Barrett Esophagus : Dysplasia Assessment

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Image Description

Assessment of dysplasia in Barrett esophagus (BE) requires evaluation of the following mucosal features:

Surface maturation (best evaluated at low magnification): In the absence of dysplasia, the nuclei in the basal portions of the glands are larger, hyperchromatic, and more stratified than those in the surface glands. There is maturation towards the surface where the cells are arranged in a monolayer and have basally located small nuclei.

Glandular architecture (best evaluated at low magnification): Normally, the glands are uniform, round, and surrounded by abundant lamina propria. Overcrowding of normal-appearing glands (back to back glands with little lamina propria) is a mild architectural abnormality. Glands with one or more of the following features are severely abnormal: variation in size and shapes, cribriform architecture, cystic dilation, and necrotic luminal debris.

Cytologic features (best evaluated at high magnification): Mild nuclear enlargement and hyperchromasia is normally seen in the basal portions of the glands. These features disappear as the glands mature towards the surface. Cytologic atypia may be reactive (in the setting of inflammation) or caused by true dysplasia. Cytologic evaluation includes nuclear polarity. Normally, the nuclei of columnar cells are parallel to each other and their long axis is perpendicular to the basement membrane. When polarity is lost, the nuclei are arranged randomly with regards to one another and to the basement membrane.

Inflammation, erosion, and ulcers: These are confounding factors which can cause cytologic atypia and make benign lesion look concerning for malignancy. Conversely, the inflammatory infiltrate can obscure a malignant lesion.

The image shows Barrett mucosa with intestinal metaplasia.

Image courtesy of: Phoenix Bell, MD.

About the Disease

Barrett esophagus (BE) is a metaplastic replacement of the stratified squamous epithelium of the distal esophagus with columnar epithelium containing goblet cells. US definition requires intestinal metaplasia. In Japan and the UK, goblet cells are not required for the diagnosis. BE is a preneoplastic lesion and increases the risk for esophageal adenocarcinoma (EAC). BE is found in about 5-10% of individuals with symptomatic gastroesophageal reflux disease. It is more common white males with a median age at diagnosis of 55 years. Diagnosis requires both endoscopic and histologic findings. At endoscopy, Barrett mucosa appears orange-pink (salmon colored) and velvety in contrast to pale pink glossy squamous mucosa. In short-segment and long-segment BE, metaplastic epithelium lines < 3 cm or ≥ 3 cm of the distal esophagus respectively. Biopsies are classified as neg. for dysplasia, indefinite for dysplasia, and positive for LGD or HGD. Patients with non-neoplastic BE develop LGD at the rate of 4.3% per year, and HGD at the rate of 0.9% per year. The rate of progression to cancer within 5 years is 20% with LGD and 50% with HGD. Abnormalities in CDKN2A and TP53 may indicate higher risk of progression. Treatment of BE without dysplasia consists of proton pump inhibitors. Patients undergo surveillance endoscopy every 3-5 years. BE with dysplasia can be treated with endoscopic ablation or resection techniques. References:Iacobuzio-Donahue, C. A. & Montgomery E. (2012). Gastrointestinal and Liver Pathology - 2nd Edition. Feldman, M., Friedman, L. S., & Brandt, L. J. (2020). Sleisenger & Fordtran's Gastrointestinal & Liver Disease - 11th Edition. Arnold C, Lam-Hamlin D, and Montgomery E. (2019). Atlas of Gastrointestinal Pathology : A Pattern Based Approach to Neoplastic Biopsies - First Edition. Odze & Goldblum Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas (2014). 3rd edition. Goldblum, J. R. et al (2018). Rosai and Ackerman's Surgical Pathology - Eleventh Edition.

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