Microscopic esophagitis and Barrett`s esophagus

Digestive and Liver Disease 43S (2011) S319–S330
Microscopic esophagitis and Barrett’s esophagus: The histology report
Roberto Fiocca a, *, Luca Mastracci a , Massimo Milione b , Paola Parente c , Vincenzo Savarino d
On behalf of the “Gruppo Italiano Patologi Apparato Digerente (GIPAD)” and of the “Società Italiana
di Anatomia Patologica e Citopatologia Diagnostica”/International Academy of Pathology,
Italian division (SIAPEC/IAP)
a Department
of Anatomic Pathology, University of Genova and S. Martino University Hospital, Genoa, Italy
of Anatomic Pathology B, IRCCS Istituto Nazionale Tumori, Milan, Italy
c Istituto Oncologico Veneto (IOV-IRCCS), Padua, Italy
d Department of Internal Medicine, University of Genoa, Genoa, Italy
2 Department
Abstract
Gastro-esophageal reflux disease (GERD) is the most common digestive disease in industrialized countries (Europe and North America) and
is associated with microscopic changes in the squamous epithelium. However, biopsy is not presently included in the routine diagnostic flow
chart of GERD. In contrast, esophageal biopsy is mandatory when diagnosing Barrett’s esophagus. High quality histology reports are necessary
to provide information on diagnosis and can also be important for research and epidemiological studies. It has been evident for decades that
pathology reports vary between institutions and even within a single institution. Standardization of reporting is the best way to ensure that
information necessary for patient management is included in pathology reports. This paper details the histological criteria for diagnosing GERDassociated microscopic esophagitis, other forms of esophagitis with specific features and columnar metaplasia in the lower esophagus (Barrett’s
esophagus). It provides a detailed description of appropriate sampling criteria, individual lesions and how they contribute to the histology report.
© 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Keywords: Barrett’s esophagus; Esophagitis; Gastro-esophageal reflux disease; GIPAD report; Histopathology
1. Introduction
Gastro-esophageal reflux disease (GERD) is extremely
widespread in industrialized countries (Europe and North
America) with a prevalence of 10–20% [1]. The prevalence
of Barrett’s esophagus among patients undergoing endoscopic
List of abbreviations: GERD, gastro-esophageal reflux disease; ERD, erosive
reflux disease; NERD, non-erosive reflux disease; EE, eosinophilic esophagitis; DIS, dilated intercellular spaces; BE, Barrett’s esophagus; ESEM, endoscopically suspected esophageal metaplasia; GEJ, gastro-esophageal junction; SCJ, squamo-columnar junction or Z line; LSBE, long segment Barrett’s esophagus; SSBE, short segment Barrett’s esophagus.
* Correspondence to: Roberto Fiocca, Department of Anatomic Pathology,
University of Genova and S. Martino University Hospital, Via De Toni 14,
16132 Genova, Italy. Tel.: +39 010-3537806; fax: +39 010-3537803.
E-mail address: fi[email protected] (R. Fiocca).
examination is 1% and reaches 3% if only the patients with
reflux symptoms are taken into account [2].
The modern approach to histological diagnosis of nonneoplastic diseases of the esophagus started with the advent
of fiber optic endoscopy and the possibility of obtaining
endoscopic biopsies. The first great contribution to a better
understanding of microscopic lesions associated with gastroesophageal reflux disease (GERD) came from Ismail-Beigi’s
study [3], while the intricate story of Barrett’s esophagus (BE)
began in 1950 [4].
The present document is an update to the “guidelines”
issued by Gruppo Italiano Patologi dell’Apparato Digerente
(GIPAD) in 1998 [5]) and it covers the following topics:
1. Indications for esophageal biopsy
2. Microscopic esophagitis
• Individual histologic lesions
1590-8658/$ – see front matter © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
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•
Histologic pattern of microscopic esophagitis
Histologic lesions associated with other esophagitis
(eosinophilic, infectious, non infectious)
3. Barrett’s esophagus
• Definition
• Endoscopic description and biopsy sampling
• Individual histologic lesions
The asterisks in the present article express the levels of
evidence, where one asterisk represents level 1 (evidence
provided by single studies); two asterisks represent level
2 (evidence provided by some clinico-pathological studies,
albeit with some notable discrepancies); and three asterisks
represent level 3 (evidence consistently estabilished by a large
body of clinico-pathological and/or follow-up studies), as described more in detail in the Foreword in this supplement [6].
•
2. Clinical indication for esophageal biopsy
2.1. Gastro-esophageal reflux disease
There are no indications for routine esophageal biopsies
in patients with esophageal or extra-esophageal symptoms of
gastro-esophageal reflux disease [7]. The rationale underlying
this statement is that histological findings do not seem to provide any additional information for patient management when
compared with endoscopy. In other words, it is sufficient to
distinguish erosive lesions of any degree by endoscopy (ERD)
from non erosive form (NERD) in the absence of endoscopically recognizable lesions. Squamous epithelium histology
can provide a better understanding of reflux disease at the
mucosal level** [8] and enable comparative assessment of the
effect of anti-reflux treatments** [9]. Biopsy contribution is
significant for research purposes only, and presently it is not
included in the routine diagnostic flow chart for GERD.
Biopsy specimens must be taken also from the proximal or
middle esophagus.
2.5. Infectious esophagitis
Biopsy is required in order to differentiate with certainty
viral or bacterial esophagitis from other types of esophagitis,
although this is a relatively rare occurrence in clinical practice.
2.6. Clinical information
As in other digestive diseases, the following information
should be provided when requiring a histological examination:
• reason for the examination;
• concomitant diseases (e.g. connective tissue diseases, skin
diseases, allergies, etc.);
• endoscopic pattern;
• previous and current treatments;
• biopsy site;
• previous histological examinations.
A list of all useful clinical and endoscopic data would be
too long and beyond the scope of this paper. The importance
of endoscopic-bioptic correlations in the diagnosis of Barrett’s
esophagus is covered in a subsequent section of this paper.
2.7. Normal esophageal mucosa (Table 1)
The esophageal mucosa is lined by stratified squamous
epithelium. Sparse T lymphocytes (usually <10/HPF) in the
suprabasal area, sparse Langerhans cells and very few mast
cells [13] are constitutively present in normal esophageal
epithelium. In contrast, no eosinophils or neutrophils are
found. Esophageal biopsy specimens should include the full
epithelial thickness, allow the recognition of the base of
papillae and be well oriented.
2.2. Barrett’s esophagus
3. Microscopic esophagitis
Esophageal biopsy is crucial when diagnosing Barrett’s
esophagus*** and for monitoring purposes after diagnosis.
Columnar metaplasia [10] of the esophageal mucosa has to
be histologically proven in order to correctly define this
complication of GERD***.
2.3. Endoscopically suspected esophageal lesions
Esophageal biopsy is mandatory in all suspected lesions
that are not clearly defined during endoscopy. Histological
examination is required whenever an endoscopic finding at
any level along the esophagus raises doubts concerning the
nature of the lesion (benign vs. malignant) [11].
2.4. Eosinophilic esophagitis
Histology is mandatory in this condition. High eosinophil
count (≥15/HPF) is required for the diagnosis of eosinophilic
esophagitis in patients with dysphagia and atopy*** [12].
3.1. Definition
The term “microscopic esophagitis” refers to a group of
histologic lesions observed in most patients with GERD,
both erosive (ERD) and non-erosive (NERD). It is not to be
confused with “esophagitis”, a term that in the gastroenterological literature designates endoscopically detectable erosive
lesions.
Table 1
Criteria for normal esophageal mucosa***
• Basal layer thickness: <20% (at the Z line); <15% (in more proximal
biopsies)†
• Papillary length: <66% (at the Z line); <50% (in more proximal
biopsies)†
• Intraepithelial T lymphocytes: <10/HPF
• Absence of intercellular spaces dilation
• Absence of intraepithelial eosinophils and neutrophils
† Figures
refer to the full thickness of the epithelium.
R. Fiocca et al. / Digestive and Liver Disease 43S (2011) S319–S330
Fig. 1. Mild hyperplasia of the basal layer (<30%) in biopsy performed at 2
cm from the Z line. (H-E, 20×)
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Fig. 2. Marked elongation of chorionic papillae (>75%) in biopsy performed
at 2 cm from the Z line. (H-E, 20×)
3.2. Individual histologic lesions
None of the histologic lesions characterizing microscopic
esophagitis is specific of and exclusive to reflux disease;
the same lesions can be observed also in other types of
esophagitis (infectious, eosinophilic, due to achalasia, etc.).
The assessment of histologic lesions should be performed
in well oriented areas of biopsy specimens where lesions are
most severe.
Basal cell hyperplasia*** – thickness of basal layer ≥20%
(esophageal side of Z line)* [14] of total epithelial thickness;
≥15% (biopsies proximal to Z line)*** [3]. The upper limit
of the basal layer is defined as the level where the nuclei of
epithelial cells are separated by a distance greater than their
diameter [15] (Fig. 1). Basal cell hyperplasia can be graded as
mild (<30%) or marked (≥30%).
Papillae elongation*** – length of papillae ≥66% (esophageal side of Z line)* of total epithelial thickness [3,14]; ≥50%
(biopsies proximal to Z line)*** [16]. The upper limit of the
papilla is defined as the upper limit of the vessel running
along its axis [15] (Fig. 2). It can be graded as mild (<75%)
or marked (≥75%).
Dilated intercellular spaces (DIS)*** – irregular dilatations
of intercellular spaces, detectable at light microscopy as
optically empty bubbles or ladders. They are more prevalent
in the lower half of the epithelium and around the papillae
[15,17]. They must not be confused with “stretching” artefacts
resulting from bioptic sampling and with intracytoplasmic
vacuoles. They can be graded as small or large (< or >
diameter of a small lymphocyte) (Fig. 3). Occasional small
dilatations may also be found in the squamous epithelium of
control subjects.
Intraepithelial eosinophils and neutrophils*** [18,19]. The
presence of intraepithelial eosinophils (Fig. 4) is the main
Fig. 3. Dilated intercellular spaces of varying sizes. (H-E, 63×)
distinguishing feature of eosinophilic esophagitis (EE). The
majority (85%) of patients with eosinophilic infiltration, however, are affected by GERD [20]. Intraepithelial neutrophils
are a rare finding (<5%) in patients with NERD [14]; their
presence is usually associated with endoscopic changes (ERD,
infectious and non-infectious esophagitis).
Erosion/healed erosion** – Erosion is characterized by the
presence of necrosis and/or granulation tissue and/or fibrin
with neutrophils, while healed erosion is characterized by
the presence of fibrosis/granulation tissue covered by thin
epithelium with regenerative changes in the absence of
necrosis [15] (Fig. 5).
Intraepithelial T lymphocytes* – Counting intraepithelial T
lymphocytes in routine specimens is difficult due to the
presence of other mononuclear cells, and their increase
contributes little to the diagnosis of microscopic esophagitis
[3,21]
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are found almost exclusively in subjects with ERD [14,23,24]
and represent the most severe end of the spectrum; whenever
they are found, microscopic esophagitis can be diagnosed
regardless of the presence of other lesions**.
3.3. Limitations of histologic diagnosis
Fig. 4. Marked infiltration of eosinophils in the squamous epithelium with a
microabscess close to the surface. (H-E, 40×)
Fig. 5. Healed erosion is characterized by the presence of fibrosis and
granulation tissue covered by thin epithelium with regenerative changes in
the absence of necrosis. (H-E, 20×)
Other lesions – Capillary ectasia, ballooning and eosinophilic
densification in the squamous epithelium have been described,
but they contribute little to the diagnosis of microscopic
esophagitis.
Basal cell hyperplasia and DIS are the individual lesions
most contributing to a diagnosis of microscopic esophagitis,
followed by papillae elongation and intraepithelial eosinophils
(Table 2) [14,22]. Basal cell hyperplasia, papillae elongation,
DIS and eosinophils show variable sensitivity and specificity. As none of these lesions is diagnostic of microscopic
esophagitis, more than one individual histologic lesion is
required for the diagnosis**. Moreover, one mild histologic
lesion may be found also in biopsies of control subjects
(especially on the esophageal side of the Z line), the most
frequent finding being a mild basal cell hyperplasia.
The sensitivity of histologic lesions such as intraepithelial
neutrophils, erosion and healed erosion is very low***. They
Histologic lesions in microscopic esophagitis may be
focal and irregularly distributed [3,14,23,24]. Consequently,
the assessment should be made in the most affected (and
technically suitable) area.
The greater the number of biopsies, the higher the diagnostic sensitivity [23].
The most distal biopsies, especially those close to the Z
line, are the most informative [14,23]; however, increased
informativeness is accompanied by decreased specificity, i.e.
one mild lesion may also be found in control subjects [14].
The assessment of basal cell hyperplasia and papillae
elongation requires well oriented biopsies [14,25].
The sensitivity and specificity of individual lesions is
variable among different studies and the results can either be
disappointing or extremely promising [22,23]. Such variability
is mainly due to case and control selection criteria [8].
Interobserver reproducibility of histologic lesions also
varies: it is influenced by common training [14,15] and
consequently it is lower in multicenter studies (Table 2).
Discrepancies arise from the choice of the microscopic
field to be assessed [15] and are minimized by the use of
preselected photographic fields.
A scoring system including multiple histologic lesions
could help to increase both sensitivity and specificity of
histological findings [14,26].
The severity of GERD-related histologic lesions is strongly
influenced by treatment with anti-secretory drugs and by antireflux surgery [15], hence the importance of knowing patient
treatment history.
3.4. Biopsy sampling
As histologic lesions in GERD are usually limited to
the distal esophagus, standard sampling should include the
Table 2
Individual histologic lesions in microscopic esophagitis: sensitivity, specificity and reproducibility
Individual histologic
lesion
Sensitivity†
Basal cell hyperplasia
Papillae elongation
DIS
Eosinophils
Neutrophils
Erosion
Healed erosion
93%
62%
86%
49%
7%
8%
ND
Specificity†
45%
80%
70%
90%
100%
100%
ND
Reproducibility (k)
Mastracci
et al. [14]†
Fiocca
et al. [15]*
0.86†
0.87†
0.91†
0.49*
0.81*
0.61*
0.87*
0.84*
0.90*
0.73*
† Mastracci et al., 2009 [14] – single-center study; *Fiocca et al., 2009 [15]
– multicenter study on photographs.
R. Fiocca et al. / Digestive and Liver Disease 43S (2011) S319–S330
last 2 cm above the Z line (2 biopsies at 2 cm and 2
biopsies on the esophageal side of the Z line)**. More
proximal biopsies are less informative [14]. In eosinophilic
esophagitis specimens should be taken from the proximalmiddle esophagus too. Moreover, samples must be obtained
from every endoscopically suspicious lesion.
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4. Non infectious esophagitis (Table 4). Non infectious
esophagitis (due to exposure to chemical or physical agents
or drugs, or associated with diseases of other organs) are
diagnosed mainly on the basis of clinical history, because
as a rule no pathognomonic lesions are found. Esophageal
involvement during bullous skin diseases is usually limited to
the proximal part of the esophagus.
3.5. Diagnostic categories
3.6. Special methods
1. Microscopic esophagitis: this diagnosis is substantiated
by the presence of more than one mild histologic lesion
or erosion/healed erosion/intraepithelial neutrophils in GERD
patients.
2. Eosinophilic esophagitis is a clinico-pathological condition characterized by [12]:
– esophageal and/or upper gastrointestinal symptoms (dysphagia, food impaction, GERD-like symptoms, etc);
– frequent association with a history of bronchial asthma;
– normal pH values;
– absent/poor response to high-dose proton pump inhibitors.
In this clinical context, the diagnosis must be confirmed
by the presence of ≥15 intraepithelial eosinophils/HPF, especially forming microabscesses in the superficial layers of
the epithelium*** (Fig. 4). Contrary to GERD-related microscopic esophagitis, the lesions are usually found also
in the proximal part of the esophagus. High intraepithelial
eosinophil counts are not exclusive to eosinophilic esophagitis, as they can be found also in GERD patients [20] and other
clinical conditions.
3. Infectious esophagitis. Infectious esophagitis is usually
characterized by necrosis of the mucosa (erosion/ulcer) and
acute inflammation. Ulcers are associated with the presence of
granulation tissue. These features are not specific and they can
also be found in other types of esophagitis. Diagnosis must
be based on the identification of viral inclusions and microorganisms by means of special staining, immunohistochemical
or molecular tests. The most common lesions are described in
Table 3.
Staining with hematoxylin and eosin is sufficient to
diagnose microscopic esophagitis. For some specific types
of esophagitis, histochemical staining (PAS/Grocot for fungal
esophagitis) or immunohistochemical staining (CMV and
HSV antibodies) may be useful. Identification of eosinophils
may be hindered by Bouin’s fixation.
3.7. How to write the diagnosis
Microscopic findings – Number and site of esophageal mucosa specimens.
Orientation: adequate/ not adequate.
Histologic lesions:
– basal cell hyperplasia (mild – marked)
– papillae elongation (mild – marked)
– dilated intercellular spaces (small – large)
– intraepithelial eosinophils (maximum number/HPF)
– intraepithelial neutrophils
– erosion/healed erosion
Other specific lesions (fungal forms, cytopathic viral
changes, etc.).
Diagnosis
– Normal findings (no lesion)/Findings are not sufficient to
justify the diagnosis of microscopic esophagitis (presence
of 1 mild histologic lesion).
– Findings are “diagnostic” for microscopic esophagitis
(>1 mild histologic lesion or erosion/healed erosion/
intraepithelial neutrophils).
Table 3
Infectious esophagitis (from Lapertosa et al. [5], with amendments)
Etiology
Clinical information
Guide lesions
Aspecific lesions
Techniques
Herpes simplex
Immunocompetence, site,
endoscopic picture
(vescicles, small ulcers)
Intranuclear eosinophilic
inclusions (Cowdry A);
multinucleate syncytia of
squamous cells
Erosion and/or ulcer, mixed
inflammatory infiltrate
HE IHC
Cytomegalovirus
Immunocompetence, site,
endoscopic picture (ulcer)
Cyto- and nucleo-megaly
with nuclear inclusions
Mucosal ulcers, mixed
inflammatory infiltrate
HE IHC
HPV
Association with squamous
papilloma and/or squamous
carcinoma
Koilocytosis
Candida
Immunocompetence, site
(often multiple sites),
endoscopic picture (erosions,
ulcers, pseudomembranes)
Hyphae and spores
HE: hematoxylin-eosin; IHC: immunohistochemistry.
HE IHC
Erosion and/or ulcer, acute
inflammation, cell debris,
fibrin
HE PAS/Grocot
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Table 4
Non-infectious esophagitis (from Lapertosa et al. [5], with amendments)
Etiology
Clinical information
Pill esophagitis
Aspecific lesions
Techniques
Drug treatment NSAIDs,
antibiotics, AZT, potassium
chloride, etc.)
Site: often at the level of
anatomical stricture
Type of lesion: ulcer
Erosion, ulcer, acute
inflammation, granulation
tissue
HE
Corrosive esophagitis
Ingestion of caustic
substances (accidental,
suicidal)
Diffuse necrosis
HE
Radiation esophagitis
Clinical history of radiation
therapy
Ulcer, edema, fibrosis
HE
Chemotherapy esophagitis
Clinical history of
chemotherapy
Epithelial nuclear atypia,
necrosis, granulation tissue
HE
Esophagitis in Crohn’s
disease
Enteric symptoms,
topography of lesion (focal
ulcers)
Ulcer
HE
Esophagitis in connective
tissue disease
Clinical history
Microscopic esophagitis-like
lesions
HE
Skin diseases
Pemphigus vulgaris
Hailey-Hailey disease
Bullous pemphigoid
Lichen planus
Guide lesions
Cell atypia, vascular changes
Focal inflammation,
granulomas
Intraepithelial bullae,
acantholysis, lymphocytes
and eosinophils
Suprabasal bulla
Subepithelial bulla, mild
inflammation
Vacuolization in the basal
area, lymphocytic infiltration
IF (IgG and C3 deposits in
intercellular spaces)
HE
IF (IgG deposits in basal
membrane)
HE
HE: hematoxylin-eosin; IF: immunofluorescence.
– Findings are “suggestive” of eosinophilic esophagitis (≥15
eosinophils/HPF, with unknown clinical context) or “diagnostic” for eosinophilic esophagitis (≥15 eosinophils/HPF
in a coherent clinical context).
– Findings are “diagnostic” for specific esophagitis (Candida,
CMV, Herpes).
4. Barrett’s esophagus
4.1. Definition
Barrett’s esophagus (BE) is defined as columnar metaplasia
of the distal esophagus, is caused by chronic GERD and
represents a risk factor for esophageal adenocarcinoma [27].
Two types of columnar epithelium may replace esophageal
stratified squamous epithelium*** [10]:
1. intestinal-type epithelium
2. cardia-type epithelium.
This definition is the result of several reassessments of
histologic and endoscopical criteria that have led to different
definitions of BE over time [10,28,29]. Therefore, the adopted
definition of BE is based on the current literature and reflects
the viewpoint of the authors of this article; however, advances
in our understanding of BE may be expected in the near
future.
The original description also included a fundic type of
Barrett’s esophagus [28]. However, when oxyntic mucosa is
found in the distal esophagus, it is generally a sign of hiatus
hernia, whereas it represents ectopia (the so-called “inlet
patches”) when found in the mid-proximal esophagus.
4.2. The border area
Even though the “anatomical” gastro-esophageal junction
(GEJ) has been variously defined, a recent consensus paper
[30] identifies it with the “proximal border of the gastric
folds” when endoscopy is performed with minimal air insufflation (Fig. 6A). The “histological” squamo-columnar
junction (SCJ) or Z line is the transition between esophageal
squamous epithelium and the glandular epithelium of the
stomach (cardia mucosa): it can be detected endoscopically
due to the colour change (white vs. pinkish). As a rule, the
two junctions overlap, but SCJ may be located up to >1 cm
proximally to GEJ also in normal subjects [31].
4.3. Endoscopic description
According to the Montreal classification [10], the term
ESEM (Endoscopically Suspected Esophageal Metaplasia)
designates the presence of “salmon pink” mucosa in the distal
esophagus at endoscopy: it describes suspected columnar
metaplasia (in the tubular esophagus), to be confirmed by
histology***.
R. Fiocca et al. / Digestive and Liver Disease 43S (2011) S319–S330
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Fig. 6. The anatomic gastric-esophageal junction (proximal limit of gastric folds [white line]) usually coincides with the squamous-columnar junction (blue line
= SCJ) (A). In Barrett’s esophagus (an example of long segment is shown) SCJ is located more proximally: distance between white and blue lines = 6.5 cm (i.e.
long Barrett segment) (B). According to the Prague criteria, the values of C (= 5 cm) & M (= 6.5 cm) are provided.
Endoscopic diagnosis is carried out in three steps [30]:
1. identification of the anatomical gastro-esophageal junction
(GEJ);
2. detection of the squamo-columnar junction (SCJ or Z line);
3. measurement of columnar segment.
The “C&M” criteria of the Prague classification [30]
provide clear rules for reporting endoscopic description and
extent of ESEM.
ESEM is measured by two descriptors expressed in cm
from GEJ (Fig. 6B):
– C: circumferential extent
– M: maximal extent
Endoscopic findings measured in this way can be classified
into three categories:
– LSBE: Long Segment Barrett’s Esophagus, ≥3 cm;
– SSBE: Short Segment Barrett’s Esophagus, <3 cm;
– irregular SCJ/Z line: irregular SCJ <1–0.5 cm (which does
not define ESEM with certainty).
The “C&M” criteria have proved to be highly reliable
and reproducible (>90%) both in GEJ detection and in
defining SSBE and LSBE. On the other hand irregular Z line
(or “ultra short” BE), deals with a heterogeneous group of
endoscopic patterns including SSBE with M <1 cm which is
characterized by low reproducibility [30,32,33].
LSBE and SSBE share the same epidemiology and likely
represent two phases of the same process [27]. The length
of the metaplastic segment and the presence of intestinal
metaplasia are currently considered major risk factors for
adenocarcinoma [34,35].
performed close to squamo-columnar junction, the percentage
rises to 94% even with fewer samples [41]. In patients being
followed up for BE, biopsies are recommended in the 4 quadrants of the distal esophagus (every 2 cm routinely and every 1
cm in case of dysplasia [42,43]: unfortunately this sampling is
not frequently performed in routine practice. The widespread
availability of new advanced endoscopic techniques (narrow
band imaging and magnification chromoendoscopy) is expected to increase the detection of dysplasia through a better
targeting of bioptic sampling.
4.5. Individual histologic lesions
Cardia epithelium: columnar epithelium characterized by
mucous-secreting cells and by PAS+ antral-like glands
(Fig. 7). Superficial columnar cells store both neutral and
acid mucins; therefore, the presence of variable alcianophilia
4.4. Biopsy sampling
Multiple biopsies are required in order to characterize
ESEM, their number being correlated to ESEM length [39]:
8 biopsies in the metaplastic segment allow detection of
intestinal epithelium in 68% of cases [40], but if biopsies are
Fig. 7. Cardia-type (or junctional) columnar metaplasia: antral-like glands
and gastric foveolar epithelium in the absence of goblet cells. (H-E, 20×)
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Fig. 8. Intestinal-type columnar metaplasia (incomplete intestinal metaplasia): presence of goblet cells interspersed with foveolar mucous cells (a). Foveolar cells
contain both neutral (PAS+) and acidic (Alcian blue+) mucins. (H-E and PAS-Alcian blue, 20×)
in the absence of goblet cell morphology is not sufficient
to diagnose intestinal metaplasia. Similarly, the presence of
PAS+ dystrophic columnar cells (pseudo-goblet cells) does
not entail intestinal metaplasia. Cardia glands may show
pancreatic acinar metaplasia.
Intestinal epithelium: columnar epithelium characterized by
goblet cells storing acid mucins. The most common variant
of intestinal metaplasia is the “incomplete type” (Fig. 8A),
i.e. devoid of absorptive and Paneth cells. Columnar cells
intermingled with goblet cells often show mixed PAS and
Alcian blue-positive mucins (Fig. 8B). The base of the crypts
may be distorted and crowded, a finding that can be easily
misinterpreted as “dysplasia” (Fig. 9).
Oxyntic gastric epithelium: surface mucous-secreting epithelium with underlying oxyntic glands. As previously reported,
the presence of oxyntic mucosa does not lead to BE diagnosis.
Problems in diagnostic assessment of Barrett’s esophagus:
BE uncertainty areas (due to the different definitions that have
been adopted over the years) regard the “short” forms and/or
the absence of intestinal metaplasia:
• Intestinal metaplasia: it is the main finding required for
BE diagnosis in American and European literature [36],
while British definition covers any “columnar” metaplasia,
including cardia metaplasia [37].
• Extent of the metaplastic segment: the “C&M” criteria
are highly reproducible for LSBE and SSBE (>1 cm).
Conversely, the reproducibility of “ultra-short” BE or irregular Z line (irregularity <1 cm) is poor [30,33]. Intestinal
metaplasia of the cardia (non-ESEM) is a frequent finding
(15–20%) and seems not to be associated with significant
cancer risk.
• Cost/effectiveness: the follow up of BE is expensive [37,
38]. A “broad” definition of BE (including ultra-short BE
without intestinal metaplasia) leads to an increase in followup costs, and makes it ineffective [32].
Fig. 9. Intestinal-type columnar metaplasia (incomplete intestinal metaplasia): the crypts show structural changes, but the surface epithelium is fully
differentiated. (H-E, 20×)
4.6. Diagnostic procedure
Algorithm: endoscopy + histology = diagnosis
BE diagnosis is the result of a two-step procedure [10]:
1. Endoscopy
2. Histology
Endoscopic detection of ESEM must be confirmed by
histology***.
ESEM becomes BE in the presence of intestinal epithelium, regardless of the endoscopic length of the metaplastic
segment (≥1 cm).
R. Fiocca et al. / Digestive and Liver Disease 43S (2011) S319–S330
ESEM becomes BE in the presence of cardia epithelium
only in LSBE: in this case re-sampling close to the SCJ easily
leads to the detection of intestinal epithelium [44].
The presence of intestinal epithelium without ESEM does
not lead to BE diagnosis: the appropriate definition in this
case would be “intestinal metaplasia of the cardia” [31].
“Irregular Z line” defines a doubtful condition that does
not enable a diagnosis of BE due to the equivocal endoscopic
picture, regardless of histological findings [32].
Dysplasia (or non-invasive neoplasia) in BE is defined by unequivocal neoplastic change that does not extend beyond the
basal membrane. Dysplasia requires exclusion of regenerative
lesions [45].
Dysplasia in BE does not equate with atypia and is
not expected to regress. Dysplasia is both a precursor of
adenocarcinoma and a cancer-associated lesion [46].
Dysplasia is endoscopically associated with flat, raised or
depressed lesions and is defined by combined cytological
atypia and architectural abnormalities (Table 5). The diagnostic criteria of dysplasia in BE are common to those used in
other parts of the gastro-intestinal tract [45].
Dysplastic glands show architectural changes (gland fusion
and budding, variable gland size, cribriform pattern) and
cytological alterations (hyperchromatic and elongated nuclei,
nuclear stratification) causing an increasing morphological
deviation from the metaplastic phenotype. Cytological and
architectural abnormalities must involve the entire length of
glands (Fig. 10).
Table 5
Dysplasia/non-invasive neoplasia: criteria to be considered
S327
Caveat
– dysplasia must extend to the surface epithelium;
– the presence of erosion and/or active inflammation requires
caution in diagnosing dysplasia.
Dysplasia associated with BE is divided into three diagnostic categories [47]:
1. Low Grade Dysplasia = LGD
2. High Grade Dysplasia = HGD
3. Indefinite for dysplasia
LGD is characterized by scanty architectural distortion and
mild cytological atypia, mainly affecting the lower half of the
crypts. Hyperchromic nuclei with irregular contours, nuclear
overlapping and dystrophic goblet cells may be present.
HGD is characterized by more complex glandular distortion; nuclear pleomorphism, hyperchromasia and nuclear
stratification are more severe.
Indefinite for dysplasia: this term only applies to cases
where the pathologist cannot decide with certainty whether
the lesion is hyperplastic/regenerative or neoplastic in nature.
This may be due to inadequate biopsy sampling (e.g. poorly
oriented biopsies that do not enable full thickness assessment)
or to the presence of cytological atypia and/or structural alterations of doubtful interpretation. This could also depend on
the specific experience of the pathologist. It is a “provisional”
diagnosis that must be followed by short-term resampling
and/or second opinion. The presence of erosion and neutrophilic infiltrate requires additional caution in diagnosing
dysplasia.
4.7. Special methods (Table 6)
1.
2.
3.
4.
Cytological abnormalities
Architectural abnormalities
Epithelial maturation
Presence of associated inflammation
Alcian Blue-PAS: it helps distinguish cardia from intestinal
epithelium; the latter only shows goblet cells with Alcian
blue-positive acid mucins.
Cytokeratins: cytokeratins 7 and 20 have been suggested as
a tool to differentiate intestinal epithelium in BE from gastric
intestinal metaplasia [48]. Far from providing conclusive
results, the validation of this panel has often revealed false
positives/negatives [49].
CDX-2: this homeobox gene promoting intestinal phenotype is useful to demonstrate the presence of intestinal
differentiation [50]. However, intestinal phenotype is also detectable with hematoxilin-eosin, in combination with Alcian
blue-PAS.
Table 6
Special techniques
Fig. 10. Low-grade epithelial dysplasia in Barrett’s esophagus: cytological
atypia extends to the entire thickness of the epithelium, including the surface
(top left). (H-E, 20×)
1.
2.
3.
4.
5.
6.
Alcian Blue-PAS: recommended
CDX-2: not recommended
CK7/CK20: not recommended
MUC: not recommended
p53: optional for dysplasia
Mib-1/Ki-67: optional for dysplasia
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R. Fiocca et al. / Digestive and Liver Disease 43S (2011) S319–S330
MUC 1-2-3-4-5: family of genes coding for the glycoproteins (mucins) that make up intra- and extracellular
mucus. The distribution of MUC in the gastrointestinal tract
varies (e.g. MUC 2 is more frequent in colonic epithelium).
Cross-reactivity of commercial antibodies has been reported
[51].
p53: nuclear accumulation of p53 can help differentiate
between a reactive/regenerative lesion and dysplasia, with
strong positivity favouring dysplasia. However, it should be
taken into account that regenerative metaplastic lesions may
be associated with a variable increase in p53 and, on the other
hand, dysplasia and carcinoma do not always accumulate p53
[47].
Mib-1/Ki-67 shows the increased extent of proliferation in
case of dysplasia. However, regenerative lesions may also be
associated with high proliferation rate.
In conclusion, so far no specific and reliable markers can
replace conventional histologic examination in the diagnosis
of BE.
4.8. How to write a diagnosis
The flow chart below describes the way in which a
diagnosis should be drafted, based on (1) histological findings,
and (2) endoscopic pattern.
The histology report should include information regarding
(1) the distance from incisors of GEJ and SCJ, (2) the length
of metaplastic segment (according with the C&M criteria),
and (3) the site of biopsies, as in the following example:
“GEJ at 40 cm; endoscopically suspected metaplastic
segment C1-M3; 2 biopsies in the circumferential area (a) and
2 in a more proximal tongue close to SCJ (b).
(a) Two samples of cardia-type mucosa with focal intestinal
metaplasia (incomplete type).
(b) Two samples of squamous epithelium with focal intestinal metaplasia (incomplete type).
Considering the endoscopic description, the above findings are diagnostic for Barrett’s esophagus with intestinal
metaplasia.”
*The term BE is suggested in this case because it is very likely that a subsequent bioptic sampling, closer to the Z line (SCJ), will show the presence of
intestinal metaplasia [44].
R. Fiocca et al. / Digestive and Liver Disease 43S (2011) S319–S330
In the absence of a complete information about the
endoscopic picture and bioptic sampling, the histological
diagnosis should be merely “descriptive”.
[10]
[11]
5. Future perspectives
[12]
These “diagnostic guidelines” have been prepared with
practical needs in mind and refer to the current literature
according to which BE length and the presence of intestinal
metaplasia are the main cancer risk factors. However, recent
studies seem to demonstrate that:
• even cardia-type BE may have some degree of intestinal
differentiation [52];
• both cardia and intestinal BE show similar alterations in
DNA content [53];
• many esophageal “minute cancers” originate in a nonintestinal background [54].
The real impact of these observations on diagnostic
practice (i.e. the reassessment of risk in cardial BE and of the
management of such patients) is still to be confirmed [55].
[13]
[14]
[15]
[16]
[17]
[18]
Aknowledgements
This paper has been supported by a grant from Fondazione
Guido Berlucchi to R. Fiocca.
Conflict of interest
The authors have no conflicts of interest to disclose.
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