A 58-year-old woman with chronic gastro-oesophageal reflux disease (GORD) for 15 years undergoes upper endoscopy for persistent dyspepsia. Biopsies from the lower oesophagus show columnar epithelium with intestinal-type glands (Barrett's oesophagus) and focal areas of dysplasia. The pathologist reports CIN 3 (high-grade dysplasia) without evidence of invasive adenocarcinoma. The patient is on proton pump inhibitors and has good symptom control. What is the most appropriate next step in management?

Question

Accepted Answer

D. Refer for endoscopic mucosal resection (EMR) or radiofrequency ablation (RFA). ## Clinical Context

This patient has **Barrett's oesophagus with CIN 3 (high-grade dysplasia)**. CIN 3 is a **high-risk precancerous lesion** with a ~90% risk of progression to invasive adenocarcinoma within 5 years if untreated. Unlike CIN 1 or CIN 2, CIN 3 requires **active endoscopic intervention**, not surveillance alone.

## Key Point:
**CIN 3 dysplasia in Barrett's oesophagus is an indication for endoscopic therapy (EMR or RFA), not observation.** The goal is to eradicate the dysplastic epithelium before it progresses to invasive cancer.

## Management Algorithm for Barrett's Dysplasia

```mermaid
flowchart TD
  A[Barrett's oesophagus confirmed on biopsy]:::outcome --> B{Dysplasia present?}:::decision
  B -->|No dysplasia| C[PPI + surveillance every 2-3 years]:::action
  B -->|CIN 1 Low-grade| D[PPI + repeat endoscopy in 6-12 months]:::action
  B -->|CIN 2 Moderate| E[PPI + repeat in 3-6 months or consider RFA]:::action
  B -->|CIN 3 High-grade| F[EMR or RFA + PPI]:::action
  F --> G[Confirm eradication with repeat endoscopy in 3 months]:::action
  G --> H{Dysplasia eradicated?}:::decision
  H -->|Yes| I[Continue PPI + surveillance every 6-12 months]:::action
  H -->|No| J[Repeat RFA or consider esophagectomy]:::urgent
```

## High-Yield:
**CIN 3 in Barrett's oesophagus:** Endoscopic mucosal resection (EMR) or radiofrequency ablation (RFA) is the standard of care. EMR is preferred if a focal nodule is present; RFA is used for diffuse dysplasia. Success rate of eradication is 80–95% with combined EMR + RFA.

## Clinical Pearl:
- **EMR** is both therapeutic (removes dysplasia) and diagnostic (allows histology to exclude invasive cancer).
- **RFA** (radiofrequency ablation) ablates the dysplastic Barrett's epithelium and allows re-epithelialization with normal squamous epithelium.
- **PPI therapy** is continued lifelong to reduce recurrence of Barrett's metaplasia and dysplasia.
- **Esophagectomy** is reserved for patients with invasive adenocarcinoma or failed endoscopic therapy.

## Comparison of Dysplasia Grades and Management

| Dysplasia Grade | Progression Risk | Management | Surveillance Interval |
|---|---|---|---|
| **No dysplasia** | 0.2–0.5% per year | PPI + surveillance | Every 2–3 years |
| **CIN 1 (Low-grade)** | 5–10% per year | Repeat endoscopy ± RFA | Every 6–12 months |
| **CIN 2 (Moderate)** | 20–30% per year | Repeat endoscopy or RFA | Every 3–6 months |
| **CIN 3 (High-grade)** | ~90% over 5 years | **EMR ± RFA** | Every 3 months post-therapy |
| **Invasive adenocarcinoma** | — | Esophagectomy ± chemo/RT | Staging-dependent |

## Why Option 1 is Correct
- CIN 3 has unacceptably high progression risk (~90% to invasive cancer in 5 years) if left untreated.
- EMR or RFA is the evidence-based standard of care for CIN 3 in Barrett's oesophagus.
- These endoscopic techniques have high success rates (80–95% eradication) and preserve the oesophagus, avoiding the morbidity of esophagectomy.
- Post-procedure surveillance is still required, but the dysplasia is actively treated, not merely observed.

Answer

A. Start chemotherapy as neoadjuvant therapy before surgical resection

Answer

B. Reassure the patient that Barrett's oesophagus does not require intervention

Answer

C. Continue PPI therapy and repeat endoscopy with biopsy in 12 months

Explanation

Clinical Context

Key Point:

Management Algorithm for Barrett's Dysplasia

High-Yield:

Clinical Pearl:

Comparison of Dysplasia Grades and Management

Why Option 1 is Correct

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Dysplasia Grade	Progression Risk	Management	Surveillance Interval
No dysplasia	0.2–0.5% per year	PPI + surveillance	Every 2–3 years
CIN 1 (Low-grade)	5–10% per year	Repeat endoscopy ± RFA	Every 6–12 months
CIN 2 (Moderate)	20–30% per year	Repeat endoscopy or RFA	Every 3–6 months
CIN 3 (High-grade)	~90% over 5 years	EMR ± RFA	Every 3 months post-therapy
Invasive adenocarcinoma	—	Esophagectomy ± chemo/RT	Staging-dependent