GERD, Barrett’s esophagus and dysplasia

Classical and some recent featuresJean-François Fléjou

Dept of Pathology, Hôpital Saint-Antoine,

Faculté de Médecine Pierre et Maris Curie, Paris, France

Gastroesophageal reflux disease (GERD)

The Castell Iceberg

- GER (10% population) : digestive symptoms (75%) or

extra-digestive (25%)

- Reflux esophagitis (10% endoscopies) : complication of

GER : lesions are secondary to acid (and alkaline?) GER

- Ulceration, stenosis, Barrett’s esophagus : complications

of esophagitis

Pathology of GERDHistological lesions on biopsies

- Non erosive esophagitis : “early oesophagitis” (Ismael

Beigi)

- Peptic esophagitis, erosive or ulcerated

- Barrett’s esophagus (French “endobrachyoesophage”)

Histological features of early reflux oesophagitis

- Basal zone hyperplasia (>15%), with mitosis and nuclearenlargement- Elongated papillae (>75%)- Papillary capillary ectasia and venular dilatation- Intraepithelial inflammatory cells (lymphocytes, eosinophils)- spongiosis, widening of intercellular spaces, balloon cells

Described on large biopsies (capsule), diagnostic significance debated, may have a role to diagnose clinically atypical cases.

Most guidelines do not recommend to biopsy when endoscopy is normal or shows typical features

However, recent renewal in the potential interest…

Early reflux oesophagitis

• increased stromal papillae length• increased basal cells thickness• increased proliferation (mitosis)• balloon cells

• widening of intercellular spaces• polymorphonuclear eosinophils

Some words on eosinophilic esophagitis

Oesophagite à éosinophiles- Diminution des parasitoses et augmentation des allergies- La plus fréquente des « …ites à éosino. » du TD- Reconnaissance récente- Pas d’éosino dans l’œsophage nal- Enfant et adulte jeune, H >> F- Pic été – automne- Symptômes variables, souvent dysphagie progressive

Oesophagite à éosinophiles• Endoscopie très variable, peut être

normale (1/3)• Risque élevé de perforation à

l’endoscopie (et en cas de dilatation)

• Dg différentiel : Reflux

• Pas de risque de cancérisation

• Tt : suppression allergènes, corticoïdes

Oesophagite à éosinophiles

• Diagnostic repose sur les biopsies– Nombreuses (1 biopsie sensibilité

55%; 10 biopsies sensibilité 100%)– Œsophage moyen, pour distinguer

de l’oesophagite par reflux– Critère principal : PNE > 15/champ

au x40• En surface• « microabcès »• Autres lésions d’oesophagite

(hyperplasie couches basales, allongement papilles…)

Barrett - Summary

• Some words on history• Definition • Barrett’s carcinogenesis

– Dysplasia– Carcinogenetic process– Alternative markers

• Novel therapeutic possibilities– importance of double muscularis mucosae

• New diagnostic methods

A short history of Barrett’s oesophagus

• Lyall, Br J Surg 1937 : “ulcers occur in the oesophagus, and are surrounded by heterotopic gastric mucosa”

• Barrett NR, Br J Surg 1950 : “chronic peptic ulcer of the oesophagus and oesophagitis”– 2 distinct lesions :

• Reflux oesophagitis• Peptic ulcer of the oesophagus, that correspond to congenital short

oesophagus with gastric ulcer in the mediastinal stomach

• Morson & Belcher, Br J Cancer 1952 : “Adenocarcinoma of the oesophagus and ectopic gastric mucosa”

A short history of Barrett’s oesophagus• Allison & Johnstone, Thorax

1953 : reflux oesophagitis, with stomach drawn up to the mediastinum by the contracting scar tissue in the stricture

19532002

A short history of Barrett’s oesophagus

• Some may be worried because I have changed my opinion• The lesion should be called “the lower esophagus lined by columnar

epithelium”• It is probably the result of a failure of the embryonic lining of the gullet to

achieve maturity.

Lord RV. Norman Barrett, “Doyen of esophageal surgery”. Ann Surg 1999;229:428.

Barrett’s oesophagus : acronyms etc.

CELLO Columnar epithelium lined lower oesophagus

CLE Columnar lined esophagus

EBO Endobrachyoesophage (France)

Lortat-Jacob JL 1957BO Barrett’s oesophagus

LSBO Long segment Barrett’s oesophagus

SSBO Short segment Barrett’s oesophagus

USSBO Ultrashort segment Barrett’soesophagus

Which kind of epithelium lines Barrett’s oesophagus?

• Initial descriptions : – “ectopic gastric mucosa”. – Accurate reading : “columnar cells, mucus secreting

units, tubular glands, no oxyntic cells” (Barrett 1957)• Morson & Belcher 1952 :

– Intestinal metaplasia• Paull et al 1976

– Classical description of 3 types of metaplastic epithelium• “Modern” period :

– Intestinal metaplasia (goblet cells) is mandatory for the diagnosis, but...

BO: practical diagnostic definitions

endoscopical and histological

• “Classical”: circumferential columnar epithelium > 30 mm above the oesophago-gastric junction (OGJ)– 3 types of columnar

epithelium (Paull 1976)• “Specialized” or intestinal

• Cardiac (junctionnal)

• Fundic (gastric)

– Now considered as “long segment BO”. Can also be present as tongues

Chatelain et alVirchows Archiv 2003

Zonal?

Mosaic?

BO: practical diagnostic definitionsendoscopical and histological

• “Short segment” BO: endoscopically visible columnar epithelium <30 mm above the oesophago-gastric junction (OGJ), circumferential and/or as tongues– 1 type of columnar epithelium : “specialized” or intestinal

• Normal appearing OGJ with intestinal metaplasia– “Ultrashort” segment BO or carditis with IM ??

General definition (AGA) : an abnormal appearing distal oesophageal lining (endoscopic BO) with histologic evidence of oesophageal intestinal metaplasia (confirmed histologic BO)

BSG guidelines for the management of CELLO

1. Biopsies diagnostic for CELLO : metaplastic mucosa + native oesophageal glands (10-15%)

2. Biopsies corroborative of an endoscopic diagnosis of CELLO : intestinal metaplasia (specialized)

- Pb : IM in a hiatus hernia, IM at the cardia

3. Biopsies in keeping with, but not specific for CELLO : cardiac +/-fundic type without IM

- Pb : OGJ ?

4. Biopsies without evidence of CELLO: squamous mucosa

What about the cardiac mucosa?

A highly controversial issue! Always short, always metaplastic?

squamous

Cardiac and oxynto-cardiac

Fundic

Fundic with gastritis (H pylori)

Intestinal metaplasia

Gastric folds

cm

cm

Normal GOJ Long segmt BO

Short segmt BOCarditis + IM

cytokeratins (and other markers) ? Still discussed, not used in routine practice

CK20CK7 Barrett type IM

Gastric type IMCK7 CK20

and for the moment, the problem is not supposed to exist…

Carcinogenesis of Barrett’s mucosa

• 10% of patients with GERD have Barrett’s oesophagus (and 1-2% of the general population).

• Almost all oesophageal adenocarcinomas develop on Barrett’s oesophagus.

• The frequency of oesophageal adenocarcinoma is increasing (including in France).

• Adenocarcinoma is preceded by intraepithelial neoplasia (dysplasia) in all prospective surveillance studies.

• The molecular mechanisms involved in the transformation of Barrett’s mucosa are still incompletely established.

Potet F and Barge J

Ann Pathol 1991

What’s new (?) on dysplasia on BO • Terminology : intraepithelial neoplasia (WHO)

• Classification : revised Vienna

• Problems: sampling (« Seattle protocol », or > 8 biopsies), reproducibility, natural history

• Solutions?: double lecture, markers, new diagnostic methods

intestinal metaplasia Low grade IEN

high grade IENadenocarcinoma

Riddell’s and Vienna classifications

Terminology in Riddell’s and Vienna Classification

Clinical consequences in patients with Barrett’s oesophagus

Category 1 Negative for dysplasia Follow-up

Category 2 Indefinite for dysplasia Follow-up. Reinforce medical treatment

Category 3 Low grade dysplasia Endoscopic treatment or reinforced follow-up

Category 4 4.1 High grade dysplasia4.2 Non invasive carcinoma

(carcinoma in situ)4.3 Suspicion of invasive carcinoma

Endoscopic or surgical treatment

Category 5 Invasive neoplasia5.1 Intramucosal carcinoma5.2 Submucosal carcinoma or

beyond

Surgical resection

Dysplasia in Barrett’s oesophagusDiagnostic reproducibility

Montgomery et al, Hum Pathol 2001

Diagnosis k 1rst set k 2nd set

Non dysplastic 0.44 0.58Indefinite 0.13 0.15Low grade 0.23 0.31High grade – cancer 0.63 0.64

Diagnostic algorithm of dysplasia in Barrett’s oesophagus (Montgomery et al, Hum Pathol 2001)

Four features 1- surface maturation in comparison with the underlying glands2 - architecture of the glands3 - cytologic pattern of the proliferating cells4 - inflammation and erosions / ulcers

Reparation Transformation (dysplasia)1 present absent2 nal or mild alteration mild (LG) or marked (HG)3 nal or atypia mild or focally LG: mild diffuse, marked focal

marked (with inflammation) HG: marked diffuse4 « cases with abundant inflammation and the other features of LGD are

usually best classified in the indefinite category »

intestinal metaplasia low grade dysplasia

high grade dysplasiaadenocarcinoma

mechanisms?

From Morales et al, Lancet 2002

Squamous epithelium

Chronic inflammation

Barrett’s metaplasia

Low-grade dysplasia

High grade dysplasia

Barrett’s carcinoma

• Growth self sufficiency Cyclin D, TGFα EGF

• Insensitivity to p16 LOH methyl. APC methyl.anti-growth signals• Avoidance of apoptosis COX2 p53 LOH mutation FasL

• Limitless replicative Telomerasepotential reactivation• Sustained angiogenesis VEGF - VEGFR

• Invasion and metastasis E-cadherinβ-catenin

Injury :Acid reflux...

Genetics :Sex, race, other... aneuploidy

Biomarkers in Barrett’s oesophagus• Any biologic measurement that can predict with reliability which

individuals will develop cancer and which will not*

• Practically, three types : – histopathology : dysplasia– other tests using endoscopical bioptic sampling, mainly molecular– alternative endoscopical or non endoscopical techniques, under

development

• As the current practice is histopathology, any new markers need increased reproducibility, sensitivity, and specificity as compared with histology

• Spechler SJ “please, not another marker of Barrett’s oesophagus!”

*Reid et al, Gastrointest Endoscopy Clin N Am 2003

Biomarkers in Barrett’s mucosa

An incomplete list of recently published biomarkers :

RANK, SPARC, cdx-2, villin, Bcl-XL, c-Src, IGF1R, Kras, BRAF, HMGI(Y), HSP27, PLA2, DAF, Neuropilin-1, RXR, Telomerase, p16, p53, DNA damage, CGH array, VEGF, CK7/20, COX2, COX1, HCA, Hep-par1, MMR, polymorphisms of cytokines, CD1a, ERK, CDK1, c-Met, CDX1, CDX2, survivin, MUC2, PITX1, MTAP, CD105, Rab11a, Claudin, CD10, MUC5AC, Defensine 5, cyclin D1, TFF1, CES2, nfKb, 7q, RUNX3, HPP1, microRNAs, Slug, racemase, GATA4, GRP78, REG1a, Ski/SnoN, AKAP12, leptin, WIF-1, SS, E2F-1, HER-2…

In routine practice, in 2009, only p53 and Ki67 can be used, with limited value +++

p53 in Barrett • 3 methods of evaluation:

LOH

gene mutation

protein expression

• Numerous phase 1-2 studies show frequent alterations, increasing with the severity of histological lesions

• in the same patient, almost never in normal mucosa, almost ever (80-90%) in cancer tissue

17p LOH in BO• Numerous phase 1-2 studies, limited number of patients,

retrospective.• Progressive increase of LOH, similar to protein

overexpression• One large scale phase 4 study

Reid et al, Am J Gastroenterol 2001

• Still not suitable in routine practice (neither p53 gene mutation)

p53 immunohistochemistry in BO• Very numerous phase 1-2 studies, limited number of

patients, retrospective, various antibodies and cut-of values• Progressive increase of positivity : ND (0-5%), LGD (10-

25%), HGD and Ca (50-90%)• Percentage of false negative (stop mutations) and false

positive (?)

A critical review of the diagnosis and management of Barrett’s esophagus: The AGA

Chicago workshop

Statement number 28“The use of flow cytometry or biomarkers (such as p53 and

p16 mutations) is promising and merits further clinical research”– Nature of evidence : II (obtained from well-designed cohort or case-

controlled studies)– Subgroup support : A (good evidence to support the statement)– Accept completely : 72%

Sharma et al, Gastroenterology 2004

• chromoendoscopy

• autofluorescence

• Pillcam

• Laser confocal endoscopy

• Optical coherence tomography

•Raman Spectroscopy

• …New endoscopical and non endoscopical methods to explore Barrett’s mucosa

New treatments of early neoplastic lesions

• “Destructive”– Laser– Photodynamic therapy– Electro-coagulation

• “Ablative”– Mucosectomy– Endoscopic submucosal dissection

For all methods, think to residual glands under reepithelialised squamous epithelium (“buried glands”)

Mucosectomy

• Orientate• Give

– the grade (dysplasia)– the stage (adenocarcinoma)– in an international classification (Vienna, WHO, pT UICC, Kudo, Paris)

• Evaluate margins– laterally (+/-)– deep (+++)

Extension in depthsm1 sm2

MM

Paris classification

sm1 < 500 μm

sm2 > 500 μm

Specific to Barrett: double muscularis mucosa

m sm

MM1

MM2

• Double MM in BO

– Constant– May be triple– External is original– Implications for

cancer staging:• Between two, it is still

mucosa• External can look as

muscularis propria– Very important on

mucosectomy specimens (Offerhaus, Virchow Archiv)

« Messages »

• Diagnose short segment BO (oesophageal IM)

• What about ultrashort BO ??• H&E is enough in most cases • Use international classifications for

dysplasia and cancer staging• Be very careful with mucosectomy

specimens• Accompany the development of new

diagnostic methods