Differences in diagnostic criteria for esophageal squamous cell carcinoma between Japanese and Western pathologists

BACKGROUND

Large discrepancies have been found between Western and Japanese pathologists in the diagnosis of adenoma/dysplasia versus carcinoma for gastric and colorectal glandular lesions. It is important to determine whether similar differences exist in the diagnosis of esophageal squamous lesions.

METHODS

Eleven expert gastrointestinal pathologists from Japan, North America, and Europe individually reviewed a set of microscopic slides containing 21 sections of biopsies and corresponding endoscopic mucosal resection specimens from Japanese patients with superficial esophageal squamous neoplastic lesions. The pathologists indicated the pathologic findings on which they based each diagnosis.

RESULTS

Invasion was the most important diagnostic criterion of carcinoma for the Western pathologists whereas nuclear and structural features were more important for the Japanese pathologists. For two sections showing low grade dysplasia according to most Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in one case and definite carcinoma in the other. For nine sections with high grade dysplasia according to the Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in two cases and definite carcinoma in seven cases. For six sections with suspected carcinoma according to most Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in one case and definite carcinoma in five cases. Four sections showed definite carcinoma according to both the Western and Japanese pathologists. Thus, there was agreement among the Western and Japanese pathologists for only 5 of the 21 sections (kappa value, 0.04). However, when high grade dysplasia, noninvasive carcinoma, and suspected carcinoma were grouped together, the agreement was excellent (19 of the 21 sections; kappa value, 0.75).

CONCLUSIONS

In Japan, esophageal squamous cell carcinoma is diagnosed mainly based on nuclear criteria, even in cases judged to be noninvasive low grade dysplasia in the West. This difference in diagnostic practice may contribute to the relatively high incidence rate and good prognosis of superficial esophageal carcinoma in Japan. To improve the comparability of research data, the authors recommend that high grade dysplasia, noninvasive carcinoma, and suspected carcinoma be grouped together into one category of "noninvasive high grade neoplasia." [See editorial on pages 969-70, this issue.]

Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus

BACKGROUND & AIMS

In view of the mortality and morbidity rates of esophagectomy and the relatively large group of inoperable patients, local therapeutic techniques are required for high-grade dysplasia and early Barrett's cancer.

METHODS

A prospective investigation of endoscopic mucosal resection was conducted in 64 patients (mean age, 65 +/- 10 years) who had early carcinoma (61 patients) or high-grade dysplasia (3 patients) in Barrett's esophagus. Thirty-five patients met the criteria for low risk: macroscopic types I, IIa, IIb, and IIc; lesion diameter up to 20 mm; mucosal lesion; and histological grades G1 and G2 and/or high-grade dysplasia (group A). The remaining 29 patients were included in group B (high risk).

RESULTS

A total of 120 resections were performed, with no technical problems encountered. The mean number of treatment sessions per patient was 1. 3 +/- 0.6 in group A and 2.8 +/- 2.0 in group B (P < 0.0005). Only one major complication occurred, a case of spurting bleeding, which was managed endoscopically. Complete local remission was achieved significantly earlier (P = 0.008) in group A than in group B. In May 1999, complete remission had been achieved in 97% of the patients in group A and in 59% of those in group B; however, 1 patient in group A and 9 in group B are still undergoing treatment or awaiting the first check-up. During a mean follow-up of 12 +/- 8 months, recurrent or metachronous carcinomas were found in 14%.

CONCLUSIONS

Endoscopic mucosal resection of early carcinoma in Barrett's esophagus is associated with promisingly low morbidity and mortality rates. The procedure may offer a new minimally invasive therapeutic alternative to esophagectomy, especially in low-risk situations. Comparisons with surgical results will need to be done when the long-term results of this procedure become available.

The effect of ammonia on omeprazole-induced reduction of gastric acidity in subjects with Helicobacter pylori infection

OBJECTIVE

Omeprazole produces a higher intragastric pH during Helicobacter pylori (H. pylori) infection than after cure. We tested the hypothesis that this difference is due to the production of ammonia by H. pylori.

METHODS

Gastric acidity and acid output (AO) were measured overnight in 12 subjects, with and without omeprazole, before and 1 and 6 months after cure of H. pylori infection. Gastric ammonia ([NH3]), total bile acid ([TBA]) and protein concentrations and plasma omeprazole levels were measured.

RESULTS

During omeprazole, median AO were 0.0 mmol/h before, 0.86 mmol/h (p = 0.003 vs before cure) at 1 month, and 0.34 mmol/h (p = 0.02) at 6 months after cure; median NH3 output was 0.17 mmol/h before, 0.03 mmol/h (p = 0.002) at 1 month, and 0.02 mmol/h (p = 0.005) at 6 months after cure. AO and NH3 output were similar 1 and 6 months after cure. When corrected for [NH3], AO and gastric pH curves were similar before and after cure. Omeprazole plasma levels increased after cure and gastric [TBA] were unchanged.

CONCLUSIONS

The higher pH observed before cure of H. pylori during omeprazole administration is attributable, in large part, to ammonia production. Other acid-neutralizing substances and changes in acid secretion may also be important, but duodenogastric reflux and omeprazole pharmacokinetics are not involved.

Gastric MALT lymphoma and its relationship to Helicobacter pylori infection: management and pathogenesis of the disease

Chronic Helicobacter pylori infection is strongly associated with the development of primary gastric B cell lymphoma of MALT-type. Therapeutic decisions in primary gastric MALT lymphomas, e.g., the choice for gastric surgery or stomach-conserving treatments in the form of radio-, chemo-, or eradication therapy, should be based on an accurate histopathological diagnosis, grading and clinical staging. Primary gastric low-grade MALT-NHLs in an early clinical stage associated with H. pylori infection were shown to respond with complete remission in approximately 77% of cases upon successful cure of the infection as only treatment modality. The effect of curing H. pylori infection on the course of a high-grade gastric MALT lymphoma is largely uncertain but preliminary results indicate a possible benefit for patients with high-grade MALT lymphoma upon eradication therapy. Concerning the pathogenetic mechanisms of lymphomagenesis, there are many questions to be addressed in the near future. In general, it is still unclear what the exact mechanisms are which lead to the malignant transformation of a reactive infiltrate. Is there a molecular-genetic or immunological point of no return? What is the biological significance of the immunoglobulin rearrangement detected with PCR? The wave of new data each year about the role of H. pylori in gastric MALT lymphoma might help that many of these questions addressed above might be answered within the next years.

[Are there differences between ex adenoma and de novo colorectal carcinomas?]

Colorectal carcinoma is a major cause of death throughout the Western world. It is increasingly recognized that any reduction in mortality must be achieved through the detection and removal of early and precancerous lesions. The primary attention for such a preventive strategy has been the polypoid adenoma and surveillance studies have shown a significant reduction in the incidence of carcinoma through systematic polypectomy of suspicious lesions. A potential problem with such a program, however, is raised by reports from Japan that some carcinomas seem to arise without a precursor polypoid adenoma, that is de novo. Although the histopathologic findings in such reports seem to clearly support this idea, this concept is not widely accepted in the Western world. We undertook a series of immunohistochemical (p53, bcl-2, Mib-1, E-cadherin, CD44, Stromelysin-3), and microsatellite analysis studies (on 17p (p53), 18q (DCC), 5q (APC), 8p, 2p and 1p), on groups of de novo and ex adenoma carcinomas in order to see if differences between the two groups of lesions exist. The results of these studies demonstrate that de novo carcinomas share several phenotypic and genotypic features with ex adenoma carcinoma (similar CD44 in the carcinomas, similar rates of LOH at APC and DCC loci), but have significantly higher rates of LOH at 17p, p53 over-expression and ST-3 expression indicating that tumor progression in de novo carcinoma is accelerated. These findings should help clarify the concept of de novo carcinoma and contribute to wider recognition of this important clinicopathologic entity.

Treatment with lansoprazole also induces hypertrophy of the parietal cells of the stomach

The aim of the present study was to investigate whether not only omeprazole but also lansoprazole leads to hypertrophy of the parietal cells of the gastric mucosa. We investigated the gastric mucosa of 295 patients with gastro-esophageal reflux disease prior to therapy, after 8 weeks of treatment with 30 mg lansoprazole/day, and after 6 and 12 months of long-term treatment with 15 or 30 mg lansoprazole, or 20 mg omeprazole/day. In a small group of 48 patients, a follow-up examination was carried out 3 months after termination of the study. Following acute treatment with 30 mg lansoprazole/day, 84% of the patients revealed parietal cell hypertrophy, while under long-term treatment this figure rose to 89%. The grade of the parietal cell hypertrophy increased continuously under long-term treatment. With regard to the incidence and grading of parietal cell hypertrophy, no significant differences were found among the three groups receiving long-term treatment. Three months after termination of treatment with these proton-pump inhibitors, the hypertrophy of the parietal cells had largely disappeared again. This study shows that hypertrophy of the parietal cells in the gastric mucosa occurs not only under treatment with omeprazole, but also under therapy with lansoprazole, and is reversible when the proton pump inhibitors are discontinued.

Differences in diagnostic criteria for esophageal squamous cell carcinoma between Japanese and Western pathologists

BACKGROUND

Large discrepancies have been found between Western and Japanese pathologists in the diagnosis of adenoma/dysplasia versus carcinoma for gastric and colorectal glandular lesions. It is important to determine whether similar differences exist in the diagnosis of esophageal squamous lesions.

METHODS

Eleven expert gastrointestinal pathologists from Japan, North America, and Europe individually reviewed a set of microscopic slides containing 21 sections of biopsies and corresponding endoscopic mucosal resection specimens from Japanese patients with superficial esophageal squamous neoplastic lesions. The pathologists indicated the pathologic findings on which they based each diagnosis.

RESULTS

Invasion was the most important diagnostic criterion of carcinoma for the Western pathologists whereas nuclear and structural features were more important for the Japanese pathologists. For two sections showing low grade dysplasia according to most Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in one case and definite carcinoma in the other. For nine sections with high grade dysplasia according to the Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in two cases and definite carcinoma in seven cases. For six sections with suspected carcinoma according to most Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in one case and definite carcinoma in five cases. Four sections showed definite carcinoma according to both the Western and Japanese pathologists. Thus, there was agreement among the Western and Japanese pathologists for only 5 of the 21 sections (kappa value, 0.04). However, when high grade dysplasia, noninvasive carcinoma, and suspected carcinoma were grouped together, the agreement was excellent (19 of the 21 sections; kappa value, 0.75).

CONCLUSIONS

In Japan, esophageal squamous cell carcinoma is diagnosed mainly based on nuclear criteria, even in cases judged to be noninvasive low grade dysplasia in the West. This difference in diagnostic practice may contribute to the relatively high incidence rate and good prognosis of superficial esophageal carcinoma in Japan. To improve the comparability of research data, the authors recommend that high grade dysplasia, noninvasive carcinoma, and suspected carcinoma be grouped together into one category of "noninvasive high grade neoplasia." [See editorial on pages 969-70, this issue.]

Photodynamic destruction of high grade dysplasia and early carcinoma of the esophagus after the oral administration of 5-aminolevulinic acid

BACKGROUND

Photodynamic therapy (PDT) is a new local, endoscopically controlled therapeutic concept based on the selective sensitization of malignant and precancerous lesions prior to light-induced tissue destruction. 5-aminolevulinic acid (5-ALA) appears to be a promising alternative photosensitizer with a high mucosa specificity without phototoxic side effects on the skin. The authors report on their experiences with this new form of PDT in 27 patients.

METHODS

Twenty-seven patients (6 females and 21 males; ages 47-79 years) with histologically proven high grade dysplasia (n = 9) and early carcinoma (normal endoultrasonography or classified as uT1N0M0; n = 19; 1 patient had 2 lesions) of the esophagus were included in this study. Approximately 4-6 hours after oral ingestion of 5-ALA in a dosage of 60 mg/kg of body weight, laser light irradiation was conducted with a dye laser system with a wavelength of 635 nanometers at a light dose of 150 J/cm(2).

RESULTS

The length of the segment of the esophagus with severe dysplasia or carcinoma of the mucosa varied between 0.5-9.0 cm (mean length, 2.5 cm). High grade dysplasia was eradicated in all patients. In addition, 19 mucosal tumors in 18 patients were treated successfully in 10 of 19 cases with an average of 1.7 treatment sessions and a mean follow-up of 16.9 months (range, 3-37 months). Method-related morbidity and mortality were not observed.

CONCLUSIONS

Severe dysplasia and superficial (</=2 mm) mucosal carcinoma of the esophagus can be ablated completely by 5-ALA-PDT. PDT with 5-ALA has few side effects and might offer an alternative to esophagectomy or radiochemotherapy.

Immunnohistological assessment of intestinal eosinophil activation in patients with eosinophilic gastroenteritis and inflammatory bowel disease

OBJECTIVE

To assess the activation grade of intestinal eosinophils in patients with eosinophilic gastroenteritis (EOG), ulcerative colitis (UC), Crohn's disease (CD), and controls by immunohistochemistry.

METHODS

Cecal biopsies were collected from healthy controls and from patients with EOG, CD, UC, and other noninflammatory GI diseases. Immunohistochemistry was performed in sequential sections stained with monoclonal antibodies directed against eosinophil cationic protein (ECP) or eosinophil protein X (EPX) stored in eosinophil granules (EG1) and that secreted by activated eosinophils (EG2). The ratio of EG1 to EG2-positive eosinophils expressed as percentage of lamina propria cells was calculated. ECP and EPX were measured in serum and feces.

RESULTS

The percentage of EG1 and EG2-positive lamina propria cells was elevated in EOG and slightly, but not significantly, in UC. The ratio of EG1 to EG2-positive cells was decreased in CD, UC, and other patients as compared to healthy controls. Particularly low EG1 to EG2 ratios were found in EOG. Correspondingly, fecal and serum levels of ECP and EPX, respectively, were highest in patients with EOG. The EG1 to EG2 ratio was negatively correlated with fecal ECP and EPX levels. At sites of actively inflamed mucosa, the EG1 to EG2 ratio was lower than in noninflamed tissue.

CONCLUSIONS

Our data strongly suggest that the EG1 to EG2 ratio may be a marker of tissue eosinophil activation. Low ratios (<1) indicate eosinophil activation, whereas ratios > or =1 are found in healthy controls. Furthermore, we show that EOG is characterized by a pronounced intestinal eosinophil accumulation and activation, whereas in CD and UC, eosinophils seem to be activated but their number is not or only slightly elevated compared to controls.

[Investigations on the sulfate concentration in milk substitutes and milk products and its effect on feces composition in calves]

In continuing investigations on effects of milk replacers with high ash and mineral contents (KAMPHUES et al., 1999a) on feces' quality and composition in calves in the present study the sulfate concentration (and its effects) in milk replacers and whey products were proved. In 13 samples of milk replacers the SO4 concentration varied between 2.4 and 6.7 g/kg dry matter, in 14 samples of dried whey products SO4- concentrations of 1.4 up to 41.8 g/kg dm were found. In general higher sulphur contents were caused by higher concentrations of sulfate. In feeding a milk replacer (6.7 g SO4/kg dm) about 20% of the consumed sulfate were excreted via feces (app. digestibility of about 80%). In experiments with elevated SO4 intake (in liquid diets: 560-1980 mg/l) the digestibility rate of sulfate decreased dose dependently (75-->65%). By analysis of milk replacers (used in previous experiments, TSCHENTSCHER, 1998) resulting in diarrhea in all treated calves unexpected SO4- concentrations were found of 16.3 and 10.2 g/kg dm. In feeding experiments (6 calves) by addition of Na2SO4 (85%) and MgSO4 (15%) sulfate concentration in the liquid diet was elevated from 560 mg to 1980 mg/l. Here the SO4 concentration in the diet and the dry matter content in calves' feces were correlated significantly (r = -0.86). Presented results on the SO4 concentration in milk replacers and the observed effects of sulfate intake on feces quality (i.e. dry matter content of feces) indicate by the first time that the SO4 content in milk replacers and dried whey products is an essential parameter when an estimation of milk replacers or whey products' quality is required.

Short Barrett: prevalence and risk factors

BACKGROUND

The incidence of adenocarcinoma at the gastro-oesophageal junction is on the increase. These carcinomas are usually diagnosed too late and thus have a poor prognosis. Only early diagnosis can improve the situation. Classical Barrett oesophagus (length, >3 cm) is a known precancerous condition. There is also specialized columnar epithelium (SCE) in the grossly unremarkable gastro-oesophageal transitional zone (short Barrett).

METHODS

To determine the frequency of SCE, 370 patients were investigated by gastroscopy (OGD) consecutively between September 1995 and February 1996.

RESULTS

Classical Barrett oesophagus was found to have an incidence of 4.6%. In contrast, microscopic evidence of SCE was observed in 13.6% of the cases. Patients with short Barrett presented with reflux symptoms (odds ratio (OR), 4.7), irregular zona serrata ('tongues') in the cardia (OR, 2.8), and reflux oesophagitis significantly more frequently. Patients with reflux symptoms and concomitant 'tongues', however, had an OR of 13.16. Careful history-taking, together with a subtle histologic work-up of the gastro-oesophageal transitional zone can improve the rate of detecting patients with short Barrett.

CONCLUSION

Patients with reflux symptoms and irregular zona serrata should be selectively biopsied at the gastro-oesophageal junction, even when the latter presents a grossly normal appearance, with the aim of detecting patients at risk of developing a Barrett carcinoma.

'Pyloric gland-type adenoma' arising in heterotopic gastric mucosa of the duodenum, with dysplastic progression of the gastric type

'Pyloric gland-type adenoma' is a recently described and very rare entity. We report a case of a pedunculated polyp of the duodenal bulb showing the features of pyloric gland-type adenoma. Heterotopic gastric mucosa was found adjacent to the tumour. Immunohistochemically, the tumour cells at the surface of the polyp showed foveolar-type mucin (M1) while most other tumour cells showed deep gastric mucin (M2), displaying a pattern of differentiation similar to the normal gastric mucosa. The polyp also showed villous or papillary structures with disorganization of gastric differentiation and marked increase of proliferating in foci cells. This is the first case of pyloric gland-type adenoma found to arise in heterotopic gastric mucosa of the duodenum, showing dysplastic progression of the gastric type.

[Changes in Helicobacter pylori gastritis caused by therapy with inhibitors of gastric acid secretion]

In patients with Helicobacter pylori (Hp) gastritis long-term treatment with omeprazole leads to a worsening of the corpus gastritis. In the present overview we have analyzed the literature and our own studies to determine whether this also applies to other proton pump inhibitors (PPI), H2-receptor antagonists (H2-RA) and antacids.

RESULTS

Every antisecretory therapy--vagotomy, antacids, H2-RA and PPI--in patients with Hp gastritis leads to a worsening of the following parameters: Grade of gastritis, activity of gastritis, grade of replacement of foveolar epithelium by regenerative epithelium and grade of mucus depletion. The incidence of intestinal metaplasia does not increase. Atrophic gastritis has not been observed after one year of treatment; after five years of treatment with PPI, development of atrophy is uncertain. In the antrum treatment with PPI, but not with antacids or H2-RA, leads to an improvement in the gastritis parameters. The question whether the aggravation of corpus gastritis under antisecretory treatment might be detrimental over the long-term, whether, for example, the more pronounced gastritis might increase the risk of a subsequent carcinoma, remains to be clarified by long-term studies.

Leptin and its receptor in normal human gastric mucosa and in Helicobacter pylori-associated gastritis

BACKGROUND

Leptin, a newly discovered weight-reducing hormone, is mainly produced in fat cells. Recently, this hormone has been reported to be produced in rat gastric mucosa cells. In the present study we analyzed the localization and expression of leptin and its receptors in normal human gastric mucosa and in patients with Helicobacter pylori-associated gastritis.

METHODS

Plasma leptin levels and gastric mucosa leptin content were determined in 39 patients with dyspepsia. Cellular localization of leptin and of the signaling receptor (Ob-RL) were assessed by immunohistochemistry. Reverse transcriptase polymerase chain reaction (RT-PCR) for leptin receptor isoforms was performed on gastric epithelial cells isolated by laser-capture-microdissection.

RESULTS

Leptin content of the corpus gastric mucosa in H. pylori-positive patients was significantly increased (4.6+/-1.2. n = 15) as compared with the H. pylori-negative group (27.5+/-0.5 pg/mg, n = 24, P = 0.006). The presence of leptin immunoreactivity was shown in the lower half of corpus epithelial glands. By RT-PCR no leptin mRNA was detectable in human gastric tissue. In contrast, expression of both Ob-R(L) and the leptin receptor isoforms could be detected in gastric epithelial cells. Leptin receptor protein was detected throughout the mucosa.

CONCLUSIONS

Leptin itself is stored and secreted but not produced in human gastric mucosa. The functional receptor and all isoforms are present in human gastric mucosa. H. pylori-associated gastritis leads to significant increases in local leptin concentration in the gastric corpus.

Laser assisted ratio analyser 13C-urea breath testing, for the detection of H. pylori: A prospective diagnostic European multicentre study

BACKGROUND

Novel technology based on laser optogalvanic spectroscopy called the LARA (Laser Assisted Ratio Analyser) system was developed to measure 12C/13C ratios in breath samples using stable 13C isotopes, to detect Helicobacter pylori infection.

AIM

To determine the sensitivity and specificity of the 13C-LARA-urea breath test in the detection of H. pylori infection in a prospective European multicentre trial; FDA-and EMEA-approved.

METHODS

Consecutive dyspeptic patients underwent diagnostic gastroscopy with biopsies for culture and histopathology, to detect H. pylori infection (gold standard). Subsequently, the LARA-urea breath test was performed using either a system without a cold trap (part I) or a system with a cold trap (part II). In both instances baseline, 30-min and 60-min breath samples were collected. The optimum cut-off level for 12C/13C ratios was determined by Receiver Operator Characteristics analysis.

RESULTS

In part I, 544 out of 604 patients were evaluable (low CO2: 47; withdrawn: 13). 284 out of 544 patients (52%) were H. pylori-positive according to the gold standard. The sensitivity of the LARA-urea breath test was 95% and the specificity 94%. In part II, 257 out of 272 were evaluable (low CO2: 14; withdrawn: 1). Sensitivity and specificity were 93% and 96%, respectively.

CONCLUSION

The LARA-technology represents an accurate and non-invasive testing system for the detection of H. pylori infection. Its major advantages are the use of stable 13C isotope, the high throughput of samples and the easy means of collecting, storing and transporting the samples, thus making the system convenient to both patient and clinician.

[Operation technique determines frequency of recurrence of colorectal carcinoma]

INTRODUCTION

In order to investigate whether operative technique determines the 5-year recurrence and survival rates, we analysed the results obtained by two surgical departments using two different operative techniques. Department A: Removal of the tumour and a number of lymph nodes; department B: En-bloc resection in accordance with the requirements of standardised tumour surgery.

PATIENTS AND METHODS

The surgical results obtained with all patients with colorectal carcinoma operated on between 1984 and 1988 (department A: 152 colon and 53 rectal carcinomas; department B: 124 colon and 177 rectal carcinomas).

RESULTS

The local recurrence rate achieved by department A was significantly higher (colon carcinoma: department A 25 %; department B 10 %; rectal carcinoma: department A 54 %; department B 16 %). The 5-year survival rate for colon carcinoma was 65 % in department A, and 66 % in department B, the corresponding figures for rectal carcinoma being 49 % and 72 %, respectively.

CONCLUSION

The results indicate that carcinoma of the colorectum should be operated on only at an institution that complies with the standards required for surgery of colorectal carcinoma.

Local treatment of early cancer in short Barrett's esophagus by means of argon plasma coagulation: initial experience

In recent years endoscopically controlled local therapeutic methods, such as photodynamic therapy, mucosectomy, or laser therapy, have been used with a curative aim for the destruction of early esophageal or gastric cancers. We report on our experience of treating histologically proven mucosal cancer in Barrett's esophagus with argon plasma coagulation (APC), in three patients. All the mucosal esophageal cancers, with a mean diameter of 4 mm, were successfully destroyed after one or two treatment sessions. Additionally, in two of the three patients the specialized columnar epithelium was replaced by normal squamous cell epithelium when APC treatment was combined with omeprazole. In the third patient with Barrett's esophagus, a partial squamous cell re-epithelialization was induced. No method-related mortality and morbidity were observed. During the mean follow-up of 24.3 +/- 1.1 months (range 23-25 months) one tumor recurrence developed which was successfully treated with photodynamic therapy. In patients with small early Barrett's carcinoma APC might offer an effective, minimally invasive alternative to mucosectomy or photodynamic therapy, as the treatment procedure is less cumbersome and the equipment less expensive.

Aberrant esophageal HLA-DR expression in a high percentage of patients with Crohn's disease

Esophageal histology is not well studied in patients with Crohn's disease (CD). We, therefore, analyzed the histologic and immunohistologic appearance of esophageal mucosa in CD. Biopsy specimens taken from the esophagus of 57 consecutive patients with known CD of the large and/or small bowel, of 200 Crohn's-free controls, of 15 cases with ulcerative colitis, and of 5 cases with viral esophagitis were evaluated. In controls, most patients had either HLA-DR negative esophageal epithelium or showed focal or diffuse basal staining. HLA-DR expression of all epithelial layers (transepithelial staining) was observed in only four (2%) control subjects, in one case with herpes esophagitis, but not in patients with ulcerative colitis. In contrast, transepithelial HLA-DR expression was found in 19 (33%) patients with CD (p < 0.0001). In CD patients, it was associated with a significantly increased epithelial content in T-cells (CD3+, TIA-1+, granzyme B+), B-cells (CD79a+), natural killer cells (CD57+), and macrophages (CD68+). There was no correlation with either histological findings elsewhere in the upper gastrointestinal tract or with laboratory findings, symptoms, CDAI, or medication. Transepithelial esophageal HLA-DR expression is common in CD. Immunohistochemistry may prove useful in supporting the histologic diagnosis of CD in staging procedures, for initial diagnosis as well as in doubtful cases.