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In a study by Sharma et al1 recently published in Gut, high-definition endoscopy and narrow band imaging (NBI) enabled detection of more areas of dysplasia than Seattle protocol. In addition, regular mucosa did not harbour high-grade dysplasia (HGD)/cancer, leading to the suggestion that biopsies could be avoided in those areas.
However, authors stated in the discussion that the routine use of NBI targeted biopsies for detection of HGD/cancer should not be recommended. To highlight this point, we would like report a case of a C10M12 Barrett's oesophagus (BO) patient with two previous macroscopic lesions with HGD and adenocarcinoma resected using multiband mucosectomy (figure 1). In a careful follow-up using the same endoscope as in the reported study,1 no macroscopic lesions were detected and biopsies were performed according to Seattle protocol. The pathological analysis in consensus by two expert gastrointestinal pathologists revealed, in areas not related to the previous resections, the presence of low-grade and high-grade multifocal crypt dysplasia (CD) with no dysplasia on the epithelial surface. Due to fact that radiofrequency ablation is unavailable in our country, due to the relevant morbidity of oesophagectomy and our experience on endoscopic submucosal dissection (ESD), a decision for endoscopic resection was made. An ESD of the 12 cm BO was performed and en bloc circular specimen was obtained. The histopathological analysis with hematoxylin-eosin, ki67 and p53 immunohistochemistry, in consensus by three expert gastrointestinal pathologists, confirmed the presence of multifocal low-grade and high-grade CD, with no dysplasia at the epithelial surface above the basal changes (figure 2).
Evidence suggests that dysplasia begins in the crypt bases and progresses, with time, to involve the full length of the crypts and surface epithelium.2 CD, also called basal CD-like atypia, is characterised by the presence of dysplasia limited to the bases of the crypts, without involvement of the surface epithelium. It was demonstrated that CD harbours proliferative and molecular abnormalities present in conventional dysplasia.3 This condition is rarely addressed in the literature but can be found in up to 7% of BO cases and is associated with increased risk for neoplastic progression. In fact, 87% of these patients have prior or concomitant dysplasia or adenocarcinoma in the remaining BO.3 On the other hand, in such cases, it can never be excluded that adjacent neoplasia grows underneath the surface mimicking such crypt foci.
It is important for gastroenterologists to be aware of the possibility of the presence of dysplasia-like changes limited to the crypts not suitable for detection even with advanced endoscopic tools. Conventional biopsies are required for its detection and in case biopsies show such dysplastic crypt foci, an adjacent neoplastic lesion should be excluded. Therefore, natural history and clinical significance of CD require further investigation.
Contributors FB-S and MM: Endoscopic procedures, conception and design, analysis and interpretation of data, drafting of the article and final approval. JL, FC and MV: analysis and interpretation of data, drafting of the article and final approval. GM: drafting of the article and final approval.
Competing interests None.
Patient consent Obtained.
Ethics approval Comissao de Etica do Hospital de Sao Joao, Porto, Portugal.
Provenance and peer review Not commissioned; internally peer reviewed.
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