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Ripensare la
definizione
istologica di
Barrett?
Roberto Fiocca
Anatomia Patologica
Università di Genova
AN EASY DIAGNOSIS HOWEVER….
1976
Barrett’s esophagus, columnar
specialized type
1976
Barrett’s esophagus, juntional
(cardia) type
2002
Barrett’s esophagus
2002
NO Barrett’s esophagus
2006
Barrett’s esophagus with
intestinal metaplasia
2006
Barrett’s esophagus without
intestinal metaplasia
Paull A. The histologic spectrum of Barrett’s esophagus.N Engl J Med 1976
Sampliner RE. Updates guidelines for the diagnosis of Barrett’s esophagus. Am J Gastreonterol 2002
Vakil N. The Montreal definition and classification of gastroesophageal reflux disease. Am J Gastroenterol 2006
ESEM
Histology
+
Barrett’s esophagus
Barrett’s Esophagus
Incomplete Gastric IM
IM at G-E Junction
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
equivocation
deals
reason
with
for
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
Ruol A (Cancer 2000)
16
Van Sandick JW (Cancer 2000)
12
Cameron AJ (Am J Gastroenterol 2002)
22
Chandrasoma P * (Dis esophagus 2007)
26
With IM
69%
100%
86%
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.
2969 patients met the criteria for Barrett’s esophagus.
Mean follow-up of 3,7 (range 1-8) years
29 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.
Gut 2006;55(12):1821-2
INTESTINAL OR GASTRIC?
THE UNSOLVED DILEMMA OF BARRETT'S METAPLASIA
HUMAN
PATHOLOGY
Massimo Rugge, Matteo Fassan, Giorgio Battaglia,
Paola Parente, Giovanni Zaninotto, Ermanno Ancona
CLINICOPATHOLOGICAL CHARACTERISTICS OF
335 CONSECUTIVE BARRETT’S ESOPHAGUS PATIENTS
IM-positive
(n = 206;
61.5%)
IM-negative
(n = 129;
38.5%)
Total
(n = 335)
p-value
Biopsies per patient Mean±SD (median &
range)
8.0±6.7
(6.0; 1-37)
3.4±3.7
(2.0; 1-18)
6.2±6.1
(4.0; 1-37)
<0.001
Velvet mucosa segment length meann + SD
(cm)
3,5 + 2,9
2,0 + 1,7
2,9 + 2,6
0.018
Prevalence of
preneoplastic/neoplastic lesions
30
(14.6%)
0
(0%)
30
(9.0%)
<0.001
Cost - Effectiveness
N° Early Neopl.
N° Barrett
EFFECTIVENESS
COST
Cost - Effectiveness
N° Early Neopl.
N° Barrett
EFFECTIVENESS
COST
Barrett’s Esophagus: the Histology Report
Morphology is SUGGESTIVE of
INTESTINAL METAPLASIA of
the CARDIA
Normal o irregular Z line
Morphology is DIAGNOSTIC for
BARRETT’s ESOPHAGUS with
INTESTINAL METAPLASIA
Samples of INTESTINAL
epithelium
SSBE >0,5-1 cm
Morphology is DIAGNOSTIC for
BARRETT’s ESOPHAGUS with
INTESTINAL METAPLASIA
LSBE
Morphology is SUGGESTIVE of
SITE-APPROPRIATE gastric
mucosa
Normal o irregular Z line
BE cannot be defined/confirmed
based on histology alone
Samples of CARDIAL
epithelium
SSBE >0,5-1 cm
Morphology is DIAGNOSTIC for
BARRETT’s ESOPHAGUS
without intestinal metaplasia
LSBE
The finding is SUGGESTIVE of
HIATUS HERNIA
distal esophagus
Samples of OXYNTIC
mucosa
The finding is DIAGNOSTIC for
ECTOPIA (inlet patch)
proximal esophagus
UNA DIAGNOSI FACILE………
CHE RICHIEDE UN APPROCCIO
CLINICO-PATOLOGICO CORRETTO