Histology of the gastroesophageal junction: an autopsy study

Barrett's esophagus: a review of the literature

Barrett's esophagus (BE) is the premalignant lesion of esophageal adenocarcinoma (EAC) defined as specialized intestinal metaplasia of the tubular esophagus that results from chronic gastroesophageal reflux. Which patients are at risk of having BE and which are at further risk of developing EAC has yet to be fully established. Many aspects of the management of BE have changed considerably in the past 5 years alone. The aim of this review is to define the critical elements necessary to effectively manage individuals with BE. The general prevalence of BE is estimated at 1.6-3% and follows a demographic distribution similar to EAC. Both short-segment (<3 cm) and long-segment (≥3 cm) BE confer a significant risk for EAC that is increased by the development of dysplasia. The treatment for flat high-grade dysplasia is endoscopic radiofrequency ablation therapy. The benefits of ablation for non-dysplastic BE and BE with low-grade dysplasia have yet to be validated. By understanding the intricacies of the development, screening, surveillance, and treatment of BE, new insights will be gained into the prevention and early detection of EAC that may ultimately lead to a reduction in morbidity and mortality in this patient population.

Controversies of cardiac glands in the proximal stomach: a critical review

Cardiac glands (CG), along with oxyntocardiac glands, in a normal human constitute cardiac mucosa (CM) that is positioned in the proximal stomach with a length of 10-30 mm, according to traditional teaching. This doctrine has been recently challenged. On the basis of studies on autopsy and biopsy materials in the esophagogastric junction region, some investigators have reported the presence of CG in only 50% of the general US population. They believed that CG were an acquired, metaplastic lesion as a result of gastroesophageal reflux disease. Subsequent recent study results from other research groups showed the presence of CG in the proximal stomach in embryos, fetuses, pediatric, and adult patients in most Europeans and Americans, and almost all Japanese and Chinese patients. These new data showed the following important findings: (i) CG are confirmed to be congenital in the proximal stomach; (ii) the length of CM is much shorter, approximately 5 mm in Caucasians in Europe and North America, and approximately 13 mm in Japanese and probably also in Chinese; (iii) CG are also present in the distal superficial esophagus underneath squamous mucosa in almost all Japanese and Chinese patients, but not so common in Caucasians in Europe, and not clear in Caucasians in North America. The recent data indicate a clear difference in the distribution of CG in the proximal stomach among different ethnic populations, and might explain different disease pathogenesis mechanisms among various ethnic patient groups.

Diagnostic challenges in the pathologic evaluation of Barrett esophagus

CONTEXT

Barrett esophagus represents an unstable epithelium resulting from chronic gastroesophageal reflux disease. Patients with Barrett esophagus routinely undergo endoscopic examination to detect dysplasia and early carcinoma. Although appropriate classification of Barrett esophagus and neoplasia is usually straightforward, persistent esophageal inflammation may induce epithelial changes that mimic, or mask, dysplasia. Recent data also indicate that specific molecular changes occur in nondysplastic Barrett mucosa and herald the development of dysplasia and/or carcinoma.

OBJECTIVE

To describe problematic aspects of biopsy interpretation in tissue samples of the gastroesophageal junction and distal esophagus, including the diagnostic criteria for Barrett esophagus, the importance of the gastric cardia, and pitfalls to the diagnosis of dysplasia. Ancillary studies that have recently emerged as potential adjuncts to the evaluation of patients with Barrett esophagus will be briefly discussed.

DATA SOURCES

A comprehensive review of the relevant literature indexed in PubMed (National Library of Medicine) was performed.

CONCLUSIONS

Barrett esophagus is currently defined as the presence of intestinal metaplasia in samples obtained from an endoscopically evident abnormality in the distal esophagus. Diagnosis and grading of dysplasia in mucosal biopsies remain the most reliable method to assess risk for neoplastic progression, but its classification may be hindered by superimposed inflammatory changes and suffers from considerable interobserver variability. Therefore, immunohistochemical studies and molecular assessment for TP53, CDKN2A , and DNA content abnormalities have emerged as potential adjuncts to the detection of dysplasia.

The histologic squamo-oxyntic gap: an accurate and reproducible diagnostic marker of gastroesophageal reflux disease

The present definition of gastroesophageal reflux disease (GERD) is based on clinical criteria that are difficult to reproduce accurately. This study provides a method to develop a histologic definition of GERD based on biopsies obtained from the affected esophagus. Pathology reports from 1655 patients who had upper gastrointestinal endoscopy and biopsy according to a systematic protocol were reviewed. Biopsies were obtained from the esophagus, around the gastroesophageal junction and the stomach: proximal, body, and antrum. Patients who had oxyntocardiac±cardiac±intestinal epithelia between the squamous epithelium proximally and the proximal limit of gastric oxyntic mucosa distally were defined as having a squamo-oxyntic gap. The length of the squamo-oxyntic gap varied from less than 1 cm in 1399 (84.5%) patients to greater than 5 cm in 80 (4.8%) of the patients. Only oxyntocardiac epithelium was seen in 190 (11.5%) of the patients, oxyntocardiac and cardiac epithelia in 898 (54.3%), and intestinal metaplasia in addition to the other 2 epithelial types in 567 (34.2%). The prevalence of intestinal metaplasia was directly proportional to length of the squamo-oxyntic gap, being 24.3% (340/1399) when the length was <1 cm, and 83.5% (147/176) with length 1 to 5 cm. All patients with a length more than 5 cm had intestinal metaplasia. The distribution of the 3 epithelia was constant irrespective of the length of the squamocolumnar gap; intestinal metaplasia, when present, was seen maximally in the proximal region of the gap, cardiac epithelium intermediate and oxyntocardiac epithelium in the most distal segment of the gap. The squamo-oxyntic gap started in a dilated region distal to the end of the tubular esophagus and distal to the proximal limit of the rugal folds and extended into the tubular esophagus. Distal gastric biopsies showed no evidence of significant inflammation, intestinal metaplasia or Helicobacter pylori infection in 1543 (93.2%) of the patients, indicating that the squamo-oxyntic gap was largely independent of gastric pathology. We provide evidence that the squamo-oxyntic gap is equivalent to the columnar-lined esophagus. Its presence is a specific and sensitive indicator of reflux and can be used as a cellular criterion to define GERD. The length of the squamo-oxyntic gap provides an accurate assessment of the severity of chronic GERD. The distal limit of the squamo-oxyntic gap, which is the junction between oxyntocardiac and gastric oxyntic epithelium is the true gastroesophageal junction. The presence of intestinal metaplasia within the squamo-oxyntic gap is the most accurate risk indicator for esophageal adenocarcinoma and defines Barrett esophagus.

Pathophysiology and treatment of Barrett’s esophagus

Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the United States. About 10%-15% of patients with GERD develop Barrett’s esophagus, which can progress to adenocarcinoma, currently the most prevalent type of esophageal cancer. The esophagus is normally lined by squamous mucosa, therefore, it is clear that for adenocarcinoma to develop, there must be a sequence of events that result in transformation of the normal squamous mucosa into columnar epithelium. This sequence begins with gastroesophageal reflux, and with continued injury metaplastic columnar epithelium develops. This article reviews the pathophysiology of Barrett’s esophagus and implications for its treatment. The effect of medical and surgical therapy of Barrett’s esophagus is compared.

Histology of metaplasia and dysplasia in Barrett's esophagus

The histologic diagnosis of Barrett's dysplasia requires the identification of intestinal metaplasia, which often presents a challenge due to sampling error, observer variation, and difficulty in histologic interpretation. Particularly problematic is the separation of negative, indefinite, and low-grade dysplasia, the varied histological appearances of high-grade dysplasia, and the diagnosis of suboptimal biopsy material. This article seeks to aid in the histological evaluation of metaplasia and dysplasia in Barrett's esophagus.

Clinical characteristics, biologic behavior, and survival after esophagectomy are similar for adenocarcinoma of the gastroesophageal junction and the distal esophagus

OBJECTIVE

The Siewert classification system differentiates between adenocarcinoma of the gastroesophageal junction and that of the distal esophagus. The purpose of this study was to evaluate whether there were differences in the location and prevalence of lymph node metastases, type of recurrence, and survival with these tumors that warrant distinguishing between them in clinical practice.

METHODS

Records of all patients who underwent resection for adenocarcinoma of the distal esophagus or gastroesophageal junction from 1987 to 2007 were retrospectively reviewed. Based on the endoscopic location of the epicenter of the tumor in relation to the gastroesophageal junction, tumors were categorized in 301 patients as being of the distal esophagus and in 208 as being of the gastroesophageal junction.

RESULTS

There were no significant differences in age, sex, or body mass index between patients with adenocarcinoma of the distal esophagus or gastroesophageal junction. Patients with adenocarcinoma of the distal esophagus were more likely to have reflux symptoms (75% vs 53%, P < .0001) and peritumoral intestinal metaplasia (73% vs 51%, P < .0001) and be in a surveillance program (54% vs 9%, P = .0005) compared with patients with adenocarcinoma of the gastroesophageal junction. However, the prevalence and location of nodal metastases was similar, and in node-positive patients mediastinal node involvement was present in more than 40% of the patients in each group (distal esophageal adenocarcinoma, 47%; gastroesophageal junction adenocarcinoma, 41%). Survival was similar (5 years: distal esophageal adenocarcinoma, 45%; gastroesophageal junction adenocarcinoma, 38%; P = .14), as was the prevalence and type of recurrence.

CONCLUSION

The prevalence and distribution of lymph node metastases in patients with adenocarcinoma of the distal esophagus and gastroesophageal junction were similar, and after esophagectomy, there was no difference in overall survival or recurrence. Efforts to differentiate between these tumors are unnecessary, and both are effectively treated with esophagectomy.

Metaplastic esophageal columnar epithelium without goblet cells shows DNA content abnormalities similar to goblet cell-containing epithelium

OBJECTIVES

The mucosa of patients with columnar-lined esophagus recognized on endoscopy usually shows epithelium with and without goblet cells. Columnar epithelium with goblet cells ("Barrett's esophagus") is generally believed to represent a premalignant lesion and has been shown to contain DNA abnormalities. However, the biological properties of non-goblet columnar epithelium remain unknown. The purpose of this study was to determine the DNA content properties of non-goblet epithelium in patients with metaplastic columnar epithelium of the esophagus.

METHODS

Mucosal biopsies of the esophagus from 68 patients with columnar metaplasia of the esophagus (22 without goblet cells and 46 with goblet cells) and 19 patients with normal gastric mucosa (controls) were histologically evaluated for the density of goblet cells. The latter group was divided into low-density, high-density, and very high-density goblet cell subgroups. Tissue sections of non-goblet epithelium and goblet cell epithelium (where present) were evaluated by image cytometry, and high-fidelity DNA histograms were created to indicate the G0/G1 peak DNA index (DI), DNA content heterogeneity index (HI), and the percentage of cells with DNA exceeding 5N (5N-EC). G0/G1 peaks with DI>1.1 were considered aneuploid.

RESULTS

Normal gastric controls showed a mean peak DI of 1.02+/-0.03 and an HI of 11.6+/-0.7. None of the controls revealed aneuploidy or 5N-EC. Patients with metaplastic columnar epithelium with goblet cells showed a DI of 1.15+/-0.12, HI of 18.2+/-2.1, mild aneuploidy in 54% of the cases, and 5N-EC in 15% of the cases, all of which were significantly higher than in controls. Patients with metaplastic columnar epithelium without goblet cells showed DNA content results statistically similar to those of patients with metaplastic columnar epithelium with goblet cells, and also revealed significantly higher values compared with those of controls. Furthermore, there were no significant differences in any of the key DNA content abnormalities between non-goblet and goblet cell-containing epithelium in patients with metaplastic columnar epithelium with goblet cells, or between these two types of epithelium according to the density of goblet cells.

CONCLUSIONS

DNA content abnormalities occur with equal frequency and extent in metaplastic columnar epithelium of the esophagus without goblet cells compared with metaplastic columnar epithelium with goblet cells. These findings suggest that metaplastic non-goblet columnar epithelium of the esophagus may have neoplastic potential.

Reflux esophagitis or Helicobacter infection? - diagnostic value of the inflammatory pattern in metaplastic mucosa at the squamocolumnar junction

OBJECTIVES

Metaplastic glandular mucosa with goblet cells at the squamocolumnar junction is induced either by reflux or by Helicobacter infection. We investigated whether the accompanying inflammation may give information about the etiology of these metaplastic changes and whether there are further criteria which are helpful in differentiating Helicobacter-induced vs. reflux-caused metaplasia.

METHODS

One hundred and nine patients with intestinal metaplasia diagnosed in biopsies obtained immediately below the Z-line were evaluated. Further biopsies were taken from the gastric body and antrum. Patients were diagnosed as having a normal Z-line, or as showing short tongues or segments of Barrett's esophagus endoscopically. Inflammation was graded according to the updated Sydney-system. Metaplasia was typed using Gomori's-aldehyde-fuchsin-Alcianblue staining.

RESULTS

Compared to patients with Barrett's esophagus, the active (p=0.0002) and chronic inflammation (p=0.0004) at the squamocolumnar junction was higher in patients with a normal Z-line and frequently accompanied by lymphoid aggregates (p<0.0001) and regular cardia- (p=0.0044) and/or corpus-type glands (p=0.0004). Pseudogoblet cells were more frequent in Barrett's esophagus (p=0.0159).

CONCLUSIONS

The endoscopic aspect of the Z-line, the inflammatory pattern, and the type of glands in biopsies from the squamocolumnar junction, as well as the presence of pseudogoblet cells are helpful tools in distinguishing Barrett's mucosa from Helicobacter-associated intestinal metaplasia.

Relationship between Barrett's esophagus and cardia adenocarcinoma

The incidence of cardia adenocarcinoma (CA) has been increasing during the past few decades. CA and esophageal adenocarcinoma (EA) are known to share the same epidemiologic features. Barrett's esophagus (BE) is judged to be the precursor of EA. Thus, the question of whether BE is a risk factor for CA is currently much discussed. In this review, we describe the progress in the study of CA, and the relationship between CA and BE.

Effect of proton pump inhibitor therapy on inflammatory changes in the gastric cardia (carditis)

The etiology of inflammation of the gastric cardia (carditis) is controversial, and gastroesophageal reflux disease (GERD) and H. pylori infection have been proposed as etiological factors. This study aimed to investigate the effect of acid suppression on histological changes in the gastric cardia. Gastric cardia biopsies of reflux patients were evaluated at baseline and after proton pump inhibitor (PPI) therapy. The updated Sydney classification was used to score the biopsies, and carditis scores (pre- and post-PPI therapy) were compared. A total of 31 patients were included, of which 5 patients were excluded, as cardiac mucosa was not documented in either pre- or post-PPI biopsies. The mean duration of PPI therapy was 30 months (SE, 3.04 months). There was no significant change in carditis scores post-PPI therapy. The mean mononuclear and neutrophil scores were 1.23 and 0.35 pre-PPI therapy and 1.73 and 0.62 post-PPI therapy, respectively. No change in mean intestinal metaplasia and atrophy scores was identified. In conclusion, acid suppressive therapy with PPI did not lead to a significant reduction in carditis scores. These results suggest that GERD probably does not play a major role in the pathogenesis of inflammation in the gastric cardia.

Distribution and significance of the oesophageal and gastric cardiac mucosae: a study of 131 operation specimens

AIMS

To clarify the distribution and significance of the oesophageal and gastric cardiac mucosae at the oesophago-gastric junction (EGJ).

METHODS AND RESULTS

Oesophagectomy specimens from 131 consecutive patients with middle and upper thoracic oesophageal cancer were examined. The surgically resected specimens including the EGJ were cut into 5 mm thick serial sections and examined histopathologically for the length of the oesophageal and gastric cardiac mucosae and the incidence of columnar epithelial islands (CEIs). We also determined the presence of short-segment Barrett's oesophagus (SSBE) and goblet cell metaplasia in SSBE. Oesophageal cardiac mucosa was found in 125 cases (95%) and gastric cardiac mucosa was found in all cases. The mean length of the oesophageal and gastric cardiac mucosa was 4 mm (range 1-26 mm) and 13 mm (range 2-64 mm), respectively. CEIs were found in 75 cases (57%). SSBE was found in 70 cases (53%), among which goblet cell metaplasia was found in 28 cases (21%). No long-segment Barrett's oesophagus was found. The mean length of oesophageal cardiac mucosa (6 mm) and gastric cardiac mucosa (17 mm) in SSBE was significantly greater than that (3 mm and 8 mm, respectively) in non-SSBE cases (P < 0.0001 and P < 0.0001). The incidence (69%) of CEIs in SSBE was significantly higher than that (44%) in non-SSBE cases (P = 0.005).

CONCLUSIONS

Oesophageal and gastric cardiac mucosae were found frequently. Oesophageal cardiac glands and CEIs might play an important role in the development of SSBE.

Videoendoscopy and histopathology of the esophagogastric junction in patients with gastroesophageal reflux disease

BACKGROUND AND AIMS

During endoscopy the stomach is considered to rise at the level of the 'gastric' folds; however, anatomical studies have demonstrated that the proximal gastric folds may in fact be esophageal. This prospective study was designed to assess the histopathology of endoscopically visible proximal gastric folds in patients with gastroesophageal reflux disease.

METHODS

35 consecutive patients (20 males) with gastroesophageal reflux disease underwent video endoscopy, including biopsy sampling from the endoscopically visible esophagogastric junction (0 cm, 0.5 cm and 1.0 cm distal to the rise of gastric folds and 0.5 cm and 1.0 cm proximal to it). Endoscopy was digitally recorded and reviewed for assignment of biopsy level. Columnar-lined esophagus and esophagitis were cataloged according to the Paull-Chandrasoma histopathologic classification and the Los Angeles endoscopic classification.

RESULTS

Endoscopy: Normal endoscopic esophagogastric junction was seen in 11 (31%) patients and visible columnar-lined esophagus < or = 0.5 cm in 24 (69%).

HISTOLOGY

Columnar-lined esophagus extended 1.0 cm in 22.8% of patients and 0.5 cm in 51.4%, distal to the rise of the gastric folds. In all patients columnar-lined esophagus was interposed between squamous epithelium and gastric oxyntic mucosa. Thus, so-called gastric folds contained mucosa of esophageal origin in all patients. Intestinal metaplasia (Barrett esophagus) was detected in eight (22.9%) patients.

CONCLUSIONS

Endoscopy cannot exclude histopathologic columnar-lined esophagus within gastric rugae. Thus, visible 'gastric' folds should not be used for definition of the esophagogastric junction but as a reference landmark for biopsy sampling during endoscopy.

The pathology of gastric cardia: a prospective, endoscopic, and morphologic study

"Carditis" (inflammation of the gastric cardiac mucosa) may be associated with gastroesophageal reflux disease (GERD), whereas other studies argue that Helicobacter pylori could play a significant role in the chronic cardiac damage. We examined prospectively histologic features of gastric cardia, esophagitis, and H. pylori status in 204 consecutive subjects with GERD symptoms (57.3% male, 42.7% female mean age 49.2 y) undergoing upper gastrointestinal endoscopy with multiple biopsies in the distal esophagus, cardiac region, and stomach. These were assessed for esophagitis landmarks [Ismail Beigi grading (g0-3)], gastritis, and H. pylori infection (Sydney classification). The average symptom duration was 10.8 months. Endoscopy showed no erosive disease in 54.5% patients, grade "A" esophagitis in 37.6%, "B" in 8%, and "C" in 1 case. Histologic examination disclosed g0 in 8.3% patients, g1 in 78.4%, g2 in 12.8%, and g3 in 1; analysis of the cardia showed oxyntic mucosa in 27.9% patients and chronic cardiac mucosa inflammation in 72.1%. Carditis was significantly related to macroscopic esophagitis (P=0.044) and heartburn score (P=0.001). H. pylori cardiac infection was present in 27.4% cases (73.2% associated with cardiac mucosa). Gastric H. pylori infection was demonstrated in 35% patients. H. pylori in the cardiac region was associated with gastric H. pylori infection (P=0.001) and with paucity of GERD symptoms (P=0.05). A good correlation between carditis and GERD, concerning symptoms and macroscopic esophagitis was found in this study. H. pylori-related carditis is likely to be differently compared with the GERD-related type.

Adenocarcinomas of the distal esophagus and "gastric cardia" are predominantly esophageal carcinomas

BACKGROUND

Adenocarcinoma of the distal esophagus and gastric cardia are defined by the relationship of its epicenter to the gastro-esophageal junction, which is presently defined as the end of the tubular esophagus. We have recently suggested that the true gastro-esophageal junction is best defined by the proximal limit of gastric oxyntic mucosa.

AIM

To reclassify adenocarcinomas of this region by the relationship of the tumor to the proximal limit of gastric oxyntic mucosa.

METHODS

Seventy-four patients who had esophago-gastrectomy for adenocarcinomas in this region were classified as adenocarcinoma of distal esophagus (38 patients) and gastric cardia (36 patients) by present criteria. The epithelial type at the epicenter and distal edge of these tumors was assessed.

RESULTS

The epicenter of the tumor in 64 patients with noncircumferential tumors had squamous (5 cases), cardiac (21 cases), oxynto-cardiac (4 cases), and intestinal (Barrett-type) (34 cases) epithelia. None had gastric oxyntic mucosa. Of the 10 patients with circumferential tumors, 7 had cardiac or oxynto-cardiac epithelium at the distal tumor edge.

CONCLUSIONS

If the gastro-esophageal junction is defined histologically as the proximal limit of oxyntic mucosa, 71/74 patients would be classified as adenocarcinoma of the distal esophagus. The other 3 patients were questionable as to gastric or esophageal origin. We suggest that this reclassification based on the proposed new definition of the gastro-esophageal junction provides an explanation for the epidemiologic relationship that exists between adenocarcinoma of the "gastric cardia" and gastro-esophageal reflux disease.

Carditis is related to Helicobacter pylori infection in dyspeptic children and adolescents

BACKGROUND

Etiology of gastric cardia inflammation is still controversial.

AIMS

To evaluate the association between carditis and Helicobacter pylori infection and the correlation among inflammatory changes observed in biopsies taken from cardia, corpus, and antrum in a well-defined group of patients.

PATIENTS

The mean age of 45 dyspeptic patients was 10.4 years (range 5.1-17.0 years); gender F/M rate: 1.6/1.

METHODS

A total of 450 specimens from esophagus (2), cardia (2), corpus (3), and antrum (4) were collected for biopsy. The presence of H. pylori was assessed by histology and a rapid urease test. The types of glandular epithelium of cardia found in specimens were identified and both inflammatory changes and H. pylori density were graded.

RESULTS

Carditis was present in specimens of 30/45 (66.7%) of the patients. Presence of H. pylori in specimens was detected in the antrum (26/45; 57.8%), in the corpus (19/45; 42.2%), and in the cardia (14/45; 31.1%). There was a strong association between carditis and presence of H. pylori infection (OR=27.08) by multivariate analysis. The scores for inflammation and activity in the cardia, corpus and antrum have shown a relationship except for both cardia and antrum H. pylori density and corpus and cardia activity. The intensity of gastritis and degree of colonization with H. pylori were significantly higher in the antrum than in both the corpus and the cardia. Pangastritis was highly associated to H. pylori infection in 22/25 (88%) of the patients.

CONCLUSIONS

1. Carditis is associated to H. pylori infection in children with symptoms of dyspepsia; 2. The degrees of gastritis found at the cardia were correlated to those at the antrum and body except for both cardia and antrum H. pylori density and corpus and cardia activity.

Identifying intestinal metaplasia at the squamocolumnar junction by using optical coherence tomography

BACKGROUND

Optical coherence tomography (OCT) is an optical imaging method that produces high-resolution cross-sectional images of the esophagus. The accuracy of OCT for differentiating tissue types at the squamocolumnar junction (SCJ) has not been established.

OBJECTIVE

The purpose of this study was to identify and validate OCT image criteria for distinguishing metaplastic from nonmetaplastic tissue at the SCJ.

DESIGN

A total of 196 biopsy-correlated OCT images of the SCJ were acquired from 113 patients undergoing upper endoscopy. A pathologist blinded to the OCT results reviewed each pathology specimen and determined the presence of the following histopathology: gastric cardia, squamous mucosa, pancreatic metaplasia, and intestinal metaplasia. An algorithm for diagnosing specialized intestinal metaplasia (SIM) was created by reviewing a training set of 40 biopsy-correlated OCT images. Two blinded investigators prospectively tested the algorithm on a validation set of 123 images.

RESULTS

OCT images of squamous mucosa were characterized by a layered appearance without epithelial glands; gastric cardia, by vertical pit and gland structure, a well-defined epithelial surface reflectivity, and relatively poor image penetration; and SIM by an irregular architecture and good image penetration. The OCT criteria were 85% sensitive and 95% specific for SIM when applied retrospectively to the training set. When applied to the validation set, the algorithm was 81% sensitive for both OCT readers and 66% and 57% specific for diagnosing SIM. The interobserver agreement was good (kappa = 0.53).

CONCLUSIONS

OCT imaging can identify SIM at the SCJ with an accuracy similar to that of endoscopy.

Pathologic Risk Factors of Adenocarcinoma of the Gastric Cardia and Gastroesophageal Junction

Available evidence supports the existence of two major pathways of neoplastic development in the gastroesophageal region: the Barrett pathway, related to gastroesophageal reflux disease, and the gastric pathway, related to Helicobacter pylori infection. The existence of an independent junctional pathway is questionable, and gastroesophageal junction adenocarcinomas share features of esophageal and gastric adenocarcinomas. It has been impossible to accommodate all data that are provided by different levels and tools of observation in tumors that develop in the gastroesophageal region in a single, coherent classification. That is why the stratification of pathologic risk in such tumors, and their respective precursors, incorporates features from topography, histology, immunohistochemistry, and molecular pathology.

Pathology of the gastroesophageal junction

The gastroesophageal junction (GEJ) is a poorly defined anatomic area that represents the junction etween the distal esophagus and the proximal stomach (cardia). The true anatomic GEJ corresponds to the most proximal aspect of the gastric folds, which represents an endoscopically apparent transition oint in most individuals. Many, if not most, adults, particularly those with either physiologic or logic GERD, have a proximally displaced Z-line indicating that the histologic squamocolumnar nction (SCJ) is located above the anatomic GEJ. The histologic characteristics of short segments of columnar mucosa located above the anatomic GEJ in these individuals are similar to the gastric cardia, ng composed of either pure mucous glands or mixed mucous glands/oxyntic glands. Although controversial, some authors believe that the cardia is normally composed, at birth, of surface mucinous columnar epithelium and underlying oxyntic glands identical to the gastric corpus, whereas others maintain that the true anatomic cardia is normally composed of mucinous columnar epithelium with underlying mucous glands or mixed mucous and oxyntic glands. However, the preponderance of evidence supports the latter theory and that the length of mucosa composed of either mucous, or mixed mucous glands/oxyntic glands, increases with age and is presumed to be related to ongoing GERD. Inflammation of the true gastric cardia (carditis), which is most often due to H. pylori infection, is difficult to distinguish from columnar metaplasia of the distal esophagus secondary to GERD. From a pathologist's perspective, the differential diagnosis of true gastric carditis from esophageal columnar metaplasia of the distal esophagus in GEJ biopsies is difficult, but a variety of clinical, pathologic, and immunohistochemical methods can be used to help separate these two disorders. Nearly one-third of patients who present for upper GI endoscopy without endoscopic evidence of BE reveal foci of intestinal metaplasia in the GEJ. There are some studies to suggest that the risk of dysplasia and cancer is different in patients with intestinal metaplasia in the cardia related to H. pylori infection versus those with metaplastic columnar epithelium in the distal esophagus related to GERD. Chronic inflammation is generally considered the predominant underlying stimulus for the development of columnar metaplasia in the GEJ, regardless of the etiology. Columnar metaplasia and intestinal metaplasia in the distal esophagus represents a squamous to columnar cell transition and there is some evidence that this occurs through an intermediate, or transitional, phase of intestinalization termed multilayered epithelium. In contrast, intestinal metaplasia that develops in the true gastric cardia secondary to H. pylori infection represents a columnar to columnar metaplastic reaction. This review will focus on the clinical, pathologic, and pathogenetic aspects of GERD and H. pylori-induced inflammation of the GEJ region.

Body mass index is associated with Barrett esophagus and cardiac mucosal metaplasia

A positive association between body mass index (BMI) and risk of esophageal adenocarcinoma has been reported. Barrett esophagus (BE) is a precursor lesion for esophageal adenocarcinoma. Cardiac mucosa (CM) and BE are both reflux-induced metaplastic columnar epithelia in the esophagus. We investigated the association between BMI and BE/CM in a case-control study. A total of 174 BE patients, 333 CM patients, and 274 controls were included in this study. Multivariate logistic regression methods were used to estimate odds ratios (OR) for BE or CM associated with BMI. Linear regression analysis was employed to examine the relationship between length of columnar lined esophagus (CLE) and BMI. A dose-dependent relationship was found between BMI and BE (P=.0004). The multivariate-adjusted OR for BE was 3.3 (95% confidence interval [CI], 1.6-6.7) when obese individuals (BMI >or=30 kg/m(2)) were compared to lean individuals (BMI < 22 kg/m(2)). Similarly, a dose-dependent relationship was found between BMI and CM (P=.03). The multivariate-adjusted OR for CM comparing obese to lean persons was 1.8 (95% CI, 1.04-3.10). The length of CLE was positively related to BMI (P=.04). In conclusion, BMI is associated with BE and CM and appears to act early in the sequence of events leading from gastroesophageal reflux disease to metaplasia (CM and BE) to dysplasia and finally to adenocarcinoma.

Cdx-2 expression in squamous and metaplastic columnar epithelia of the esophagus

The molecular pathogenesis of Barrett's esophagus is poorly understood. Evidence suggests that at a phenotypic level, the metaplastic process begins with the transformation of squamous epithelium in the distal esophagus to cardiac mucosa, which subsequently becomes intestinalized. The homeobox gene Cdx-2 has been shown to be an important transcriptional regulator of embryonic differentiation and maintenance of adult intestinal type epithelium. We hypothesized that Cdx-2 gene expression levels increase with the phenotypic transformation of normal squamous mucosa to the intestinalized columnar mucosa of Barrett's esophagus. Endoscopic biopsies were obtained at the gastroesophageal junction in patients with symptoms of gastroesophageal reflux disease and classified according to histology: normal squamous mucosa (n = 62), cardiac mucosa (n = 19), oxynto-cardiac mucosa (n = 14), and intestinal metaplasia (n = 15). Duodenal biopsies (n = 26) served as the columnar control. After laser capture microdissection and RNA isolation, gene expression levels of Cdx-2 were measured in each tissue type by quantitative reverse transcription polymerase chain reaction. Consistent with its known function, Cdx-2 gene expression levels were highest in duodenal mucosa and nearly absent in squamous epithelium. There was a stepwise increase in Cdx-2 gene expression from cardiac to Barrett's epithelium (P < 0.001). Expression levels of Cdx-2 in cardiac and oxynto-cardiac mucosa were 40-70 times higher and Barrett's mucosa 400 times higher than that found in squamous epithelium. Relative expression of the homeobox gene Cdx-2, known to induce differentiation of intestinal type epithelium, increases in a stepwise fashion during the phenotypic transformation of distal esophageal squamous mucosa to cardiac columnar mucosa and to the intestinalized columnar mucosa of Barrett's esophagus. Therefore, Cdx-2 may be a potential biomarker to detect the early transition to Barrett's esophagus.

Pathogenesis and classification of cancer around the gastroesophageal junction--not so different in Japan

Japanese patients with early adenocarcinoma of the esophagus have well-preserved gastric acid secretion, consistent with other parts of the world, reinforcing the likely importance of the luminal environment for pathogenesis. Progress in researching carcinomas that occur around the gastroesophageal junction would be facilitated by consensus-based review of the inadequate approaches currently used for classification of these tumors with subsequent development and widespread adoption of improved criteria.

Cancer of the gastric cardia

Current evidence indicates that cardia cancers are of at least two distinct and disparate aetiologies. One type resembles cancer of the more distal stomach (Type A), being a consequence of atrophic gastritis due to Helicobacter pylori infection or more rarely autoimmune atrophic gastritis. Another type (Type B) resembles oesophageal adenocarcinoma and is likely to be a consequence of short-segment gastro-oesophageal reflux disease. The two cancers are themselves indistinguishable but examination of the gastric phenotype indicates the aetiology: Type A occurring in patients with evidence of atrophic gastritis whereas Type B occurs in subjects with healthy acid secreting stomachs. In subjects with healthy acid secreting stomachs the cardia has a specific luminal chemistry remaining highly acidic and unbuffered following a meal and having very active nitrosative chemistry due to the acidification of nitrite in saliva. This luminal chemistry may contribute to the high incidence of metaplasia and neoplasia at this anatomical site.

Differences and similarities of adenocarcinomas of the esophagus and esophagogastric junction

During the last few decades there has been an alarming rise in the incidence of tumors originating at the esophagogastric junction (EGJ) [1]. The reason for this is unknown. Tumors of the EGJ can be categorized in two types of cancer divided according to their anatomical origin: distal esophageal adenocarcinoma and adenocarcinoma of the gastric cardia. However, due to their location, in the transitional zone of the esophagus and stomach, there is constant debate about the proper classification, staging, and management of these tumors. The etiology of distal esophageal adenocarcinoma is clearly related to gastroesophageal reflux disease (GERD) and the development of a Barrett's esophagus [2]. The etiology of adenocarcinoma of the gastric cardia is less well understood. In the present paper, we will discuss the clinical characteristics and clinical management of esophagogastric tumors. Special attention will be given to differences and similarities of adenocarcinomas of the gastric cardia and distal esophagus.

A proposal for a new validated histological definition of the gastroesophageal junction

Present definitions of the gastroesophageal junction (GEJ) are the point of flaring of the tubular esophagus and the proximal limit of the gastric rugal folds. Neither of these has been validated as the true GEJ. This study aims to validate the location of the true GEJ using the criterion of esophageal submucosal glands. Ten esophagogastrectomy specimens, in which there was a well-defined point of flaring of the tubular esophagus that coincided with the proximal limit of gastric rugal folds, were examined by complete histological mapping to evaluate the distribution of esophageal submucosal glands and surface epithelial types. Oxyntocardiac and cardiac mucosa with or without intestinal metaplasia were present under rugal folds distal to the end of tubular esophagus in all patients to a length of 0.31 to 2.05 cm. Submucosal glands were present in the tubular esophagus and in the proximal pouch distal to the tubular esophagus in a distribution that closely coincided with squamous epithelium, oxyntocardiac, cardiac, and intestinal epithelia. Submucosal glands were never found under oxyntic mucosa. We conclude that a variable part of the saccular region distal to the tubular esophagus contains esophageal submucosal glands, therefore representing reflux-damaged distal esophagus. This results in an error, where up to 2.05 cm of distal reflux-damaged dilated esophagus can be mistaken as proximal stomach when presently accepted definitions for the GEJ are used. The true GEJ is the proximal limit of gastric oxyntic mucosa defined by histology.

Small-bowel metaplasia arising in the remnant esophagus after esophagojejunostomy--a [corrected] prospective study in patients with a history of total gastrectomy

OBJECTIVES

The pathogenesis of Barrett's mucosa is incompletely understood. Acidic gastro-esophageal reflux is considered an essential causative factor. The aim of this study was to detect esophageal columnar metaplasia after total gastrectomy with esophagojejunostomy, a condition of enteric, but nonacidic reflux.

METHODS

In a prospective study, patients with a history of total gastrectomy and esophagojejunostomy were investigated for the presence of columnar metaplasia in the remnant esophagus. Patients with such history, who were now referred for esophagogastroduodenoscopy, were included during a 2-yr period. Biopsies for histopathology were taken from the anastomosis and any columnar metaplasia of the esophagus.

RESULTS

In 8 of 25 patients (32%) with a history of gastrectomy, columnar metaplasia was found in the remnant esophagus, mostly in shape of tongues, partly associated with erosive reflux esophagitis. Histopathology showed a typical small-bowel mucosa, but with some villous atrophy. In a resection specimen, a double-layered muscularis mucosa was present, which proved the metaplastic nature of the intestinal mucosa. Length of the columnar metaplasia correlated with the time interval since surgery.

CONCLUSIONS

Esophageal mucosa, if exposed long term to an enteric, but nongastric refluxate, can evolve into a highly differentiated intestinal metaplasia, which resembles small-bowel mucosa. This proves that complete-type intestinal metaplasia may arise not only in the stomach, but also in the esophagus. Esophageal intestinalization seems to reflect adaptation to enteric reflux.

On the origin of cardiac mucosa: A histological and immunohistoc-hemical study of cytokeratin expression patterns in the developing esophagogastric junction region and stomach

AIM To examine the fetal and neonatal esophagogastric junction region (EGJ) histologically for the presence of an equivalent to adult cardiac mucosa (CM); to study the expression patterns of all cytokeratins (CK) relevant to the EGJ during gestation; to compare the CK profile of the gestational and the adult EGJ; and to determine the degree of development in the adult EGJ histology and CK profile during gestation.

METHODS: Forty-eight fetal autopsy specimens of the EGJ were step-sectioned and stained with hematoxylin and eosin (H&E) to select sections showing the mucosal lining. Immunohistochemistry for CK5, 7, 8, 13, 18, 19, and 20 was performed. Antibody staining was then graded for location, intensity, and degree.

RESULTS: The distal esophagus was lined by simple columnar epithelium from 12-wk gestational age (GA). The proximal part of this segment consisted of mucus-producing epithelium, devoid of parietal cells. CK5 and 13 were present exclusively in multilayered epithelia and CK8, 18, and 19 predominantly in simple columnar epithelium. There were no differences in the frequencies of the co-ordinate CK7+/20+ and the CK7-/20- immunophenotypes between different locations. The prevalence of the CK7+/20- immunophenotype decreased, and that of the CK7-/20+ immunophenotype increased significantly from the distal esophagus to the distal stomach.

CONCLUSION: Fetal columnar-lined lower esophagus (fetal CLE) may be the equivalent and precursor of the short segments of columnar epithelium found in the distal esophagus of some normal adult subjects. Esophageal simple columnar epithelium without parietal cells (ESN) may be the precursor of adult CM. The similarities between the fetal and adult EGJ and stomach CK expression patterns support the conclusion that adult CM has an identifiable precursor in the fetus. This would then indicate that at least a part of the adult CM has a congenital origin.

Unraveling the mystery of the gastroesophageal junction: a pathologist's perspective

The gastroesophageal junction (GEJ), which is defined as the point where the distal esophagus joins the proximal stomach (cardia), is a short anatomic area that is commonly exposed to the injurious effects of GERD and/or Helicobacter pylori infection. These disorders often lead to inflammation and intestinal metaplasia (IM) of this anatomic region. The true gastric cardia is an extremely short segment (<0.4 mm) of mucosa that is typically composed of pure mucous glands, or mixed mucous/oxyntic glands that are histologically indistinguishable from metaplastic mucinous columnar epithelium of the distal esophagus. In patients with GERD, whether physiologic or pathologic, the length of cardia-type epithelium increases and extends proximally above the level of the anatomic GEJ into the distal esophagus. Columnar metaplasia of the distal esophagus represents a squamous to columnar metaplastic reaction that develops from an esophageal stem cell and may pass through an intermediate phase characterized by the presence of a type of epithelium that possesses a mixture of squamous and columnar features, termed multilayered epithelium. In contrast, IM of the gastric cardia represents a columnar to columnar cell metaplastic reaction that develops from a gastric stem cell located in the deep foveolar compartment of the gastric mucosa. Intestinal metaplasia, particularly the incomplete type, is widely believed to represent the precursor lesion upon which dysplasia and cancer arises. The frequency of IM is probably greater in metaplastic columnar epithelium in the esophagus secondary to GERD, than in cases of true gastric carditis secondary to H. pylori, and may be a reason why there is a higher risk of carcinoma in the former compared to the latter. A variety of clinical, endoscopic, histologic, and histochemical methods can be used to distinguish GERD-induced columnar metaplasia of the distal esophagus from H. pylori-induced inflammation of true gastric cardia, and these are outlined in this review, but further controlled studies are needed to critically evaluate these techniques. Further prospective trials are needed to adequately evaluate the different etiologic and pathogenetic mechanisms and, most importantly, the risk of malignancy in these two conditions.

Prevalence of precancerous and other metaplasia in the distal oesophagus and gastro-oesophageal junction

OBJECTIVE

The epidemiology of Barrett's oesophagus (BO) is characterized by divergent results. The aim of this study was to estimate the prevalence of BO and intestinal metaplasia (IM) at the gastro-oesophageal junction (GOJ) in a population-based series of patients referred for first-time gastroscopy.

MATERIAL AND METHODS

Consecutive patients who underwent endoscopy for the first time at endoscopy units exclusively serving defined catchment areas were invited to take part in the study. Biopsies were taken immediately below the GOJ and from the distal oesophagus, and clinical data were recorded.

RESULTS

A total of 769 patients (mean age 53 years, 43% M) were examined. Overall IM prevalence was 14%. BO was noted in 4%. Overall, the prevalence of IM increased by 8% (95% CI 6-10%) per year of age. BO patients were predominately women (69%). Presence of cardia-type mucosa in the cardia increased with age from 25% among the youngest to 59% among the oldest patients. Pancreatic acinar metaplasia (PAM) was found in 18%.

CONCLUSIONS

While BO is not common among Swedish gastroscopy patients, IM and PAM are found in every 7th and 6th patient, respectively. Age-dependent increments in prevalence suggest that not only BO and IM, but also cardia-type mucosa are acquired and/or progressive lesions.

Controversies of the cardiac mucosa and Barrett's oesophagus

Confusion regarding the diagnosis of Barrett's oesophagus exists because of a false dogma that cardiac mucosa is normally present in the gastro-oesophageal junctional region. Recent data indicate that the only normal epithelia in the oesophagus and proximal stomach are squamous epithelium and gastric oxyntic mucosa. When this fact is recognized, it becomes easy to develop precise histological definitions for the normal state (presence of only squamous and oxyntic mucosa), metaplastic oesophageal columnar epithelium (cardiac mucosa with and without intestinal metaplasia, and oxynto-cardiac mucosa), the gastro-oesophageal junction (the proximal limit of gastric oxyntic mucosa), the oesophagus (that part of the foregut lined by squamous and metaplastic columnar epithelium), reflux disease (the presence of metaplastic columnar epithelium), and Barrett's oesophagus (cardiac mucosa with intestinal metaplasia). It is also possible to assess accurately the severity of reflux which is directly proportional to the amount of metaplastic columnar epithelium, and the risk of adenocarcinoma which is related to the amount of dysplasia in intestinal metaplastic epithelium present within the columnar lined segment of the oesophagus. Histopathological precision cannot be matched by any other modality and can convert the confusion that exists regarding diagnosis of Barrett's oesophagus to complete lucidity in a manner that is simple, accurate, and reproducible.

Gland ducts and multilayered epithelium in mucosal biopsies from gastroesophageal-junction region are useful in characterizing esophageal location

SUMMARY. There is controversy as to whether oxynto-cardiac mucosa (OCM), cardiac mucosa (CM) and intestinal metaplasia (IM) found in the gastroesophageal-junction region line the anatomic stomach, esophagus or both. A total of 785 retroflex biopsies taken at the endoscopic gastroesophageal junction in 244 patients were evaluated for the presence of gland ducts and multilayered epithelium which are two recognized markers of esophageal mucosa. Oxyntic mucosa was found in 287 biopsies, OCM in 283, CM in 158, IM in 30 and squamous epithelium in 53 (some biopsies had more than one epithelial type). Esophageal gland ducts and multilayered epithelium were absent in all biopsies with oxyntic mucosa. Sixty-four (13.6%) of 471 biopsies with OCM, CM and IM contained esophageal gland ducts, and 68 of 471 (14.4%) contained multilayered epithelium. Ninety-eight of 471 (20.8%) biopsies contained either gland ducts or multilayered epithelium. This study shows that 20.8% of biopsies at the gastroesophageal junction with OCM, CM and IM can be definitively characterized as lining the anatomic esophagus by the finding of gland ducts and multilayered epithelium. The absence of these markers in oxyntic mucosa confirms this epithelium as gastric. The presence of gland ducts and multilayered epithelium can be used by pathologists to objectively ascribe an esophageal or gastric location to a biopsy from the gastroesophageal junction.

Expression of Cdx2 in early GRCL of Barrett's esophagus induced in rats by duodenal reflux

The intestine-specific caudal-related homeobox transcription factor Cdx2 is widely accepted to play a key role in intestinal development and differentiation in mammals. We studied the role of Cdx2 in the development of Barrett's esophagus (BE). In previous studies, we have shown a sequence of morphological changes of squamous epithelium leading to BE, found a peculiar metaplastic change common to other parts of gut, and proposed the concept of a "gut regenerative cell lineage" (GRCL). The GRCL is characterized by pyloric-foveolar metaplasia with goblet cell metaplasia, which occurs in the regenerative process in response to chronic inflammation. BE very likely develops through the GRCL, and we studied the expression of Cdx2 in various lesions of rat esophageal mucosa induced by duodenal reflux, using reverse transciptase-polymerase chain reaction and immunohistochemistry against Cdx2. We found that Cdx2 was expressed not only in specialized columnar epithelium (SCE) of BE, but also in several pyloric gland and foveolar metaplastic cells which developed in the basal layer of the squamous epithelium at an earlier stage of SCE development. These findings indicate that Cdx2 plays a crucial role in directing intestinal-type differentiation of the GRCL.

Carcinoma of the cardia: classification as esophageal or gastric cancer?

INTRODUCTION

The cardia is the anatomical borderland between the esophagus and stomach. Carcinomas of the cardia are regarded to share features of both, esophageal and gastric cancers. Controversy exists concerning their appropriate classification and whether these tumors comprise--in respect to tumor biology, pathophysiology as well as clinical features--an entirely separate entity.

CLASSIFICATION

In order to distinguish cardia carcinomas from other adenocarcinomas arising within the vicinity of the esophagogastric junction, a classification system has been introduced from a surgical viewpoint, and is now well established and increasingly used worldwide. According to the topography of the main tumor mass, cardia carcinomas (AEG II) are distinguished from adenocarcinomas of the distal esophagus (AEG I) and subcardiac gastric cancers (AEG III). The tumor-node-metastasis (TNM) staging system by the International Union Against Cancer (UICC) does not provide a separate classification for tumors of the esophagogastric junction. The use of the classification for esophageal or for gastric cancers is recommended, irrespective of the elementary differences in the classification of lymphatic spread implemented herein.

DISCUSSION

New aspects concerning this controversial debate are discussed based on current insights into the pathogenesis and the cellular origin of these entities. The controversies concerning the classification of cardia carcinomas and the failure of the current esophageal and gastric cancer staging systems to reflect the peculiarities of this entity accurately, present a strong argument in favor of a new classification system.

Cardiac mucosa in the remnant esophagus after esophagectomy is an acquired epithelium with Barrett's-like features

BACKGROUND

The cervical esophagus is normally lined by squamous epithelium and is usually not exposed to gastroesophageal reflux. The aims of this study were, first, to investigate whether cardiac mucosa can be acquired in the remnant cervical esophagus after esophagectomy and cervical esophagogastrostomy and, second, to characterize this mucosa if present.

METHODS

The medical records of 100 patients who had undergone esophagectomy with gastric pull-up reconstruction were studied retrospectively to identify those who had biopsies from the cervical esophagus proximal to the gastroesophageal anastomosis during postoperative follow-up. The histopathology and immunohistochemical stains were reviewed to assess similarity to Barrett's mucosa (cytokeratins [CK] 7 and 20 and DAS-1), cellular proliferation (topoisomerase 2alpha), and the potential for dysplasia (cyclo-oxygenase 2 [COX-2] and ornithine decarboxylase [ODC]).

RESULTS

Supra-anastomotic biopsies were performed in 20 patients. Cardiac mucosa was present in 10 of 20 (50%) patients in whom biopsies were performed. Four patients had areas of intestinal metaplasia, and dysplasia, and adenocarcinoma developed in 1 patient. The CK7/20 and DAS-1 staining of the columnar mucosa showed a pattern similar to Barrett's mucosa. Topoisomerase 2alpha protein expression was present in 50% of patients with cardiac mucosa. DAS-1 protein was expressed in cervical columnar mucosa but not in normal squamous esophagus mucosa. The cardiac mucosa stained weakly for COX-2 and ODC.

CONCLUSIONS

Cardiac mucosa can be acquired. Its expression profile is similar to cardiac mucosa and intestinal metaplasia found in Barrett's esophagus, and different from normal esophageal or gastric mucosa. The development of cardiac mucosa is likely to be related to reflux of acid into the remnant cervical esophagus as the first step in the development of Barrett's esophagus. These findings are applicable to the development of similar changes at the gastroesophageal junction.

Cardia-type metaplasia arising in the remnant esophagus after cardia resection

BACKGROUND

Specialized intestinalized metaplasia in the distal esophagus (Barrett's esophagus) is a recognized precursor of esophageal adenocarcinoma, but its pathogenesis is incompletely understood. The aim of this study was to investigate the mucosal effects of esophagogastrostomy, an artificial interface between esophageal squamous and gastric oxyntic epithelium.

METHODS

EGD was performed in 14 consecutive patients (median age 63 years, range 26-71 years) who had undergone esophagogastrostomy from 3 to 88 months earlier. Biopsy specimens were obtained in 13 patients from the anastomosis and, when present, columnar epithelium in the remnant esophagus.

RESULTS

In 10 patients, EGD demonstrated tongue-shaped segments of columnar epithelium extending from 0.3 to 7 cm into the remnant esophagus. Biopsy specimens revealed cardia-type mucosa in all patients, whether at the anastomosis or proximally in esophageal segments of columnar epithelium. Magnification endoscopy of cardia-type mucosa visualized a long-oval, tubular, or ridged surface pattern. In 3 cases, complete intestinal metaplasia was observed within the cardia-type mucosa.

CONCLUSIONS

The frequent transformation of squamous epithelium into cardia-type mucosa in the distal remnant esophagus after esophagogastrostomy supports the concept that cardia-type mucosa is a reflux-induced metaplasia that may give rise to the subsequent development of specialized intestinalized metaplasia.

TFF3 expression at the esophagogastric junction is increased in gastro-esophageal reflux disease (GERD)

At the gastric cardia, the molecular mechanisms of inflammation and metaplasia are incompletely understood. Thus, the aim of this study was to determine the expression of TFF1, TFF2 and TFF3 at this site and correlate these data with Helicobacter pylori infection or gastro-esophageal reflux disease (GERD). In 27 patients without intestinal metaplasia at the cardia, endoscopic biopsies were obtained for histology and RT-PCR. TFF1 and TFF2 were expressed in all cardia samples. TFF3 expression was significantly more frequent at the cardia (n = 15/24) than in the corpus (n = 2/26). TFF3 expression at the cardia was mainly observed in GERD patients, and there was a clear tendency towards higher interleukin-8 (IL-8) transcription levels; whereas TFF3 expression was not correlated with the H. pylori status or to tumor necrosis factor-alpha (TNF-alpha) expression. The expression of TFF3 at the cardia may represent an adaptation to GERD and precede the development of Barrett's esophagus.

Distinction between intestinal metaplasia in the cardia and in Barrett's esophagus: the role of histology and immunohistochemistry

Intestinal metaplasia in Barrett's esophagus (BIM) is a precancerous condition, whereas the carcinogenic potential of intestinal metaplasia of the cardia (CIM) is uncertain. Although clinically important, histological distinction between both conditions by endoscopic biopsies is considered problematic. In the present study, 4-mm samples of BIM (n=31) and CIM (n=9) were selected from esophagectomy specimens that had been resected for esophageal cancer. Slides were coded and stained with hematoxylin and eosin (H&E), Alcian blue-periodic acid-Schiff (PAS), cytokeratins (CK) 7 and 20, and CD10, which labels the intestinal brush border. The predictive value of these stains for the recognition of BIM and CIM was evaluated independently by two senior pathologists. With the use of H&E-stained slides exclusively, BIM samples were categorized correctly in 93.5% and 83.9% of cases (pathologists 1 and 2, respectively), and CIM samples, in 100% and 88.9% of cases. Alcian blue-PAS-positive goblet cells were identified by both investigators in all BIM and CIM samples. BIM-typical CK 7 and 20 immunostaining pattern was identified in 90.3%/83.9% of BIM but only in 11.1%/11.1% of CIM. CD10-positive brush border was present in 32.3%/25.8% of BIM and in 88.9%/88.9% of CIM. When HE-stained slides and immunohistologically stained slides were used together for tissue recognition, BIM were categorized correctly in 90.3%/80.6% of cases, and CIM, in 88.9%/88.9% of cases. In conclusion, BIM and CIM can be usually distinguished on the basis of HE sections. CK 7 and CK 20 expression pattern analysis discriminates correctly between BIM and CIM in the majority of cases. CD10-positive intestinal brush border is present in the majority of CIM but only in a minority of BIM. However, immunohistochemical investigations could not improve the diagnostic accuracy of HE histology alone.

Barrett's esophagus: histopathologic definitions and diagnostic criteria

Adenocarcinoma of the distal esophagus is rising more rapidly in incidence than any other visceral malignancy in the Western world. It is well established that most, if not all, of these tumors develop in Barrett's esophagus via the metaplasia-dysplasia-carcinoma sequence and could theoretically be detected at an early stage, but despite this, the majority of these tumors are still detected late in their course. This highlights the fact that the goal of effective surveillance for patients at risk for developing an adenocarcinoma of the distal esophagus is still far off. In addition, adenocarcinomas of the esophagogastric junction and gastric cardia are also rising in incidence, but their carcinogenesis and their relation to Barrett's esophagus are still being defined, as are the meaning and significance of the relatively new entities "short-segment Barrett's" and "ultra-short-segment Barrett's". This review attempts to clarify the main histopathologic issues concerned with the definition of Barrett's esophagus, its distinction from intestinal metaplasia of the gastric cardia, as well as the criteria for the histologic diagnosis of dysplasia and carcinoma in Barrett's esophagus.

The presence and mucin histochemistry of cardiac type mucosa at the esophagogastric junction

OBJECTIVES

Traditionally, the gastric cardia has been described as a native part of the stomach connecting to the esophagus. In recent literature, however, it is suggested that the cardia is an acquired lesion that develops due to gastroesophageal reflux disease. As a contribution to this debate, we evaluated the presence of cardiac mucosa at the esophagogastric junction (EGJ) in a random group of patients who presented at our endoscopy unit.

METHODS

In 253 unselected patients, biopsies were taken from the EGJ. In order to prevent sampling error, we selected only those EGJ biopsies in which the squamocolumnar junction (SCJ) was present in the histological biopsy material. Fifty-five patients were excluded since the SCJ was located proximal to the EGJ in the esophagus. The type of columnar mucosa immediately distal to the SCJ, and its mucin histochemistry, were assessed. The columnar mucosa was categorized as purely cardiac, oxyntocardiac, or fundic mucosa.

RESULTS

In 63 of the 198 patients, the SCJ was actually present in the EGJ biopsies. Purely cardiac mucosa was present in 39 (62%) biopsies and oxyntocardiac mucosa was present in 24 (38%) biopsies. Fundic mucosa was not seen directly adjacent to squamous epithelium. Acid mucins were present in 23 (37%) patients and they correlated with histological esophagitis and presence of H. pylori in the cardia.

CONCLUSIONS

Cardiac mucosa was uniformly present adjacent to the squamous epithelium at the EGJ. This argues against the hypothesis that the gastric cardia is an acquired metaplastic lesion. The presence of acid mucins was frequently observed and could be a pathological condition as it was associated with histological esophagitis and the presence of H. pylori in the cardia.

'Cardiac-type' (mucinous) mucosa and carditis are both associated with Helicobacter pylori-related gastritis

BACKGROUND

Adenocarcinoma of the gastro-oesophageal junction is rapidly increasing in incidence and there is much interest in precursor lesions. The aetiology of inflammation of the gastric cardia (carditis) and the concept of the cardia as a native zone of mucinous gastric glands are disputed.

AIMS

To investigate the relationship between the type of cardiac mucosa and carditis with various histological and clinical parameters.

METHODS

Ninety-eight sets of gastric biopsies (cardia, corpus, incisura and antrum) were obtained prospectively in young patients (median age 40 years) who presented to the outpatient clinic with symptoms of gastro-oesophageal reflux (n = 25) or other upper gastrointestinal symptoms. Patients with neoplasia or Barrett's oesophagus were excluded. The presence (n = 19) or absence of oesophagitis at endoscopy was recorded. The degree of inflammation, Helicobacter pylori density, intestinal metaplasia and atrophy were scored according to the Sydney classification and the type of cardiac mucosa (oxyntic or mucinous) was noted.

RESULTS

We found that carditis and mucinous-type cardiac mucosa were strongly associated with H. pylori-related gastritis (P = 0.00019 and P = 0.006, respectively) but not with clinical or endoscopic gastro-oesophageal reflux. Mucinous mucosa in the cardia was only seen in 17% of biopsies.

CONCLUSION

H. pylori-related gastritis is associated with mucinous-type cardiac mucosa as well as with carditis. The former strongly points to expansion of mucinous cardiac mucosa in H. pylori gastritis. This probably represents metaplasia of oxyntic to mucinous mucosa and raises the possibility of a role in carcinogenesis of the gastro-oesophageal junction.