Barrett Esophagus : Prognosis

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Prognosis: Barrett esophagus (BE) is a preneoplastic lesion that increases the risk for subsequent development of esophageal adenocarcinoma (EAC). The metaplasia-dysplasia-adenocarcinoma sequence is well-recognized in BE. Patients with non-neoplastic BE develop low-grade dysplasia (LGD) at the rate of 4.3% per year, and high-grade dysplasia (HGD) at the rate of 0.9% per year.

The annual risk of progression to EAC in patients with nondysplastic BE is approximately 0.12-0.33% per year. The risk is much higher in patients with dysplasia associated with BE. The rate of progression to EAC in 5 years is about 50% with HGD and 20% with LGD. With LGD, accurate estimation of the risk of progression is complicated by the lack of reproducibility in the diagnosis of LGD.

Although most cases of BE do not develop into EAC, there are no well-established prognostic markers to help determine cases that will progress. Some studies have suggested that cases with abnormalities in CDKN2A and TP53 may have increased risk of progression.

About this image: High-grade dysplasia in BE (higher magnification of the previous image). The glands are variable in size and shape. There is nuclear pleomorphism with piling up of nuclei. There is nuclear hyperchromasia, high N:C ratios, prominent nucleoli and increased mitotic activity as well. When viewed at low magnification, the dysplastic areas stand out due to their basophilia and loss of mucus.

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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