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?

Explanation

## 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.