Diagnostic Approach to Early Barrett's Neoplasia: Japanese Perspective

Background: The incidence of Barrett's esophagus-related neoplasia is increasing worldwide, with a growing number of cases reported in Japan. While early stage lesions are suitable for endoscopic resection, accurate endoscopic detection, and histological assessment remain difficult, particularly in long-segment Barrett's esophagus (LSBE), where lesions often exhibit flat morphology and indistinct margins. These characteristics reduce endoscopic visibility and are associated with lower endoscopic R0 resection rates compared with short-segment Barrett's neoplasias. In Japan, image-enhanced magnifying endoscopy with targeted biopsy is the preferred diagnostic approach, whereas Western guidelines recommend random biopsies according to the Seattle protocol. This review discusses current diagnostic approaches and challenges from a Japanese perspective. Summary: Current diagnostic strategies for superficial Barrett's esophagus-related neoplasia (SBERN) incorporate high-resolution modalities such as white-light endoscopy and magnifying narrow-band imaging with or without acetic acid enhancement. The Japan Esophageal Society Barrett's Esophagus (JES-BE) classification provides a standardized framework for evaluating mucosal and vascular patterns in magnifying endoscopy, thereby improving diagnostic consistency. Nevertheless, histological interpretation, particularly for SBERNs arising in LSBE, poses major challenges due to interobserver variability in differentiating true dysplasia from inflammation-associated atypia and in grading dysplasia, even among expert gastrointestinal pathologists. In Japan, immunohistochemical markers such as p53 and Ki-67 are widely used in routine practice to support histological assessment, particularly for lesions indefinite for dysplasia. Key Messages: Given the increasing clinical burden of SBERN, further standardization of endoscopic criteria and histological assessment is expected to establish more reliable surveillance strategies tailored to segment extent of BE.