Can medical treatment lead to regression of dysplasia?

R.E. Sampliner (Tucson)

Although "intensive medical treatment" is recommended for patients with Barrett's esophagus and dysplasia demonstrated by biopsy [1 ], there is little data to substantiate the natural history of dysplasia, let alone its response to therapy. Two major caveats have to be kept in mind when evaluating data on regression of dysplasia:

1. The adequacy of biopsy sampling and the problem of sampling error; and

2. The issue of observer variability - even in the presence of high-grade dysplasia, the interobserver agreement is only in the 85-87% range [2].

Hameeteman et al. reported 50 patients with Barrett's esophagus actively treated when reflux esophagitis was seen at endoscopy. Treatment consisted of H₂-receptor antagonists, omeprazole and six patients underwent antireflux surgery. In spite of this therapy of active inflammatory disease, five patients progressed from negative or low-grade dysplasia to carcinoma and 13 patients either developed or continued to have dysplasia [3]. High-grade dysplasia without progression was present in two patients for 36 and 44 months.

Reid et al. described a prospective endoscopic surveillance of 62 patients with Barrett's esophagus. Although the therapy of these patients is not described, four out of nine patients with high-grade dysplasia remained stable, histologically, over an 11-20-month interval. In addition, four out of 20 patients with indefinite or low-grade dysplasia subsequently did not have dysplasia during follow-up [4].

In conclusion, data are lacking which indicate that medical therapy leads to regression or stabilization of dysplasia in Barrett's esophagus. Due to the relative infrequency of dysplasia, multicenter studies with standardized observations and central pathology readings will be necessary to define the natural history of dysplasia and the response to therapy.

References

1. Spechler SJ, Goyal RK. Barrett's esophagus. N Engl J Med 1986;315:362-371.

2. Reid BJ, Haggitt RC, Rubin CE et al. Observer variation in the diagnosis of dysplasia in Barrett's esophagus Hum Pathol 1988;19:166-178.

3. Hameeteman W, Tytgat GNJ, Houthoff HJ et al. Barrett's esophagus: development of dysplasia and adenocarcinoma. Gastroenterology 1989;96:1249-1256.

4. Reid BJ, Blount PL, Rubin CE et al. Flow-cytometric and histologic progression to malignancy in Barrett's esophagus: prospective endoscopic surveillance of a cohort. Gastroenterology 1992;102:1212-1219.