How should extra‐large Lugol‐unstained lesions of the esophagus be treated? Results from a population‐based cohort study

BACKGROUND: Current guidelines recommend only severe dysplasia and above (SDA) lesions of the esophageal squamous epithelium for clinical intervention. However, the histopathologic diagnosis derived from tissue biopsies may be subject to underestimation of severity. METHODS: 1073 participants from whom biopsies were taken at baseline chromoendoscopic examination in a population‐based screening trial were enrolled in this study. The size of the Lugol‐unstained lesions (LULs) was mainly analyzed. The outcome was defined as SDA lesions either identified at baseline screening, or during follow‐up, collectively referred to as the cumulative risk of SDA. Multivariable logistic regression models were used to evaluate the cumulative risk of SDA. RESULTS: One hundred and forty‐six SDA cases were identified in the study period. Participants with large LULs had a high cumulative incidence of SDA (cumulative incidence(16–20mm): 55.88%; cumulative incidence(>20mm): 76.92%) in the median of 7‐year duration. LULs of large size were significantly associated with a higher cumulative risk of SDA, regardless of the pathologic diagnosis (adjusted OR(16–20mmvs.≤5mm) = 21.02, 95% CI: 7.56–58.47; adjusted OR(>20mmvs.≤5mm) = 33.62, 95% CI: 11.79–95.87). CONCLUSIONS: Results from this study suggest physician–patient shared decision‐making regarding clinical treatment or intensive surveillance should be carried out for LULs >20 mm in the esophagus, regardless of the histologic diagnosis. For those with LULs of 16–20 mm, intensive surveillance would also best be considered.