Difference between revisions of "Esophagus"

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[[Image:Tractus intestinalis esophagus.svg|thumb|250px|A schematic of the esophagus.]]
'''Esophagus''' connects the pharynx to the [[stomach]].  It is afflicted by tumours on occasion. Probably the most common affliction is [[gastroesophageal reflux disease]] (GERD). Most biopsies revolve around the questions: 1. intestinal metaplasia? 2. dysplasia? and 3. cancer?
'''Esophagus''' connects the pharynx to the [[stomach]].  It is afflicted by tumours on occasion. Probably the most common affliction is [[gastroesophageal reflux disease]] (GERD). Most biopsies revolve around the questions: 1. intestinal metaplasia? 2. dysplasia? and 3. cancer?


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==Sign out==
==Sign out==
===Nonspecific inflammation===
<pre>
Esophagus, Distal, Biopsy:
- Columnar epithelium with moderate chronic inflammation.
- Reactive squamous epithelium.
- NEGATIVE for intestinal metaplasia.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.
</pre>
====Block letters====
<pre>
<pre>
ESOPHAGUS, DISTAL, BIOPSY:
ESOPHAGUS, DISTAL, BIOPSY:
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|
|
| incr. risk of Barrett's
| incr. risk of Barrett's
|
| [[Image:Gastroesophageal reflux disease -- low mag.jpg|center|thumb|125px|c/w GERD. (WC)]]
|-  
|-  
|Eosinophilic esophagitis
|[[Eosinophilic esophagitis]]
| abundant eosinophils
| abundant eosinophils
| elongated (epithelial) papillae, basal cell hyperplasia, lymphocytes
| elongated (epithelial) papillae, basal cell hyperplasia, lymphocytes
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| [[Image:Eosinophilic_esophagitis_-_2_-_very_high_mag.jpg|center|thumb|125px|Eosinophilic esophagitis. (WC/Nephron)]]
| [[Image:Eosinophilic_esophagitis_-_2_-_very_high_mag.jpg|center|thumb|125px|Eosinophilic esophagitis. (WC/Nephron)]]
|-  
|-  
|Barrett's type change
|[[Barrett's esophagus|Barrett's type change]]
| goblet cells
| goblet cells
| no dysplasia
| no dysplasia
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| [[Image:Barretts_alcian_blue.jpg|center|thumb|125px|Barrett's esophagus. Alcian blue. (WC)]]
| [[Image:Barretts_alcian_blue.jpg|center|thumb|125px|Barrett's esophagus. Alcian blue. (WC)]]
|-  
|-  
|Dysplasia, low grade
|[[Columnar dysplasia of the esophagus|Dysplasia, low grade]]
| nuclear crowding at surface
| nuclear crowding at surface
| hyperchromasia, mild arch. complexity, no necrosis
| hyperchromasia, mild arch. complexity, no necrosis
|
|
| incr. risk of carcinoma
| incr. risk of carcinoma
|
| [[Image:Low-grade columnar dysplasia of the esophagus -- intermed mag.jpg|thumb|110px|LGH - intermed. mag.]]
|-  
|-  
|Dysplasia, high grade
| [[Columnar dysplasia of the esophagus|Dysplasia, high grade]]
| cribriforming and/or necrosis  
| [[cribriform]]ing and/or necrosis  
| nuclei often round & large, hyperchromasia
| nuclei often round & large, hyperchromasia
|
|
| marked incr. risk of carcinoma
| marked incr. risk of carcinoma
|
| [[Image:High-grade columnar dysplasia of the esophagus -- high mag.jpg|thumb|110px|HGD - high mag.]]
<!--
<!--
|Entity
|Entity
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| -
| -
| -
| -
| Image
| [[Image:Tinci%C3%B3n_hematoxilina-eosina.jpg|center|thumb|125px|Normal esophagus. (WC)]]
|-  
|-  
|Barrett's esophagus  
|Barrett's esophagus  
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| -
| -
| follow-up
| follow-up
| Image
| [[Image:Low-grade columnar dysplasia of the esophagus -- intermed mag.jpg|thumb|110px|LGH - intermed. mag.]]
|-  
|-  
|High-grade columnar dysplasia  
|High-grade columnar dysplasia  
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| moderate-to-marked nuclear atypia (usu. plump round nuclei), hyperchromasia, +/-necrosis
| moderate-to-marked nuclear atypia (usu. plump round nuclei), hyperchromasia, +/-necrosis
| -
| -
| EMR, surgery
| [[EMR]], surgery
| Image
| [[Image:High-grade columnar dysplasia of the esophagus -- high mag.jpg|thumb|110px|HGD - high mag.]]
|-  
|-  
|Intramucosal adenocarcinoma  
|Intramucosal adenocarcinoma  
| no maturation
| no maturation
| single cells or '''back-to-back irregular glands''' with budding and/or '''cribriforming''' and/or '''gland dilation''' or glands with long axis along muscularis mucosae
| single cells or '''back-to-back irregular glands''' with budding and/or '''[[cribriform]]ing''' and/or '''gland dilation''' or glands with long axis along muscularis mucosae
| moderate-to-marked nuclear atypia - usu. round large nuclei, hyperchromasia, +/-necrosis
| moderate-to-marked nuclear atypia - usu. round large nuclei, hyperchromasia, +/-necrosis
| -
| -
| EMR, surgery
| [[EMR]], surgery
| Image
| [[Image:Esophageal_adenocarcinoma_-_high_mag.jpg|thumb|110px|Adenocarcinoma - high mag.]]
|}
|}


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|-
|-
|}
|}
====Decision tree for columnar dysplasia====
Odze has made an algorithm - see: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861756/figure/fig8/ Diagnostic algorithm (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>


==Indications==
==Indications==
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===Herpes esophagitis===
===Herpes esophagitis===
====General====
{{Main|Herpes esophagitis}}
Etiology:
*[[Herpes simplex virus]].
 
====Gross/endoscopic====
Features:
*Ulcers with a "punched-out" appearance with a brown/red edge.
 
=====Images=====
<gallery>
Image:Herpes_esophagitis.JPG | Herpes esophagitis - endoscopy. (WC)
</gallery>
www:
*[http://library.med.utah.edu/WebPath/GIHTML/GI003.html Herpes esophagitis - gross (utah.edu)].
*[http://www.gastrohep.com/images/image.asp?id=648 Herpes esophagitis - endoscopy (gastrohep.com)].
 
====Microscopic====
Features (3 Ms):
*'''M'''oulding.
*'''M'''ultinucleation.
*'''M'''argination of chromatin.
 
=====Images=====
<gallery>
Image:Herpes_esophagitis_-_very_high_mag.jpg | HSV esophagitis - very high mag. (WC/Nephron)
Image:Herpes_esophagitis_-_intermed_mag.jpg | HSV esophagitis - intermed. mag. (WC/Nephron)
</gallery>


===Human papillomavirus esophagitis===
===Human papillomavirus esophagitis===
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*[http://commons.wikimedia.org/wiki/File:Low-grade_sil_and_endocx.jpg LSIL & endocervix (WC)].
*[http://commons.wikimedia.org/wiki/File:Low-grade_sil_and_endocx.jpg LSIL & endocervix (WC)].


=Other=
=Non-neoplastic disease=
The group of conditions doesn't fit neatly with the others.  It is a mixture of different non-neoplastic conditions.
The group of conditions doesn't fit neatly with the others.  It is a mixture of different non-neoplastic conditions.
==Gastroesophageal reflux disease==
==Gastroesophageal reflux disease==
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==Esophageal varices==
==Esophageal varices==
===General===
{{Main|Esophageal varices}}
*Arise due to [[portal hypertension]].
**This is usually due to [[cirrhosis]] that in turn is most often due to [[alcoholism]].
*Usually a clinical [[diagnosis]].
*Major cause of death in cirrhotics.<ref name=pmid21086193>{{Cite journal  | last1 = Tsochatzis | first1 = EA. | last2 = Triantos | first2 = CK. | last3 = Garcovich | first3 = M. | last4 = Burroughs | first4 = AK. | title = Primary prevention of variceal hemorrhage. | journal = Curr Gastroenterol Rep | volume = 13 | issue = 1 | pages = 3-9 | month = Feb | year = 2011 | doi = 10.1007/s11894-010-0160-x | PMID = 21086193 }}</ref>
 
===Gross===
*Prominent blood vessels in the distal eosphagus.
 
Note:
*At [[autopsy]] its best demonstrated by inversion of the esophagus.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref>
 
Image:
*[http://commons.wikimedia.org/wiki/File:Esophageal_varices_-_wale.jpg Esophageal varices - endoscopy (WC)].
 
===Microscopic===
Features:
*Large dilated submucosal [[blood vessels|veins]] - '''key feature'''.
*+/-Blood.
 
Image:
*[http://www.pathguy.com/sol/15419.jpg Esophageal varix (pathguy.com)].<ref>URL: [http://www.pathguy.com/lectures/guts.htm http://www.pathguy.com/lectures/guts.htm]. Accessed on: 24 April 2013.</ref>


==Acute esophagitis==
==Acute esophagitis==
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==Benign esophageal stricture==
==Benign esophageal stricture==
{{Main|Esophageal stricture}}
{{Main|Esophageal stricture}}
==Esophageal duplication cyst==
{{Main|Foregut duplication cyst}}
==Zenker's diverticulum==
{{Main|Zenker's diverticulum}}
*[[AKA]] ''cricopharyngeal diverticulum'', ''pharyngoesophageal diverticulum'' and ''hypopharyngeal diverticulum''.
==Radiation esophagitis==
{{Main|Radiation esophagitis}}


=Preneoplastic=
=Preneoplastic=
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*[[AKA]] ''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>
*[[AKA]] ''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>
* [[AKA]] ''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>
* [[AKA]] ''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>
 
{{Main|Columnar dysplasia of the esophagus}}
===General===
*Arises in the setting of ''[[Barrett esophagus]]''.
 
====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.<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====
*[http://www.nature.com/nrgastro/journal/v6/n8/fig_tab/nrgastro.2009.103_F4.html Intestinal metaplasia (nature.com)].
Indefinite for columnar dysplasia:
*[http://www.nature.com/nrgastro/journal/v6/n8/fig_tab/nrgastro.2009.103_F8.html Indefinite for columnar dysplasia (nature.com)].
Low-grade columnar dysplasia:
*[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>
High-grade columnar dysplasia:
*[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>
 
===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>


==Squamous dysplasia of the esophagus==
==Squamous dysplasia of the esophagus==
*[[AKA]] ''eosphageal squamous dysplasia''.
*[[AKA]] ''esophageal squamous dysplasia''.
===General===
===General===
*Precursor of [[esophageal squamous cell carcinoma]].<ref name=pmid11936262>{{Cite journal  | last1 = Dry | first1 = SM. | last2 = Lewin | first2 = KJ. | title = Esophageal squamous dysplasia. | journal = Semin Diagn Pathol | volume = 19 | issue = 1 | pages = 2-11 | month = Feb | year = 2002 | doi =  | PMID = 11936262 }}</ref>
*Precursor of [[esophageal squamous cell carcinoma]].<ref name=pmid11936262>{{Cite journal  | last1 = Dry | first1 = SM. | last2 = Lewin | first2 = KJ. | title = Esophageal squamous dysplasia. | journal = Semin Diagn Pathol | volume = 19 | issue = 1 | pages = 2-11 | month = Feb | year = 2002 | doi =  | PMID = 11936262 }}</ref>
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==Squamous cell carcinoma of the esophagus==
==Squamous cell carcinoma of the esophagus==
*[[AKA]] ''esophageal squamous cell carcinoma'', abbreviated ''esophageal SCC''.
*[[AKA]] ''esophageal squamous cell carcinoma'', abbreviated ''esophageal SCC''.
{{Main|Squamous carcinoma}}
{{Main|Squamous cell carcinoma of the esophagus}}
===General===
*Like squamous cell carcinoma elsewhere.
 
Risk factors:<ref name=Ref_APBR104>{{Ref APBR|104 Q1}}</ref>
*[[Ethanol abuse|Alcohol consumption]].
*[[Smoking|Tobacco use]].
*Food with nitrosamines.
*Burning-hot beverages.
 
Note:
*Reflux is ''not'' a risk factor for esophageal SCC.
 
===Microscopic===
:See ''[[Squamous carcinoma]]''.
 
Note:
*Just to make things confusing, the ''Staging'' of early SCC differs from that of early adenocarcinoma!
 
DDx:
*[[Squamous dysplasia of the esophagus]].
 
====Images====
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig08/ Carcinoma in situ (nih.gov)].<ref name=pmid23330004>{{Cite journal  | last1 = Terada | first1 = T. | title = A clinicopathologic study of esophageal 860 benign and malignant lesions in 910 cases of consecutive esophageal biopsies. | journal = Int J Clin Exp Pathol | volume = 6 | issue = 2 | pages = 191-8 | month =  | year = 2013 | doi =  | PMID = 23330004 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig09/ Squamous cell carcinoma of the esophagus (nih.gov)].
 
===Sign out===
<pre>
ESOPHGAUS, BIOPSY:
- INVASIVE SQUAMOUS CELL CARCINOMA, KERATINIZING, MODERATELY DIFFERENTIATED.
 
COMMENT:
Benign squamous epithelium at least partially overlies the invasive squamous
cell carcinoma; this may mask the true extent of the lesion on endoscopy.
</pre>
 
====Micro====
The sections show a squamous mucosa with focal moderate atypia of the squamous cells,
keratinization and easily identified mitotic figures. The atypical cells are partially
covered by benign squamous cells, and there is a very sharp transition between the cells
with atypia and those without. The atypical squamous cells extend into the subepithelial tissue in irregularly shaped nests and cords. A small amount of benign muscle is present.


==Esophageal adenocarcinoma==
==Esophageal adenocarcinoma==
*[[AKA]] ''adenocarcinoma of the esophagus''.
*[[AKA]] ''adenocarcinoma of the esophagus''.
 
{{Main|Esophageal adenocarcinoma}}
===General===
*Often a prognosis poor - as diagnosed in a late stage.
*May be difficult to distinguish from adenocarcinoma of the stomach.
**By convention (in the ''[[CAP checklist]]'') gastroesophageal junction carcinomas are staged as esophageal carcinomas.<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Esophagus_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Esophagus_11protocol.pdf]. Accessed on: 6 April 2012.</ref>
 
====Tx====
*Adenocarcinoma in situ (AIS) - may be treated with endoscopic mucosal resection & follow-up.<ref name=pmid19306943/>
*Surgery - esophagectomy.
 
====Esophagus vs. stomach====
The convention is it's esophageal if both of the following are true:<ref name=Ref_WMSP168>{{Ref WMSP|168}}</ref>
#Epicenter of tumour is in the esophagus.
#Barrett's mucosa is present.
 
===Microscopic===
Features:
*Adenocarcinoma:
**Cell clusters that form glands.
**Nuclear atypia of malignancy:
***Size variation.
***Shape variation.
***Staining variation.
**Mitoses common.
 
=====Images=====
<gallery>
Image:Esophageal_adenocarcinoma_-_very_low_mag.jpg |Esophageal adenocarcinoma - very low mag. (WC)
Image:Esophageal_adenocarcinoma_-_intermed_mag.jpg |Esophageal adenocarcinoma - intermed. mag. (WC)
</gallery>
====Grading====
Graded like other adenocarcinoma:<ref name=Ref_WMSP168>{{Ref WMSP|168}}</ref>
*>95 % of tumour in glandular arrangement = ''well-differentiated''.
*95-50% of tumour in glandular arrangement= ''moderately-differentiated''.
*<50% of tumour in glandular arrangment = ''poorly-differentiated''.
 
====Staging====
Early esophageal adenocarcinoma has its own staging system:<ref>{{Cite journal  | last1 = Pech | first1 = O. | last2 = May | first2 = A. | last3 = Rabenstein | first3 = T. | last4 = Ell | first4 = C. | title = Endoscopic resection of early oesophageal cancer. | journal = Gut | volume = 56 | issue = 11 | pages = 1625-34 | month = Nov | year = 2007 | doi = 10.1136/gut.2006.112110 | PMID = 17938435 | PMC = 2095648 }}</ref><ref>{{Cite journal  | last1 = Thosani | first1 = N. | last2 = Singh | first2 = H. | last3 = Kapadia | first3 = A. | last4 = Ochi | first4 = N. | last5 = Lee | first5 = JH. | last6 = Ajani | first6 = J. | last7 = Swisher | first7 = SG. | last8 = Hofstetter | first8 = WL. | last9 = Guha | first9 = S. | title = Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis. | journal = Gastrointest Endosc | volume =  | issue =  | pages =  | month = Nov | year = 2011 | doi = 10.1016/j.gie.2011.09.016 | PMID = 22115605 | URL = http://www.sciencedirect.com/science/article/pii/S0016510711022048 }}</ref>
*M1 = lamina propria.
*M2 = superficial muscularis mucosae.
*M3 = submucosa.
*M4 = muscularis propria.
 
===IHC===
*CK7 +ve.
*CK20 +ve.
 
To rule-out SCC:
*p63 -ve.
*HWMK -ve.


=Weird stuff=
=Weird stuff=
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==Glycogenic acanthosis of the esophagus==
==Glycogenic acanthosis of the esophagus==
===General===
{{Main|Glycogenic acanthosis of the esophagus}}
*Uncommon.
*Benign.
*Possible association with ingestion of hot liquids.<ref name=pmid20524767/>
 
===Gross/endoscopic===
*Distinctive endoscopic appearance - grey/white raised lesion.<ref name=pmid20524767>{{Cite journal  | last1 = Lopes | first1 = S. | last2 = Figueiredo | first2 = P. | last3 = Amaro | first3 = P. | last4 = Freire | first4 = P. | last5 = Alves | first5 = S. | last6 = Cipriano | first6 = MA. | last7 = Gouveia | first7 = H. | last8 = Sofia | first8 = C. | last9 = Correia-Leitão | first9 = M. | title = Glycogenic acanthosis of the esophagus: an unusually endoscopic appearance. | journal = Rev Esp Enferm Dig | volume = 102 | issue = 5 | pages = 341-2 | month = May | year = 2010 | doi =  | PMID = 20524767 | URL = http://www.grupoaran.com/mrmUpdate/lecturaPDFfromXML.asp?IdArt=4618820&TO=RVN&Eng=1 }}</ref>
 
Image:
*[http://en.wikipedia.org/wiki/File:Glycogenic_acanthosis.jpg Glycogenic acanthosis (WP)].
===Microscopic===
Features:<ref name=pmid20524767/>
*Squamous epithelium with:
**Superficial clearing of the cytoplasm.
**Thickening.
 
Images:
*[http://scielo.isciii.es/pdf/diges/v102n5/carta3.pdf Glycogenic acanthosis (isciii.es)].


==Achalasia==
==Achalasia==
===General===
{{main|Achalasia}}
*Uncommon.
*Risk factor for [[squamous cell carcinoma]] (in men and women) and [[esophageal adenocarcinoma|adenocarcinoma]] (in men).<ref>{{Cite journal  | last1 = Zendehdel | first1 = K. | last2 = Nyrén | first2 = O. | last3 = Edberg | first3 = A. | last4 = Ye | first4 = W. | title = Risk of esophageal adenocarcinoma in achalasia patients, a retrospective cohort study in Sweden. | journal = Am J Gastroenterol | volume = 106 | issue = 1 | pages = 57-61 | month = Jan | year = 2011 | doi = 10.1038/ajg.2010.449 | PMID = 21212754 }}</ref>
*Due to loss of ganglion cells.<ref name=pmid24395614>{{Cite journal  | last1 = Blatnik | first1 = JA. | last2 = Ponsky | first2 = JL. | title = Advances in the Treatment of Achalasia. | journal = Curr Treat Options Gastroenterol | volume =  | issue =  | pages =  | month = Jan | year = 2014 | doi = 10.1007/s11938-013-0007-2 | PMID = 24395614 }}</ref>
 
Clinical:
*Dysphagia (difficulty swallowing) liquids ''and'' solids.<ref name=pmid24395614/>
 
===Microscopic===
Features:<ref name=pmid16128783>{{Cite journal  | last1 = Kjellin | first1 = AP. | last2 = Ost | first2 = AE. | last3 = Pope | first3 = CE. | title = Histology of esophageal mucosa from patients with achalasia. | journal = Dis Esophagus | volume = 18 | issue = 4 | pages = 257-61 | month =  | year = 2005 | doi = 10.1111/j.1442-2050.2005.00478.x | PMID = 16128783 }}</ref>
*Mucosa typically normal - even in long-standing achalasia.
 
Note:<ref name=pmid16128783/>
*Achalasia seen in the context of a resection usually has inflammation.
*Post-Heller myotomy often has inflammation.
 
===Sign out===
<pre>
ESOPHAGUS, BIOPSY:
- SQUAMOUS EPITHELIUM WITH A MILD DEEP LYMPHOCYTIC INFILTRATE, EDEMA, AND
  REACTIVE CHANGES, NO EOSINOPHILS APPARENT.
- SCANT COLUMNAR EPITHELIUM WITH MINIMAL STROMA, NO APPARENT SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
 
====Alternate====
<pre>
GASTROESOPHAGEAL JUNCTION, BIOPSY:
- COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INFLAMMATION.
- REACTIVE SQUAMOUS EPITHELIUM.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>


==Esophageal inlet patch==
==Esophageal inlet patch==
Line 771: Line 526:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3197178/figure/fig4/ Esophageal inlet patch (nih.gov)].<ref name=pmid22091379>{{Cite journal  | last1 = Behrens | first1 = C. | last2 = Yen | first2 = PP. | title = Esophageal inlet patch. | journal = Radiol Res Pract | volume = 2011 | issue =  | pages = 460890 | month =  | year = 2011 | doi = 10.1155/2011/460890 | PMID = 22091379 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3197178/figure/fig4/ Esophageal inlet patch (nih.gov)].<ref name=pmid22091379>{{Cite journal  | last1 = Behrens | first1 = C. | last2 = Yen | first2 = PP. | title = Esophageal inlet patch. | journal = Radiol Res Pract | volume = 2011 | issue =  | pages = 460890 | month =  | year = 2011 | doi = 10.1155/2011/460890 | PMID = 22091379 }}</ref>


==Squamous papilloma of the eosphagus==
===Sign out===
*[[AKA]] ''esophageal squamous papilloma''.
<pre>
===General===
Esophagus at 22 cm, Biopsy:
*Uncommon.
    - Gastric type mucosa with mild chronic inactive inflammation, see comment.
    - Scant unremarkable squamous epithelium.
    - NEGATIVE for intestinal metaplasia.
    - NEGATIVE for dysplasia.


===Microscopic===
Comment:
Features:
This is in keeping with an "inlet patch", also known as "heterotopic gastric mucosal patch of the proximal esophagus".
*Papillomaous projections - low power.
</pre>


====Image====
==Squamous papilloma of the esophagus==
www:
{{Main|Squamous papilloma of the esophagus}}
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig03/ Squamous papilloma (nih.gov)].<ref name=pmid23330004>{{Cite journal  | last1 = Terada | first1 = T. | title = A clinicopathologic study of esophageal 860 benign and malignant lesions in 910 cases of consecutive esophageal biopsies. | journal = Int J Clin Exp Pathol | volume = 6 | issue = 2 | pages = 191-8 | month =  | year = 2013 | doi =  | PMID = 23330004 }}</ref>
<gallery>
Image:Squamous papilloma of the esophagus, HE 1.jpg|SP of the esophagus. (WC)
Image:Squamous papilloma of the esophagus, HE 2.jpg|SP of the esophagus. (WC)
</gallery>


=See also=
=See also=
Line 796: Line 549:


[[Category:Gastrointestinal pathology]]
[[Category:Gastrointestinal pathology]]
[[Category:Esophagus|Esophagus]]

Latest revision as of 22:57, 27 January 2022

A schematic of the esophagus.

Esophagus connects the pharynx to the stomach. It is afflicted by tumours on occasion. Probably the most common affliction is gastroesophageal reflux disease (GERD). Most biopsies revolve around the questions: 1. intestinal metaplasia? 2. dysplasia? and 3. cancer?

Normal esophagus

General:

  • Stratified squamous non-keratinized epithelium.

Normal (esophageal) squamous epithelium:

  • Should "mature" to the surface like good stratified squamous epithelium does.
    • No nuclei at luminal surface.
    • Cells should become less hyperchromatic as you go toward the lumen.
    • Mitoses should be rare and should NOT be above the basal layer.
  • Inflammatory cells should be very rare.

Sign out

Nonspecific inflammation

Esophagus, Distal, Biopsy:
- Columnar epithelium with moderate chronic inflammation.
- Reactive squamous epithelium.
- NEGATIVE for intestinal metaplasia.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.

Block letters

ESOPHAGUS, DISTAL, BIOPSY:
- COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INFLAMMATION.
- REACTIVE SQUAMOUS EPITHELIUM.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Diagnoses

Common

  • Normal.
  • Metaplasia (Barrett's esophagus).
  • Dysplasia.
  • Adenocarcinoma.

Less common

  • Squamous cell carcinoma.
  • Eosinophilic esophagitis.
  • Candidiasis.
  • CMV esophagitis.

Tabular summary

Simplified overview

Entity Key feature Other features IHC/Special Clinical Image
Normal squamous epi. matures to surface no inflammation, no atypia - -
Normal esophagus. (WC)
GERD inflammation (eosinophils, lymphocytes) elongated (epithelial) papillae, basal cell hyperplasia incr. risk of Barrett's
c/w GERD. (WC)
Eosinophilic esophagitis abundant eosinophils elongated (epithelial) papillae, basal cell hyperplasia, lymphocytes unresponsive to PPIs
Eosinophilic esophagitis. (WC/Nephron)
Barrett's type change goblet cells no dysplasia Alcian blue +ve incr. risk of adenocarcinoma
Barrett's esophagus. Alcian blue. (WC)
Dysplasia, low grade nuclear crowding at surface hyperchromasia, mild arch. complexity, no necrosis incr. risk of carcinoma
LGH - intermed. mag.
Dysplasia, high grade cribriforming and/or necrosis nuclei often round & large, hyperchromasia marked incr. risk of carcinoma
HGD - high mag.

Columnar dysplasia

Entity Surface maturation Architecture Cytology Other Clinical Image
Normal matures round glands no nuclear atypia - -
Normal esophagus. (WC)
Barrett's esophagus matures round glands, normal gland density +/-scant nuclear atypia goblet cells clinical diagnosis Image
Indefinite for columnar dysplasia minimal maturation or cannot see surface round glands, normal gland density mild nuclear atypia, nuclear pseudostratification, no necrosis - follow-up Image
Low-grade columnar dysplasia minimal-to-scant maturation round glands, +/-rare budding, increased gland density mild-to-moderate nuclear atypia, nuclear pseudostratification, no necrosis - follow-up
LGH - intermed. mag.
High-grade columnar dysplasia no maturation incr. density of irregular glands with budding and/or rare cribriforming and/or gland dilation moderate-to-marked nuclear atypia (usu. plump round nuclei), hyperchromasia, +/-necrosis - EMR, surgery
HGD - high mag.
Intramucosal adenocarcinoma no maturation single cells or back-to-back irregular glands with budding and/or cribriforming and/or gland dilation or glands with long axis along muscularis mucosae moderate-to-marked nuclear atypia - usu. round large nuclei, hyperchromasia, +/-necrosis - EMR, surgery
Adenocarcinoma - high mag.

Columnar dysplasia - another table

Feature Indefinite for columnar dysplasia Low-grade columnar dysplasia High-grade columnar dysplasia Intramucosal carcinoma (IMCa) Utility
Depth of glands superficial only superficial only superficial/deep deep low vs. high
Gland density normal near normal increased back-to-back low vs. high vs. IMCa
Gland morphology round round irregular/rare cribriforming irregular/cribriform/sheeting low vs. high vs. IMCa
Necrosis none none may be present may be present low vs. high & IMCa
Hyperchromasia +/- present present present indef. vs. low
Palisaded/crowded nuclei present present absent/present uncommon low vs. high
Round nuclei + enlargement absent absent present/absent present low vs. high
Desmoplasia absent absent absent +/- (uncommon) high vs. IMCa
Surface involvement present (required) present (required) +/- +/- low vs. high

Decision tree for columnar dysplasia

Odze has made an algorithm - see: Diagnostic algorithm (nih.gov).[1]

Indications

  • Pyrosis = heartburn.[2]

Infectious esophagitis

Main article: Microorganisms

Is a relatively common problem, especially in those that live at the margins (EtOH abusers) and immunosuppressed individuals (HIV/AIDS).

Useful stains

Overview

  • Candida - worms.
  • HPV - koilocytes.
  • CMV - large nuclei.
  • HIV - non-specific.

Candida esophagitis

Main article: Candidiasis
  • AKA esophageal candidiasis.

Gross (endoscopic)

Features:

  • White patches.

DDx (endoscopic):[3]

Microscopic

Features:

  • Worm-like micro-organisms - key feature.
    • Pseudohyphae (single cells).
    • Thickness ~ 1/3-1/2 of squamous cell nucleus.
    • Should be within (squamous) epithelium.
  • Superficial inflammation - esp. neutrophils - important.

Notes:

  • On top of epithelium does not count,[4] i.e. it is likely an artifact.
  • Bacilli and cocci may accompany the candida. They are typically ignored.

DDx:

Image

  • Esophageal candidiasis. (WC)

Sign out

ESOPHAGUS, BIOPSY:
- ESOPHAGITIS WITH FUNGAL ORGANISMS CONSISTENT WITH CANDIDA.

ESOPHAGUS, BIOPSY:
- ACUTE ESOPHAGITIS WITH FUNGAL ORGANISMS CONSISTENT WITH CANDIDA.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA.

Cytomegalovirus esophagitis

Microscopic

Features:

  • Classically at the base of the ulcer; within endothelial cells - key point.

Note:

  • Biopsying the the base of an ulcer usually just yields (non-diagnostic) necrotic debris; so, clinicians are told to biopsy the edge of the lesion. A suspected CMV infection is the exception to this rule!

Herpes esophagitis

Main article: Herpes esophagitis

Human papillomavirus esophagitis

General:

Microscopic

Features:

  • Koilocytes:
    • Perinuclear clearing.
    • Nuclear changes.
      • Size similar (or larger) to those in the basal layer of the epithelium.
      • Nuclear enlargement should be evident on low power, i.e. 25x. [7]
      • Central location - nucleus should be smack in the middle of the cell.

Images:

Non-neoplastic disease

The group of conditions doesn't fit neatly with the others. It is a mixture of different non-neoplastic conditions.

Gastroesophageal reflux disease

  • Abbreviated GERD or GORD (gastro-oesophageal reflux disease).
  • AKA reflux esophagitis.
Main article: Gastroesophageal reflux disease

Eosinophilic esophagitis

  • Abbreviated EE.
Main article: Eosinophilic esophagitis

Erosive esophagitis

DDx

Work-up

Pill esophagitis

Classic causes:

Esophageal varices

Main article: Esophageal varices

Acute esophagitis

Main article: Acute esophagitis

Benign esophageal stricture

Main article: Esophageal stricture

Esophageal duplication cyst

Main article: Foregut duplication cyst

Zenker's diverticulum

Main article: Zenker's diverticulum
  • AKA cricopharyngeal diverticulum, pharyngoesophageal diverticulum and hypopharyngeal diverticulum.

Radiation esophagitis

Main article: Radiation esophagitis

Preneoplastic

Barrett esophagus

Main article: Barrett esophagus

Neoplastic

Columnar dysplasia of the esophagus

  • AKA esophageal columnar dysplasia, abbreviated ECD.[5]
  • AKA dysplasia in the columnar-lined esophagus.[6]
  • AKA columnar epithelial dysplasia.[7]
Main article: Columnar dysplasia of the esophagus

Squamous dysplasia of the esophagus

  • AKA esophageal squamous dysplasia.

General

Microscopic

Features:

  • Squamous cell nuclear atypia.
  • Lack of maturation to the surface.

Note:

  • Grading differences between Western pathologists and those of the east.[8]

DDx:

Images

A set of cases from Japan:[9]

IHC

  • Ki-67 may be useful:[10]
    • Reactive changes/normal: ~98% negative, ~2% intermediate.
    • Low-grade esophageal squamous intraepithelial neoplasia (LGESIN): ~80% intermediate, ~20% negative.
    • High-grade esophageal squamous intraepithelial neoplasia (HGESIN): ~37% intermediate, ~63% strong.

Definitions:[10]

  • Negative defined as: < 25% of epithelium +ve and staining only in lower quarter of epithelium.
  • Intermediate defined: >=25% and <=50% of epithelium +ve and only in the lower half of the epithelium.
  • Strong defined: >50% of epithelium +ve or upper half of epithelium.

Leiomyoma of the esophagus

Main article: Leiomyoma

General

  • Benign.
  • Uncommon.
    • Before the time of GISTs - this was a relatively common diagnosis.
  • Like leiomyomas elswhere.

Microscopic

See: Leiomyoma.

DDx:

Gastrointestinal stromal tumour

Main article: Gastrointestinal stromal tumour

Cancer

General

Risks:

Squamous cell carcinoma of the esophagus

  • AKA esophageal squamous cell carcinoma, abbreviated esophageal SCC.
Main article: Squamous cell carcinoma of the esophagus

Esophageal adenocarcinoma

  • AKA adenocarcinoma of the esophagus.
Main article: Esophageal adenocarcinoma

Weird stuff

  • Inflammatory polyp - assoc. trauma/previous intervention.
  • Giant fibrovascular polyp - loose connective tissue covered with squamous epithelium.
  • Granular cell tumour.
  • Squamous papilloma - koilocytes.
  • Heterotopic gastric mucosa ("inlet patch") - benign appearing gastric mucosa.

Granular cell tumour

Main article: Granular cell tumour

Microscopic

Features:

  • Abundant eosinophilic granular cytoplasm key feature.
    • Granules:
      • Size: 1-3 micrometers.
      • Poorly demarcated.
  • Usu. bland (cytologically non-malignant) nuclei.

Images

Esophagitis dissecans superficials

General

  • Rare & benign condition that resolves without lasting pathology.[11]
    • Case report - chronic with strictures.[12]
  • Sloughing of large fragments of the esophageal mucosa - seen on endoscopy.

Microscopic

Features:[11]

  • Flaking of superficial squamous epithelium.
  • Focal bullous separation of the layers.
  • Parakeratosis.
  • Variable acute or chronic inflammation.

Glycogenic acanthosis of the esophagus

Main article: Glycogenic acanthosis of the esophagus

Achalasia

Main article: Achalasia

Esophageal inlet patch

  • AKA inlet patch, AKA cervical inlet patch.

General

  • Benign and likely not of any significance.[13]

Gross

  • Proximal esophagus - salmon coloured lesion.[13]

Microscopic

Features:

Image:

Sign out

Esophagus at 22 cm, Biopsy:
     - Gastric type mucosa with mild chronic inactive inflammation, see comment.
     - Scant unremarkable squamous epithelium.
     - NEGATIVE for intestinal metaplasia.
     - NEGATIVE for dysplasia.

Comment:
This is in keeping with an "inlet patch", also known as "heterotopic gastric mucosal patch of the proximal esophagus".

Squamous papilloma of the esophagus

Main article: Squamous papilloma of the esophagus

See also

References

  1. ↑ 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.
  2. ↑ URL: http://dictionary.reference.com/browse/pyrosis. Accessed on: 21 June 2010.
  3. ↑ Odze, Robert D.; Goldblum, John R. (2009). Surgical pathology of the GI tract, liver, biliary tract and pancreas (2nd ed.). Saunders. pp. 244. ISBN 978-1416040590.
  4. ↑ ALS. 4 October 2010.
  5. ↑ 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.
  6. ↑ Levine, DS. (Sep 1997). "Management of dysplasia in the columnar-lined esophagus.". Gastroenterol Clin North Am 26 (3): 613-34. PMID 9309409.
  7. ↑ 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.
  8. ↑ 8.0 8.1 8.2 Dry, SM.; Lewin, KJ. (Feb 2002). "Esophageal squamous dysplasia.". Semin Diagn Pathol 19 (1): 2-11. PMID 11936262.
  9. ↑ 9.0 9.1 Terada, T. (2013). "A clinicopathologic study of esophageal 860 benign and malignant lesions in 910 cases of consecutive esophageal biopsies.". Int J Clin Exp Pathol 6 (2): 191-8. PMID 23330004.
  10. ↑ 10.0 10.1 Wang, WC.; Wu, TT.; Chandan, VS.; Lohse, CM.; Zhang, L. (Oct 2011). "Ki-67 and ProExC are useful immunohistochemical markers in esophageal squamous intraepithelial neoplasia.". Hum Pathol 42 (10): 1430-7. doi:10.1016/j.humpath.2010.12.009. PMID 21420715.
  11. ↑ 11.0 11.1 11.2 Carmack, SW.; Vemulapalli, R.; Spechler, SJ.; Genta, RM. (Dec 2009). "Esophagitis dissecans superficialis ("sloughing esophagitis"): a clinicopathologic study of 12 cases.". Am J Surg Pathol 33 (12): 1789-94. doi:10.1097/PAS.0b013e3181b7ce21. PMID 19809273.
  12. ↑ Coppola, D.; Lu, L.; Boyce, HW. (Oct 2000). "Chronic esophagitis dissecans presenting with esophageal strictures: a case report.". Hum Pathol 31 (10): 1313-7. doi:10.1053/hupa.2000.18470. PMID 11070124.
  13. ↑ 13.0 13.1 Chong, VH. (Jan 2013). "Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus.". World J Gastroenterol 19 (3): 331-8. doi:10.3748/wjg.v19.i3.331. PMID 23372354.
  14. ↑ 14.0 14.1 Behrens, C.; Yen, PP. (2011). "Esophageal inlet patch.". Radiol Res Pract 2011: 460890. doi:10.1155/2011/460890. PMID 22091379.
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