esophagus workshop

7/29/2019 Esophagus Workshop

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ESOPHAGUS

DR AISHA AKBAR



– Lamina propria: Loose connective tissue, mucous glands in distalportion (cardiac glands)

– Muscularis Mucosae: Thicker than other parts of GI tract.

– Submucosa: Submucosal glands, ducts open in lumen.

– Muscularis propria: Admixture of striated & smooth muscle in theupper quarter, only smooth muscle in the rest of the organ.

– No serosal layer, except for the most distal portion.

– Autonomic nervous system: Meissner’s plexus in submucosa (sparse);Auerbach (Myenteric) plexus in muscularis propria (denser in the distalportion).

– Lymphatics: Upper third drains into the cervical nodes, the middlethird into the paraesophageal and paratracheal nodes, and lower thirdinto nodes around aorta and celiac axis.



.•45yr old female on anti depressants presented

with dysphagia and heartburn



REFLUX ESOPHAGITIS



Inflammation in esophagus due to relux of gastric contents

Pathogenesis» Alcohol/tobacco

» Obesity

» CNS depressants

» Pregnancy

»

Inc gastric vol/delayed emptying

» Grossly, severe lesions appear markedly hyperemic.

» Early microscopic lesions consists of epithelial hyperplasia, infiltrationby neutrophils and eosinophils and sometimes by epithelial necrosis.

» The papillary height of lamina propria and degree of basal cellproliferation are high.



» Dilated and congested venules are seen in top of lengthened papillae .

» Intraepithelial eosinophils frequently.

» The short tubular structure distal to the ulcer is seenmicroscopically to be lined by gastric mucosa and assuch it is regarded as an expression of Barrett'sesophagus.

» Occasionally inflammatory reaction is severe enoughto result in a pseudoepitheliomatousappearance.



60yrs old male, known case of GERD for the

last 15yrs now presented with hematemesis



“ Defined as occurrence of a specialized columnar epitheliumlining a segment of distal esophagus

above the level of lower esophageal sphincter.”



» Adults

» Genetic predisposition

“No Goblets no Barrett's”-

Another more questionable requirementincorporated into definition of Barrett’sesophagus by Practice Parameters committeeof American College of Gastroentrologists isthat this change

“can be recognized at

endoscopy”-the biologic significance of intestinalmetaplasia of lower esophagus should be thesame whether or not the endoscopist was ableto recognize it.



ENDOSCOPIC FEATURES

Barretts

No information of barretts,however biopsy is from GE

junction

No site / no endoscopicevidence of barretts

Normal gastric mucosa

INTERPRETATION

C/W Barretts

Cardiac mucosa withgoblet cells

Intestinalized mucosa,either barretts mucosa or cardiac mucosa withgoblet cells depending onthe the endoscopic

findings

Hiatal hernia b/c barrettsesophagus can never be anormal cardiac mucosa



Important features:

» Reduplication of muscularis mucosa» Long/short segment of barrets

» MUC2

» MUC5AC/MUC6

Main complications include

» peptic ulcer,

» stricture,

» bleeding

» development of dysplasia and carcinoma.



» Carcinoma is the most important complication of Barrett’s

esophagus and it is nearly always accompanied by

dysplasia.

» Dysplasia nearly always arises in an area of incomplete

intestinal metaplasia, and should be distinguished from

reactive dysplasia secondary to inflammatory injury and graded according to its severity.



Diagnostic criteria according to the 1988 consensus conference for grading dysplasia in Barrett's esophagus

Negative for dysplasia:

˃ Architecture within normal limits

˃ Nuclei do not vary greatly in size˃ or shape and are located basally

˃ N/C ratio is not increased.

˃ Nuclear envelope is smooth, nucleoli are not markedlyenlarged.

» Cytoplasmic mucin - may be depleted, progressive inc in mucincontent towards surface epithelial cells.

I d fi it f d l i (IND)



Indefinite for dysplasia (IND):

– The architecture may be mildly

distorted

– Nuclear abnormalities are less

marked than in dysplasia.

– Other futures include

» more numerous dystrophic Gobletcells,

» more extensive nuclear stratification

» diminished or absent mucus

production

» increased cytoplasmic basophilia

» increased mitoses



Positive for low-grade dysplasia (LGD)

or high grade dysplasia (HGD):

depend on severity of architectural and cytologic criteria

that suggest neoplastic transformation of the columanrepithelium.

Architectural abnormalities may include budding,

branching, crowded or irregularly shaped glands,

papillary extensions into gland lumina and

villiform configuration of the mucosal surface.

Nuclear features may include marked variation

in size and shape, nuclear and/or nucleolarenlargement, increased N/C ratio,

hyperchromatism, and increased number of

abnormal mitoses.

Architecture Low grade High grade



Architecture Low grade High grade

Villiform change – +/ –

Crypt budding/branching +/ – ++

Crowded (back-to-back)

crypts

+/ – ++

Irregular crypt shapes +/ – +

Intraluminal

papilla/ridges

– +/ –

Lamina propria between

glands

+ +/ –

Feature Low Grade High Grade



Feature Low Grade High Grade

Cytology

N/C ratio + ++

Loss of cell polarity – +

Atypical mitosis +/ – +

Full-thickness nuclear

stratification

– + ( crypts & surface)

Decreased goblet cells

(+/ – dystrophic)

+ ++

Irregular nuclear

contour

+ ++

Nuclear pleomorphism – +



Intramucosal carcinoma:

˃ Carcinoma that has penetrated through thebasement membrane of the glands into laminapropria but not yet invaded through themuscularis mucosae into the submucosa.

˃

Dysplasia is found in Barrett’s esophagusabsence of carcinoma in 5-10% of cases and inassociation with carcinoma in 68% to 100% of cases.



ADENOCARCINOMA ARISING

IN ESOPHAGUS

» Invasive carcinoma arising in Barrett'sesophagus is almost always

adenocarcinoma.

» The main feature suggestive of origin of adenocarcinoma from Barrett’s esophagus isassociation with dysplastic or non-dysplasticBarrett’s mucosa and location of more than

half of the tumor in the esophagus.



» Unusual types include ˃ Adenosquamous carcinoma

˃Squamous cell carcinoma

˃ Sarcomatoid carcinoma

˃ various type of neuroendocrine carcinoma

˃ Choriocarcinoma

˃ And yolk sac tumor

Sometimes alone and sometimes in association withadenocarcinoma.

hi l i



WHO histologicclassification

Epithelial tumors

» Squamous cell papilloma

» Intraepitheilal neoplasia

» Carcinoma

» Adeno ca

»

Sq cell ca» Verrucous ca

» Basaloid ca

» Spindle cell ca

» Adenosquamous ca

» mucoepidermoid ca» Adenoid cystic ca

» Small cell ca

» Undifferentiated ca

» Other

» Carcinoid

Non epithelial tumors

LeiomyomaLipoma

GIST

Rhabdomyosarcoma

Kaposi

Malignant melanoma

Secondary tumors



A 40 year old male presented with odynophagia

and weight loss



HERPES SIMPLEX ESOPHAGITIS



Case

A 60 year old chinese male smoker presented withprogressive dysphagia and weight loss



General and clinical features:

Male > 50yrs

RISK FACTORS

˃ Smoking and alcohol.

˃ Association with achlasia

˃ lye strictures

˃ Plummer Vinson syndrome

˃ Diverticula

˃celiac sprue

˃ history of irradiation.



Microscopically

˃ Occasionally lack of cohesion of tumor cells results in

glandular configuration

˃ With extensive search or ultrastructural examination, true

glandular or mucus secreting components are found focally in

one fifths of the cases. When extensive the tumor is designated

as adenosquamous carcinoma.



METASTASIS

High frequency of lymph node metastasis in the periesophageal area, below the diaphragm and upward into

the cervical nodes.

» Metastasis to liver, lung and adrenal gland is common.

» Tumor may metastasize to submucosa of stomach probably through submucosal lymphatic plexus.

» Poor prognosis



Prognostic markers:

» Sex

» Stage» Lymph node metastasis

» Depth of invasion

» Microscopic grade

» Vascular/lymphatic invasion

» Peritumoral fibrosis/lymphocytic reaction» Surgical margins

» DNA ploidy

» EGFR

» P53

» Response to therapy



REPORTING ESOPHAGEAL BIOPSYMACROSCOPIC

*Specimen Type

*___ Incisional biopsy*___ Excisional biopsy

*Tumor Site

*Specify, if known:

* Not specified*MICROSCOPIC

*Histologic Type

*Squamous cell carcinoma

*___ Adenocarcinoma

*___ Adenosquamous carcinoma

*___ Small cell carcinoma

*___ Undifferentiated carcinoma

*___ Other (specify): ____

*___ Carcinoma, type cannot be determined

*Hi t l i G d



*Histologic Grade

*___ Not applicable

*___ GX: Cannot be assessed

*___ G1: Well differentiated

*___ G2: Moderately differentiated

*___ G3: Poorly differentiated

*___ G4: Undifferentiated

*Extent of Invasion

*___ Cannot be assessed

*___ Epithelium only (no invasion)*___ Lamina propria

*___ Submucosa

*___ Muscularis propria

*Additional Pathologic Findings (check all that apply)

*___ None identified

*___ Intestinal metaplasia

*___ Dysplasia

*___ Esophagitis (type): _________________________

*___ Other (specify): __________________________

*Comment(s)

» ESOPHAGEAL RESECTION:



» ESOPHAGEAL RESECTION: MACROSCOPIC

Specimen Type

___ Esophageal resection

___ Esophagogastrectomy ___ Other (specify):

___ Not specified

Tumor SiteSpecify, if known:

___ Not specified

Tumor Size

Greatest dimension: ___ cm

*Additional dimensions: ___ x ___ cm

___ Cannot be determined (see Comment)

MICROSCOPIC



MICROSCOPIC

Histologic Type

___ Squamous cell carcinoma

___ Adenocarcinoma ___ Adenosquamous carcinoma

___ Small cell carcinoma

___ Undifferentiated carcinoma

___ Other (specify): _

___ Carcinoma, type cannot be determined

» Histologic Grade

» ___ Not applicable

» ___ GX: Cannot be assessed

» ___ G1: Well differentiated

» ___ G2: Moderately differentiated

» ___ G3: Poorly differentiated

» ___ G4: Undifferentiated

Pathologic Staging (pTNM)Primary Tumor (pT)



y (p )

___ pTX: Cannot be assessed

___ pT0: No evidence of primary tumor

___ pTis: Carcinoma in situ

___ pT1: Tumor invades lamina propria or submucosa

*___ pT1a: Tumor invades lamina propria

*___ pT1b: Tumor invades submucosa

___ pT2: Tumor invades muscularis propria ___ pT3: Tumor invades adventitia

___ pT4: Tumor invades adjacent structures

Regional Lymph Nodes (pN)

___ pNX: Cannot be assessed

___ pN0: No regional lymph node metastasis

___ pN1: Regional lymph node metastasis

*___ pN1a: 1 to 3 nodes involved*___ pN1b: 4 to 7 nodes involved

*___ pN1c: More than 7 nodes involved

Specify: Number examined: ___

Number involved: ___

Distant Metastasis (pM)

___ pMX: Cannot be assessed

___ pM1: Distant metastasis, cannot further subclassify ___ pM1a: Lower thoracic esophagus: metastasis in celiac lymph nodes;

Mid-thoracic esophagus: not applicable;

Upper thoracic esophagus: metastasis in cervical nodes

___ pM1b: Lower thoracic esophagus: other distant metastasis;

Mid-thoracic esophagus: nonregional lymph nodes and/or other distant metastasis;

Upper thoracic esophagus: other distant metastasis

Specify location of other distant metastases, if possible:

Margins (check all that apply)



Proximal Margin

___ Cannot be assessed

___ Uninvolved by invasive carcinoma

___ Involved by invasive carcinoma

___ Carcinoma in situ absent at proximal margin

___ Carcinoma in situ present at proximal margin

Distal Margin

___ Cannot be assessed

___ Uninvolved by invasive carcinoma


___ Carcinoma in situ absent at distal margin

___ Carcinoma in situ present at distal margin

Circumferential (Adventitial) Margin

___ Cannot be assessed ___ Uninvolved by invasive carcinoma


If all margins uninvolved by invasive carcinoma:

Distance of invasive carcinoma from closest margin: ___ mm

Specify margin: __________________________



Venous (Large Vessel) Invasion (V)

*___ Absent

*___ Present

*___ Indeterminate

*Lymphatic (Small Vessel) Invasion (L)

*___ Absent

*___ Present

*___ Indeterminate

*Additional Pathologic Findings (check all that apply)*___ None identified

*___ Intestinal metaplasia

*___ Dysplasia

*___ Esophagitis (type): ___________________________

*___ Gastritis (type): ___________________________

*___ Other (specify): ___________________________

*Comment(s)

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