title: The Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol.
abstract: OBJECTIVE
  The optimal management of high-grade dysplasia in Barrett's esophagus remains controversial. A biopsy protocol consisting of 4 quadrant jumbo biopsies (every 1 cm) with biopsies of mucosal abnormalities (the Seattle protocol) is considered to be the optimal method for detecting early cancers in patients with high-grade dysplasia, although it has never been validated. This study aimed to determine the frequency of unsuspected carcinoma at esophagectomy in Barrett's esophagus patients with high-grade dysplasia who underwent the Seattle protocol and to compare the findings with those of a less rigorous biopsy protocol.
  
  
  METHODS
  Thirty-three patients with high-grade dysplasia underwent esophagectomy. None had obvious mass lesions at preoperative endoscopy. Patients were divided into group 1 (preoperative surveillance biopsies according to Seattle protocol) and group 2 (4 quadrant biopsies every 2 cm). Preoperative and postoperative diagnoses were confirmed by 2 expert gastrointestinal pathologists.
  
  
  RESULTS
  Unsuspected intramucosal cancer was found in 8 of 20 (40%) patients in group 1 versus 4 of 13 (30%) in group 2 (P = .6). Preoperative mucosal nodularity was observed in 4 of 8 (50%) postoperative intramucosal cancers from group 1 versus 3 of 4 (75%) from group 2. Multifocal high-grade dysplasia was seen preoperatively in 7 of 8 (87.5%) postoperative intramucosal cancers in group 1 versus 2 of 4 (50%) in group 2. No patient had submucosal cancer or lymph node metastases at surgery.
  
  
  CONCLUSIONS
  Intense preoperative biopsy sampling by the Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol. This calls into question the concept that extensive sampling with the Seattle protocol consistently detects early cancers arising in Barrett's esophagus patients with high-grade dysplasia.
authors.affiliation: Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Revital
authors.initials: R
authors.lastname: Kariv
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Plesec
authors.forename: John R
authors.initials: JR
authors.lastname: Goldblum
authors.forename: Mary
authors.initials: M
authors.lastname: Bronner
authors.forename: Mary
authors.initials: M
authors.lastname: Oldenburgh
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Rice
authors.forename: Gary W
authors.initials: GW
authors.lastname: Falk
mesh_terms: D000368:Aged; D001471:Barrett Esophagus / Q000150:complications*; D001706:Biopsy / Q000379:methods*; D004938:Esophageal Neoplasms / Q000175:diagnosis* / Q000601:surgery*; D016629:Esophagectomy; D004947:Esophagus / Q000473:pathology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012680:Sensitivity and Specificity