The Role of Adjunct Imaging in Endoscopic Detection of Dysplasia in Barrett’s Esophagus

Advances in imaging technologies have demonstrated promise in early detection of dysplasia and cancer in Barrett’s esophagus (BE). Optical chromoendoscopy, dye-based chromoendoscopy, and novel technologies have provided the opportunity to visualize the cellular and subcellular structures. Only narrow-band imaging and acetic acid chromoendoscopy have reached benchmarks for clinical use. Volumetric laser endomicroscopy and molecular imaging are not established for routine use. Best practice in management of BE should be focused on careful endoscopic examination, resection, or ablation of the entire abnormal lesion, as well as the use of available imaging technique that has good diagnostic accuracy.

Key points

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Advances in imaging technologies have demonstrated promise in early detection of dysplasia and cancer in Barrett’s esophagus (BE).
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Optical chromoendoscopy (eg, narrow-band imaging [NBI]), dye-based chromoendoscopy, and novel technologies such as confocal laser endomicroscopy have provided the opportunity to visualize the cellular and subcellular structures.
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Currently, only NBI and acetic acid chromoendoscopy have reached benchmarks for clinical use to guide biopsy.
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New-generation optical tomography (volumetric laser endomicroscopy) has demonstrated significant promise in dysplasia detection in BE given its quick and wide-field, cross-sectional, high-resolution imaging.

Background

Barrett’s esophagus (BE) is a condition in which the distal squamous epithelium of the esophagus is replaced with columnar epithelium and there is presence of histologically proven intestinal metaplasia (IM). Gastroesophageal reflux disease is a major risk factor for BE and development of esophageal adenocarcinoma (EAC). The evolution of EAC starts from the sequence of low-grade dysplasia (LGD); high-grade dysplasia (HGD); and, eventually, EAC. The incidence of EAC is rising in United States. For the diagnosis of BE, at least 8 random biopsies, as well as targeted sampling of visible mucosal abnormalities, should be obtained to increase the yield of IM on histology in patients with suspected BE. However, in patients with a short segment (1–2 cm) in which 8 biopsies in not obtainable, at least 4 biopsies per centimeter of circumferential BE should be obtained. IM (with goblet cells) is required for the diagnosis of BE because it is suspected to be the predominant type of esophageal columnar epithelium that predisposes to cancer. The missed rates of dysplastic or neoplastic lesions with standard protocol biopsies in patients with BE is as great as 57%. The introduction of advanced imaging technologies has increased the detection of dysplasia and has reduced the number of biopsies in patients with BE. Early detection of precursor lesions during surveillance endoscopy and subsequent classification into categories such as no dysplasia, LGD, and HGD increases the survival in patients with EAC. New advanced imaging is rapid, easy to use and acquisitions of high-resolution (HR) images have made these modalities an important tool for surveillance endoscopy in BE. This article discusses the new technologies and adjunct imaging in BE. Various imaging technologies used to identify red flag lesions in BE are illustrated in Table 1 .

Table 1

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