Columnar dysplasia of the esophagus

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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.

Columnar dysplasia of the esophagus
Diagnosis in short
Synonyms columnar dysplasia, esophageal dysplasia (nonspecific)
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)

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:

  • Endoscopic mucosal resection.[4]
  • Surgical resection (esophagectomy).

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:

Low-grade columnar dysplasia:

High-grade columnar dysplasia:

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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