Adenomas arising in Barrett's esophagus with adenocarcinoma. Report of three cases

The changing role of the pathologist in the management of Barrett's oesophagus

Pathological specimens from columnar-lined oesophagus (CLO) comprise a considerable proportion of the workload of gastrointestinal pathologists in Western countries. There remain controversies concerning the diagnostic role of pathology. More recently, in the UK at least, the diagnosis has been regarded as primarily an endoscopic endeavour, with pathology being corroborative and only diagnostic when endoscopic features are equivocal or when there are additional features that make the endoscopic diagnosis unclear. There is also recognition that demonstration of intestinalisation or 'goblet cells' is not paramount, and should not be required for the diagnosis. There have been notable changes in the management of CLO neoplasia: pathologists are centrally involved in its management. Pathological assessment of endoscopic mucosal resection (EMR) specimens provides the most useful means of determining the management of early neoplasia and of determining indications for surgery. This represents an extraordinarily rapid change in management, in that, <10 years ago, laborious Seattle-type biopsy protocols were recommended, and high grade dysplasia was an indication for resectional surgery. Now, individual patient management is paramount: multi-professional meetings determine management after biopsy and EMR assessment. One significant change is that major resections are undertaken less often, in Western countries, for CLO neoplasia.

Gastrointestinal dysplasia

The term dysplasia (intraepithelial neoplasia) is used to refer to neoplastic but non-invasive epithelium. Dysplasia in the gastrointestinal tract is considered a carcinoma precursor and a marker of high cancer risk for the site at which it is found. It is diagnosed by pathologists using a set of cytological and architectural features. There are many pitfalls in the diagnosis of gastrointestinal dysplasia. One reason for difficulty in dysplasia diagnosis is the significant heterogeneity in the appearances of each grade of dysplasia. In addition, the features that characterise dysplasia are only subtly different from those of regenerating epithelium, particularly at the low end of the spectrum, making this distinction difficult. For these reasons, and because of significant implications of this diagnosis for patient care, the interpretations of biopsies taken for dysplasia surveillance are considered challenging by most pathologists. In this article, we review definition, classification, and histological features and grading of gastrointestinal dysplasia with focus on Barrett's oesophagus (BE) related dysplasia, gastric epithelial dysplasia (GED) and dysplasia arising in the background of inflammatory bowel disease (IBD). We also discuss observer variability and the role of adjunctive markers in dysplasia diagnosis, and limitation with regard to surveillance of patients with BE and IBD due to sampling error.

Impact of antireflux operation on columnar-lined esophagus

BACKGROUND

The effect of antireflux operation on the natural history of columnar-lined esophagus (CLE) is not fully understood. The aim of this study was to assess a single center's experience and review the literature on the impact of antireflux operation on CLE without high-grade dysplasia.

STUDY DESIGN

The medical records of 26 patients with CLE but without high-grade dysplasia who underwent antireflux operation in our unit were retrospectively analyzed at longterm followup with detailed endoscopic investigation. Thirteen patients presented with intestinal metaplasia (6 had short segments, and 1 had preoperative laser ablation) and 13 without intestinal metaplasia. For the group of 13 patients presenting with intestinal metaplasia, the mean endoscopic followup was 74.7 months (median 46 months). Three of six with short-segment lesion and two of seven with circumferential involvement had complete regression of intestinal metaplasia (one after laser therapy). None had progression to dysplasia or carcinoma.

RESULTS

For the group of 13 patients without intestinal metaplasia, mean endoscopic followup was 43.9 months (median 28 months). One had complete regression of CLE, and none developed intestinal metaplasia during surveillance.

CONCLUSIONS

Our study suggests that antireflux operation can alter the natural history of CLE, allowing disease stabilization in a substantial proportion of patients. After antireflux operation, total regression of CLE is possible, but in an unpredictable manner.

Polypoid esophageal adenocarcinoma—a clinicopathological variant of esophageal cancer?

PURPOSE

Neoplastic polyps are common in the colon, but not elsewhere in the gastrointestinal tract. They are rare at the gastroesophageal junction, especially associated with Barrett's dysplasia or adenocarcinoma. We identify a subset of early esophageal adenocarcinomas that present as symptomatic polyps with gastrointestinal bleeding, reflux, and even dysphagia. Because little is known about polypoid esophageal adenocarcinomas, we examine the clinical presentation, pathological features, and postoperative outcomes of these lesions.

METHODS

We defined esophageal polyps as macroscopic, well-demarcated projections above the mucosa that project the greater percentage of their mass into the lumen without central ulceration. From a consecutive series of 400 patients who underwent esophagectomies for adenocarcinoma (1988 to 2000), 14 (4%) had polyps on presentation. Clinical records, pathology reports, photographs, and original slides of these resected specimens were reviewed.

RESULTS

All patients with polyps had early staged esophageal adenocarcinomas. Lymph node involvement was found in only 4 patients, and no patients with distant metastases were found. All but 1 patient (13 of 14; 93%) were symptomatic at diagnosis. Most presented either with gastrointestinal bleeding or gastroesophageal reflux (11 of 14; 79%). Only 2 patients complained of mild dysphagia, and mean weight loss of the series was minimal at 1.3 +/- 4.0 kg (range, 0 to 15 kg). Barrett's was present in 10 patients (71%), and in 80% of these cases, high-grade dysplasia was found. The polyps were small 3.4 +/- 1.1 cm, and most contained poorly differentiated adenocarcinomas. No postoperative mortalities occurred, and follow-up was complete at 100%. Actuarial 2-year survival was 88%, with a mean survival of 61.3 months. Recurrent disease was identified in 4 patients.

CONCLUSIONS

Polypoid adenocarcinomas of the distal esophagus are a subset of esophageal cancer that produce clear symptoms at an early tumor stage, which allows prompt detection and favorable prognosis. Their pathological features and demographics suggest an origin via the Barrett's esophagus-dysplasia-carcinoma sequence.

Barrett's esophagus

The columnar replacement of squamous epithelium in the lower esophagus is the result of gastroesophageal reflux. Whether the squamous cells are replaced or undergo metaplasia is still conjectural. This neoepithelium is unstable in the presence of continued reflux and prone to complications of stricture, ulceration, and adenocarcinoma. Considerable evidence supports the hypothesis that duodenal contents play a role in the development of Barrett's esophagus and its complications. The increasing incidence of adenocarcinoma in Barrett's esophagus is of concern in the Western World. Surveillance programs in some centers have been successful in early diagnosis, and excellent survival periods have been reported following resection in these cases. Both medical and surgical antireflux treatment is successful in symptom relief, but even in the absence of symptoms, reflux may continue. Surgery offers better overall results than proton pump inhibition of gastric acid and has been more popular since less aggressive (minimally invasive) techniques have been popularized. Mucosal ablation and antireflux measures by medicine or surgery are still in the experimental stages but hold considerable promise for the future.

Multiple polyposis and adenocarcinoma arising in Barrett's esophagus

Adenomatous polyps of the esophagus are rare in comparison with those of the lower gastrointestinal tract. Like adenomatous colon polyps, they have been associated with malignancy. We describe a case of early adenocarcinoma and multiple polyposis of the esophagus arising in a Barrett's epithelium, treated with surgical resection.