Aims
Barrett’s esophagus (BE) with early neoplasia is an indication for endoscopic treatment. Patients with non-dysplastic BE are typically enrolled in an endoscopic surveillance program to enable early detection, and treatment, of BE related neoplasia. In contrast, a subset of patients with early BE neoplasia is concurrently diagnosed with BE and early neoplasia. Our goal was to distinguish cases detected through endoscopic surveillance programs (i.e. initial detection of non-dysplastic BE with progression to neoplasia later in time (metachronous neoplasia)) from cases where BE and neoplasia were diagnosed simultaneously (synchronous neoplasia).

Methods
We obtained data from the Dutch Barrett Expert Center Registry, a comprehensive nationwide registry encompassing data from all BE patients who underwent endoscopic treatment in Barrett Expert Centers across the Netherlands. To enhance data completeness, we supplemented the registry with pathology reports sourced from the national pathology registry (PALGA). Primary endpoint was the proportion of patients diagnosed with BE and neoplasia simultaneously (synchronous neoplasia). Enrollment in an endoscopic surveillance program was defined as the presence of at least one endoscopy with non-dysplastic BE ≥12 months prior to endoscopic treatment initiation.

Results
A total of 1,386 patients were identified from the registry with a mean age of 65 years (SD±10) and 81% of the cohort being male. Median BE length was C2M5 (IQR 0-5; 3-8) and treatment indication encompassed low-grade dysplasia (LGD; 27%), high-grade dysplasia (HGD; 31%), or low-risk cancer (42%).
Overall, 699/1,386 patients (50%) underwent an endoscopy that revealed a new diagnosis of BE with synchronous neoplasia. Conversely, the remaining 687/1,386 patients (50%) were enrolled in endoscopic surveillance programs at the moment neoplasia was diagnosed, with a median duration of endoscopic surveillance spanning 8 years (IQR 4-13).
The proportion of patients with new BE and synchronous neoplasia increased along with more severe histology at the moment of treatment. Specifically, the proportion of patients with synchronous neoplasia was 39% (147/375) for a treatment indication of LGD, 49% (205/422) for HGD and 59% (347/589) for cancer (P <0.01). There was no significant difference observed concerning varying lengths of BE.

Conclusions
Remarkably, only half of the patients with early Barrett’s neoplasia receive a neoplasia diagnosis following enrollment in endoscopic surveillance programs, while the remaining half presents with de novo diagnosis of BE containing synchronous neoplasia. Notably, for patients with more severe histologic changes at the moment of treatment, the proportion of de novo BE with synchronous neoplasia is even higher. These findings support further critical view regarding the efficacy and cost-effectiveness of BE surveillance.

Laura Boer

Appearances