The incidence of esophageal
adenocarcinoma is increasing in the USA, now accounting for at least 4% of US
cancer-related deaths.
Barrett's esophagus is the main risk factor for the development of esophageal
adenocarcinoma. The annual incidence of development of
adenocarcinoma in
Barrett's esophagus is approximately 0.5% per year, representing at least a 30-40-fold increase in risk from the general population. High-grade dysplasia is known to be the most important risk factor for progression to
adenocarcinoma. Traditionally,
esophagectomy has been the standard treatment for
Barrett's esophagus with high-grade dysplasia. This practice is supported by studies revealing unexpected
adenocarcinoma in 29-50% of esophageal resection specimens for high-grade dysplasia. In addition,
esophagectomy employed prior to
tumor invasion of the muscularis mucosa results in 5-year survival rates in excess of 80%. Although
esophagectomy can result in improved survival rates for early-stage
cancer, it is accompanied by significant morbidity and mortality. Recently, more accurate methods of surveillance and advances in endoscopic
therapies have allowed scientists and clinicians to develop treatment strategies with lower morbidity for high-grade dysplasia. Early data suggests that carefully selected patients with high-grade dysplasia can be managed safely with endoscopic
therapy, with outcomes comparable to surgery, but with less morbidity. This is an especially attractive approach for patients that either cannot tolerate or decline surgical
esophagectomy. For patients that are surgical candidates, high-volume centers have demonstrated improved morbidity and mortality rates for
esophagectomy. The addition of laparoscopic
esophagectomy adds a less invasive surgical resection to the treatment armanentarium.
Esophagectomy will remain the gold-standard treatment of
Barrett's esophagus with high-grade dysplasia until clinical research validates the role of endoscopic
therapies. Current treatment strategies for
Barrett's esophagus with high-grade dysplasia will be reviewed.