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Sugawara K, Fukuda T, Kishimoto Y, Oka D, Kawashima Y, Inoshita N, Kanda H. Combined tubular adenocarcinoma, neuroendocrine carcinoma and adenocarcinoma with enteroblastic differentiation arising in Barrett esophagus. Clin J Gastroenterol 2023:10.1007/s12328-023-01791-0. [PMID: 37027114 DOI: 10.1007/s12328-023-01791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
Adenocarcinoma (AC) with neuroendocrine carcinoma (NEC) or enteroblastic (ENT) differentiation rarely develops in Barrett's esophagus (BE). A 76-year-old man was diagnosed with Barrett's AC (cT1bN0M0) and underwent thoracoscopic esophagectomy. A type 0-IIc + 0-Is lesion measuring 26 × 21 mm was macroscopically observed on a background of long segment BE (pT1bN0M0). The tumor comprised three different histological types of carcinoma (NEC, AC with ENT differentiation and moderately differentiated AC). NEC showed positivity for synaptophysin, chromogranin A and insulinoma-associated protein 1 with a Ki-67 index of 60.6%. ENT tumors were immunopositive for AFP and sal-like protein 4, and focally immunopositive for human chorionic gonadotrophin. The amounts of NEC, ENT and AC were 40%, 40% and 20%, respectively. p53 expression was positive throughout the tumor. Rb expression was negative at the NEC, but positive at the ENT and AC. CD4 and CD8 densities were lower in the NEC segment than in the AC and ENT segments, and PD-L1 expression was negative throughout the tumor. Early cancer arising in BE with a combination of tubular AC, ENT tumors and NEC is very rare. Our observations might contribute to understanding the carcinogenetic pathways and tumor microenvironment of NEC and ENT tumors.
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Affiliation(s)
- Kotaro Sugawara
- Department of Gastroenterological Surgery, Saitama Cancer Center Hospital, Saitama, Japan
| | - Takashi Fukuda
- Department of Gastroenterological Surgery, Saitama Cancer Center Hospital, Saitama, Japan
| | - Yutaka Kishimoto
- Department of Gastroenterological Surgery, Saitama Cancer Center Hospital, Saitama, Japan
| | - Daiji Oka
- Department of Gastroenterological Surgery, Saitama Cancer Center Hospital, Saitama, Japan
| | - Yoshiyuki Kawashima
- Department of Gastroenterological Surgery, Saitama Cancer Center Hospital, Saitama, Japan
| | - Naoko Inoshita
- Department of Pathology, Moriyama Memorial Hospital, Tokyo, Japan
- Department of Pathology, Saitama Cancer Center Hospital, 780 Komuro Inamachi, Kitaadachi-Gun, Saitama, 362-0806, Japan
| | - Hiroaki Kanda
- Department of Pathology, Saitama Cancer Center Hospital, 780 Komuro Inamachi, Kitaadachi-Gun, Saitama, 362-0806, Japan.
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Sugano K, Spechler SJ, El-Omar EM, McColl KEL, Takubo K, Gotoda T, Fujishiro M, Iijima K, Inoue H, Kawai T, Kinoshita Y, Miwa H, Mukaisho KI, Murakami K, Seto Y, Tajiri H, Bhatia S, Choi MG, Fitzgerald RC, Fock KM, Goh KL, Ho KY, Mahachai V, O'Donovan M, Odze R, Peek R, Rugge M, Sharma P, Sollano JD, Vieth M, Wu J, Wu MS, Zou D, Kaminishi M, Malfertheiner P. Kyoto international consensus report on anatomy, pathophysiology and clinical significance of the gastro-oesophageal junction. Gut 2022; 71:1488-1514. [PMID: 35725291 PMCID: PMC9279854 DOI: 10.1136/gutjnl-2022-327281] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/03/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE An international meeting was organised to develop consensus on (1) the landmarks to define the gastro-oesophageal junction (GOJ), (2) the occurrence and pathophysiological significance of the cardiac gland, (3) the definition of the gastro-oesophageal junctional zone (GOJZ) and (4) the causes of inflammation, metaplasia and neoplasia occurring in the GOJZ. DESIGN Clinical questions relevant to the afore-mentioned major issues were drafted for which expert panels formulated relevant statements and textural explanations.A Delphi method using an anonymous system was employed to develop the consensus, the level of which was predefined as ≥80% of agreement. Two rounds of voting and amendments were completed before the meeting at which clinical questions and consensus were finalised. RESULTS Twenty eight clinical questions and statements were finalised after extensive amendments. Critical consensus was achieved: (1) definition for the GOJ, (2) definition of the GOJZ spanning 1 cm proximal and distal to the GOJ as defined by the end of palisade vessels was accepted based on the anatomical distribution of cardiac type gland, (3) chemical and bacterial (Helicobacter pylori) factors as the primary causes of inflammation, metaplasia and neoplasia occurring in the GOJZ, (4) a new definition of Barrett's oesophagus (BO). CONCLUSIONS This international consensus on the new definitions of BO, GOJ and the GOJZ will be instrumental in future studies aiming to resolve many issues on this important anatomic area and hopefully will lead to better classification and management of the diseases surrounding the GOJ.
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Affiliation(s)
- Kentaro Sugano
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Stuart Jon Spechler
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center, Dallas, Texas, USA
| | - Emad M El-Omar
- Microbiome Research Centre, St George & Sutherland Clinical Campuses, School of Clinical Medicine, Faculty of Medicine & Health, Sydney, New South Wales, Australia
| | - Kenneth E L McColl
- Division of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kaiyo Takubo
- Research Team for Geriatric Pathology, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | | | - Hiroto Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Kobe, Japan
| | - Ken-ichi Mukaisho
- Education Center for Medicine and Nursing, Shiga University of Medical Science, Otsu, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Oita University Faculty of Medicine, Yuhu, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hisao Tajiri
- Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | | | - Myung-Gyu Choi
- Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, The Republic of Korea
| | - Rebecca C Fitzgerald
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, UK
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Duke NUS School of Medicine, National University of Singapore, Singapore
| | | | - Khek Yu Ho
- Department of Medicine, National University of Singapore, Singapore
| | - Varocha Mahachai
- Center of Excellence in Digestive Diseases, Thammasat University and Science Resarch and Innovation, Bangkok, Thailand
| | - Maria O'Donovan
- Department of Histopathology, Cambridge University Hospital NHS Trust UK, Cambridge, UK
| | - Robert Odze
- Department of Pathology, Tuft University School of Medicine, Boston, Massachusetts, USA
| | - Richard Peek
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Massimo Rugge
- Department of Medicine DIMED, Surgical Pathology and Cytopathology Unit, University of Padova, Padova, Italy
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Jose D Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Friedrich-Alexander University Erlangen, Nurenberg, Germany
| | - Justin Wu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Duowu Zou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Peter Malfertheiner
- Medizinixhe Klinik und Poliklinik II, Ludwig Maximillian University Klinikum, Munich, Germany,Klinik und Poliklinik für Radiologie, Ludwig Maximillian University Klinikum, Munich, Germany
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3
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Telomere lengths in Barrett's esophagus as a precancerous lesion. Esophagus 2022; 19:287-293. [PMID: 34559348 DOI: 10.1007/s10388-021-00884-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND We have reported that precancerous conditions and lesions invariably have shorter telomeres and associated chromosomal instability relative to normal tissue. METHODS Using the Q-FISH method and our original software, Tissue Telo, we estimated telomere lengths in cardiac- and intestinal-type mucosae in 48 cases of Barrett's esophagus (short-segment (SS) n = 18; long-segment (LS) n = 30). RESULTS There were no significant differences in telomere length between the cardiac and intestinal types in any of the 48 cases, suggesting that the presence or absence of goblet cells in the columnar segments is unrelated to telomere-dependent chromosomal instability in Barrett's esophagus. In LS Barrett's esophagus, telomeres were shorter in cardiac-type than in intestinal-type mucosa, suggesting that the former may play a more important role than the latter as a precancerous lesion in LS. Telomeres in cardiac-type mucosa were longer in SS than in LS, supporting the possibility that cardiac-type LS may pose a higher risk as a precancerous lesion than cardiac-type SS. CONCLUSIONS Although it has been considered that Barrett's carcinoma arises only from intestinal-type mucosa, our present findings support previous histogenetic studies suggesting that cardiac-type mucosa is more important as a precancerous condition in Barrett's esophagus than anticipated.
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Montgomery EA, Arnold CA, Lam-Himlin DM, McDonald OG, Poveda JC, Salimian KJ, Voltaggio L, Waters KM, Wood LD, Singhi AD. Some Morphology Frontiers of Dysplasia in the Tubular Gastrointestinal Tract: The Rodger C. Haggitt Memorial Lecture. Am J Surg Pathol 2022; 46:e1-e14. [PMID: 33284191 DOI: 10.1097/pas.0000000000001637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This review, based on the content of the 2020 US Gastrointestinal Pathology Society's Rodger Haggitt Lecture, concerns an array of tubular gastrointestinal tract dysplastic or possible "predysplastic lesions" with an almost purely morphologic focus based on our collaborative efforts over the past few years. These processes include esophageal epidermoid metaplasia, Barrett esophagus-associated dysplasia, polypoid gastric dysplastic lesions, small intestinal dysplasia, and the ability of metastases to mimic it, the controversial "serrated epithelial change" encountered in the setting of long-standing ulcerative and Crohn colitis, and recently described anal columnar human papilloma virus-associated neoplasms.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Laura D Wood
- Department of Pathology, Johns Hopkins, Baltimore, MD
| | - Aatur D Singhi
- Department of Pathology, The University of Pittsburgh, Pittsburgh, PA
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5
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Abstract
Barrett's esophagus (BE) is a precancerous disease that can lead to esophageal adenocarcinoma (EAC). Recently, the incidence of EAC arising from BE has been increasing, and EAC has now become a threat in many countries. However, there are many gaps among the various countries in terms of definitions and concepts and these gaps prevent discussing BE on the same footing. In order to eradicate BE, it is a global necessity to fill in these remaining gaps. We focused on the gaps and reviewed recent evidence and trends as well as the background of gaps between the US and Japan as two of the leading countries in the field of medical research. We also review the rapid advances in endoscopic techniques in relation to both diagnosis and therapy that are considered to be useful to eliminate the gaps between countries.
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Affiliation(s)
- Manami Oda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Anthony Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, USA
| | - Kazuhiro Mizukami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Akira Sawa
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
- Department of Neuroscience, Johns Hopkins University School of Medicine, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, USA
- Department of Mental Health, Johns Hopkins University Bloomberg School of Medicine, USA
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Cook MB, Thrift AP. Epidemiology of Barrett's Esophagus and Esophageal Adenocarcinoma: Implications for Screening and Surveillance. Gastrointest Endosc Clin N Am 2021; 31:1-26. [PMID: 33213789 PMCID: PMC7887893 DOI: 10.1016/j.giec.2020.08.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the United States, the incidence of esophageal adenocarcinoma increased markedly since the 1970s with a recent stabilization. Despite evolving screening and surveillance strategies to diagnose, risk triage, and intervene in Barrett's esophagus patients to prevent esophageal adenocarcinoma, most cases present with advanced disease and poor resultant survival. Epidemiologic studies have identified the main risk factors for these conditions, including increasing age, male sex, white race, gastroesophageal reflux disease, abdominal obesity, cigarette smoking, and lack of infection with Helicobacter pylori. This review summarizes the current epidemiologic evidence with implications for screening and surveillance in Barrett's esophagus and esophageal adenocarcinoma.
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Affiliation(s)
- Michael B Cook
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, 6E430, Rockville, MD 20850, USA.
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, and Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, One Baylor Plaza, MS: BCM307, Room 621D, Houston, TX 77030, USA
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Kumarasinghe MP, Armstrong M, Foo J, Raftopoulos SC. The modern management of Barrett's oesophagus and related neoplasia: role of pathology. Histopathology 2020; 78:18-38. [PMID: 33382493 DOI: 10.1111/his.14285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022]
Abstract
Modern management of Barrett's oesophagus and related neoplasia essentially focuses upon surveillance to detect early low-risk neoplastic lesions and offering organ-preserving advanced endoscopic therapies, while traditional surgical treatments of oesophagectomy and lymph node clearance with or without chemoradiation are preserved only for high-risk and advanced carcinomas. With this evolution towards figless invasive therapy, the choice of therapy hinges upon the pathological assessment for risk stratifying patients into those with low risk for nodal metastasis who can continue with less invasive endoscopic therapies and others with high risk for nodal metastasis for which surgery or other forms of treatment are indicated. Detection and confirmation of neoplasia in the first instance depends upon endoscopic and pathological assessment. Endoscopic examination and biopsy sampling should be performed according to the recommended protocols, and endoscopic biopsy interpretation should be performed applying standard criteria using appropriate ancillary studies by histopathologists experienced in the pathology of Barrett's disease. Endoscopic resections (ERs) are both diagnostic and curative and should be performed by clinicians who are skilled with advanced endoscopic techniques. Proper preparation and handling of ERs are essential to assess histological parameters that dictate the curative nature of the procedure. Those parameters are adequacy of resection and risk of lymph node metastasis. The risk of lymph node metastasis is determined by depth invasion and presence of poor differentiation and lymphovascular invasion. Those adenocarcinomas with invasion up to muscularis mucosae (pT1a) and those with superficial submucosal invasion (pT1b) up to 500 µ with no poor differentiation and lymphovascular invasion and negative margins may be considered cured by endoscopic resections.
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Affiliation(s)
- M Priyanthi Kumarasinghe
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Michael Armstrong
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Jonathan Foo
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Spiro C Raftopoulos
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
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Mukaisho KI, Kanai S, Kushima R, Nakayama T, Hattori T, Sugihara H. Barretts's carcinogenesis. Pathol Int 2019; 69:319-330. [PMID: 31290583 PMCID: PMC6851828 DOI: 10.1111/pin.12804] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 03/22/2019] [Indexed: 12/14/2022]
Abstract
Barrett's esophagus is considered a precancerous lesion of esophageal adenocarcinoma (EAC). Long‐segment Barrett's esophagus, which is generally associated with intestinal metaplasia, has a higher rate of carcinogenesis than short‐segment Barrett's esophagus, which is mainly composed of cardiac‐type mucosa. However, a large number of cases reportedly develop EAC from the cardiac‐type mucosa which has the potential to involve intestinal phenotypes. There is no consensus regarding whether the definition of Barrett's epithelium should include intestinal metaplasia. Basic researches using rodent models have provided information regarding the origins of Barrett's epithelium. Nevertheless, it remains unclear whether differentiated gastric columnar epithelium or stratified esophageal squamous epithelium undergo transdifferentiation into the intestinal‐type columnar epithelium, transcommittment into the columnar epithelium, or whether the other pathways exist. Reflux of duodenal fluid including bile acids into the stomach may occur when an individual lies down after eating, which could cause the digestive juices to collect in the fornix of the stomach. N‐nitroso‐bile acids are produced with nitrites that are secreted from the salivary glands, and bile acids can drive expression of pro‐inflammatory cytokines via EGFR or the NF‐κB pathway. These steps may contribute significantly to carcinogenesis.
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Affiliation(s)
- Ken-Ichi Mukaisho
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
| | - Shunpei Kanai
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
| | - Ryoji Kushima
- Division of Diagnostic Pathology, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Takahisa Nakayama
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
| | - Takanori Hattori
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
| | - Hiroyuki Sugihara
- Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science, Otsu, Japan
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9
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Abstract
Transcription factors (TFs) are proteins that control the transcription of genetic information from DNA to mRNA by binding to specific DNA sequences either on their own or with other proteins as a complex. TFs thus support or suppress the recruitment of the corresponding RNA polymerase. In general, TFs are classified by structure or function. The TF, Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), is expressed in all cell types and tissues. NF-κB signaling and crosstalk are involved in several steps of carcinogenesis including in sequences involving pathogenic stimulus, chronic inflammation, fibrosis, establishment of its remodeling to the precancerous niche (PCN) and transition of a normal cell to a cancer cell. Triggered by various inflammatory cytokines, NF-κB is activated along with other TFs with subsequent stimulation of cell proliferation and inhibition of apoptosis. The involvement of NF-κB in carcinogenesis provides an opportunity to develop anti-NF-κB therapies. The complexity of these interactions requires that we elucidate those aspects of NF-κB interactions that play a role in carcinogenesis, the sequence of events leading to cancer.
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American Registry of Pathology Expert Opinions: Evaluation and reporting of biopsies from the columnar-lined esophagus and gastro-esophageal junction (GEJ). Ann Diagn Pathol 2019; 39:111-117. [DOI: 10.1016/j.anndiagpath.2019.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 02/06/2023]
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Montgomery E, Arnold CA, Lam-Himlin D, Salimian K, Waters K. Some observations on Barrett esophagus and associated dysplasia. Ann Diagn Pathol 2018; 37:75-82. [PMID: 30312881 DOI: 10.1016/j.anndiagpath.2018.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 09/26/2018] [Indexed: 02/08/2023]
Abstract
Biopsy samples from esophageal columnar metaplasia and dysplasia are commonly encountered in Western pathology practice and knowing a few pitfalls can save both pathologists and patients a great deal of anxiety. Herein we discuss criteria for Barrett esophagus, evaluation of dysplasia, and some pitfalls in reviewing endoscopic mucosal resections. Also included is a summary of suggested follow-up for patients with Barrett esophagus.
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Affiliation(s)
| | - Christina A Arnold
- Department of Pathology, Ohio State University, United States of America
| | - Dora Lam-Himlin
- Department of Pathology, Mayo Clinic Scottsdale, United States of America
| | - Kevan Salimian
- Department of Pathology, Johns Hopkins University, United States of America
| | - Kevin Waters
- Department of Pathology, Cedars Sinai Health System, United States of America
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12
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Abstract
This review has provided a summary of the biology of goblet cell metaplasia in CLE as it pertains to BE. Goblet cells are terminally differentiated nonproliferative cells that have many overlapping histochemical characteristics with mucinous columnar cells and pseudogoblet cells. There is an abundance of evidence that suggests that use of goblet cells as a biomarker of BE, and its progression to malignancy, is problematic. Some of these limitations include the fact that the background non-goblet epithelium in most patients with CLE is biologically intestinalized and contains molecular abnormalities similar to goblet cell CLE, goblet cells fluctuate with time and decrease in number with progression of neoplasia, and pathologists have problems with interpretation, and distinction, of goblet cells from other types of cells in the esophagus. Sampling error results in sensitivity and specificity issues that limit its positive predictive value. Goblet cells are fewest in number in the same population of patients with CLE that are hardest to detect endoscopically (i.e., those with short or ultrashort CLE). Nevertheless, the risk of cancer in patients with short-segment BE, a condition difficult to distinguish from the stomach, is very low regardless of the presence or absence of goblet cells so it is unclear what the role of goblet cells is in these patients as a biomarker. Nevertheless, if the answer to the following question, "Would you as a gastroenterologist recommend surveillance for a patient with clear endoscopic evidence of CLE, particularly if it is ≥ 3 cm in length, but in which goblet cells were not reported to be present by the pathologist," is yes, then the US requirement for goblet cells as part of the criteria for "BE" is superfluous.
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13
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Bellizzi AM, Hafezi‐Bakhtiari S, Westerhoff M, Marginean EC, Riddell RH. Gastrointestinal pathologists’ perspective on managing risk in the distal esophagus: convergence on a pragmatic approach. Ann N Y Acad Sci 2018; 1434:35-45. [DOI: 10.1111/nyas.13680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/13/2018] [Accepted: 02/24/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew M. Bellizzi
- Department of PathologyUniversity of Iowa Hospitals and Clinics and Carver College of Medicine Iowa City Iowa
| | | | - Maria Westerhoff
- Department of PathologyUniversity of Michigan Ann Arbor Michigan
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14
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Biswas S, Quante M, Leedham S, Jansen M. The metaplastic mosaic of Barrett's oesophagus. Virchows Arch 2018; 472:43-54. [PMID: 29500519 PMCID: PMC5849653 DOI: 10.1007/s00428-018-2317-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/01/2017] [Accepted: 12/05/2017] [Indexed: 12/20/2022]
Abstract
Barrett's oesophagus surveillance biopsies represent a significant share of the daily workload for a busy histopathology department. Given the emphasis on endoscopic detection and dysplasia grading, it is easy to forget that the benefits of these screening programs remain unproven. The majority of patients are at low risk of progression to oesophageal adenocarcinoma, and periodic surveillance of these patients is burdensome and costly. Here, we investigate the parallels in the development of Barrett's oesophagus and other scenarios of wound healing in the intestine. There is now increased recognition of the full range of glandular phenotypes that can be found in patients' surveillance biopsies, and emerging evidence suggests parallel pathways to oesophageal adenocarcinoma. Greater understanding of the conditions that favour progression to cancer in the distal oesophagus will allow us to focus resources on patients at increased risk.
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Affiliation(s)
- Sujata Biswas
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Michael Quante
- II. Medizinische Klinik, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Simon Leedham
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Marnix Jansen
- UCL Cancer Institute, London, UK. .,University College London Hospital, London, UK.
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DE Carli DM, Araujo AFD, Fagundes RB. LOW PREVALENCE OF BARRETT'S ESOPHAGUS IN A RISK AREA FOR ESOPHAGEAL CANCER IN SOUTH OF BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2017; 54:305-307. [PMID: 28954045 DOI: 10.1590/s0004-2803.201700000-45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/04/2017] [Indexed: 10/17/2023]
Abstract
BACKGROUND Barrett's esophagus a complication of gastroesophageal reflux disease (GERD) is a precursor of esophageal adenocarcinoma. The incidence of esophageal adenocarcinoma has been increasing in most Western countries. Rio Grande do Sul (RS), the Southernmost state of Brazil has the highest rates of esophageal cancer with low prevalence of esophageal adenocarcinoma. OBJECTIVE To investigate the prevalence of Barrett's esophagus among patients underwent to upper gastrointestinal endoscopy in the last 5 years. METHODS The records of patients underwent upper gastrointestinal endoscopy between 2011 and 2015 were analyzed. Demographic data, GERD symptoms, endoscopic findings, extension and histological diagnosis of columnar epithelia of the esophagus were recorded. Significance among the variables was accessed by chi-square test and Fisher's exact test with 95% CI. RESULTS A total of 5996 patients underwent to upper gastrointestinal endoscopy in the period were included. A total of 1769 (30%) patients with GERD symptoms or esophagitis and 107 (1.8%) with columnar lined esophagus were identified. Except for eight patients, the others with columnar lined esophagus had GERD symptoms or esophagitis. Barrett's esophagus defined by the presence of intestinal metaplasia occurred in 47 patients; 20 (43%) with segments over 3 cm and 27 (57%) with segments shorter than 3 cm. The global prevalence of Barrett's esophagus was 0.7% and in GERD patients 2.7%. The odds ratio for the occurrence of columnar lined esophagus in patients with GERD was 30 (95%CI=15.37-63.34). The odds ratio for the presence of intestinal metaplasia in long segments was 8 (95%CI=2.83-23.21). CONCLUSION GERD patients had a risk 30-folds greater to present columnar lined esophagus than patients without GERD symptoms. Long segments of columnar lined esophagus, had a risk eight-folds higher to have Barrett's esophagus than short segments. Barrett's esophagus overall prevalence was 0.7%. In GERD patients, the prevalence was 2.7%. Long Barrett's esophagus represented globally 0.3% and 1.1% in GERD patients.
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Affiliation(s)
- Diego Michelon DE Carli
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Maria, RS, Brazil
| | | | - Renato Borges Fagundes
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Maria, RS, Brazil
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16
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ten Kate FJC, van Olphen SH, Bruno MJ, Wijnhoven BPL, van Lanschot JJB, Looijenga LHJ, Fitzgerald RC, Biermann K. Loss of SRY-box2 (SOX2) expression and its impact on survival of patients with oesophageal adenocarcinoma. Br J Surg 2017; 104:1327-1337. [PMID: 28692180 PMCID: PMC5600089 DOI: 10.1002/bjs.10553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/27/2016] [Accepted: 03/06/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Oesophageal adenocarcinoma (OAC) is a highly aggressive malignancy with poor survival, which is highly variable amongst patients with comparable conventional prognosticators. Therefore molecular biomarkers are urgently needed to improve the prediction of survival in these patients. SRY (sex determining region Y)-box 2, also known as SOX2, is a transcription factor involved in embryonal development of the gastrointestinal tract as well as in carcinogenesis. The purpose of this study was to see whether SOX2 expression is associated with survival in patients with OAC. METHODS SOX2 was studied by immunohistochemistry in patients who had undergone potentially curative oesophagectomy for adenocarcinoma. Protein expression of SOX2 was evaluated using tissue microarrays from resection specimens, and results were analysed in relation to the clinical data by Cox regression analysis. SOX2 was evaluated in two independent OAC cohorts (Rotterdam cohort and a multicentre UK cohort). RESULTS Loss of SOX2 expression was independently predictive of adverse overall survival in the multivariable analysis, adjusted for known factors influencing survival, in both cohorts (Rotterdam cohort: hazard ratio (HR) 1·42, 95 per cent c.i. 1·07 to 1·89, P = 0·016; UK cohort: HR 1·54, 1·08 to 2·19, P = 0·017). When combined with clinicopathological staging, loss of SOX2 showed an increased effect in patients with pT1-2 tumours (P = 0·010) and node-negative OAC (P = 0·038), with an incrementally adverse effect on overall survival for stage I OAC with SOX2 loss (HR 3·18, 1·18 to 8·56; P = 0·022). CONCLUSION SOX2 is an independent prognostic factor for long-term survival in OAC, especially in patients with stage I OAC.
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Affiliation(s)
- F. J. C. ten Kate
- Department of PathologyErasmus Medical CentreRotterdamThe Netherlands
| | - S. H. van Olphen
- Department of PathologyErasmus Medical CentreRotterdamThe Netherlands
- Departments of Gastroenterology and HepatologyErasmus Medical CentreRotterdamThe Netherlands
| | - M. J. Bruno
- Departments of Gastroenterology and HepatologyErasmus Medical CentreRotterdamThe Netherlands
| | | | | | | | - R. C. Fitzgerald
- Medical Research Council (MRC) Cancer Cell Unit, Hutchison/MRC Research CentreCambridgeUK
| | - K. Biermann
- Department of PathologyErasmus Medical CentreRotterdamThe Netherlands
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17
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Early Barrett esophagus-related neoplasia in segments 1 cm or longer is always associated with intestinal metaplasia. Mod Pathol 2017; 30:1170-1176. [PMID: 28548120 DOI: 10.1038/modpathol.2017.36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/12/2017] [Accepted: 03/13/2017] [Indexed: 12/20/2022]
Abstract
The assumption that intestinal metaplasia is a prerequisite for intraepithelial neoplasia/dysplasia and adenocarcinoma in the distal esophagus has been challenged by observations of adenocarcinoma without associated intestinal metaplasia. This study describes our experience of intestinal metaplasia in association with early Barrett neoplasia in distal esophagus and gastroesophageal junction. We reviewed the first endoscopic mucosal resection of 139 patients with biopsy-proven neoplasia. In index endoscopic mucosal resection, 110/139 (79%) cases showed intestinal metaplasia. Seven had intestinal metaplasia on prior biopsy specimens and three had intestinal metaplasia in subsequent specimens, totaling 120/139 (86%) patients showing intestinal metaplasia at some point supporting the theory of sampling error for absence of intestinal metaplasia in some cases. Those without intestinal metaplasia (13%) were enriched for higher stage disease (T1a Stolte m2 or above) supporting the assertion of obliteration of intestinal metaplasia by the advancing carcinoma. All cases of intraepithelial neoplasia and T1a Stolte m1 carcinomas had intestinal metaplasia (42/42). The average density of columnar-lined mucosa showing goblet cells was significantly less in shorter segments compared to those ≥3 cm (0.31 vs 0.51, P=0.0304). Cases where segments measured less than 1 cm were seen in a higher proportion of females and also tended to lack intestinal metaplasia. We conclude that early Barrett neoplasia is always associated with intestinal metaplasia; absence of intestinal metaplasia is attributable to sampling error or obliteration of residual intestinal metaplasia by neoplasia and those with segments less than 1 cm show atypical features for Barrett-related disease (absent intestinal metaplasia and female gender), supporting that gastroesophageal junction adenocarcinomas are heterogeneous.
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Intestinal Metaplasia is Present in Most if Not All Patients Who Have Undergone Endoscopic Mucosal Resection for Esophageal Adenocarcinoma. Am J Surg Pathol 2016; 40:537-43. [PMID: 26813746 DOI: 10.1097/pas.0000000000000601] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Barrett esophagus is presently defined in the United States by the presence of intestinal metaplasia in columnar-lined esophagus based on the premise that the risk for adenocarcinoma depends on the presence of intestinal metaplasia. Recently, arguments have been made that nonintestinalized cardiac epithelium is also at risk and should be included in the definition of Barrett esophagus, as it is in England and Japan. One of these arguments is that residual intestinal metaplasia is frequently absent around early adenocarcinomas removed by endoscopic mucosal resection (EMR). We reviewed 27 EMRs performed in 21 patients. Residual intestinal metaplasia was absent in 10/27 (37%) EMR specimens. An in-depth study of these 10 cases showed that 3 had intestinal metaplasia in a concurrent second EMR specimen, 4 had intestinal metaplasia in prior biopsy material available in our unit, and 2 had intestinal metaplasia in an esophagectomy that followed the EMR. The single patient in whom no intestinal metaplasia was found, neither in biopsies nor in EMR, and who did not undergo an esophagectomy had been under surveillance for Barrett esophagus for over 20 years. We conclude that the frequent absence of residual intestinal metaplasia around an adenocarcinoma in an EMR specimen is the result of sampling error. When evaluated in depth by looking at history, biopsies preceding the EMR, and esophagectomy following the EMR, all of these patients with adenocarcinoma had intestinal metaplasia in their columnar-lined esophagus. This indicates that intestinal metaplasia is a necessary precursor to adenocarcinoma of the esophagus.
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Ghaus S, Neumann H, Muhammad H, Tontini GE, Ishaq S. Diagnosis and Surveillance of Barrett's Esophagus: Addressing the Transatlantic Divide. Dig Dis Sci 2016; 61:2185-2193. [PMID: 27038446 DOI: 10.1007/s10620-016-4138-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/19/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Barrett's esophagus is a premalignant condition of the esophagus leading to esophageal adenocarcinoma. No consensus exists between the UK and USA concerning the diagnosis of Barrett's esophagus. Although the diagnostic procedure is common, the required findings and diagnostic criteria vary. Both guidelines require endoscopy showing columnar epithelia lining the esophagus, but the US guidelines require the additional finding of intestinal metaplasia on biopsy to confirm diagnosis. Achievement of a consensus is of particular importance due to the established progression from Barrett's esophagus to esophageal adenocarcinoma. Of further importance is the increasing incidence of esophageal adenocarcinoma, a condition with poor overall survival, leading to various opinions on the utility of surveillance in patients. DISCUSSION A review of the vast array of literature revealed that substantial evidence exists in favor of both diagnostic criteria; hence, there is no easy way to identify the "correct" method of diagnosing Barrett's esophagus. USA recommends surveillance of Barrett's esophagus, whereas UK does not advocate it unless dysplasia is present. Surveillance was found to be effective, but this varied as did cost-effectiveness. Further research into diagnostic methods for Barrett's esophagus is needed to address areas of limited understanding, such that agreement can be reached and practice standardized. Surveillance was generally advocated, but with different criteria and time intervals, and new methods are being evaluated.
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Affiliation(s)
- Saad Ghaus
- Gastroenterology Department, Dudley Group Hospitals, Birmingham City University, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Helmut Neumann
- Department of Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Humayun Muhammad
- Gastroenterology Department, Dudley Group Hospitals, Birmingham City University, Birmingham, UK
| | - Gian Eugenio Tontini
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Sauid Ishaq
- Gastroenterology Department, Dudley Group Hospitals, Birmingham City University, Birmingham, UK.
- St. George's University, St. George, Grenada, West Indies.
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20
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Lavery DL, Martinez P, Gay LJ, Cereser B, Novelli MR, Rodriguez-Justo M, Meijer SL, Graham TA, McDonald SAC, Wright NA, Jansen M. Evolution of oesophageal adenocarcinoma from metaplastic columnar epithelium without goblet cells in Barrett's oesophagus. Gut 2016; 65:907-13. [PMID: 26701877 PMCID: PMC4893117 DOI: 10.1136/gutjnl-2015-310748] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/10/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Barrett's oesophagus commonly presents as a patchwork of columnar metaplasia with and without goblet cells in the distal oesophagus. The presence of metaplastic columnar epithelium with goblet cells on oesophageal biopsy is a marker of cancer progression risk, but it is unclear whether clonal expansion and progression in Barrett's oesophagus is exclusive to columnar epithelium with goblet cells. DESIGN We developed a novel method to trace the clonal ancestry of an oesophageal adenocarcinoma across an entire Barrett's segment. Clonal expansions in Barrett's mucosa were identified using cytochrome c oxidase enzyme histochemistry. Somatic mutations were identified through mitochondrial DNA sequencing and single gland whole exome sequencing. RESULTS By tracing the clonal origin of an oesophageal adenocarcinoma across an entire Barrett's segment through a combination of histopathological spatial mapping and clonal ordering, we find that this cancer developed from a premalignant clonal expansion in non-dysplastic ('cardia-type') columnar metaplasia without goblet cells. CONCLUSION Our data demonstrate the premalignant potential of metaplastic columnar epithelium without goblet cells in the context of Barrett's oesophagus.
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Affiliation(s)
| | - Pierre Martinez
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Laura J Gay
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | | | - Marco R Novelli
- Department of Pathology, University College London, London, UK
| | | | - Sybren L Meijer
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Trevor A Graham
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | | | | | - Marnix Jansen
- Barts Cancer Institute, Queen Mary University of London, London, UK
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
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21
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Neoplastic Barrett’s oesophagus and long-term follow-up after endoscopic therapy: complete histological eradication of Barrett associated with high-grade dysplasia significantly decreases neoplasia relapse. Surg Endosc 2016; 30:5410-5418. [DOI: 10.1007/s00464-016-4898-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/26/2016] [Indexed: 01/28/2023]
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