**12.2 Focal HGD**

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

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 occur with no visible mucosal abnormality.

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) can also be taken in this setting.

#### **12.3 Intramucosal carcinoma**

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).
