Purpose: Takubo, et al. (Takubo K et al. Cardiac rather than intestinal-type background in endoscopic resection specimens of minute Barrett adenocarcinoma. Hum Pathol 2009;40:65-74) recently reported that in 113 endoscopic mucosal resection (EMR) specimens from esophageal columnar epithelium (ECE), microadenomas were found adjacent to cardiac metaplasia (CM) or fundic metaplasia (FM) in 70% of cases and intestinal metaplasia (IM) was entirely absent in 56% of specimens. Because of their findings, Takubo, et al. proposed that Barrett esophagus (BE) would be better defined as the presence of any metaplastic columnar epithelium proximal to the top of the gastric folds. In view of their findings, we postulated that cardiac and fundic metaplasia should be substantially present in surveillance biopsies obtained from ECE in the absence of adenocarcinoma.
Methods: 56 biopsy specimens obtained during consecutive pretreatment confirmatory endoscopies performed on 20 patients with a history of histologically confirmed BE referred for cryoablation between 12/2006 & 6/2009 were reviewed. EMR specimens obtained from ECE were not reviewed. An expert GI pathologist reexamined the original H&E stained specimens for purposes of specifically determining the presence or absence of cardiac and fundic metaplasia. The presence of IM, CM, FM and dysplasia (low or high grade or indefinite), was recorded.
Results: All patients studied were white men (mean age 54 yrs). Median number of esophageal mucosal biopsies obtained from ECE from each patient was 3 (range 1-7). The median Prague C and M scores were 2 cm and 3.5 cm respectively. While IM (in more than one biopsy specimen in each patient) was observed in all but 1 patient, areas of CM and/or FM (present in at least one biopsy specimen in each patient) were identified adjacent to IM in all the 20 patients. In 12/20 (60%) patients, both CM and FM were found adjacent to IM. In 5/20 (25%) patients, only CM was identified, whereas in 3/20 (15%), only FM was identified. 13/20 (65%) patients had long segment ECE (Prague M ≥ 3). In 31% (4/13) of these patients, CM was seen throughout ECE. Low and/or high grade or indefinite dysplasia (at least one biopsy specimen with dysplasia) were present in 19/20 (95%) patients. 4 out of these 19 (21%) patients had at least one biopsy with low grade dysplasia occurring in CM.
Conclusion: All patients who had mucosal biopsies from endoscopically visible ECE had cardiac and/or fundic metaplasia in addition to intestinal metaplasia. Additionally, pre cancerous dysplastic changes were observed arising in CM in a small proportion of patients.