Acetic acid allows effective selection of areas for obtaining biopsy samples in Barrett's esophagus

Seattle Protocol Is More Effective in Detection of Dysplasia Compared to Technology-Assisted Targeted Biopsies in Patients with Barrett’s Esophagus

Background and aims: With the development of narrow-band imaging (NBI) in the endoscopic evaluation of patients with Barrett’s esophagus (BE), the role of random biopsies according to the Seattle protocol (SP) has been questioned. We aim to compare the utility of advanced imaging to SP in patients with BE. Methods: A prospective cohort of patients with proven BE was retrospectively analyzed. All biopsies were reviewed by an expert GI pathologist. Advanced imaging was tandemly used with SP in each endoscopic procedure. Results: A total of 155 out of 340 patients (45.5%) with BE were diagnosed with dysplasia during a median follow-up of 4.7 years (IQR 3.4–6.1 years) and were part of the statistical analysis. A total of 82 patients had a diagnosis of dysplasia at presentation, whereas 84 patients developed dysplasia during follow up. A total of 67 out of 82 patients with dysplasia at presentation (81.7%), and 65 out of 84 patients that were diagnosed with dysplasia during follow-up (77.4%) were diagnosed using SP. In addition, whereas all the events of EAC were diagnosed using targeted biopsies, 57.1% of the events of HGD and 86.3% of LGD were diagnosed using SP. Conclusion: Our findings demonstrate the significance of SP in the detection of low- and high-grade dysplasia in patients with BE. SP should remain the mainstay of endoscopic surveillance in this population.

Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer

The Japan Gastroenterological Endoscopy Society has developed endoscopic submucosal dissection/endoscopic mucosal resection guidelines. These guidelines present recommendations in response to 18 clinical questions concerning the preoperative diagnosis, indications, resection methods, curability assessment, and surveillance of patients undergoing endoscopic resection for esophageal cancers based on a systematic review of the scientific literature.

How Should We Report Endoscopic Results in Patient's with Barrett's Esophagus?

Barrett's esophagus is the only known pre-cancerous lesion for esophageal adenocarcinoma and is diagnosed by high-definition white light endoscopy demonstrating a columnar-lined esophagus along with biopsy evidence of intestinal metaplasia. With accurate performance and reporting of the endoscopic procedure, an evidence-based management strategy can be developed for treatment of Barrett's dysplasia. However, cross-sectional data demonstrate that there is still inconsistency among gastroenterologists in performance and reporting of endoscopic findings in patients with Barrett's esophagus. Here, we present an evidence-based review of how to report endoscopic findings in Barrett's esophagus.

Impact of advanced endoscopic imaging on Barrett's esophagus in daily clinical practice

BACKGROUND AND AIMS

Several advanced imaging techniques have been proposed to improve the visualization of dysplastic regions within Barrett's epithelium, with some evidence for the use of narrow-band imaging (NBI) and acetic acid chromoendoscopy (AAC).

METHODS

We retrospectively analyzed consecutive cases of Barrett's esophagus, diagnosed using white-light endoscopy and confirmed histologically by the presence of intestinal metaplasia, between April 2007 and April 2010 in a large community hospital. A change in practice was then instituted, whereby a Barrett's team consisting of specialist endoscopists was formed in an attempt to standardize and improve the quality of surveillance. Barrett's epithelium was inspected with both white-light imaging and NBI in all patients. Where the length of Barrett's epithelium was 3 cm or more, AAC was also used. One and a half percent acetic acid was sprayed onto the Barrett's segment and loss of aceto-whitening observed after a 2-minute period. Any abnormal areas noted during advanced imaging underwent target biopsy sampling. We subsequently compared the dysplasia detection rate in Barrett's epithelium identified between April 2011 and April 2014 after these changes. Observed differences between the cohorts were analyzed with the Fisher exact test and the Student t test.

RESULTS

From 2007 to 2010 Barrett's esophagus was identified during 560 gastroscopies in 392 individual patients. The mean maximal Barrett's esophagus recorded length was 4.4 cm (range, 1-10), with an average of 4.7 esophageal biopsy specimens taken per endoscopy. In comparison, from 2011 to 2014 Barrett's esophagus was identified during 856 endoscopies in 630 patients. From 2011 to 2014 the Barrett's team performed 85% of all procedures using the aforementioned techniques. The mean maximal Barrett's esophagus length was 3.8 cm (range, 1-16), with an increased average of 5.8 biopsy specimens per endoscopy taken (P < .01). Both cohorts were comparable in age and gender distribution. Our data demonstrated no significant difference in the relative frequencies of occurrence of dysplasia detected between both cohorts of patients. From 2007 to 2010 dysplasia was detected in 11.0% (n = 43) of patients. This consisted of low-grade dysplasia in 7.7% of patients and high-grade dysplasia or cancer 3.3%. From 2011 to 2014 this compared with dysplasia in 11.3% (n = 71) of patients, with low-grade dysplasia in 9.4% and high-grade dysplasia or cancer in 1.9%.

CONCLUSIONS

Our data show that the use of NBI and AAC in the imaging of Barrett's esophagus did not result in an increased detection rate of dysplasia in routine clinical practice. These findings concur with the recommendations of existing Barrett's esophagus surveillance guidelines, which advocate the continued use of quadratic biopsy sampling within general surveillance programs.

Applications of acetic acid spray combined with narrow band imaging in diagnosis of early gastrointestinal cancers and precancerous lesions

Many new endoscopic techniques have been used for the diagnosis of early gastrointestinal cancers and precancerous lesions, such as magnifying endoscopy, narrow-band imaging (NBI), Fuji intelligent chromoendiscopy, i-scan imaging, confocal laser endomicroscopy, and chromoendoscopy (Lugol's iodine, indigo carmine, methylene blue, acetic acid, and crystal violet). Each technique has its own advantages and disadvantages (e.g., being expensive and prolonged examination duration). Spraying acetic acid onto the mucosal surface can enhance the recognition of mucosal surface architecture, and NBI has the advantage to display the microvascular morphology. Thus, acetic acid spray combined with NBI endoscopy can greatly improve the diagnosis of early gastrointestinal cancers and precancerous lesions. Since this combination has low cost and no adverse reactions, they can be used in primary hospitals without magnification endoscopy.

Acetic acid chromoendoscopy: Improving neoplasia detection in Barrett's esophagus

Barrett’s esophagus (BE) is an important condition given its significant premalignant potential and dismal five-year survival outcomes of advanced esophageal adenocarcinoma. It is therefore suggested that patients with a diagnosis of BE undergo regular surveillance in order to pick up dysplasia at an earlier stage to improve survival. Current “gold-standard” surveillance protocols suggest targeted biopsy of visible lesions followed by four quadrant random biopsies every 2 cm. However, this method of Barrett’s surveillance is fraught with poor endoscopist compliance as the procedures are time consuming and poorly tolerated by patients. There are also significant miss-rates with this technique for the detection of neoplasia as only 13% of early neoplastic lesions appear as visible nodules. Despite improvements in endoscope resolution these problems persist. Chromoendoscopy is an extremely useful adjunct to enhance mucosal visualization and characterization of Barrett’s mucosa. Acetic acid chromoendoscopy (AAC) is a simple, non-proprietary technique that can significantly improve neoplasia detection rates. This topic highlight summarizes the current evidence base behind AAC for the detection of neoplasia in BE and provides an insight into the direction of travel for further research in this area.

ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for adopting real-time imaging-assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett's esophagus

BACKGROUND AND AIMS

Endoscopic real-time imaging of Barrett's esophagus (BE) with advanced imaging technologies enables targeted biopsies and may eliminate the need for random biopsies to detect dysplasia during endoscopic surveillance of BE. This systematic review and meta-analysis was performed by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee to specifically assess whether acceptable performance thresholds outlined by the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) document for clinical adoption of these technologies have been met.

METHODS

We conducted meta-analyses calculating the pooled sensitivity, negative predictive value (NPV), and specificity for chromoendoscopy by using acetic acid and methylene blue, electronic chromoendoscopy by using narrow-band imaging, and confocal laser endomicroscopy (CLE) for the detection of dysplasia. Random effects meta-analysis models were used. Statistical heterogeneity was evaluated by means of I(2) statistics.

RESULTS

The pooled sensitivity, NPV, and specificity for acetic acid chromoendoscopy were 96.6% (95% confidence interval [CI], 95-98), 98.3% (95% CI, 94.8-99.4), and 84.6% (95% CI, 68.5-93.2), respectively. The pooled sensitivity, NPV, and specificity for electronic chromoendoscopy by using narrow-band imaging were 94.2% (95% CI, 82.6-98.2), 97.5% (95% CI, 95.1-98.7), and 94.4% (95% CI, 80.5-98.6), respectively. The pooled sensitivity, NPV, and specificity for endoscope-based CLE were 90.4% (95% CI, 71.9-97.2), 98.3% (95% CI, 94.2-99.5), and 92.7% (95% CI, 87-96), respectively.

CONCLUSIONS

Our meta-analysis indicates that targeted biopsies with acetic acid chromoendoscopy, electronic chromoendoscopy by using narrow-band imaging, and endoscope-based CLE meet the thresholds set by the ASGE PIVI, at least when performed by endoscopists with expertise in advanced imaging techniques. The ASGE Technology Committee therefore endorses using these advanced imaging modalities to guide targeted biopsies for the detection of dysplasia during surveillance of patients with previously nondysplastic BE, thereby replacing the currently used random biopsy protocols.

Endoscopic Therapy of Early Carcinoma of the Oesophagus

Background

Oesophageal cancer is a comparatively rare disease in the Western world. Prognosis is highly dependent on the choice of treatment. Early stages can be treated by endoscopic resection, whereas surgery needs to be performed in the case of advanced carcinomas. Technical progress has enabled high-definition endoscopes and technical add-ons which help the endoscopist in finding fine irregularities in the oesophageal mucosa, though interpretation still remains challenging.

Methods

In this review, we discuss both novel and old diagnostic procedures and their value, as well as the current recommendations for the diagnosis and treatment of early oesophageal carcinomas. The database of PubMed and Medline was searched and analysed to provide all relevant literature for this review.

Results and Conclusion

Endoscopic resection is the therapy of choice in early oesophageal cancer. In case of adenocarcinoma it is mandatory to perform subsequent ablation of all residual Barrett's mucosa to avoid metachronous lesions.

Acetic acid chromoendoscopy for the diagnosis of early neoplasia and specialized intestinal metaplasia in Barrett's esophagus: a meta-analysis

BACKGROUND AND AIMS

Barrett's esophagus (BE) surveillance with random biopsies is time-consuming, invasive, and can lead to sampling error. Acetic acid chromoendoscopy (AAC) with targeted biopsies has been proposed as an effective alternative. The aim of this study was to assess the diagnostic accuracy of AAC for the detection of early neoplasia (high-grade dysplasia [HGD] or early cancer [EC]) and specialized intestinal metaplasia (SIM) in patients with BE.

METHODS

We performed a meta-analysis of all primary studies that compared AAC-based diagnoses (index test) with histopathology as the reference standard. The data were extracted on a per-patient, per-area, and per-procedure basis whenever available.

RESULTS

Thirteen prospective studies met the inclusion criteria. For the diagnosis of HGD/EC, the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for all included studies (9 studies, 1379 patients) were 0.92 (95% confidence interval [CI], 0.83-0.97), 0.96 (95% CI, 0.85-0.99), 25.0 (95% CI, 5.9-105.3), and 0.08 (95% CI, 0.04-0.18), respectively. Results were not significantly different when considering only studies with a per-patient analysis. For the characterization of SIM, the pooled sensitivity, specificity, LR+, and LR- for all the included studies (8 studies, 516 patients) were 0.96 (95% CI, 0.83-0.99), 0.69 (95% CI, 0.54-0.81), 3.0 (95% CI, 2.0-4.7), and 0.06 (95% CI, 0.01-0.26), respectively. No significant sources of heterogeneity were identified on subgroup analysis.

CONCLUSION

AAC has an overall high diagnostic accuracy for detecting HGD/EC in patients with BE. For SIM characterization, AAC sensitivity is very high but has poor specificity, suggesting that histological confirmation is necessary when AAC is positive.

Advances in the management of Barrett's esophagus and early esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has markedly increased in the United States over the last few decades. Barrett’s esophagus (BE) is the most significant known risk factor for this malignancy. Theoretically, screening and treating early BE should help prevent EAC but the exact incidence of BE and its progression to EAC is not entirely known and cost-effectiveness studies for Barrett’s screening are lacking. Over the last few years, there have been major advances in our understanding of the epidemiology, pathogenesis and endoscopic management of BE. These developments focus on early recognition of advanced histology and endoscopic treatment of high-grade dysplasia. Advanced resection techniques now enable us to endoscopically treat early esophageal cancer. In this review, we will discuss these recent advances in diagnosis and treatment of Barrett’s esophagus and early esophageal adenocarcinoma.

The role of acetic acid in the management of Barrett's oesophagus

Barrett's oesophagus is of significant importance due to its premalignant potential. Acetic acid chromoendoscopy is a simple technique that can be used with any endoscope system. It has been utilised for the identification of Barrett's intestinal metaplasia; and more importantly, for the localisation of early neoplasia within Barrett's, which is often focal, subtle and very easy to miss by random quadrantic biopsies alone. Acetic acid is routinely utilised in specialised centres and its use is expanding. This article examines the evidence base behind acetic acid chromoendoscopy and looks at where further research needs to be directed.

Glacial Acetic Acid Adverse Events: Case Reports and Review of the Literature

Glacial acetic acid is a dangerous chemical that has been associated with several adverse drug events involving patients over recent years. When diluted to the proper concentration, acetic acid solutions have a variety of medicinal uses. Unfortunately, despite warnings, the improper dilution of concentrated glacial acetic acid has resulted in severe burns and other related morbidities. We report on 2 additional case reports of adverse drug events involving glacial acetic acid as well as a review of the literature. A summary of published case reports is provided, including the intended and actual concentration of glacial acetic acid involved, the indication for use, degree of exposure, and resultant outcome. Strategies that have been recommended to improve patient safety are summarized within the context of the key elements of the medication use process.

[Esophageal precancerous lesions: early diagnosis, treatment, and preservation of quality of life]

Modern high-resolution video endoscopes allow detailed examination of the esophageal mucosa and diagnosis of early neoplastic changes in the gastrointestinal tract. Whereas Barrett's esophagus is a precancerous condition that can develop into adenocarcinoma, there is no defined precancerous lesion for squamous cell carcinoma. Various diseases are associated with the development of esophageal squamous cell carcinoma. Chromoendoscopy has become an established method in the diagnostic work-up for better visualization of early neoplasia. If Barrett's esophagus is present, acetic acid spraying or virtual chromoendoscopy can be used to accentuate the display of superficial gyriform structures in the mucosa. The gold standard for detecting squamous cell carcinoma is still the use of Lugol solution. When early neoplasia is suspected, diagnostic endoscopic resection should be performed. This allows precise histological assessment of the tumor. Early diagnosis of neoplastic changes in the esophagus provides patients not only with the option of curative therapy but also with a good quality of life through preservation of the esophagus.

Screening for precancerous lesions of upper gastrointestinal tract: from the endoscopists' viewpoint

Upper gastrointestinal tract cancers are one of the most important leading causes of cancer death worldwide. Diagnosis at late stages always brings about poor outcome of these malignancies. The early detection of precancerous or early cancerous lesions of gastrointestinal tract is therefore of utmost importance to improve the overall outcome and maintain a good quality of life of patients. The desire of endoscopists to visualize the invisibles under conventional white-light endoscopy has accelerated the advancements in endoscopy technologies. Nowadays, image-enhanced endoscopy which utilizes optical- or dye-based contrasting techniques has been widely applied in endoscopic screening program of gastrointestinal tract malignancies. These contrasting endoscopic technologies not only improve the visualization of early foci missed by conventional endoscopy, but also gain the insight of histopathology and tumor invasiveness, that is so-called optical biopsy. Here, we will review the application of advanced endoscopy technique in screening program of upper gastrointestinal tract cancers.

Indications, stains and techniques in chromoendoscopy

Early detection of malignancies within the gastrointestinal tract is essential to improve the prognosis and outcome of affected patients. However, conventional white light endoscopy has a miss rate of up to 25% for gastrointestinal pathology, specifically in the context of small and flat lesions within the colon. Chromoendoscopy and other advanced imaging techniques aim at facilitating the visualization and detection of neoplastic lesions and have been applied throughout the gastrointestinal tract. Chromoendoscopy, particularly in combination with magnifying endoscopy has significantly improved means to detect neoplastic lesions in the gastrointestinal mucosa, particularly in ulcerative colitis and Crohn's colitis. In addition, chromoendoscopy is beneficial in the upper gastrointestinal tract, especially when evaluating Barrett's oesophagus (BO) for the presence of dysplasia. Furthermore, it also improves characterization, differentiation and diagnosis of endoscopically detected suspicious lesions, and helps to delineate the extent of neoplastic lesions that may be amenable to endoscopic resection. This review discusses the dyes, indications and advanced endoscopic imaging methods used in various chromoendoscopic techniques, and presents a critical overview of the existing evidence supporting their use in current practice with a particular emphasis on the role in inflammatory bowel disease and BO.

Endoscopic probe optics for spectrally encoded confocal microscopy

Spectrally encoded confocal microscopy (SECM) is a form of reflectance confocal microscopy that can achieve high imaging speeds using relatively simple probe optics. Previously, the feasibility of conducting large-area SECM imaging of the esophagus in bench top setups has been demonstrated. Challenges remain, however, in translating SECM into a clinically-useable device; the tissue imaging performance should be improved, and the probe size needs to be significantly reduced so that it can fit into luminal organs of interest. In this paper, we report the development of new SECM endoscopic probe optics that addresses these challenges. A custom water-immersion aspheric singlet (NA = 0.5) was developed and used as the objective lens. The water-immersion condition was used to reduce the spherical aberrations and specular reflection from the tissue surface, which enables cellular imaging of the tissue deep below the surface. A custom collimation lens and a small-size grating were used along with the custom aspheric singlet to reduce the probe size. A dual-clad fiber was used to provide both the single- and multi- mode detection modes. The SECM probe optics was made to be 5.85 mm in diameter and 30 mm in length, which is small enough for safe and comfortable endoscopic imaging of the gastrointestinal tract. The lateral resolution was 1.8 and 2.3 µm for the single- and multi- mode detection modes, respectively, and the axial resolution 11 and 17 µm. SECM images of the swine esophageal tissue demonstrated the capability of this device to enable the visualization of characteristic cellular structural features, including basal cell nuclei and papillae, down to the imaging depth of 260 µm. These results suggest that the new SECM endoscopic probe optics will be useful for imaging large areas of the esophagus at the cellular scale in vivo.

[Usefulness of endoscopic biopsy in Barrett's esophagus]

BACKGROUND AND OBJECTIVE

Endoscopy with random biopsies is the standard technique for the diagnosis of Barrett's esophagus (BE). We studied the usefulness of endoscopic biopsies in the diagnosis and surveillance of patients with BE.

PATIENTS

We reviewed all patients with BE controlled at the Hospital Clínic from February 2002 to March 2010.

RESULTS

During the study period, 493 endoscopies were performed in 206 patients. We excluded 86 patients who had undergone one endoscopy only, hence the final sample consisted of 117 patients (mean age 61 [12] years, 73% men) with 407 endoscopies and a mean follow-up of 45 (38) months. Fifty-seven patients had a short-BE (49%), 28 a long-BE (24%) and 32 (27%) could not be inferred from the report. In 25 cases (21%), intestinal metaplasia (IM) was not detected at the endoscopic index. During follow-up, biopsies were negative for IM at some point in 45 patients (38.4%) and there was a change in the histologic grade in 100 cases (24.6%). The presence of a short-BE (43% in short-BE vs 7% in long-BE, P=.001) and few biopsies (3 [1.5] vs 6.2 [4.5]; P=.005) were associated with a higher frequency of negative biopsies for IM.

CONCLUSION

Random endoscopic biopsies are not a good tool for diagnosis and surveillance of patients with BE.

Endoscopic methods

Endoscopic methods to recognise and treat early gastrointestinal malignancies have increased in recent years. This has resulted in more lesions being diagnosed at an early stage and a shift away from invasive surgery towards endoscopic resection. However, it is necessary for the endoscopist to understand the key principles behind advanced endoscopic diagnosis and the new therapeutic options available. This chapter will review the advances in endoscopic techniques and methods which are changing the way we diagnose and treat these cancers. It will examine the general principles behind advanced endoscopy and then examine their application in Barrett's neoplasia, gastric cancer and the dysplasia associated lesions or masses associated with ulcerative colitis. It will focus on the best techniques for each of the above pathology.

Incidence of macroscopically occult neoplasias in Barrett's esophagus: are random biopsies dispensable in the era of advanced endoscopic imaging?

OBJECTIVES

The gold standard for endoscopic surveillance of Barrett's esophagus (BE) includes targeted biopsies (TBs) from abnormalities as well as stepwise four-quadrant biopsies (4QBs) for detection of invisible high-grade intraepithelial neoplasias (HGINs) or early carcinomas (ECs). In a large mixed BE population, we investigated the rate of HGINs/ECs that are macroscopically occult to enhanced visualization with high-resolution endoscopy plus acetic acid chromoendoscopy.

METHODS

From January 2007 to December 2009, 701 consecutive BE patients were enrolled in a prospective study at a tertiary referral center. Of these, 406 patients had a history of HGIN/EC (high-risk group) and 295 patients did not (low-risk group).

RESULTS

In 701 patients, 459 TBs and 5,485 4QBs were obtained. Altogether, 92 patients with 132 lesions containing HGINs/ECs were detected. For the diagnosis of HGINs/ECs, patient-related sensitivity and specificity rates of endoscopic imaging with TBs were 96.7 and 66.5%, with a positive and negative predictive value of 30.4 and 99.3%, respectively. In the high-risk group, 4QBs identified three additional patients (3.3%) with macroscopically occult HGINs/ECs. In the low-risk group, no HGINs/ECs were identified with either biopsy approach.

CONCLUSIONS

Advanced endoscopic imaging identifies the vast majority of BE patients with early neoplasias, and the additive effect of 4QB is minimal. Therefore, in low- and high-risk patients, limiting endoscopic surveillance to guided biopsies is justified in specialized high-volume centers with permanent quality control. However, we do not advocate abandoning 4QB outside this setting.

Acetic acid spray is an effective tool for the endoscopic detection of neoplasia in patients with Barrett's esophagus

BACKGROUND & AIMS

Diagnosis of Barrett's neoplasia requires collection of large numbers of random biopsy samples; the process is time consuming and can miss early-stage cancers. We evaluated the role of acetic acid chromoendoscopy in identifying Barrett's neoplasia.

METHODS

Data were collected from patients with Barrett's esophagus examined at a tertiary referral center, between July 2005 and November 2008 using Fujinon gastroscopes and EPX 4400 processor (n = 190). All procedures were performed by a single experienced endoscopist. Patients were examined with white light gastroscopy and visible abnormalities were identified. Acetic acid (2.5%) dye spray was used to identify potentially neoplastic areas and biopsy samples were collected from these, followed by quadrantic biopsies at 2 cm intervals of the remaining Barrett's mucosa. The chromoendoscopic diagnosis was compared with the ultimate histological diagnosis to evaluate the sensitivity of acetic acid chromoendoscopy.

RESULTS

Acetic acid chromoendoscopy had a sensitivity of 95.5% and specificity of 80% for the detection of neoplasia. There was a correlation between lesions predicted to be neoplasias by acetic acid and those diagnosed by histological analysis (r = 0.98). There was a significant improvement in the detection of neoplasia using acetic acid compared with white light endoscopy (P = .001).

CONCLUSIONS

Analysis of this large series showed that acetic acid-assisted evaluation of Barrett's esophagus detects neoplasia better than white light endoscopy, with sensitivity and specificity equal to that of histological analysis.

Columnar lined (Barrett's) esophagus: future perspectives

Columnar lined esophagus (CLE) or Barrett's esophagus is the precursor for esophageal adenocarcinoma. Future advances in understanding and management of this condition as well as improving the quality of care of CLE patients depends on answering essential questions. It is important to standardize the criteria for CLE definition. The rapid increase in incidence of CLE and adenocarcinoma raises serious concerns that the current management of gastroesophageal reflux disease (GERD) needs reassessment. The risk factors that determine who will and will not develop CLE are as yet undetermined. There is a need to develop a clinical risk stratification tool, which will help in determining who should be screened. The impact of elimination of GERD on the natural history of CLE is one important area for future research. The benefit of surveillance strategies remains unproven and the ideal endoscopic frequency, protocols and markers of cancer risk are unknown. Dysplasia may not provide the gold standard marker of cancer risk because of some inherited problems. A better technique than the current endoscopic pinch biopsy protocol is needed. To overcome the limitations of histological markers, many other markers of cancer risk needs to be developed and validated. The key question as to whether cancer risk is actually reduced by the new ablation modalities remains unanswered. The natural history of dysplasia and its management needs to be clarified. Although many questions have to be answered, it seems, however, that at least some answers exist, and these and proposals for answering some of these questions are underlined throughout this review.