Part 1 A pragmatic approach to common problems in esophageal biopsy pathology How I can help more patients than I hurt Barbara J McKenna University of Michigan barbmcke@med.umich.edu Case 1 The following biopsies are taken from the distal esophagus of a 57 year old man who has a history of Barrett s esophagus. He had a diagnosis of indefinite for dysplasia made one year ago. Surface epithelium not as concerning Collection of crowded tubules in deep mucosa 1
What is your diagnosis? How sure are you? Why is dysplasia in the setting of Barrett s esophagus our most common consultation case? Dysplastic mucosa has no reliable endoscopic features. Mucosal elevation Flat mucosa 2
The consequences of a diagnosis of dysplasia are significant. More frequent endoscopy A surgical procedure While some specimens with dysplasia are very common... Colorectal adenoma Surveillance biopsies of Barrett s mucosa are less common specimens So we have fewer opportunities to define our thresholds, and fewer chances to see follow up. 3
The features of dysplasia and regeneration may be only subtly different, making the distinction maddeningly difficult! It would be great if we could define precancerous epithelium by its molecular changes, but until this is practical on a day to day basis we must make morphologic diagnoses! Terminology for dysplasia Two grades: Low grade High grade Indefinite for dysplasia introduced at the same time as 2-grade system for cases that are not clearly dysplastic, nor clearly regenerative. 4
Management recommendations for Barrett s are based on this 2-grade system. Diagnosis Management Negative Indefinite for dysplasia Low grade dysplasia Moderate dysplasia High grade dysplasia Follow up at routine interval Follow up at shortened interval Confirmation by expert Follow up at shortened interval Confirmation by expert Resection or Ablative therapy or Follow up at very short interval What are the histologic features we use to diagnose dysplasia? Cytologic abnormalities Nuclear enlargement, hyperchromasia, pleomorphism Increased mitoses, especially near or at surface Loss of cytoplasmic maturation, including decrease or loss in mucin 5
Architectural abnormalities Nuclear stratification, loss of polarity Complex arrangements, crowded tubules Abnormal surface villiform rather than flat Low Grade Dysplasia Mild, or no architectural abnormalities Nuclear stratification usually not full thickness of epithelium Polarity retained These features involve the surface, not just the epithelium deep in the mucosa. What are the criteria for high grade dysplasia? Worse than low grade dysplasia! How much worse? 6
High Grade Dysplasia Architectural abnormalities, often marked Nuclear stratification and cytologic abnormalities more marked than low grade, loss of polarity What are the criteria for indefinite for dysplasia? Probably not definable Published criteria include: Marked nuclear abnormalities in deep mucosa, with surface that matures or mostly matures Biopsies with disturbing cytologic/architectural abnormalities, but with significant inflammation or lack of evaluable surface 7
Journals and textbooks make these criteria seem straightforward. Are these images good examples of low and high grade dysplasia? Do most of your biopsies look like this? Practice Parameters Committee of the American College of Gastroenterology: An expert pathologist should confirm the interpretation of low and high-grade dysplasia. The most common type of GI consultation case handled at UM is the Barrett s biopsy sent for diagnosis/confirmation and grading of dysplasia. 8
Starting in late 2003, we began recording our votes on Barrett s and colitic dysplasia cases. Also, in cases of adenomas with a question of invasive carcinoma or not. Over ~18 months we voted on 432 biopsies from 332 cases. The consult diagnoses were different from those of the submitting pathologist 66% of the time. In 45% of cases the different diagnoses would indicate different management. Diagnosis Management Negative Indefinite for dysplasia Low grade dysplasia High grade dysplasia Carcinoma Follow up at routine interval Follow up at shortened interval Confirmation by expert, Follow up at shortened interval Confirmation by expert Resection or Ablative therapy or Follow up at very short interval Resect, either endoscopically or open, possible neoadjuvant Rx 9
What happens to the cases diagnosed as high grade dysplasia and sent for confirmation? HGD 3% Neg 29% Indef/LGD 35% HGD 25% Susp for CA 8% CA So, maybe the recommendation to have diagnoses of high grade dysplasia reviewed is appropriate? What happens with other diagnoses that we reviewed? Contributors diagnosis Negative Negative Indefinite/ Low grade High grade/ suspicious for carcinoma Carcinoma 76% 15% 6% 3% Indefinite/ Low grade 22% 50% 27% <1% High grade/ suspicious for carcinoma Carcinoma U of Michigan consultant diagnosis <2% 24% 56% 19% 0 0 14% 86% 10
How much did the 3 consultants agree? All three agreed: 46% 2 of 3 agreed: 46% No agreement: 8% What do we agree on the most? Negative 84% Indefinite 34% Low grade 23% At least low grade 23% High grade 50% Suspicious for CA 52% Carcinoma 74% How much did our disagreements involve management difference? 33% of all biopsies 10% between Neg and Indef/LG 15% between Indef/LG and HG 8% between HG and Carcinoma 11
Summary: The consultation diagnosis significantly differs from the contributed diagnosis 45% of the time. There is significant disagreement among the consultants 33% of the time. Who is right? The contributing pathologist? Appelman? Greenson? McKenna? Who Knows? Some of our internal differences were between suspicious for carcinoma and carcinoma. Does this matter? 12
HGD in Barrett s as a marker for Carcinoma Literature tells us that 30-50% of Barrett s patients with HGD on biopsy will have carcinoma in esophagectomy. Yet, when patients with HGD are followed closely with repeat endoscopy and biopsy, only 8-10% develop carcinoma on follow up. At Michigan 127 Esophagectomies resected for biopsy diagnoses of HGD or HGD/susp for ca 69 of the biopsies were reviewed and reclassified Neg LGD HGD Susp for CA CA In our cases at Michigan: Only one of 21 HGD biopsies had CA in the resection, 4.8% Much different than the 30-50% that we read in the literature! 13
In our cases at Michigan: 72% of those we classified as suspicious for carcinoma had carcinoma in the resection 74% of those we classified as carcinoma had carcinoma in the resection Thus, a diagnosis of suspicious for carcinoma is the same as an outright diagnosis of carcinoma in our practice! What do we use to diagnose a Barrett s biopsy as suspicious for carcinoma? First, What are the criteria to diagnose carcinoma in Barrett s mucosa? Carcinoma invading the submucosa elicits a characteristic desmoplastic stromal reaction 14
Intramucosal carcinoma definition: carcinoma cells extending beyond basement membrane into lamina propria How does one recognize carcinoma cells extending beyond the basement membrane? Criteria used by those who studied intramucosal carcinoma in Barrett s Syncytial growth pattern Abortive microglands Small clusters of epithelial cells infiltrating lamina propria between glands Irregularly shaped tubules Solid nests of neoplasm Interobserver agreement on this diagnosis is not great (kappa ~ 0.5) Downs-Kelly E, et al. Am J Gastroenterol 2008;103:2333 2340 Syncytial/ solid growth pattern? 15
Abortive microglands???? Small clusters of epithelial cells infiltrating lamina propria between glands Irregularly shaped, atypical tubules infiltrating between benign-looking tubules Irregularly shaped, atypical tubules with infiltrative pattern 16
Solid/cribriform pattern Riddell OESO, 1998 The only criterion for the confident diagnosis of invasive carcinoma in the lamina propria is the pathologist s own subjective and personal interpretation that invasion may or may not be present. Greenson: I know it when I see it What features did we use to classify a biopsy as suspicious for carcinoma? Many are similar to those used to diagnose intramucosal carcinoma Cribriform architecture of tubules Dilated tubules containing necrotic debris Extensive neutrophilic infiltrate in highly dysplastic epithelium Squamous epithelial invasion by tubules 17
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Cribriform architecture of tubules Dilated tubules containing necrotic debris Extensive neutrophilic infiltrate in highly dysplastic epithelium Squamous epithelial invasion by tubules When one of these features was present in the biopsy, there was carcinoma in the subsequent resection in 40% of cases. When 2 or more were present, the rate was >80%! Zhu et al. AJCP 2009;132:94-100 Let s look at some of these cases.. 20
10307c 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma All three consultants called Negative Why negative? Slightly enlarged nuclei at base, maturation at surface. 10307c 21
10307d 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma 2 consultants called indefinite 1 called low grade 22
The question of whether this is low grade dysplasia depends on your interpretation of the surface epithelium. 13170 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. 13170 Carcinoma All 3 consultants called this carcinoma. 23
Very 13170 complex architecture Small nests of cells that seem to invading lamina propria 12875 12875 24
1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma Two consultants called this at least low grade. 1 called it high grade. One of us thought surface nuclear abnormalities were sufficient for high grade; Two didn t think the architecture 12875 was complex enough. The previous photos were from the 179 biopsies we all voted on. Some of the sections and stains are less than ideal. Perhaps I didn t choose the microscopic fields that the others would have The next set of photos are ones for which the votes were placed on the IMAGE, rather than the glass slide. 25
1 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma Two consultants called high grade I said suspicious for carcinoma 1 Nuclear abnormalities and architecture sufficiently abnormal for high grade. Tubule with necrotic debris raised concern for carcinoma. 26
4 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma 4 Two consultants called high grade I said at least low grade 4 The one who stuck with at least low grade did so because he didn t think the architectural abnormalities were sufficiently complex. 27
5 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma Two consultants called it low grade I said at least low grade 5 This focus must have looked like it was approaching high grade to one of us. At least all agreed that it was dysplastic. 28
6 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma Two consultants called it indefinite 1 said low grade 6 The surface looks abnormal and that bothered all of us, but there is not much else here. One thought that was enough. 29
8 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma All three consultants called it low grade 8 Finally! Something we can all agree on! 30
9 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma All three consultants called it high grade No problem here very atypical, disorganized, architecturally complex. 9 31
11 1. Negative 2. Low grade dysplasia 3. At least low grade dysplasia 4. High grade dysplasia 5. Suspicious for carcinoma 6. Indefinite for dysplasia 7. Carcinoma Two consultants called it negative 1 said indefinite 11 And here, I included this as one we could all agree on as negative! Just goes to show you 32
What does that go to show us? Histologic criteria for low and high grade dysplasia have been defined, and you can read about them and see lovely pictures in any GI pathology text. Presumably these criteria are based on what is known about follow up and outcome for these type of epithelia. We also find that: Applying the criteria to real life cases is difficult, and reproducibility is poor. Consultants (at least 3 we know) disagree with submitting pathologists more than half of the time, and with each other about a third of the time. These same consultants change more low grade outside diagnoses to high grade than the converse. How many of your diagnoses matched at least one of ours? Remember.we all agreed only 46% of the time! 33
Until something better comes along We must all do the best we can with our histologic diagnoses Adjust our thresholds to our colleagues, especially those who have more experience with follow up of cases and are therefore more expert. Until something better comes along Accept that fact that we cannot agree much of the time, and that disagreeing does not in itself make anyone wrong. Case #2 These esophageal biopsies were obtained from a 14 year old boy who complains of dysphagia. 34
Upper esophagus 35
Distal esophagus 36
What is your diagnosis? Sure looks like a case of eosinophilic esophagitis! How specific are you able to be in your report? What terminology do you use? Eosinophilic esophagitis is an increasingly prevalent and recognized esophageal disease, and attempts to diagnose this disease result in many of our esophageal biopsies. First reported in the 1970 s with scattered case reports over the next two decades. Dramatic rise in patients diagnosed with EoE and publications concerning EoE since mid 1990 s. Now known to be a worldwide disease. The classic patient with EoE is young, more likely male, more likely Caucasian, but.. EoE can occur in people of any age, gender, or ethnicity. 37
The clinical presentation tends to be different in young children than in adults. Failure to thrive Vomiting Nausea Regurgitation Epigastric or chest pain Dysphagia/food impaction Nausea, vomiting Heartburn A personal and family history of atopic disorders (asthma, eczema, allergic rhinitis is present in more than half of patients. Many studies suggest that food allergy is the cause of most cases of EoE. Removal of dietary antigens with an elemental diet improves symptoms and histology in 98% of patients. Results of allergy testing are good at guiding effective dietary therapy, via elimination diets. However, there is likely a role for aeroallergens in some patients, as well. Maybe because some environmental allergens cross react with food allergens (grass and wheat)? Dietary therapy alone, however, does not work in many patients. Dietary modification is not easy, and can be costly (elemental formulas). Corticosteroids, either systemic or swallowed are often effective. A combined approach, using dietary therapy, swallowed corticosteroids, and proton pump inhibitors has been found to be effective in >90% of patients, but many patients relapse. Experimental studies of IL-5 blockers are showing promise. (IL-5 involved in recruitment, proliferation and survival of eosinophils.) 38
The diagnosis depends on recognizing suggestive symptoms and performing upper endoscopy with biopsy. Some patients have endoscopic abnormalities and some do not, so biopsies are required for the diagnosis. At least a third of patients have normal appearance. Rings White exudates Not everyone with these findings has EoE! Furrows Narrow caliber The diagnostic histologic findings are patchy, so the diagnostic sensitivity of biopsies increases with the number of biopsies. At least four biopsies from each the upper and lower esophagus are recommended. 39
The classic histologic appearance of EoE intraepithelial eosinophilia superficial layering of eosinophils eosinophil microabscesses basal zone hyperplasia increased lymphocytes and mast cells Huge numbers of eosinophils, eosinophil microabscesses, superficial layering of eosinophils Some of the eosinophils are degranulated. 40
Basal zone hyperplasia It is hard to see the lymphocytes and mast cells in the background, but they are there! Lamina propria fibrosis shows up in a deep biopsy or resection. 41
Reflux esophagitis also has eosinophils, but usually far fewer that EoE, although there is overlap. Fortunately, Reflux E almost always has < 5-10 eos/hpf, and EoE usually has more than 20, like 30-40 Reflux esophagitis Eosinophilic esophagitis The pathologic diagnosis of EoE has been evolving, but has involved mostly the quantitation of the intraepithelial eosinophils. An AGA consensus statement in 2007 (Furuta, et al, Gastroenterol 133:1342-63) defined EoE as requiring greater than or equal to 15 intraepithelial eosinophils/hpf in one or more biopsies, and the absence of GERD based on ph monitoring and the lack of response to PPI. Based on that recommendation, here is how we have been signing out any esophageal biopsy with eosinophils: Esophagitis with eosinophils, maximum count of per HPF 42
A recent updated consensus document (2011) upholds the 15 eosinophils/hpf criterion, but adds the following statement: Pathologists should report all abnormalities associated with EoE, such as the peak eosinophil value (obtained from the area with the highest density of eosinophils), eosinophilic microabscesses, surface layering of eosinophils, extracellular eosinophil granules, basal cell hyperplasia, dilated intercellular spaces, and lamina propria fibrosis. Liacouras, et al. J Allergy Clin Immunol July, 2011 Now what should we do? What do you do? Eosinophilic esophagitis is a recognized clinicopathologic entity, in which pathologists play a pivotal role in diagnosis. At the very least, it is incumbent upon us to give a count of the maximum concentration of eosinophils. You will have to work with your gastroenterologists to see what else, if anything, they require. 43
Case 3 56 year old woman with multiple medical problems, on multiple medications She presents with chest pain and dysphagia, and undergoes upper endoscopy as part of the evaluation. Endoscopic findings: White plaques or membranes present in mid- and distal esophagus. Biopsies and brushings obtained. Requisition says, R/O Candida 44
Squamous mucosa and strips of detached surface epithelial cells Detached layer of necrotic superficial epithelium No fungus The intact squamous mucosa has a sharply delineated superficial layer of squamous cells with eosinophilic cytoplasm and pyknotic nuclei. 45
What is this? Sloughing esophagitis A small group of cases (4) was described in abstract form. Patients had endoscopic membranes, detached superficial necrotic epithelium, and tended to be debilitated patients. Moore RJ, et al. Sloughing esophagitis: a distinct histologic and endoscopic entity. Mod Pathol 1999;12:81A 24 cases of sloughing esophagitis at UM: Compared with a group of 34 controls, Sloughing esophagitis patients were significantly more likely to: Be older (median age of 53.5 vs. 43.5) Taking multiple prescription medications, especially CNS depressants and medications known to injure the esophagus (Fe, ASA, KCl, etc.) Be chronically debilitated, bedridden, on home O 2, have metastatic cancer, have an organ transplant, be on immunosuppressive therapy have died in the interval between the biopsy and the study, mean time to death 120 days Have a history of peptic ulcer disease 46
Sloughing Control Age 56 43.5 5 or more medications 77% 32% CNS depressants 65% 32% Drugs assoc w esoph 55% 18% injury (Fe, ASA, KCl) Peptic ulcers 55% 24% Renal insuff 16% 0 GERD sx 45% 74% 24 cases of sloughing esophagitis at the University of Michigan: Compared with a group of 34 controls, Sloughing esophagitis patients were significantly LESS likely to: Have GERD There was no difference between SE patients and controls with respect to dysmotility disorders irritable bowel disease atherosclerotic valvular disease. 24 cases of sloughing esophagitis at the University of Michigan: Conclusions: Sloughing esophagitis is a unique endoscopic and histologic entity that occurs in debilitated patients and is associated with medications known to injure squamous mucosa. It is likely to be a direct toxic injury, rather than an ischemic injury. 47
Is there such a thing as ischemic esophageal injury? Necrotizing esophagitis: The Black Esophagus A rare condition characterized by upper gastrointestinal bleeding (life threatening) associated with the endoscopic finding of a back esophageal mucosa. No history of corrosive or toxic agent. This black mucosa is necrotic and hemorrhagic. Underlying conditions that are believed to predispose patients to an ischemic black esophagus include coronary and peripheral vascular diseases low flow states (e.g., shock) gastric volvulus or gastric-outlet obstruction Pancreatitis cancer acute fatty liver of pregnancy overwhelming infection severe hypothermia severe emesis hyperglycemia (particularly in diabetic ketoacidosis). The necrosis can progress to become full thickness with rupture and lead to death. 48
Other cases of sloughing esophagitis.. 49
Is sloughing esophagitis a rare condition? We come across a case or two per month. With awareness of the endoscopic appearance, which looks to the endoscopist like Candida and attention to the desquamated necrotic superficial squamous layers I suspect you will begin to recognize a case from time to time. Dr. Elizabeth Montgomery Department of Pathology, Johns Hopkins: Our job is to make sure the patient gets appropriately waited on. In an attempt to follow Dr. Montgomery s advice, these are the questions I am always asking myself: What is my role in making a diagnosis or guiding therapy? What does the provider need to know? What information should I leave out because it is confusing or potentially misleading? What new entities are emerging that I can help gastroenterologists recognize? 50
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