Biopsy Approach to Barrett’s EsophagusBarrett’s Esophagus

Robert D. Odze, MD, FRCPCChief, Division of GI Pathology

Professor of PathologyBrigham and Women’s Hospital

Harvard Medical SchoolBoston, MA

Barrett’s EsophagusLecture Outline

1. Definition/Diagnosis (BE vs. Carditis)

2. Dysplasia - Pathology/diagnostic difficulties

- Unusual variants

- Adjunctive tests

3. Natural History

4. Management

5. Future biomarkers

Rising Incidence of Esophageal Adenocarcinoma

Relative change in Relative change in incidence of EAincidence of EAMelanomaMelanomaProstateProstateLungLungBreastBreastColorectalColorectal

Pohl and Welch, JNCI 2005; 97: 142-46

ColorectalColorectal

Dysplasia and Cancer in Barrett’s(Multicenter Cohort)

N=1376

Diagnosis Adenocarcinoma

Prevalent Incident* Incidence(per year)(per year)

N 1376 618 -LGD detection 7.3% 16.1% 4.3%

HGD detection 3% 3.5% 0.9%

AdenoCa detection 6.6% 1.9% 0.5%

*1 618 with ≥ 1 year follow-up Sharma et al, Clin Gastroenterol Hepat 2006;4:566-72

Definition of Barrett’sNorth American (ACG)

• Endoscopically recognizable columnar mucosa in esophaguscolumnar mucosa in esophagus

• Goblet cells identified on biopsy

Normal GEJ

Photo by J. Bergman

Diagnosis• Columnar mucosa, mixed mucous/

oxyntic type

• Squamous mucosa with reactive

changeschanges

• No goblet cell identified

• No dysplasia

Is this Barrett’s?

Management?

Barrett’s Definition

• North America– endoscopy +– goblet cell +

• UK• UK– endoscopy +– columnar epithelium +

• Japan– endoscopy +– lower limit of palisade vessels– columnar epithelium +

Problems with North American Def’n of Barrett’s

• IM not defined by goblet cells

• Sampling error• Sampling error

• Non-goblet epithelium at risk for neoplasia

• Barrett’s esophagus without goblets

• Barrett’s Esophagus vs. Gastric Carditis with IM

Non-Goblet Epithelium in Barrett’s Esophagus is “Intestinalized”

Marker Goblet-CellDeficient

N=72

Goblet-CellPoorN=96

Goblet-CellRichN=112

CDX-2 6% 42% 100%*

DAS-1 39% 29% 96%*

MUC-2 11% 33% 75%*

MUC-1 11% 17% 18%

Ki-67 33% 29% 46%

*p<0.001 Hahn et al, Am J Surg Pathol 2009;33(7):1006-15

Detection of IM in BE:Need for a Minimum of 8 Biopsies

Harrison et al. Am J Gastroenterol 2007;102:1154-1161

N=125

# of biopsies % of cases with IM

1-4 35%

5-8 68%

9-12 74%

13-16 71%

>16 100%

Cardiac Rather than Intestinal-type Background in Endoscopic Resection Specimens of Minute Barrett

AdenocarcinomaTakubo et al, Hum Pathol 2008; In Press

Cancer Type of Epithelium

(< 2 cm in size) Cardiac/Fundic Intestinal(Goblet)

Cardia -Intestinal(Goblet) Intestinal

<3 cm from GEJ (N=43)

79% 16% 5%

≥ 3 cm from GEJ (N=69)

71% 20% 9%

Total (N=141) 71% 22% 7%

Barrett’s Oesophagus: Intestinal Metaplasia is Not Essential for Cancer Risk

Kelty et al, Scan J Gastroenterol 2007;42:1271-1274*

Feature Background Epithelium

Int Met No Int MetInt Met No Int Met

# Patients (N=712) 379(55%) 309(45%)

Adenocarcinoma 17(4.5%) 11(3.6%)

*12 year follow up

Endoscopically “Visible” Columnar Metaplasia

Ultrashort segment (<1 cm)

Terminology Management (Surveillance) Risk of Malignancy

Current Proposed Current Proposed

No goblets ? BE non-goblet type

or Columnar met of esoph

or Columnar-lined esoph

None None

-need more research

Controversial

Evidence says yes

Goblets (few) BE BE, goblet-cell poor

3 years ?>3 years Yes, unknown degree

Goblets (many) BE BE, goblet-cell rich

3 years 3 years Yes, unknown degree

Short (Ultrashort) BE vs. Chronic Carditis

• Distinction important• Distinction important

• Different clinical, etiologic, pathologic, outcome, risk of malignancy

Irregular Z-Line with Intestinal Metaplasia

Esophageal Metaplasia vs Gastric CarditisPathologic Features

Feature Metaplasia Carditis

Squamous re-epithelialization + -Hybrid glands + -Esophageal glands/ducts + -Esophageal glands/ducts + -Multilayered epithelium + -Marked atrophy/disarray + -Diffuse incomplete IM + +/-Esophagitis ++ +/-Distal Gastritis +/- ++Eosinophils ++ +/-Neutrophils/lymphocytes/plasma +/- ++H.Pylori +/- ++

Fig 3. Squamous mucosa over intestinalized crypts in BE

Fig 1. BE with crypt disarray, atrophy and diffuse IM

Fig 5. Hybrid glands (arrows) were seen exclusively in BE

Fig 7. Esophageal duct (arrow) in BE

Multilayered Epithelium and GERDProspective

Feature BE GERD Control

N=27 N=12 N=14

Multilayered 33% 33% 0%

Associated Epithelium

-Goblet cells 56% 0% N/A

-Non-goblet 44% 100% N/A

Length of columnar distal to SCJ

N/A 1.4 1.1

Glickman et al, Am J Surg Pathol 2009;33(6):818-825

BE vs Carditis with IMProposed Markers

CK 7/20 CDX-2

HID HepHID Hep

Alcian/blue CD-10

MUC 1-6 DAS-1

Villin Other

Dysplasia in Barrett’s Esophagus

Unequivocal neoplasia confined Unequivocal neoplasia confined to basement membrane

Neoplasia without Dysplasia*

Esoph - Barrett’s

- Squamous dysplasia

Stomach “Atypical Int Met”Stomach “Atypical Int Met”

“Pit dysplasia”

Pyloric gland “adenoma”

Tubule neck “dysplasia”

Colon - IBD dysplasia

- Hyperplastic/serrated polyps

*Odze et al, Arch Pathol Lab Med 2009 (In Press)

Normal Colon Barrett’s Esophagus

Esophagitis MetaplasiaDysplasiaLG HG

Carcinoma

Enviro

nm

enta

lChanges

Bile acids and pH changesCell interactions

(cadherins, catenins)

MMPs and angiogenesis

Gastrin and other growth factors

Cell cycle and apoptosis changes

Inflammatory response/infiltrate

Modified from: Atherfold PA, Jankowski JA. Molecular Biology of Barrett’s Cancer. Best Pract Res Clin Gastroenterol 2006;20:813-27.

Genetic

Changes

CDx mutations

p53 mutations

Aneuploidy

APC LOH

p16, cyclin D1,p53 mutations

Multiple aneuploidy

Barrett's Metaplasia is a Neoplasm

• Hyperproliferative– Gulizia et al. Hum Pathol 1999; 30:412–8– Gray et al. Gastroenterology 1992;

103:1769–76

• Clonal• Clonal– Maley et al. Cancer Research 2004; 64:3414–27

• Progressive: 0.2–2% per year – Sharma et al. Clin Gastroent Hepatol 2003;

4:566–72

• Does not regress without intervention• Both metaplastic and neoplastic

Vienna System and Dysplasia Morphology Study GroupClassification of Dysplasia in GI Tract

_______________________________________________________________________

Vienna DMSG_________________________________________________________________

1. Negative for neoplasia/dysplasia Negative for dysplasia2. Indefinite for neoplasia/dysplasia Indefinite for dysplasia3. Non-invasive low-grade neoplasia Low-grade dysplasia

(low-grade adenoma/dysplasia)(low-grade adenoma/dysplasia)4. Non-invasive high-grade neoplasia High-grade dysplasia

4.1 High-grade adenoma/dysplasia4.2 Non-invasive carcinoma

(carcinoma in situ)4.3 Suspicious of invasive carcinoma

5. Invasive Neoplasia Adenocarcinoma*5.1 Intramucosal Adenocarcinoma Intramucosal5.2 Submucosal carcinoma or beyond Invasive

__________________________________________________________________*not described by DMSG

Gastric Epith Barrett Eso ph Basal Crypt Dysplasia

Low -grade Dysplasia High -grade Dysplasia Intra -mucosal CALow -grade Dysplasia High -grade Dysplasia Intra -mucosal CA

Poor Agreement in the Diagnosis of Barrett’s Dysplasia in Community

Practice

Poor Agreement in the Diagnosis of Barrett’s Dysplasia in Community

Practice

Gastric metaplasiaGastric metaplasiaIM without dysplasiaIM without dysplasiaLow-grade dysplasiaLow-grade dysplasiaHigh-grade dysplasiaHigh-grade dysplasia

100100

8080

6060

Alikhan M, et al. Gastrointest Endosc 1999; 50:23Alikhan M, et al. Gastrointest Endosc 1999; 50:23

6060

4040

2020

00

%Agreement

%Agreement

Pathologists’ ReadingPathologists’ Reading

DysplasiaFactors Affecting Fate (and detection)

Endoscopic Recognition • Incident vs. Prevalent dysplasia• Visible vs. invisible• Number of biopsies• Frequency of surveillance endoscopy• Interfering factors (strictures, polyps)• Interfering factors (strictures, polyps)• Focality of dysplasia• Recurrence of dysplasia

Pathologic Interpretation• Correct interpretation (inter-observer variation)• Unusual (non-conventional) morphologic variants• Growth pattern (flat vs. elevated)• Extent

Pathologic InterpretationInterobserver Variability

Regeneration vs. DysplasiaRegeneration vs. Dysplasia

High grade vs. Carcinoma

Low Grade vs. High Grade

How much high grade dysplasia is needed to classify a biopsy as classify a biopsy as

“high grade”?

Extent of DysplasiaOutcome

Buttar et al, Gastroenterol 2001;120:1630-1639*

Feature Cancer Free Survival

N 1 year 3 years RRN 1 year 3 years RR

Diffuse HGD 67 62% 44% 3.7

Focal HGD 33 93% 86% 1.0

*retrospective Focal = ≤ 5 crypts Diffuse >5 crypts or >1 biopsy

Extent of DysplasiaOutcome

Dar et al, Gut 2003;52:486-489*

Feature N Carcinoma at resection

Buttar criteria

Diffuse HGD 21 67% 54%

Focal HGD 21 48% 72%

*retrospective Focal = HGD in 1 level Diffuse = HGD > 1 level

Extent of Dysplasia and Cancer Risk

80

100

120

0

20

40

60

80

Total Low Grade High Grade

Progressors

Non-Progressors

#

Dys Crypts/

Patient

Srivastava et al, Am J Gastroenterol 2007;102(3):483-93

Pathologic InterpretationUnusual (Non-conventional) Variants

Dysplasia with Surface Maturation Dysplasia with Surface Maturation

Non-Adenomatous

Foveolar

Serrated

Other

Basal Crypt Dysplasia

Basal Crypt Dysplasia

Crypt Dysplasia With Surface Maturation. A Clinical, Pathologic and Molecular Study of a Barrett’s Cohort

___________________________________________________________________

Feature Basal Crypt Barrett’s pDysplasia ControlsN=15 N=191

___________________________________________________________________

Associated full-crypt 47% 12% 0.002Associated full-crypt 47% 12% 0.002Dysplasia

Mib-1 Proliferation*1 0.46 0.27 <0.0001

P53 Positivity 60% 13% <0.02

Molecular Abnormality*2 80% 52% 0.05___________________________________________________________________*1 Similar to full crypt dysplasia Lomo et al, Am J Surg Pathol 2006;30(4):423-435*2 9pLOH, 17pLOH, ↑ 4N, Aneuploidy

Gastric Barrett’s Crypt Low Grade High GradeDysplasia Dysplasia Dysplasia

S

DNA Content in Barrett’s NeoplasiaSuperficial vs. Basal Crypts

S

B

Aneuploidy 0% 39% 50% 67% 100%Zhan et al, Lab Invst 2007;87(s1):133A

Non-Adenomatous DysplasiaDysplasia

Non-Adenomatous Dysplasia in Barrett’s

Flow Abnormality

Tetraploidy or Aneuploidy

Tetraploidy and Aneuploidy

Tetraploidy and/or Aneuploidy

Patient Group N (1 Abnormality) (2 Abnormalities) (1, 2, or Both Abnormalities)Patient Group N (1 Abnormality) (2 Abnormalities) (1, 2, or Both Abnormalities)

Non-adenomatous dysplasia 13 23% 15% 38%

Adenomatous dysplasia 17 24% 12% 35%

Low-grade 9 33% 11% 44%

High-grade 8 13% 13% 25%

Rucker-Schmidt et al. Am J Surg Pathol 2009;33(6):886-93

Non-Adenomatous Dysplasia in Barrett’s

Maximum diagnosis upon Follow-up

Dysplasia Grade

Patient Group N Metaplasia/Indefinite (%) Low (%) High (%) EA (%)

Nonadenomatous dysplasia

18 6% 0% 78% 17%

Adenomatous dysplasia

24 - 25% 54% 21%

Low-grade 13 - 46% 31% 23%

High-grade 11 - - 82% 18%

Rucker-Schmidt et al. Am J Surg Pathol 2009;33(6):886-93

Adjunctive Diagnostic TechniquesProliferation Markers

DNA content (aneuploidy)

TelomeraseTelomerase

Genetic mutations (p53, p16, Kras, APC, B catenin)

Growth Factors

Apoptosis Inhibitors

Cyclooxygenase 2

AMACR Immunostaining is Useful in Detecting Dysplastic Epithelium in BE, UC and CD__________________________________________

Dysplasia BE Sensitivity Specificity__________________________________________

Negative 0% - -Indefinite 21% - -Low Grade 38% 38% 100%High Grade 81% 81% 100%AdenoCa 72% 72% 100%__________________________________________

Dorer et al, Am J Surg Pathol 2006;30:871-877

A B C

Figure 1. AMACR expression in Barrett’s esophagus wi thout dysplasia (regeneration) (A), with high-grade dysplasia (B), and invasive adenoca rcinoma (C).

AMACR in Barrett’s

Pathology N AMACR

BE* 39 0%

LGD 19 11%

HGD 22 64%

Adeno 12 75%Lisovsky et al, Hum Pathol 2006;37:1601-6*Including “reactive atypia”

p53

Squamous

No dysplasia

Dysplasia

Natural History

of of

Barrett’s Dysplasia

Low-Grade Dysplasia Outcome

Study N Years Follow-up

Incident Cancer

Reid (2000) 43 3.9 3 (7%)

Schnell (2001) 738 7.3 10 (1.3%)

Weston (2001) 48 3.4 1 (1.0%)

Murray (2003) 171 3.7 7 (4.0%)

Dulai (2005) 134 3.2 1 (0.7%)

Sharma (2006) 156 5.0 5 (3.2%)

Vieth (2007) 67 2.3 23 (34%)

Wani et al Clin Gastroenterol and Hepat 2009;7:27-32

Progression of Low-Grade Dysplasia to Carcinoma

__________________________________________________________________________Author # Cases # Pathologists Progression

Agree to HGD1 or Cancer2

____________________________________________________________________________________________________________

Odze (2006) 77 3 31.8%2

Skacel (2000) 25 2 41.0%1,2

3 80.0%1,2

Montgomery (2001) 15 Majority 47.0%1,2

(>6/12)________________________________________________________________________

Odze et al. Am J Gastro 2007;102(3):483-493Skacel et al. Am J Gastro 2000; 95 (12) 3383-3387Montgomery et al. Hum Pathol 2001; 32; 379-398

High-Grade DysplasiaOutcome

Study N Years Follow-up

Incident Cancer

Weston (2000) 15 3 4 (27%)

Reid (2000) 76 4 42 (55%)

Schnell (2001) 75 7.3 12 (16%)

Overholt (2005) 70 1.5 20 (28%)Wani et al, Clin Gastroetnerol and Hepat 2009;7:27-32

Management• Controversial

• Varies between institutions• Varies between institutions• Dependent on surveillance techniques

ACG guidelines for Surveillance in Barrett’s esophagus: (Wang et al, Am J Gastroenterol 108(3):788-797, 2008)

Chronic GERD Symptoms

Screening Endoscopy with Biopsies

Negative for dysplasia Low grade dysplasia High-grade dysplasiax2 endoscopiesx2 endoscopies

Repeat endoscopy with biopsyExpert pathologist opinion

3 year surveillance Repeat x 1Focal Mucosal Multifocal

Annual surveillance irregularityUntil no dysplasia 3 months Intervention

surveillance EMR (surgical)

Low-Grade DysplasiaManagement

• Confirm with experienced GI Pathologist

• Determine extent of dysplasia

• Consider advanced endoscopy• Consider advanced endoscopy- high resolution, narrow band imaging

confocal endomicroscopy

• Consider other biomarkers - aneuploidy, P16, P53

Low-Grade DysplasiaTreatment Options

• PPI/NSAIDS: ? effect• PPI/NSAIDS: ? effect

• Surveillance: 6 mth-1 year

• Ablation (RFA, Cryo)

High Grade DysplasiaTreatment Options

1. Aggressive surveillance

2. Endoscopic ablation- Radiofrequency ablation- Radiofrequency ablation- Photodynamic therapy- Laser photoablation

3. Endoscopic mucosal resection

4. Esophagectomy

Ablation* in Barrett’sMetanalysis

Diagnosis AdenocarcinomaIncidence/1,000 pt years

No Ablation AblationNo AblationN=6,847

AblationN=1,457

BE 6.0 1.6

LGD 17.0 1.6

HGD 66.0 16.8Wani et al. Am J Gastroenterol 2009;104:502-13*APC, Laser, PDT, RFA

Radiofrequency Ablation in Barrett’s with Dysplasia

N=127

Patient Group Ablation Control(Sham)

BE 77% 2.3%

LGD 91% 23%

HGD 81% 19%

Disease Progression 3.6% 16%

Cancer outcome 1.2% 9.3%

Shaheen et al, N Engl J Med 2009;360:2277-88

Endoscopic Mucosal Resection(EMR)

• Removes mucosa/superficialsubmuocsa

• Increases diagnostic accuracy• Increases diagnostic accuracy- Grading of dysplasia

- Depth of invasion

- Lymphovascular invasion

• Therapy for dysplasia/superficial carcinoma

Endoscopic Mucosal ResectionRole of Pathologist

• Dysplasia grade

• Depth of invasion• Depth of invasion

• LVI

• Margins (37-50% recurrence

if positive)

Biomarkers in BE__________________________________________________# Studies

Biomarkers Phase of trial Comment1 or 2 3 4

__________________________________________________Dysplasia grade multiple - - Poor reproductivityNeg/Indef/LGD - - 5 Poor Ca predictorHGD - 1 3 Inconsistent resultsDNA content Multiple - 3 Strong Ca predictorP53 mutation Multiple - - ?P53 immuno Multiple 4 - High false neg/posP16 multiple - - ?Proliferation multiple - 1 Not indep. predictorCyclin D multiple 1 - Strong Ca predictor__________________________________________________________

Dysplasia gradeDysplasia gradeSeattle CriteriaSeattle Criteria

4 Biopsies per 1-2 cm plusTargeted Biopsies

Pro

babi

lity

of C

ance

r

Pro

babi

lity

of C

ance

r

All 3 biomarkers abnormal2 biomarkers abnormal1 biomarker abnormalno abnormalities

p16, p53, ploidy Biomarker Panel Progression to EA

Biomarker panel Biomarker panel ((99pLOH, pLOH, 1717pLOH, abnormal ploidy)pLOH, abnormal ploidy)

43%

21%

<HGD

Time (months)

Pro

babi

lity

of C

ance

r

HGD

Time (months)

Pro

babi

lity

of C

ance

r

1 Biopsy per 2 cm

Summary

1. Diagnosis of BE controversial2. Short segment BE distinguished from carditis in

20-30% cases20-30% cases3. Recognition and grading of dysplasia has many

limitations4. Extent of dysplasia important prognostically5. Natural history and treatment of dysplasia

evolving: esophagectomy ablation