RFA or Biopsy?

This 65 yr old patient attends following EMR of an IMca for RFA
WHAT WOULD YOU DO NOW?

■ Go ahead and RFA

No that nodule is a show-stopper!

■ First take another set of biopsies

Or go ahead and EMR!

explanation

The BSG guideline as of 2013 (and updated on the topic of RFA for LGD in 2015), is very simple; RFA may be offered for flat dysplasia. 

The reality is often a little less clear-cut. For example, dysplastic Barrett's often appear slightly lumpy or with areas of superficial ulceration. When does a 'bumpy Barrett's' cross over into 'non-flat dysplasia'?  

I think that this is an example of 'not flat enough for RFA'. In fact, analysis of the original EMR specimen had reported a positive lateral margin! Expecting a local recurrence I actually went straight ahead and EMR'd the nodule which was confirmed as IMca.  

You will get the odd patient with Barrett's who fails to get his RFA because each time there is another little nodule to remove. Of course there are no hard and fast rules but these patients probably have 'bad disease' and are better served by an oesophagectomy. Of course, many of these are too old for surgery in which case you have no option but to keep nibbling away at their Barrett's mucosa until some adverse histological feature sends them along for chemoradiotherapy (CRT). In my experience these patients often don't do well. When chromosomal copy number analysis becomes a mainstay tool, I think that we'll see why ...