Difference between revisions of "Columnar dysplasia of the esophagus"

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#redirect [[Esophagus#Columnar_dysplasia_of_the_esophagus]]
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = High-grade_columnar_dysplasia_of_the_esophagus_-_alt_--_intermed_mag.jpg
| Width      =
| Caption    = High-grade columnar dysplasia of the esophagus. [[H&E stain]].
| Synonyms  = columnar dysplasia, [[esophageal dysplasia]] (nonspecific term)
| Micro      =
| Subtypes  = low-grade, high-grade
| LMDDx      = [[intestinal metaplasia of the esophagus]], [[esophageal adenocarcinoma]], [[basal crypt dysplasia]]
| Stains    =
| IHC        =
| EM        =
| Molecular  =
| IF        =
| Gross      =
| Grossing  =
| Site      = [[esophagus]] - distal
| Assdx      = [[Barrett's esophagus]], [[esophageal adenocarcinoma]], [[GERD]]
| Syndromes  =
| Clinicalhx = [[GERD]]
| Signs      =
| Symptoms  =
| Prevalence = uncommon
| Bloodwork  =
| Rads      =
| Endoscopy  =
| Prognosis  = pre-malignant (benign)
| Other      =
| ClinDDx    =
| Tx        = low-grade: followup with biopsy; high-grade: resection (surgery, endoscopic mucosal resection)
}}
'''Columnar dysplasia of the esophagus''' is a pre-malignant lesion the [[esophagus]] associated with [[Barrett's esophagus]]. It is considered the precursor of [[esophageal adenocarcinoma]].


It is also known as '''esophageal columnar dysplasia''' (abbreviated '''ECD'''),<ref name=pmid21809994>{{Cite journal  | last1 = Feng | first1 = W. | last2 = Zhou | first2 = Z. | last3 = Peters | first3 = JH. | last4 = Khoury | first4 = T. | last5 = Zhai | first5 = Q. | last6 = Wei | first6 = Q. | last7 = Truong | first7 = CD. | last8 = Song | first8 = SW. | last9 = Tan | first9 = D. | title = Expression of insulin-like growth factor II mRNA-binding protein 3 in human esophageal adenocarcinoma and its precursor lesions. | journal = Arch Pathol Lab Med | volume = 135 | issue = 8 | pages = 1024-31 | month = Aug | year = 2011 | doi = 10.5858/2009-0617-OAR2 | PMID = 21809994 }}</ref>
'''dysplasia in the columnar-lined esophagus''',<ref>{{Cite journal  | last1 = Levine | first1 = DS. | title = Management of dysplasia in the columnar-lined esophagus. | journal = Gastroenterol Clin North Am | volume = 26 | issue = 3 | pages = 613-34 | month = Sep | year = 1997 | doi =  | PMID = 9309409 }}</ref>
and '''columnar epithelial dysplasia'''.<ref name=pmid3825997>{{Cite journal  | last1 = Hamilton | first1 = SR. | last2 = Smith | first2 = RR. | title = The relationship between columnar epithelial dysplasia and invasive adenocarcinoma arising in Barrett's esophagus. | journal = Am J Clin Pathol | volume = 87 | issue = 3 | pages = 301-12 | month = Mar | year = 1987 | doi =  | PMID = 3825997 }}</ref>
==General==
*Arises in the setting of ''[[Barrett esophagus]]''.
*Precursor of [[esophageal adenocarcinoma]].
===Classification===
#Indefinite for dysplasia.
#*[[Diagnosis]] used in the context of uncertainty (like ''[[gynecologic cytopathology|ASCUS]]'' and ''[[prostate gland|ASAP]]''); the classic reason for its use is: the surface (epithelium) cannot be seen (which precludes assessment of maturation); may be used in the context of inflammation.
#Low grade dysplasia.
#High grade dysplasia.
===Management===
Low grade dysplasia & indefinite for dysplasia:
*Follow-up.
High grade dysplasia:
*[[Endoscopic mucosal resection]] (EMR).<ref name=pmid19306943>{{cite journal |author=Sampliner RE |title=Endoscopic Therapy for Barrett's Esophagus |journal=Clin. Gastroenterol. Hepatol. |volume= |issue= |pages= |year=2009 |month=March |pmid=19306943 |doi=10.1016/j.cgh.2009.03.011 |url=}}</ref>
*Surgical resection (esophagectomy).
==Microscopic==
Features to assess:<ref name=Ref_GLP46>{{Ref GLP|46}}</ref>
# Lack of surface maturation - very common, occasionally absent.<ref name=pmid16625087>{{Cite journal  | last1 = Lomo | first1 = LC. | last2 = Blount | first2 = PL. | last3 = Sanchez | first3 = CA. | last4 = Li | first4 = X. | last5 = Galipeau | first5 = PC. | last6 = Cowan | first6 = DS. | last7 = Ayub | first7 = K. | last8 = Rabinovitch | first8 = PS. | last9 = Reid | first9 = BJ. | title = Crypt dysplasia with surface maturation: a clinical, pathologic, and molecular study of a Barrett's esophagus cohort. | journal = Am J Surg Pathol | volume = 30 | issue = 4 | pages = 423-35 | month = Apr | year = 2006 | doi =  | PMID = 16625087 }}</ref>
#*Lack of lighter staining at surface.
#*Nuclear crowding at surface.
#*Nuclei at the surface not smaller.
# Architecture - esp. at low power.
#* Glands not round.
#** Low-grade feature: gland budding.
#** High-grade features: cribriforming, cystic dilation, necrotic debris.
#* Gland density:
#** Increased & round - think low-grade dysplasia.
#** Increased & irregular - think high-grade dysplasia.
# Cytology, esp. at high magnification.
#* Nuclear abnormalities in: size, staining, shape.
#* Loss of "nuclear polarity" = high-grade feature
#** Loss of palisaded appearance, rounding-up of nuclei.
# Inflammation, erosions & ulceration.
#* Marked inflammation should prompt consideration of knocking down the diagnosis one step, i.e. low-grade becomes indefinite ''or'' high-grade becomes low-grade.
Negatives:
#No desmoplasia.
#*Stromal fibrotic reaction to the tumour.
#**Desmoplasia is rare in the superficial esophagus.<ref name=Ref_GLP49>{{Ref GLP|49}}</ref>
#No single cells.
#No extensive back-to-back glands.
Notes:
*Changes similar to those see in colorectal tubular adenomas; however, what would be low-grade dysplasia in the rectum is high-grade dysplasia in the esophagus.
*Presence of goblet cells suggests it is not dysplasia.<ref>GAG. January 2009.</ref>
*Desmoplasia present = invasive adenocarcinoma.<ref name=Ref_GLP54>{{Ref GLP|54}}</ref>
*Some literature suggests community pathologists should ''not'' make this call, i.e. it should be diagnosed by an expert.<ref name=pmid10385717>{{Cite journal  | last1 = Alikhan | first1 = M. | last2 = Rex | first2 = D. | last3 = Khan | first3 = A. | last4 = Rahmani | first4 = E. | last5 = Cummings | first5 = O. | last6 = Ulbright | first6 = TM. | title = Variable pathologic interpretation of columnar lined esophagus by general pathologists in community practice. | journal = Gastrointest Endosc | volume = 50 | issue = 1 | pages = 23-6 | month = Jul | year = 1999 | doi =  | PMID = 10385717 }}</ref>
DDx:
*[[Intestinal metaplasia of the esophagus]].
*[[Esophageal adenocarcinoma]].
===Images===
No dysplasia - only intestinal metaplasia:
*[http://www.nature.com/nrgastro/journal/v6/n8/fig_tab/nrgastro.2009.103_F4.html Intestinal metaplasia (nature.com)].
====Indefinite for columnar dysplasia====
www:
*[http://www.nature.com/nrgastro/journal/v6/n8/fig_tab/nrgastro.2009.103_F8.html Indefinite for columnar dysplasia (nature.com)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861756/figure/fig6/ Indefinite for columnar dysplasia (nih.gov)].<ref name=pmid17021130/>
====Low-grade columnar dysplasia====
<gallery>
Image: Low-grade columnar dysplasia of the esophagus -- low mag.jpg | LGD - low mag. (WC)
Image: Low-grade columnar dysplasia of the esophagus -- intermed mag.jpg | LGD - intermed. mag. (WC)
Image: Low-grade columnar dysplasia of the esophagus -- high mag.jpg | LGD - high mag. (WC)
Image: Low-grade columnar dysplasia of the esophagus -- very high mag.jpg | LGD - very high mag. (WC)
</gallery>
www:
*[http://www.nature.com/nrgastro/journal/v6/n8/fig_tab/nrgastro.2009.103_F5.html Low-grade columnar dysplasia (nature.com)].<ref name=pmid19581906>{{Cite journal  | last1 = Odze | first1 = RD. | title = Barrett esophagus: histology and pathology for the clinician. | journal = Nat Rev Gastroenterol Hepatol | volume = 6 | issue = 8 | pages = 478-90 | month = Aug | year = 2009 | doi = 10.1038/nrgastro.2009.103 | PMID = 19581906 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861756/figure/fig2/ Low-grade columnar dysplasia (nih.gov)].<ref name=pmid17021130>{{Cite journal  | last1 = Odze | first1 = RD. | title = Diagnosis and grading of dysplasia in Barrett's oesophagus. | journal = J Clin Pathol | volume = 59 | issue = 10 | pages = 1029-38 | month = Oct | year = 2006 | doi = 10.1136/jcp.2005.035337 | PMID = 17021130 }}</ref>
====High-grade columnar dysplasia====
<gallery>
Image: High-grade columnar dysplasia of the esophagus -- low mag.jpg | HGD - low mag.
Image: High-grade columnar dysplasia of the esophagus -- intermed mag.jpg | HGD - intermed. mag.
Image: High-grade columnar dysplasia of the esophagus - alt -- intermed mag.jpg | HGD - intermed. mag.
Image: High-grade columnar dysplasia of the esophagus -- high mag.jpg | HGD - high mag.
</gallery>
www:
*[http://www.nature.com/nrgastro/journal/v6/n8/fig_tab/nrgastro.2009.103_F6.html High-grade columnar dysplasia (nature.com)].<ref name=pmid19581906/>
*[http://www.nature.com/ajg/journal/v104/n10/fig_tab/ajg2009390f3.html High-grade columnar dysplasia (nature.com)].<ref name=pmid19623166>{{Cite journal  | last1 = Riddell | first1 = RH. | last2 = Odze | first2 = RD. | title = Definition of Barrett's esophagus: time for a rethink--is intestinal metaplasia dead? | journal = Am J Gastroenterol | volume = 104 | issue = 10 | pages = 2588-94 | month = Oct | year = 2009 | doi = 10.1038/ajg.2009.390 | PMID = 19623166 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861756/figure/fig3/ High-grade columnar dysplasia (nih.gov)].<ref name=pmid17021130/>
==Sign out==
<pre>
ESOPHAGUS, DISTAL, BIOPSY:
- LOW-GRADE COLUMNAR EPITHELIAL DYSPLASIA, SEE COMMENT.
- COLUMNAR EPITHELIUM WITH GOBLET CELL METAPLASIA.
- REACTIVE SQUAMOUS EPITHELIUM.
COMMENT:
This was reviewed with Dr. X and they agree with the diagnosis.
</pre>
====Alternate====
<pre>
ESOPHAGUS, 30 CM, BIOPSY:
- LOW-GRADE COLUMNAR DYSPLASIA WITH INTESTINAL METAPLASIA AND MILD CHRONIC
  INFLAMMATION.
- NEGATIVE FOR MALIGNANCY.
</pre>
==See also==
*[[Esophagus]].
*[[Esophageal adenocarcinoma]].
==References==
{{Reflist|2}}
[[Category:Esophagus]]
[[Category:Diagnosis]]
[[Category:Diagnosis]]

Latest revision as of 06:25, 14 January 2015

Columnar dysplasia of the esophagus
Diagnosis in short

High-grade columnar dysplasia of the esophagus. H&E stain.
Synonyms columnar dysplasia, esophageal dysplasia (nonspecific term)
Subtypes low-grade, high-grade
LM DDx intestinal metaplasia of the esophagus, esophageal adenocarcinoma, basal crypt dysplasia
Site esophagus - distal
Associated Dx Barrett's esophagus, esophageal adenocarcinoma, GERD
Clinical history GERD
Prevalence uncommon
Prognosis pre-malignant (benign)
Treatment low-grade: followup with biopsy; high-grade: resection (surgery, endoscopic mucosal resection)

Columnar dysplasia of the esophagus is a pre-malignant lesion the esophagus associated with Barrett's esophagus. It is considered the precursor of esophageal adenocarcinoma.

It is also known as esophageal columnar dysplasia (abbreviated ECD),[1] dysplasia in the columnar-lined esophagus,[2] and columnar epithelial dysplasia.[3]

General

Classification

  1. Indefinite for dysplasia.
    • Diagnosis used in the context of uncertainty (like ASCUS and ASAP); the classic reason for its use is: the surface (epithelium) cannot be seen (which precludes assessment of maturation); may be used in the context of inflammation.
  2. Low grade dysplasia.
  3. High grade dysplasia.

Management

Low grade dysplasia & indefinite for dysplasia:

  • Follow-up.

High grade dysplasia:

Microscopic

Features to assess:[5]

  1. Lack of surface maturation - very common, occasionally absent.[6]
    • Lack of lighter staining at surface.
    • Nuclear crowding at surface.
    • Nuclei at the surface not smaller.
  2. Architecture - esp. at low power.
    • Glands not round.
      • Low-grade feature: gland budding.
      • High-grade features: cribriforming, cystic dilation, necrotic debris.
    • Gland density:
      • Increased & round - think low-grade dysplasia.
      • Increased & irregular - think high-grade dysplasia.
  3. Cytology, esp. at high magnification.
    • Nuclear abnormalities in: size, staining, shape.
    • Loss of "nuclear polarity" = high-grade feature
      • Loss of palisaded appearance, rounding-up of nuclei.
  4. Inflammation, erosions & ulceration.
    • Marked inflammation should prompt consideration of knocking down the diagnosis one step, i.e. low-grade becomes indefinite or high-grade becomes low-grade.

Negatives:

  1. No desmoplasia.
    • Stromal fibrotic reaction to the tumour.
      • Desmoplasia is rare in the superficial esophagus.[7]
  2. No single cells.
  3. No extensive back-to-back glands.

Notes:

  • Changes similar to those see in colorectal tubular adenomas; however, what would be low-grade dysplasia in the rectum is high-grade dysplasia in the esophagus.
  • Presence of goblet cells suggests it is not dysplasia.[8]
  • Desmoplasia present = invasive adenocarcinoma.[9]
  • Some literature suggests community pathologists should not make this call, i.e. it should be diagnosed by an expert.[10]

DDx:

Images

No dysplasia - only intestinal metaplasia:

Indefinite for columnar dysplasia

www:

Low-grade columnar dysplasia

  • LGD - low mag. (WC)

  • LGD - intermed. mag. (WC)

  • LGD - high mag. (WC)

  • LGD - very high mag. (WC)

www:

High-grade columnar dysplasia

  • HGD - low mag.

  • HGD - intermed. mag.

  • HGD - intermed. mag.

  • HGD - high mag.

www:

Sign out

ESOPHAGUS, DISTAL, BIOPSY:
- LOW-GRADE COLUMNAR EPITHELIAL DYSPLASIA, SEE COMMENT.
- COLUMNAR EPITHELIUM WITH GOBLET CELL METAPLASIA.
- REACTIVE SQUAMOUS EPITHELIUM.

COMMENT:
This was reviewed with Dr. X and they agree with the diagnosis.

Alternate

ESOPHAGUS, 30 CM, BIOPSY:
- LOW-GRADE COLUMNAR DYSPLASIA WITH INTESTINAL METAPLASIA AND MILD CHRONIC
  INFLAMMATION.
- NEGATIVE FOR MALIGNANCY.

See also

References

  1. ↑ Feng, W.; Zhou, Z.; Peters, JH.; Khoury, T.; Zhai, Q.; Wei, Q.; Truong, CD.; Song, SW. et al. (Aug 2011). "Expression of insulin-like growth factor II mRNA-binding protein 3 in human esophageal adenocarcinoma and its precursor lesions.". Arch Pathol Lab Med 135 (8): 1024-31. doi:10.5858/2009-0617-OAR2. PMID 21809994.
  2. ↑ Levine, DS. (Sep 1997). "Management of dysplasia in the columnar-lined esophagus.". Gastroenterol Clin North Am 26 (3): 613-34. PMID 9309409.
  3. ↑ Hamilton, SR.; Smith, RR. (Mar 1987). "The relationship between columnar epithelial dysplasia and invasive adenocarcinoma arising in Barrett's esophagus.". Am J Clin Pathol 87 (3): 301-12. PMID 3825997.
  4. ↑ Sampliner RE (March 2009). "Endoscopic Therapy for Barrett's Esophagus". Clin. Gastroenterol. Hepatol.. doi:10.1016/j.cgh.2009.03.011. PMID 19306943.
  5. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 46. ISBN 978-0443066573.
  6. ↑ Lomo, LC.; Blount, PL.; Sanchez, CA.; Li, X.; Galipeau, PC.; Cowan, DS.; Ayub, K.; Rabinovitch, PS. et al. (Apr 2006). "Crypt dysplasia with surface maturation: a clinical, pathologic, and molecular study of a Barrett's esophagus cohort.". Am J Surg Pathol 30 (4): 423-35. PMID 16625087.
  7. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 49. ISBN 978-0443066573.
  8. ↑ GAG. January 2009.
  9. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 54. ISBN 978-0443066573.
  10. ↑ Alikhan, M.; Rex, D.; Khan, A.; Rahmani, E.; Cummings, O.; Ulbright, TM. (Jul 1999). "Variable pathologic interpretation of columnar lined esophagus by general pathologists in community practice.". Gastrointest Endosc 50 (1): 23-6. PMID 10385717.
  11. ↑ 11.0 11.1 11.2 Odze, RD. (Oct 2006). "Diagnosis and grading of dysplasia in Barrett's oesophagus.". J Clin Pathol 59 (10): 1029-38. doi:10.1136/jcp.2005.035337. PMID 17021130.
  12. ↑ 12.0 12.1 Odze, RD. (Aug 2009). "Barrett esophagus: histology and pathology for the clinician.". Nat Rev Gastroenterol Hepatol 6 (8): 478-90. doi:10.1038/nrgastro.2009.103. PMID 19581906.
  13. ↑ Riddell, RH.; Odze, RD. (Oct 2009). "Definition of Barrett's esophagus: time for a rethink--is intestinal metaplasia dead?". Am J Gastroenterol 104 (10): 2588-94. doi:10.1038/ajg.2009.390. PMID 19623166.
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