ, Fitzgerald RC, Prasad GA, Wang KK: History, molecular mechanisms, and endoscopic treatment of Barrett's esophagus. Gastroenterology 2010;138:854-869.
4.
Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology: Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus. Am J Gastroenterol 2002;97:1888-1895.
5.
Chandrasoma P: Pathophysiology of Barrett's esophagus. Semin Thorac Cardiovasc Surg 1997;9:270-278.
6.
Hahn HP, Blount PL, Ayub K, Das KM, Souza R, Spechler S, Odze RD: Intestinal differentiation in metaplastic, nongoblet columnar epithelium in the esophagus. Am J Surg Pathol 2009;33:1006-1015.
7.
Liu W, Hahn H, Odze RD, Goyal RK: Metaplastic esophageal columnar epithelium without goblet cells shows DNA content abnormalities similar to goblet cell-containing epithelium. Am J Gastroenterol 2009;104:816-824.
8.
Takubo K, Aida J, Naomoto Y, Sawabe M, Arai T, Shiraishi H, Matsuura M, Ell C, May A, Pech O, Stolte M, Vieth M: Cardiac rather than intestinal-type background in endoscopic resection specimens of minute Barrett adenocarcinoma. Hum Pathol 2009;40:65-74.
9.
Kelty CJ, Gough MD, Van Wyk Q, Stephenson TJ, Ackroyd R: Barrett's oesophagus: intestinal metaplasia is not essential for cancer risk. Scand J Gastroenterol 2007;42:1271-1274.
10.
Playford RJ: New British Society of Gastroenterology (BSG) guidelines for the diagnosis and management of Barrett's oesophagus. Gut 2006;55:442.
11.
Westerhoff M, Hovan L, Lee C, Hart J: Effects of dropping the requirement for goblet cells from the diagnosis of Barrett's esophagus. Clin Gastroenterol Hepatol 2012;10:1232-1236.
12.
Spechler SJ: Barrett's esophagus: is the goblet half-empty? Clin Gastroenterol Hepatol 2012;10:1237-1238.
13.
Schnell TG, Sontag SJ, Chejfec G, Aranha G, Metz A, O'Connell S, Seidel UJ, Sonnenberg A: Long-term nonsurgical management of Barrett's esophagus with high-grade dysplasia. Gastroenterology 2001;120:1607-1619.
14.
Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology: Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus. Am J Gastroenterol 2008;103:788-797.
15.
Rastogi A, Puli S, El-Serag HB, et al: Incidence of esophageal adenocarcinoma in patients with Barrett's esophagus and high-grade dysplasia: a meta-analysis. Gastrointest Endosc 2008;67:394-398.
16.
Shaheen NJ, Sharma P, Overholt BF, Wolfsen HC, Sampliner RE, Wang KK, Galanko JA,Bronner MP, Goldblum JR, Bennett AE, Jobe BA, Eisen GM, Fennerty MB, Hunter JG, Fleischer DE, Sharma VK, Hawes RH, Hoffman BJ, Rothstein RI, Gordon SR, Mashimo H, Chang KJ, Muthusamy VR, Edmundowicz SA, Spechler SJ, Siddiqui AA, Souza RF, Infantolino A, Falk GW, Kimmey MB, Madanick RD, Chak A, Lightdale CJ: Radiofrequency ablation in Barrett's esophagus with dysplasia. N Engl J Med 2009;360:2277-2288.
17.
Dunbar KB, Spechler SJ: The risk of lymph node metastases in patients with high grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review. Am J Gastroenterol 2012;107:850-862.
18.
Leers JM, DeMeester SR, Oezcelik A, et al: The prevalence of lymph node metastases in patients with T1 esophageal adenocarcinoma a retrospective review of esophagectomy specimens. Ann Surg 2011;253:271-278.
19.
Manner H, May A, Pech O, Gossner L, Rabenstein T, Günter E, Vieth M, Stolte M, Ell C: Early Barrett's carcinoma with ‘low-risk' submucosal invasion: long-term results of endoscopic resection with a curative intent. Am J Gastroenterol 2008;103:2589-2597.
20.
Badreddine RJ, Prasad GA, Lewis JT, Lutzke LS, Borkenhagen LS, Dunagan KT, Wang KK: Depth of submucosal invasion does not predict lymph node metastasis and survival of patients with esophageal carcinoma. Clin Gastroenterol Hepatol 2010;8:248-253.
21.
Waxman I, Raju GS, Critchlow J, Antonioli DA, Spechler SJ: High-frequency probe ultrasonography has limited accuracy for detecting invasive adenocarcinoma in patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma: a case series. Am J Gastroenterol 2006;101:1773-1779.
22.
Larghi A, Lightdale CJ, Memeo L, Bhagat G, Okpara N, Rotterdam H: EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett's esophagus. Gastrointest Endosc 2005;62:16-23.
23.
Curvers WL, ten Kate FJ, Krishnadath KK, Visser M, Elzer B, Baak LC, Bohmer C, Mallant-Hent RC, van Oijen A, Naber AH, Scholten P, Busch OR, Blaauwgeers HG, Meijer GA, Bergman JJ: Low-grade dysplasia in Barrett's esophagus: overdiagnosed and underestimated. Am J Gastroenterol 2010;105:1523-1530.
24.
Wani S, Falk G, Hall M, Gaddam S, Wang A, Gupta N, Singh M, Singh V, Chuang KY, Boolchand V, Gavini H, Kuczynski J, Sud P, Reddymasu S, Bansal A, Rastogi A, Mathur SC, Young P, Cash B, Lieberman DA, Sampliner RE, Sharma P: Patients with nondysplastic Barrett's esophagus have low risks for developing dysplasia or esophageal adenocarcinoma. Clin Gastroenterol Hepatol 2011;9:220-227.
25.
Hur C, Choi SE, Rubenstein JH, Kong CY, Nishioka NS, Provenzale DT, Inadomi JM: The cost effectiveness of radiofrequency ablation for Barrett's esophagus. Gastroenterology 2012;143:567-575.
26.
Fleischer DE, Odze R, Overholt BF, Carroll J, Chang KJ, Das A, Goldblum J, Miller D, Lightdale CJ, Peters J, Rothstein R, Sharma VK, Smith D, Velanovich V, Wolfsen H, Triadafilopoulos G: The case for endoscopic treatment of non-dysplastic and low-grade dysplastic Barrett's esophagus. Dig Dis Sci 2010;55:1918-1931.
27.
El-Serag HB, Graham DY: Routine polypectomy for colorectal polyps and ablation for Barrett's esophagus are intellectually the same. Gastroenterology 2011;140:386-388.
28.
Fleischer DE, Overholt BF, Sharma VK, Reymunde A, Kimmey MB, Chuttani R, Chang KJ, Muthasamy R, Lightdale CJ, Santiago N, Pleskow DK, Dean PJ, Wang KK: Endoscopic radiofrequency ablation for Barrett's esophagus: 5-year outcomes from a prospective multicenter trial. Endoscopy 2010;42:781-789.
29.
Gray NA, Odze RD, Spechler SJ: Buried metaplasia after endoscopic ablation of Barrett's esophagus: a systematic review. Am J Gastroenterol 2011;106:1899-1908.
30.
Titi M, Overhiser A, Ulusarac O, Falk GW, Chak A, Wang K, Sharma P: Development of subsquamous high-grade dysplasia and adenocarcinoma after successful radiofrequency ablation of Barrett's esophagus. Gastroenterology 2012;143:564-566.
31.
Gupta N, Mathur SC, Dumot JA, Singh V, Gaddam S, Wani SB, Bansal A, Rastogi A, Goldblum JR, Sharma P: Adequacy of esophageal squamous mucosa specimens obtained during endoscopy: are standard biopsies sufficient for postablation surveillance in Barrett's esophagus? Gastrointest Endosc 2012;75:11-18.
32.
Zhou C, Tsai TH, Lee HC, Kirtane T, Figueiredo M, Tao YK, Ahsen OO, Adler DC, Schmitt JM, Huang Q, Fujimoto JG, Mashimo H: Characterization of buried glands pre- and post-radiofrequency ablation using three-dimensional optical coherence tomography. Gastrointest Endosc 2012;76:32-40.
33.
Gondrie JJ, Pouw RE, Sondermeijer CM, Peters FP, Curvers WL, Rosmolen WD, Ten Kate F, Fockens P, Bergman JJ: Effective treatment of early Barrett's neoplasia with stepwise circumferential and focal ablation using the HALO system. Endoscopy 2008;40:370-379.
34.
Shaheen NJ, Overholt BF, Sampliner RE, Wolfsen HC, Wang KK, Fleischer DE, Sharma VK, Eisen GM, Fennerty MB, Hunter JG, Bronner MP, Goldblum JR, Bennett AE, Mashimo H, Rothstein RI, Gordon SR, Edmundowicz SA, Madanick RD, Peery AF, Muthusamy VR, Chang KJ, Kimmey MB, Spechler SJ, Siddiqui AA, Souza RF, Infantolino A, Dumot JA, Falk GW, Galanko JA, Jobe BA, Hawes RH, Hoffman BJ, Sharma P, Chak A, Lightdale CJ: Durability of radiofrequency ablation in Barrett's esophagus with dysplasia. Gastroenterology 2011;141:460-468.
35.
Vaccaro BJ, Gonzalez S, Poneros JM, Stevens PD, Capiak KM, Lightdale CJ, Abrams JA: Detection of intestinal metaplasia after successful eradication of Barrett's esophagus with radiofrequency ablation. Dig Dis Sci 2011;56:1996-2000.
36.
Spechler SJ: Barrett's esophagus without dysplasia: wait or ablate? Dig Dis Sci 2011;56:1926-1928.
© 2013 S. Karger AG, Basel
2013
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