High-grade dysplasia represents a significant change in cell appearance and organization within tissues, indicating a high potential for progression to invasive cancer if not addressed. This condition, often described as a severe precancerous lesion, requires active treatment to remove or destroy the abnormal cells and prevent malignancy. The specific treatment approach depends heavily on the location of the dysplasia, such as the esophagus, cervix, or colon, and the extent of the cellular changes. Treating high-grade dysplasia is generally a proactive step taken to intercept the development of cancer, rather than simply monitoring the condition.
Treatment for Esophageal High-Grade Dysplasia
High-grade dysplasia in the esophagus most often occurs in the context of Barrett’s esophagus, a condition where the normal lining is replaced by cells similar to those in the intestine. Endoscopic procedures have become the preferred first-line therapy for this condition, offering similar long-term survival rates to surgery but with less associated morbidity and mortality.
Endoscopic mucosal resection (EMR) is used to remove visible, raised areas or nodules of high-grade dysplasia from the esophageal lining. During this procedure, a physician uses an endoscope to inject a solution underneath the abnormal tissue to lift it, making it easier to cut away with a heated wire loop or snare. EMR is typically reserved for lesions smaller than two centimeters.
Ablation therapies are often used following EMR to destroy any remaining flat areas of Barrett’s esophagus that still contain high-grade dysplasia. Radiofrequency ablation (RFA) is a commonly used method that delivers heat energy to the tissue surface, causing the abnormal cells to be eliminated. This process encourages the growth of a new, healthy esophageal lining in its place. Other ablative options include cryotherapy, which uses extreme cold to destroy the cells, and photodynamic therapy, which uses a light-sensitive drug activated by a laser.
For patients with extensive or multifocal high-grade dysplasia, or those who fail to respond to endoscopic treatments, a surgical procedure called an esophagectomy may be considered. This major operation involves removing a portion of the esophagus and is reserved for cases where the risk of invasive cancer is highest or when less invasive methods have failed.
Treatment for Cervical High-Grade Dysplasia
High-grade dysplasia of the cervix, known as Cervical Intraepithelial Neoplasia Grade 2 or 3 (CIN 2/3), is most commonly caused by persistent infection with high-risk types of the human papillomavirus (HPV). The standard treatment involves a procedure that removes a cone-shaped section of the cervix, a process called conization. This technique removes the transformation zone, which is the area where most abnormal cell changes occur.
One common method for conization is the Loop Electrosurgical Excision Procedure (LEEP), which uses a thin, electrified wire loop to excise the abnormal tissue. LEEP is often performed in an outpatient setting using a local anesthetic and typically has a shorter recovery time. The electrosurgical current seals blood vessels as it cuts, which minimizes bleeding during the procedure.
The second method is cold knife conization (CKC), which uses a surgical scalpel to remove the cone of tissue and is generally performed under general anesthesia in a hospital setting. CKC provides a specimen with clearer margins for the pathologist to examine because it does not involve the heat-related artifacts that LEEP can create. Cold knife conization is often preferred when there is suspicion of micro-invasive cancer or glandular cell involvement, as the quality of the tissue sample is considered superior for detailed analysis.
Treatment success rates are high, and the procedure also serves as a final diagnostic step to ensure that no hidden invasive cancer exists within the removed tissue. In rare cases where the abnormal cells are not completely removed, a repeat procedure or a total hysterectomy may be necessary.
Treatment for Colonic High-Grade Dysplasia
High-grade dysplasia found in the colon usually occurs within precancerous growths called adenomatous polyps. The treatment focus in the colon is the complete removal of the polyp to prevent it from developing into colorectal cancer. Because the majority of these polyps can be removed endoscopically, this approach is the gold standard of care.
Most colonic polyps with high-grade dysplasia are removed during a colonoscopy using a technique called polypectomy. This involves passing a wire loop, or snare, through the colonoscope to encircle the base of the polyp, followed by the application of heat to cut and cauterize the tissue. For larger or flatter polyps, endoscopic mucosal resection (EMR) may be employed, which involves injecting a solution beneath the polyp to lift it away from the muscular wall before removal.
An alternative technique for larger or more complex lesions is endoscopic submucosal dissection (ESD), which allows for the removal of the polyp in a single, intact piece. Removing the lesion in one piece, or “en bloc,” is particularly beneficial for high-grade dysplasia because it provides the pathologist with the best specimen for determining if the lesion has invaded the deeper layers of the colon wall. ESD is a more technically demanding procedure but is associated with a lower rate of recurrence for high-risk polyps compared to piecemeal removal methods.
If a polyp is too large or technically challenging to remove endoscopically, or if pathology shows the dysplasia has invaded deeper layers, surgical resection of that segment of the colon may be necessary. This option, performed laparoscopically or through open surgery, ensures that all abnormal tissue and potentially affected lymph nodes are removed. The choice between endoscopic removal and surgery is guided by the size, location, and specific characteristics of the dysplasia.
Follow-Up and Surveillance
The risk of dysplasia recurring, or of new precancerous lesions developing, remains elevated even after successful removal. Surveillance is critical to detect any new or recurrent changes as early as possible.
For esophageal dysplasia treated with endoscopic methods, surveillance typically involves a schedule of repeat endoscopies with biopsies, often starting three months after the completion of treatment, and then at increasing intervals. The aim is to confirm the sustained eradication of the Barrett’s esophagus and dysplasia. The frequency of these follow-up procedures is determined by the patient’s risk profile and the initial success of the treatment.
After treatment for cervical high-grade dysplasia, patients usually undergo a combination of Pap tests and HPV testing at specific intervals, often every six to twelve months initially. Guidelines recommend continued surveillance for a significant period, sometimes for 25 years, to monitor for any recurrence. The long-term follow-up is designed to ensure that any future abnormal cell changes are identified and addressed before they can progress.
Similarly, patients who have had colonic polyps with high-grade dysplasia removed require more frequent follow-up colonoscopies than the general population. The first surveillance colonoscopy may be recommended as soon as three to six months after the initial removal to ensure complete excision, with subsequent procedures scheduled based on the findings. Detecting and removing any new adenomas during these surveillance visits is the final step in the strategy to prevent colorectal cancer.