**11. Management of low-grade dysplasia**

Patients with LGD should undergo repeat endoscopy with adherence to a 'gold standard' biopsy regimen 8-12 weeks after the commencement of PPI therapy. A repeat endoscopy should then be performed at 6 months, and if LGD persists, endoscopy should be repeated 6-monthly unless regression to normal Barrett's or squamous epithelium occurs, at which time surveillance can be reduced to 2 yearly intervals. (BSG Working Party, 2005)

In some cases of multifocal, persistent LGD, endoscopic mucosal ablation therapy could be considered, particularly if there is a strong patient desire for intervention (BSG Working Party, 2005) (although evidence for this statement is limited and widespread treatment of LGD is not cost-effective and is not recommended).

Endoscopic Detection and Eradication of Dysplastic Barrett's Oesophagus 163

Patients with multifocal disease are at a significant risk (up to 30%) of an undetected metachronous cancer and therefore warrant definitive treatment. Surgical oesophagectomy should still be considered as the first line treatment option for patients with persistent HGD provided they are deemed low operative risk and have a long life expectancy. Surgery must

Those patients with confirmed persistent multifocal HGD who are deemed unfit for an oesophagectomy should receive ER to visible areas of HGD and subsequent ablation of the entire Barrett's segment. Several ablative treatments (using different modalities) may be required to establish complete remission. Patients will subsequently require lifelong

Patients should be initially managed by ER of the affected area to confirm the diagnosis and exclude early malignancy. Those with a limited area of histologically confirmed HGD should undergo subsequent mucosal ablation of the whole Barrett's segment. Young

Clinicians should have a high level of suspicion for cancer and if suspected appropriate investigations e.g. endoscopic ultrasound and PET-CT should be considered. Nodularity on endoscopy should particularly raise concern although occult intramucosal tumours can

Patients with HGD should initially undergo three monthly endoscopy with quadrantic biopsies every 1cm – shown to half the chance of missing oesophageal adenocarcinoma compared to 2cm biopsies. (Reid et al., 2000a) Jumbo biopsies (using large capacity forceps)

All patients with confirmed oesophageal cancer should undergo formal tumour staging to establish the presence or absence of distant or locoregional metastases. Surgery should be regarded as the treatment of choice for patients deemed fit enough to tolerate oesophagectomy. Patients with high operative risk with T1a (and possibly T1sm1) tumours confirmed on ER should be considered for endoscopic therapy (ER followed by ablation).

All treatment decisions should be discussed in a multidisciplinary team meeting once every effort has been made to ensure the correct diagnosis has been reached. Patients (and families) should be fully informed and involved in the decision making process. All surgical and endoscopic procedures should be performed by specialists in recognised cancer units. ER should be used as a potentially curative treatment for IMC and focal HGD, and also has an emerging role in aiding histological diagnosis. Following ER the goal should be to ablate the entire Barrett's segment. Due to the technical difficulties and costs associated with PDT, its role is increasingly being superseded by that of RFA. Following initial ablative therapy, further treatments (using the same or different treatment modalities) should be given in an attempt to destroy any remaining metaplastic / dysplastic epithelium. The aim should be complete squamous regeneration, however even if successful, surveillance should be lifelong as glands with malignant potential may persist burried beneathe the regenerated mucosa.

patients who are fit for major surgery should be considered for oesophagectomy.

be carried out in specialist centres where mortality rates do not exceed 5%.

**12.1 Multifocal HGD** 

endoscopic surveillance.

occur with no visible mucosal abnormality.

can also be taken in this setting.

**12.3 Intramucosal carcinoma** 

**13. Summary** 

**12.2 Focal HGD** 
