GI Path Online
Barrett's Esophagus -
Dysplasia and Esophagus
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is defined as replacement of the lower esophageal squamous mucosa
by specialized columnar epithelium as a result of chronic
- Short segment Barrett's esophagus (SSBE)-Replacement of less than 3cm of distal esophagus by specialized columnar epithelium.
- Ultrashort segment Barrett's esophagus (USSBE)- Intestinal metaplasia within the Z-line of the esophago-gastric junction (intestinal metaplasia of gastric cardia).
The shorter length of Barrett's esophagus are at an increased risk of adenocarcinoma.
It has been suggested that there is a close relationship between USSBE and gastric Helicobacter pylori infection.
The patient with cardia intestinal metaplasia should be evaluated in context of endoscopic finding , histologic and serologic findings for H pylori infection and findings from the biopsies of distal stomach.
Histologically, Barrett's esophagus may show specialized metaplastic mucosa, cardiac or junctional type mucosa, atrophic fundic type mucosa.
In Barret's esophagus there is superficial and deep CK7 positivity and only superficial CK20 staining.
Sulphated sialomucin expression is associated with the development of dysplasia and subsequent carcinoma.
Sulphated mucins or sulphomucin and nonsulphated mucins or sialomucin are acid mucins.
Histochemistry: High iron diamine/ Alcian Blue pH2.5 :
Sialomucin stains blue and sulphomucin stains brown.
What are the different types of intestinal metaplasia?
Goblet cells-Sialomucins and sulphomucin.
Type2 - Incomplete:
Goblet cells- Sialomucins and sulphomucin
Type3 - Incomplete:Goblet cells- Sialomucins and sulphomucins
Dysplasia in Barrett's Esophagus
Dysplasia in Barrett's esophagus is defined as presence of neoplastic epithelium that is confined within the basement membrane of the gland within which it arises.
Dysplasia in Barrett's esophagus is reported as-
1. Negative for dysplasia
2. Positive for dysplasia- i)Low grade ii)High grade
3. Indefinite for dysplasia.
Low grade dysplasia-
-Minimal distortion of crypt architecture
-Atypical nuclei present in the basal half of the crypts
-Nuclear character- variable hyperchromasia
- Marked reduction in the number of goblet cells in the dysplastic area
High grade dysplasia-
- Severe cytological atypia characterized by nuclear hyperchromatism , pleomorphism & nuclear stratification towards the luminal surface.
- Severe architectural atypia characterized by complex
Site: Usually lower esophagus. Commonly arise from Barrett's metaplastic mucosa. (rarely from gastric heterotopic mucosa).
Age: Usually in middle aged white male . Average age is 57 years.
Macroscopic features: Flat, ulcerating , infiltrative lesion.
Microscopic features: Wide range of glandular features are noted (resemble gastric adenocarcinoma).
The backround Barrett's type mucosa may demonstrate areas of high grade dyspalsia.
The tumour usually penetrates through the muscle coat.
Perineural invasion is noted.
Lymphnode metastasis is present.
The tumour has a poor prognosis.
What is intramucosal carcinoma of the esophagus?
Sometimes it can be extremely difficult to distinguish between high grade dysplasia and intramucosal carcinoma.
Problems faced by Pathologist:
1. Sampling error- Dysplastic changes is sometimes limited to a small area which may be left unsampled.
2. There may be interobserver variation among pathologists, in the diagnosis of dysplasia.
Sometimes the distinction of regenerative changes and true dysplasia can be very difficult specially in the presence of inflammation or ulceration.
Indefinite dysplasia - Rebiopsy after
Low grade - Rebiopsy to exclude a worse lesion and then regular follow up.
High grade - Most regard
this as an indication for esophagectomy (this is controversial). The
slide should be reviewed by experienced pathologist.
Prospective multivariate analysis of clinical, endoscopic, and histological factors predictive of the development of Barrett's multifocal high-grade dysplasia or adenocarcinoma.
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