Endoscopic eradication therapy of Barrett's dysplasia and early adenocarcinoma: where we stand and what's next.

Barrett's esophagus (BE) is the only recognized precursor to esophageal adenocarcinoma (EAC). Endoscopic monitoring of BE allows for early detection and prevention against advanced cancer, which carries high morbidity and mortality. Over the past two decades, management of early EAC has shifted from esophagectomy toward organ-preserving endoscopic eradication therapy (EET), including endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and ablative modalities such as radiofrequency ablation, cryotherapy, and hybrid argon plasma coagulation. EMR remains standard for most lesions with pre-invasive neoplasia and small intramucosal EAC, while ESD provides technical advantages for larger or complex neoplasia, though comparative long-term outcome data are limited. Ablation after resection achieves durable clearance of dysplasia and intestinal metaplasia, with emerging therapies showing promise in refractory or high-risk cases. Structured post-EET surveillance is critical, as recurrence risk is highest within 1-2 years of achieving remission, but persists at lower levels long-term. The risk of recurrence is influenced by lesion characteristics, treatment strategy, and center experience. Personalized, risk-adapted surveillance is increasingly supported, incorporating clinical factors such as BE length, baseline histology and prior treatment. More recently, molecular biomarkers and artificial intelligence (AI)-driven integration of clinical and genomic features have shown promising results. Future research should optimize tissue acquisition, refine biomarker panels, and validate AI-enabled predictive models to improve patient selection, minimize recurrence, and guide cost-effective, individualized care.