Roberto Fiocca

Anatomia Patologica

Università di Genova

Ripensare la definizione istologica di

Barrett?

AN EASY DIAGNOSIS HOWEVER….

1976 Barrett’s esophagus, columnar specialized type

2002 Barrett’s esophagus

2006 Barrett’s esophagus with intestinal metaplasia

1976 Barrett’s esophagus, juntional (cardia) type

2002 NO Barrett’s esophagus

2006Barrett’s esophagus without intestinal metaplasia

Paull A. The histologic spectrum of Barrett’s esophagus.N Engl J Med 1976Sampliner RE. Updates guidelines for the diagnosis of Barrett’s esophagus. Am J Gastreonterol 2002Vakil N. The Montreal definition and classification of gastroesophageal reflux disease. Am J Gastroenterol 2006

Barrett’s esophagus

+

ESEM Histology

Barrett’s Esophagus

IM at G-E Junction

Incomplete Gastric IM

The exact definition of

biopsy site and the

endoscopic picture are

crucial in defining

Barrett’s esophagus

Circumference Maximum extent

Patient with 5 cm long Barrett’s, distal 2 cm circumferential and proximal 3 cm in form of a tongue

Barrett’s: C5 M6,5

The principal reason for

equivocation deals with the

presence of intestinal

metaplasia as an essential

factor for diagnosing Barrett’s

esophagus.

Presently most western pathologists follow this definition of Barrett’s

Esophagus

Most EG Junction Adenocarcinomas arise in

Intestinal Metaplasia

Early AC, n With IMRuol A (Cancer 2000) 16 69%Van Sandick JW (Cancer 2000) 12 100%Cameron AJ (Am J Gastroenterol 2002) 22 86% Chandrasoma P * (Dis esophagus 2007) 26 92%

* The prevalence of intestinal metaplasia was 100% in all tumors that were less than 1 cm in max diameter and all intramucosal tumors. These data strongly support the contention that adenocarcinomas of this region, including those in the gastric cardia, arise in intestinal metaplastic epithelium.

… the DNA histograms of columnar mucosa with or without goblet cells showed similar abnormalities, including aneuploid G0/G1 peaks, elevated heterogeneity index (HI), increased cells in the S phase and occasional cells with DNA index (DI)>5N.

More than 70% primary small adenocarcinomas (<2cm) of the esophagus were adjacent to cardiac/fundic-type rather than intestinal-type mucosa.

Intestinal metaplasia was not observed in any areas of the endoscopic mucosal resection specimens in 64 (56.6%) of the 113 cases

Intestinal metaplasia was more commonly detected in longer segment length and increasing number of biopsies taken.

After 5 yrs follow-up, 54,8% of patients without IM at index endoscopy demonstrated IM, and 90,8% after 10 yrs.

British Society of Gastroenterology guidelines for the diagnosis of Barrett’s Esophagus: ARE WE CASTING THE NET TOO WIDE?

Murphy SJ, Johnston BT, Murray LJ.

Gut 2006;55(12):1821-2

2969 patients met the criteria for Barrett’s esophagus.Mean follow-up of 3,7 (range 1-8) years29 malignancies were found

For patients with intestinal metaplasia the risk was 0,40 (95% CI 0,26 to 0,59).For those without intestinal metaplasia the risk was 0,06 (95% CI 0 to 0,32)

In other words, if intestinal metaplasia was absent in biopsy specimen, the risk of oesophageal malignancy was not significantly higher than that in normal population.

INTESTINAL OR GASTRIC? THE UNSOLVED DILEMMA OF

BARRETT'S METAPLASIA

INTESTINAL OR GASTRIC? THE UNSOLVED DILEMMA OF

BARRETT'S METAPLASIA

Massimo Rugge, Matteo Fassan, Giorgio Battaglia, Paola Parente, Giovanni Zaninotto,

Ermanno Ancona

Massimo Rugge, Matteo Fassan, Giorgio Battaglia, Paola Parente, Giovanni Zaninotto,

Ermanno Ancona

HUMAN PATHOLOGY

<0.00130

(9.0%)

0 (0%)

30 (14.6%

)

Prevalence of preneoplastic/neoplastic

lesions

0.0182,9 + 2,62,0 + 1,73,5 + 2,9

Velvet mucosa segment length meann + SD (cm)

p-valueTotal

(n = 335)

IM-negative(n = 129; 38.5%)

IM-positive(n = 206; 61.5%)

CLINICOPATHOLOGICAL CHARACTERISTICS OF 335 CONSECUTIVE BARRETT’S ESOPHAGUS PATIENTS

<0.0016.2±6.1 (4.0;

1-37)

3.4±3.7

(2.0; 1-18)

8.0±6.7 (6.0;

1-37)

Biopsies per patient Mean±SD (median & range)

Cost - Effectiveness

N° Early Neopl.

EFFECTIVENESS

N° Barrett

COST

Cost - Effectiveness

N° Early Neopl.

EFFECTIVENESS

N° Barrett

COST

Barrett’s Esophagus: the Histology Report

Samples of INTESTINAL epithelium

Morphology is SUGGESTIVE of INTESTINAL METAPLASIA of the CARDIA

Morphology is DIAGNOSTIC for BARRETT’s ESOPHAGUS with INTESTINAL METAPLASIA

Morphology is DIAGNOSTIC for BARRETT’s ESOPHAGUS with INTESTINAL METAPLASIA

Normal o irregular Z line

Normal o irregular Z line

SSBE >0,5-1 cm

SSBE >0,5-1 cm

LSBE

LSBE

Samples of CARDIAL epithelium

Normal o irregular Z line

Normal o irregular Z line

SSBE >0,5-1 cm

SSBE >0,5-1 cm

LSBE

LSBE

Morphology is SUGGESTIVE of SITE-APPROPRIATE gastric mucosa

BE cannot be defined/confirmed based on histology alone

Morphology is DIAGNOSTIC for BARRETT’s ESOPHAGUS without intestinal metaplasia

Samples of OXYNTIC mucosa

The finding is SUGGESTIVE of HIATUS HERNIA

The finding is DIAGNOSTIC for ECTOPIA (inlet patch)

distal esophagus

distal esophagus

proximal esophagus

proximal esophagus

UNA DIAGNOSI FACILE………CHE RICHIEDE UN APPROCCIOCLINICO-PATOLOGICO CORRETTO