Amisha Ahuja, MD, Andrew C. Elden, MD, Christina Tofani, MD, Anthony Infantolino, MD, FACG
Thomas Jefferson University Hospital, Philadelphia, PA
Introduction: Barrett’s esophagus (BE) is defined by length, which has been shown to correlate with the risk for esophageal adenocarcinoma (EAC). Although long-segment ( >3 cm) and short-segment (between 1 and 3 cm) BE are well-established definitions, current ACG practice guidelines recommend against defining columnar goblet-cell metaplasia in the distal esophagus < 1 cm as BE. This specific variation of metaplasia disease has been officially defined as “specialized IM of the esophagogastric junction” (SIM-EGJ) over alternatives such as ultra-short segment BE. Given the relatively low incidence of EAC in this group and the high degree of inter-observer variability in defining metaplasia of this length, current guidelines recommend against biopsy in this setting. Individual cases in practice however have demonstrated reasons to question this paradigm.
A 42 year old white man with obesity and 10 years of reflux symptoms was diagnosed with a GE junction nodule on index endoscopy. Cold forceps biopsy of the nodule revealed high grade dysplasia, prompting referral to the BE Treatment Center at Thomas Jefferson University Hospital (TJUH). His repeat EGD revealed salmon-colored mucosa suggestive of intestinal metaplasia in an area less than 1 cm in length (Z-line at 39 cm). An 8 mm nodule was identified in the area of abnormal mucosa and removed by endoscopic mucosal resection. Pathology of the nodule revealed a T1a moderately differentiated intramucosal adenocarcinoma arising in BE. All margins were negative for invasive carcinoma, dysplasia, and intestinal metaplasia. The patient patients underwent endoscopic eradication therapy (EET) with radiofrequency ablation at the GE junction and in subsequent endoscopy achieved complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D).
Discussion: Although current guidelines advise against biopsying < 1 cm of variability in Z line given its status as a relatively low risk lesion, data used to generate many of these risk predictions for EAC exclude visible lesions in their studies. Therefore in practice there may be under-evaluation of SIM-EGJ, potentially missing advanced dysplastic or cancerous disease. This case illustrates that the consideration BE risk factors and all endoscopic findings, such as nodules, need to be taken together when assessing abnormal mucosa at the GE junction, even with < 1cm variability of the Z line.
Citation: Amisha Ahuja, MD, Andrew C. Elden, MD, Christina Tofani, MD, Anthony Infantolino, MD, FACG. P0309 - ESOPHAGEAL ADENOCARCINOMA ARISING FROM <1CM OF INTESTINAL METAPLASIA AT THE GASTROESOPHAGEAL JUNCTION: IS <1CM ACTUALLY LOW RISK?. Program No. P0309. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.