Virtually all cancers in Barren's esophagus (BE) arise from intestinal metaplasia. Methylene blue (MB) selectively stains intestinal metaplasia (IM) in BE, including cells with dyplasia. AIM: In an ongoing prospective controlled sequential trial, we compared the diagnostic yield and cost of endoscopic surveillance using MB-directed biopsy (MBDB) with 4-quadrant random biopsy (RB). METHODS: Using large particle biopsy forceps, we performed EGD+MBDB and EGD+RB in a randomized order on consecutive patients with BE 3-4 weeks apart. Half had EGD+RB then EGD+MBDB and the other half had MBDB first. We stratified patients into 3 groups by length of BE: short (< 3 cm columnar-type epithelium), limited-(3-6 cm), and long-segment(> 6 cm). A single endoscapist performed MB staining and biopsied stained and unstained mucosa separately. An experienced pathologist unaware of the endoscopic results estimated the proportions of intestinal metaplasia, cardiac, fundic, and squamous epithelium in each biopsy and graded dysplasia as indefinite, low-grade (LCD), high grade (HGD), intramucosal CA, or invasive CA. We calculated the relative direct cost of endoscopic surveillance for EGD+MBDB vs. EGD+RB using local 1995 technical and professional fees as well as Medicare reimbursement. RESULTS: 31 patients (52% male, mean age=58) were evaluated. 8 had short-,9 had limited-, and 14 had long-segment BE. Total Mean Biopsies Median %IM Mean % Dysplasia %Pts with Dysplasia Bx per EGD(Range) in each Bx in biopsy in any biopsy RB 326 14 (3-27) 63%(0-100) 8.6% 40% MBDB 246 9 (3-28) 100%(40-100) 11.4% 52% MBDB led to a significantly lower total number and average number of biopsies obtained per patient at each EGO compared to RB (p=.001), particularly in patients with long BE. Furthermore, MBDB led to a much larger proportion of IM in each biopsy than RB (p=.0006), especially in patients with limited-segment (54% vs. 94%) and long-segment BE(72% vs. 92%). Despite fewer biopsies per patient, MBDB diagnosed dysplasia in more patients with long-segment BE than RB (18.7% vs. 11%. p=0.03). MBDB detected LGD (n=6) and HGD (n=3) in all patients diagnosed by RB. Moreover, MDBD found LGD (n=6), HGD (n=1), and CA (n=1) in patients not diagnosed by RB. MBDB missed 1 focal LGD in 1 patient. Neither MBDB nor RB found dysplasia in patients with short BE. The estimated average direct cost of endoscopic surveillance/patient using MBDB was significantly lower compared to RB. The mean diff was $7179 (using charges, p=.0001) and $2993 (using Medicare reimbursement, p=.0001), with cost savings of $17,645/dysplastic biopsy. CONCLUSION: MBDB has a significantly higher diagnostic yield for IM and dysplasia than RB. This advantage is most prominent in patients with longer lengths of BE. In future studies, MBDB may prove to be a more cost-effective method of performing endoscopic surveillance in patients with BE.
ASJC Scopus subject areas
- Radiology Nuclear Medicine and imaging