The changing role of the pathologist in the management of Barrett's oesophagus

Abstract

Pathological specimens from columnar-lined oesophagus (CLO) comprise a considerable proportion of the workload of gastrointestinal pathologists in Western countries. There remain controversies concerning the diagnostic role of pathology. More recently, in the UK at least, the diagnosis has been regarded as primarily an endoscopic endeavour, with pathology being corroborative and only diagnostic when endoscopic features are equivocal or when there are additional features that make the endoscopic diagnosis unclear. There is also recognition that demonstration of intestinalisation or 'goblet cells' is not paramount, and should not be required for the diagnosis. There have been notable changes in the management of CLO neoplasia: pathologists are centrally involved in its management. Pathological assessment of endoscopic mucosal resection (EMR) specimens provides the most useful means of determining the management of early neoplasia and of determining indications for surgery. This represents an extraordinarily rapid change in management, in that, <10 years ago, laborious Seattle-type biopsy protocols were recommended, and high grade dysplasia was an indication for resectional surgery. Now, individual patient management is paramount: multi-professional meetings determine management after biopsy and EMR assessment. One significant change is that major resections are undertaken less often, in Western countries, for CLO neoplasia.

Dysplasia in Barrett's oesophagus: p53 immunostaining is more reproducible than haematoxylin and eosin diagnosis and improves overall reliability, while grading is poorly reproducible

“…The evidence provided here, together with evolving clinical management, suggests that the time is approaching to consider moving to a single category of 'definite dysplasia' while at the same time retaining the very useful category of 'indefinite for dysplasia'. This idea was also mooted in a recent review by Hopcroft and Shepherd, 32 and the current study gives further weight to this proposal. This will, of course, place even more onus on the pathologist to diagnose true dysplasia reliably irrespective of grade, and not overdiagnose LGD.…”

The indications for biopsy in routine upper gastrointestinal endoscopy

“…35,36 However, these developments demonstrate much closer alignment between UK and North American practice than hitherto. 37 So, if the histological features of Barrett's oesophagus are not specific to that disease, with potentially identical changes being seen in mucosa from the proximal stomach, and if we accept that no adjunctive test, whether histochemical, immunohistochemical, or otherwise, shows diagnostic features of Barrett's oesophagus, 38,39 some have questioned whether biopsies are required at all, at the index endoscopy, when classic Barrett's oesophagus has been demonstrated endoscopically. Indeed, one of us has argued that perhaps the most important indication for such biopsies is the demonstration of dysplasia complicating CLO, as this is occasionally seen at the index endoscopy.…”

“…Indeed, one of us has argued that perhaps the most important indication for such biopsies is the demonstration of dysplasia complicating CLO, as this is occasionally seen at the index endoscopy. 38 The whole question of how important IM is for the diagnosis of Barrett's oesophagus is now further modified, because we recognise that there is a histological phenotype that is highly characteristic, although not pathognomonic, of Barrett's oesophagus. It was Jansen et al who first demonstrated that CLO very characteristically, and possibly universally, shows consistent continuity of lower gastric-type glands with more superficial intestinal-type glands (Figure 4).…”