Can Pathologists Distinguish Barrett's Gastric-Type Dysplasia from Reactive Gastric Cardiac Mucosa in GERD?
DT Patil, AE Bennett, D Mahajan, D Allende, C Fraser, MP Bronner. Cleveland Clinic Foundation, Cleveland
Background: Morphologic identification of dysplasia remains the gold standard marker of cancer risk in Barrett's esophagus. Despite this, reproducible histologic diagnosis is difficult due in part to obscuring inflammation. Gastric-type Barrett's dysplasia is a recently recognized dysplasia subtype that is characterized by non-stratified, basally oriented but enlarged nuclei with only mild pleomorphism. The distinction between Barrett's gastric-type dysplasia and reactive gastric cardiac mucosa in gastroesophageal reflux disease (GERD) has not been systematically studied and forms the basis of this report.
Design: A total of 3,698 endoscopic biopsies from a cohort of 461 Barrett's patients were reviewed to identify 43 patients (80 biopsies) with gastric-type Barrett's dysplasia (13 LGD, 30 HGD) using previously defined criteria (Mahajan D, et al. Mod Pathol, 2009). These were compared histologically to biopsies from 60 GERD patients with markedly inflamed and reactive epithelial changes of gastric cardiac mucosa.
Results: Surface nuclear stratification was exclusively found in reactive epithelium (80% vs 0%, p<0.00001). Nuclear atypia was restricted to the upper/surface epithelium (top-heavy atypia) in reactive cardia, compared to full thickness atypia in gastric-type Barrett's dysplasia (0% vs 80%, p<0.00001). Crowded glandular architecture was significantly associated with gastric-type dysplasia (78% vs 0%, p<0.00001), while villiform architecture was more common in reactive cardia (53% vs 6%, p=0.0006). Cytologically, gastric-type dysplasia showed a trend toward mild nuclear pleomorphism (35% vs 10%, p=0.09), while prominent nucleoli were more commonly noted in gastric-type dysplasia (33% vs 79%) (p=0.0003). Considerable overlap of nuclear size existed, rendering this final feature unhelpful in the differential diagnosis.
Conclusions: Nuclear stratification and surface predominant or “top-heavy” atypia accompanied by non-crowded, villiform architecture are features that most reliably distinguish marked reactive cardiac atypia in GERD from gastric-type Barrett's dysplasia.
Monday, March 22, 2010 9:30 AM
Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 104, Monday Morning