Endoscopic treatment of high-grade intraepithelial neoplasia and early cancer in Barrett oesophagus

In the last 5 years, endoscopic therapy for high-grade intraepithelial neoplasia (HGIN) and early cancer (EC) in Barrett oesophagus has emerged as an effective and safe alternative to surgery. Adequate work-up of patients includes histopathological review of the initial biopsies, a high-resolution endoscopy with four-quadrant random biopsies every 1 cm of Barrett mucosa and staging with endoscopic ultrasonography. Endoscopic resection (ER) forms the mainstay of the endoscopic treatment since it provides large tissue specimens for optimal histopathological evaluation. The ER-cap technique with submucosal injection and the ‘suck-band-and cut’ method are the resection methods most widely used in Barrett oesophagus patients. ER monotherapy for HGIN or EC in Barrett oesophagus is associated with recurrent lesions in up to 30% of treated patients. ER may be combined with ablative techniques such as photodynamic therapy (PDT) to treat all of the mucosa at risk for neoplastic progression. Unlike ER, PDT lacks histopathological correlation and residual Barrett mucosa may remain after treatment or may be hidden underneath the neosquamous epithelium. Management of Barrett oesophagus patients with HGIN or EC should be performed in centres with multi-disciplinary experience in this field and future studies should focus on development of ER techniques that allow radical resection of the whole Barrett segment.