Extent of low-grade dysplasia in Barrett's esophagus: is it useful for risk stratification?

Low-grade dysplasia remains one of the great enigmas of Barrett's esophagus. Limited information is available on the natural history of this lesion, and studies suggest that cancer risk in patients with low-grade dysplasia is intermediate between that of intestinal metaplasia without dysplasia and high-grade dysplasia. Natural history studies of low-grade dysplasia are hampered by problems with interobserver variability among pathologists and sampling variability among endoscopists. To date, the extent of low-grade dysplasia has not been examined as a potential risk factor for the subsequent development of adenocarcinoma. Srivastava et al., in this issue of the American Journal of Gastroenterology, found that the extent of low-grade dysplasia, as measured by several different methods, was a risk factor for progression to cancer. While these findings are novel and provocative, it is premature to request your pathologist to count the number of crypts or biopsies with low-grade dysplasia just yet. However, these findings, if confirmed by studies utilizing a simpler measure of the extent of low-grade dysplasia, may help us determine the prognostic significance of this lesion in the future.