Shifting boundaries in the management of early Barrett's adenocarcinoma

Barrett’s esophagus (BE) is the main precursor lesion of esophageal adenocarcinoma (EAC), a malignancy with a rapidly increasing incidence and poor prognosis when diagnosed at an advanced stage. Endoscopic surveillance aims to detect dysplasia and early cancer at a curable stage; however, only a minority of BE patients will progress to cancer. This creates an important clinical challenge: preventing advanced disease while avoiding unnecessary surveillance and overtreatment in low-risk individuals.
This thesis focuses on improving risk assessment and management strategies across the spectrum of BE and early EAC. The studies demonstrate that current risk stratification models based on clinical characteristics alone have limited predictive accuracy and are insufficient for individualized surveillance strategies. In addition, the natural course of high-grade dysplasia appears more heterogeneous and less aggressive than traditionally assumed, suggesting that treatment decisions should better account for life expectancy, comorbidity, and patient preferences.
A major focus of this thesis is the management of early esophageal adenocarcinoma, particularly submucosal (T1b) disease. Historical surgical series have reported high risks of lymph node metastasis, forming the basis for recommendations favoring esophagectomy. However, the findings presented in this thesis suggest that these risks may have been overestimated due to limitations in older pathology assessment and patient selection. Prospective and retrospective endoscopy-oriented cohorts demonstrated low rates of metastatic progression and disease-specific mortality following radical endoscopic resection with structured surveillance.
Together, the findings support a shift toward more personalized and risk-adapted management of BE and early EAC, balancing oncologic safety with treatment burden, quality of life, and competing mortality risks.