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Salimian KJ, Birkness-Gartman J, Waters KM. The path(ology) from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. Pathology 2021; 54:147-156. [PMID: 34711413 DOI: 10.1016/j.pathol.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
This review seeks to summarise the steps in the path from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. The epidemiology, clinical presentation, definitions, pathological features, diagnostic pitfalls, and emerging concepts are reviewed for each entity. The histological features of reflux oesophagitis can be variable and are not specific. Cases of reflux oesophagitis with numerous eosinophils are difficult to distinguish from eosinophilic oesophagitis and other oesophagitides with eosinophils (Crohn's disease, medication effect, and connective tissue disorders). In reflux oesophagitis, the findings are often most pronounced in the distal oesophagus, the eosinophils are randomly distributed throughout the epithelium, and eosinophilic abscesses and degranulated eosinophils are rare. For reflux oesophagitis with prominent lymphocytes, clinical history and ancillary clinical studies are paramount to distinguish reflux oesophagitis from other causes of lymphocytic oesophagitis pattern. For Barrett oesophagus, the definition remains a hotly debated topic for which the requirement for intestinal metaplasia to make the diagnosis is not applied unanimously across the globe. Assessing for dysplasia is a challenging aspect of the histological interpretation that guides clinical management. We describe the histological features that we find useful in making this evaluation. Oesophageal adenocarcinoma has been steadily increasing in incidence and has a poor prognosis. The extent of invasion can be overdiagnosed due to a duplicated muscularis mucosae. We also describe the technical factors that can lead to challenges in distinguishing the mucosal and deep margins of endoscopic resections. Lastly, we give an overview of targeted therapies with emerging importance and the ancillary tests that can identify the cases best suited for each therapy.
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Affiliation(s)
- Kevan J Salimian
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Kevin M Waters
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA.
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2
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Zhang L, Sun B, Zhou X, Wei Q, Liang S, Luo G, Li T, Lü M. Barrett's Esophagus and Intestinal Metaplasia. Front Oncol 2021; 11:630837. [PMID: 34221959 PMCID: PMC8252963 DOI: 10.3389/fonc.2021.630837] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 05/31/2021] [Indexed: 02/05/2023] Open
Abstract
Intestinal metaplasia refers to the replacement of the differentiated and mature normal mucosal epithelium outside the intestinal tract by the intestinal epithelium. This paper briefly describes the etiology and clinical significance of intestinal metaplasia in Barrett’s esophagus. This article summarizes the impact of intestinal metaplasia on the diagnosis, monitoring, and treatment of Barrett’s esophagus according to different guidelines. We also briefly explore the basis for the endoscopic diagnosis of intestinal metaplasia in Barrett’s esophagus. The identification techniques of goblet cells in Barrett’s esophagus are also elucidated by some scholars. Additionally, we further elaborate on the current treatment methods related to Barrett’s esophagus.
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Affiliation(s)
- Lu Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - Binyu Sun
- Department of Endoscope, Public Health Clinical Medical Center of Chengdu, Chengdu City, China
| | - Xi Zhou
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - QiongQiong Wei
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - Sicheng Liang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - Gang Luo
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
| | - Tao Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu City, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
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3
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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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4
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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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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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6
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Definition of Barrett Esophagus in the United States: Support for Retention of a Requirement for Goblet Cells. Am J Surg Pathol 2019; 42:264-268. [PMID: 29016405 DOI: 10.1097/pas.0000000000000971] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Barrett esophagus (BE) predisposes patients to the development of esophageal adenocarcinoma (EAC). However, the global definition of BE is controversial. Pathologists in Europe and the United States require intestinal metaplasia (IM) within columnar-lined mucosa (CLM) in the tubular esophagus to diagnose BE, whereas in the UK and Japan only the presence of CLM is required. To aid in establishing an appropriate definition for BE, we evaluated whether IM accompanies EAC in a US patient cohort. We examined a series of 139 consecutive patients who underwent endoscopic mucosal resections or esophagectomies for EAC performed at a US tertiary care center. The resection specimens were evaluated for the presence (IM+) or absence (IM-) of IM within CLM. Ninety-seven (70%) patients were IM+. Tumors found in IM- patients tended to be advanced at the time of resection (57% pT3 or greater, IM-; 31% pT3 or greater, IM+; P=0.02) such that the tumor may have "overgrown" zones of IM. We hypothesized that changes as a result of neoadjuvant chemotherapy or radiation might mask preexisting IM. When evaluating this hypothesis, we found that 34 of 39 of treatment-naive patients were IM+. Two of the 5 IM- patients had prior IM+ biopsies resulting in 92% of treatment-naive patients who were IM+. In our US hospital population, CLM with IM in the tubular esophagus is found in association with EAC in 70% to 92% of patients. We believe that based on these data the United States definition of BE should continue to require the presence of IM.
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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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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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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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Gora MJ, Simmons LH, Quénéhervé L, Grant CN, Carruth RW, Lu W, Tiernan A, Dong J, Walker-Corkery B, Soomro A, Rosenberg M, Metlay JP, Tearney GJ. Tethered capsule endomicroscopy: from bench to bedside at a primary care practice. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:104001. [PMID: 27689919 PMCID: PMC5043371 DOI: 10.1117/1.jbo.21.10.104001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/12/2016] [Indexed: 05/23/2023]
Abstract
Due to the relatively high cost and inconvenience of upper endoscopic biopsy and the rising incidence of esophageal adenocarcinoma, there is currently a need for an improved method for screening for Barrett’s esophagus. Ideally, such a test would be applied in the primary care setting and patients referred to endoscopy if the result is suspicious for Barrett’s. Tethered capsule endomicroscopy (TCE) is a recently developed technology that rapidly acquires microscopic images of the entire esophagus in unsedated subjects. Here, we present our first experience with clinical translation and feasibility of TCE in a primary care practice. The acceptance of the TCE device by the primary care clinical staff and patients shows the potential of this device to be useful as a screening tool for a broader population.
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Affiliation(s)
- Michalina J. Gora
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
- Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115, United States
- Strasbourg University, CNRS, ICube Laboratory, 1 Place de l’Hopital, Strasbourg 67091, France
| | - Leigh H. Simmons
- Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115, United States
- Massachusetts General Hospital, Division of General Internal Medicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Lucille Quénéhervé
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
- Institut des Maladies de l’Appareil Digestif, CHU Nantes, Hôtel Dieu, place Alexis Ricordeau, Nantes 44000, France
| | - Catriona N. Grant
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Robert W. Carruth
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Weina Lu
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Aubrey Tiernan
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Jing Dong
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
- Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115, United States
| | - Beth Walker-Corkery
- Massachusetts General Hospital, Division of General Internal Medicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Amna Soomro
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Mireille Rosenberg
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
- Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115, United States
| | - Joshua P. Metlay
- Massachusetts General Hospital, Division of General Internal Medicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
| | - Guillermo J. Tearney
- Massachusetts General Hospital, Wellman Center for Photomedicine, 55 Fruit Street, Boston, Massachusetts 02114, United States
- Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115, United States
- Massachusetts General Hospital, Department of Pathology, 55 Fruit Street, Boston, Massachusetts 02114, United States
- Harvard-MIT Division of Health Sciences Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
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