Diagnostic Approach to Early Barrett’s Neoplasia: Western Perspective

BACKGROUND: Barrett's esophagus (BE) is the replacement of normal squamous epithelium in the distal esophagus by columnar epithelium. The prognosis of esophageal adenocarcinoma depends largely on the stage at diagnosis. Advances in endoscopic imaging and quality standards have significantly improved the early detection of BE-associated neoplasia. This review summarizes current classification systems, sampling protocols, and adjunct tools for diagnosing early neoplasia in BE in Western practice. SUMMARY: In Western practice, the diagnosis of BE relies on consensus criteria requiring endoscopic evidence and histopathological confirmation of columnar epithelium proximal to the gastroesophageal junction. However, there are discrepancies regarding the minimum BE extent and the necessity of intestinal metaplasia for diagnosis. Detecting early neoplasia in BE is challenging due to the flat and subtle nature of dysplastic lesions. High-definition white-light endoscopy (HD-WLE) is the standard modality for BE surveillance and is used to assess for characteristic features of neoplasia, including nodularity, surface irregularity, color changes, and demarcated areas. Image-enhancing techniques - such as virtual chromoendoscopy (e.g., narrow-band imaging [NBI], texture and color enhancement imaging [TXI], blue light imaging [BLI], linked color imaging [LCI]), and acetic acid chromoendoscopy - have improved dysplasia detection when applied alongside validated classification systems. Despite technological advances, random four-quadrant biopsies (4QBs) remain the standard for dysplasia detection. Estimating lesion depth is based primarily on HD-WLE, with limited contribution from chromoendoscopy and ancillary imaging techniques (i.e., endoscopic ultrasound [EUS], confocal laser endomicroscopy, optical coherence tomography). KEY MESSAGES: Early Barrett's neoplasia is challenging to detect. HD-WLE and image-enhancing techniques improve visualization, but random 4QBs remain central to the diagnostic process. Lesion depth is primarily assessed using endoscopic features and, to a limited extent, ancillary techniques.