Grading of gastric foveolar-type dysplasia in Barrett's esophagus

Abstract

Dysplasia is the gold standard biomarker of cancer risk in Barrett's esophagus, but its diagnosis remains difficult. This is due in part to its multitude of histological appearances. One aspect receiving little attention concerns gastric-type Barrett's dysplasia, which is distinctly different from the well-established intestinal variant. Recognition of gastric-type dysplasia and development of separate grading criteria are required. The prevalence, diagnostic criteria, and natural history of gastric-type Barrett's dysplasia were systematically evaluated in 1854 endoscopic biopsies from a cohort of 200 consecutive Barrett's dysplasia patients. Goblet cells were present in all cases, confirming the utility of this defining feature of Barrett's esophagus. The prevalence of Barrett's gastric-type dysplasia was 15% at the patient level (30 of 200 patients) and 20% at the biopsy level (166 of 852 dysplastic biopsies). Gastric-type dysplasia uniformly showed non-stratified, basally oriented nuclei as the major criterion for distinguishing it from intestinal-type Barrett's dysplasia. As such, loss of nuclear polarity, as the most objective criterion to distinguish intestinal-type low-and high-grade dysplasia, cannot be applied to gastric-type dysplasia. Rather, discriminatory features included increased nuclear size with a high-grade dysplasia cutoff by receiver operating characteristic (ROC) analysis approximating 3-4 times the size of a mature lymphocyte, providing an optimal sensitivity, specificity, and area under the curve of 0.78, 0.90, and 0.90 (95% CI: (0.87, 0.93)), respectively. Crowded, irregular glandular architecture (Po0.001) was more common in high-grade lesions (Po0.001), as was eosinophilic and oncocytic cytoplasm relative to the mucinous cytoplasm (Po0.001), prominent nucleoli (Po0.001), mild nuclear pleomorphism (Po0.001), and villiform architecture (Po0.001). During follow-up, 64% (7 of 11) of patients with pure gastric and 26% (5 of 19) with mixed gastric and intestinal dysplasia underwent neoplastic progression. The recognition of Barrett's gastric-type dysplasia and use of the proposed grading criteria should promote better diagnostic classification of the Barrett's neoplastic spectrum.

Role of brush cytology in the diagnosis of Barrett's esophagus: An analysis of eight cases

“…They stressed on the need for further studies in this regard. 17 Cameron et al stated in their article that esophageal adenocarcinomas occurring in the absence of BE, represent cases, where the metaplastic mucosa has been destroyed by the tumor. 18 To conclude, diagnosing BE is of paramount importance, as it can subsequently develop dysplasia and carcinoma.…”

“…As per Fenoglio-Preister, dysplasia and carcinoma virtually never develop in any columnar epithelium other than in an intestinal metaplastic one. 2 However, in one of the most recent studies, Mahajan et al 17 showed that even cases with the gastric foveolar type of Barrett's esophagus can undergo dysplastic and carcinomatous transformation. They stressed on the need for further studies in this regard.…”

Overdiagnosis of high-grade dysplasia in Barrett's esophagus: a multicenter, international study

“…[5][6][7][8][11][12][13][14][15] Because of its recent description, the gastric variant of Barrett's dysplasia was not separately analyzed in this study. [16][17][18] This omission is unlikely to have affected the reported results; however, because gastric-type Barrett's dysplasia represents a minority of dysplasia cases (B15%). It is also substantially more subtle than intestinal-type dysplasia, leading to under rather than over diagnosis, the subject of this study.…”

The Transcription Factor MIST1 Is a Novel Human Gastric Chief Cell Marker Whose Expression Is Lost in Metaplasia, Dysplasia, and Carcinoma

“…For example, goblet cells by themselves are not reliable indicators of progression, 13,[92][93][94][95][96] and only certain subtypes show unequivocal association with carcinoma. 52,88,97 As a result, the term paracancerous has been introduced to characterize IM lesions.…”