Barrett s Esophagus Lecture Outline

Biopsy Approach to Barrett’s Esophagus Robert D. Odze, MD, FRCPC Chief, Division of GI Pathology Professor of Pathology Brigham and Women’s Hospital H...
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Biopsy Approach to Barrett’s Esophagus Robert D. Odze, MD, FRCPC Chief, Division of GI Pathology Professor of Pathology Brigham and Women’s Hospital Harvard Medical School Boston, MA

Barrett’s Esophagus Lecture Outline 1. Definition/Diagnosis (BE vs. Carditis) 2. Dysplasia - Pathology/diagnostic difficulties - Unusual variants - Adjunctive tests 3. Natural History 4. Management 5. Future biomarkers

Rising Incidence of Esophageal Adenocarcinoma Relative change in incidence of EA Melanoma Prostate Lung Breast Colorectal

Pohl and Welch, JNCI 2005; 97: 142-46

Dysplasia and Cancer in Barrett’s (Multicenter Cohort) N=1376 Diagnosis

Adenocarcinoma Prevalent

Incident*

Incidence (per year)

N

1376

618

-

LGD detection

7.3%

16.1%

4.3%

HGD detection

3%

3.5%

0.9%

6.6%

1.9%

0.5%

AdenoCa detection *1 618 with ≥ 1 year follow-up

Sharma et al, Clin Gastroenterol Hepat 2006;4:566-72

Definition of Barrett’s North American (ACG) • Endoscopically recognizable columnar mucosa in esophagus • Goblet cells identified on biopsy

Normal GEJ

Photo by J. Bergman

Diagnosis • Columnar mucosa, mixed mucous/ oxyntic type • Squamous mucosa with reactive changes • No goblet cell identified • No dysplasia

Is this Barrett’s? Management?

Barrett’s Definition • North America – endoscopy + – goblet cell +

• UK – endoscopy + – columnar epithelium +

• Japan – endoscopy + – lower limit of palisade vessels – columnar epithelium +

Problems with North American Def’n of Barrett’s • • • • •

IM not defined by goblet cells Sampling error Non-goblet epithelium at risk for neoplasia Barrett’s esophagus without goblets Barrett’s Esophagus vs. Gastric Carditis with IM

Non-Goblet Epithelium in Barrett’s Esophagus is “Intestinalized” Marker

Goblet-Cell Deficient

Goblet-Cell Poor

Goblet-Cell Rich

N=72

N=96

N=112

CDX-2

6%

42%

100%*

DAS-1

39%

29%

96%*

MUC-2

11%

33%

75%*

MUC-1

11%

17%

18%

Ki-67

33%

29%

46%

*p16

100%

Cardiac Rather than Intestinal-type Background in Endoscopic Resection Specimens of Minute Barrett Adenocarcinoma Takubo et al, Hum Pathol 2008; In Press

Cancer

Type of Epithelium

(< 2 cm in size)

Cardiac/Fundic

Intestinal (Goblet)

Cardia Intestinal

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