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Roberto Fiocca Anatomia Patologica Università di Genova

Ripensare la definizione istologica di Barrett ? . Roberto Fiocca Anatomia Patologica Università di Genova. AN EASY DIAGNOSIS HOWEVER…. Paull A. The histologic spectrum of Barrett’s esophagus.N Engl J Med 1976

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Roberto Fiocca Anatomia Patologica Università di Genova

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  1. Ripensare la definizione istologica di Barrett? Roberto Fiocca Anatomia Patologica Università di Genova

  2. AN EASY DIAGNOSIS HOWEVER….

  3. Paull A. The histologic spectrum of Barrett’s esophagus.N Engl J Med 1976 Sampliner RE. Updates guidelines for the diagnosis of Barrett’s esophagus. Am J Gastreonterol 2002 Vakil N. The Montreal definition and classification of gastroesophageal reflux disease. Am J Gastroenterol 2006

  4. ESEM Histology + Barrett’s esophagus

  5. Barrett’s Esophagus Incomplete Gastric IM IM at G-E Junction

  6. The exact definition of biopsy site and the endoscopic picture are crucial in defining Barrett’s esophagus

  7. Circumference Maximum extent Patient with 5 cm long Barrett’s, distal 2 cm circumferential and proximal 3 cm in form of a tongue Barrett’s: C5 M6,5

  8. The principalreason for equivocationdeals with the presence of intestinal metaplasia as an essentialfactor for diagnosingBarrett’sesophagus.

  9. Presently most western pathologists follow this definition of Barrett’s Esophagus

  10. Most EG Junction Adenocarcinomas arise in Intestinal Metaplasia Early AC, nWith IM RuolA(Cancer 2000) 16 69% Van Sandick JW(Cancer 2000) 12 100% Cameron AJ(Am J Gastroenterol 2002) 22 86% Chandrasoma P * (Dis esophagus 2007) 26 92% * The prevalence of intestinal metaplasia was 100% in all tumors that were less than 1 cm in max diameter and all intramucosal tumors. These data strongly support the contention that adenocarcinomas of this region, including those in the gastric cardia, arise in intestinal metaplastic epithelium.

  11. … the DNA histograms of columnar mucosa with or without goblet cells showed similar abnormalities, including aneuploid G0/G1 peaks, elevated heterogeneity index (HI), increased cells in the S phase and occasional cells with DNA index (DI)>5N.

  12. More than 70% primary small adenocarcinomas (<2cm) of the esophaguswereadjacent to cardiac/fundic-typeratherthanintestinal-type mucosa.Intestinal metaplasia wasnotobserved in anyareas of the endoscopicmucosalresectionspecimens in 64 (56.6%) of the 113 cases

  13. Intestinal metaplasia was more commonly detected in longer segment length and increasing number of biopsies taken. After 5 yrs follow-up, 54,8% of patients without IM at index endoscopy demonstrated IM, and 90,8% after 10 yrs.

  14. British Society of Gastroenterology guidelines for the diagnosis of Barrett’s Esophagus: ARE WE CASTING THE NET TOO WIDE? Murphy SJ, Johnston BT, Murray LJ. 2969 patients met the criteria for Barrett’s esophagus. Mean follow-up of 3,7 (range 1-8) years 29 malignancies were found For patients with intestinal metaplasia the risk was 0,40 (95% CI 0,26 to 0,59). For those without intestinal metaplasia the risk was 0,06 (95% CI 0 to 0,32) In other words, if intestinal metaplasia was absent in biopsy specimen, the risk of oesophageal malignancy was not significantly higher than that in normal population. Gut 2006;55(12):1821-2

  15. INTESTINAL OR GASTRIC? THE UNSOLVED DILEMMA OF BARRETT'S METAPLASIA HUMAN PATHOLOGY Massimo Rugge, Matteo Fassan, Giorgio Battaglia, Paola Parente, Giovanni Zaninotto, Ermanno Ancona CLINICOPATHOLOGICAL CHARACTERISTICS OF 335 CONSECUTIVE BARRETT’S ESOPHAGUS PATIENTS IM-positive (n = 206; 61.5%) IM-negative (n = 129; 38.5%) Total (n = 335) p-value Biopsies per patient Mean±SD (median & range) 8.0±6.7 (6.0; 1-37) 3.4±3.7 (2.0; 1-18) 6.2±6.1 (4.0; 1-37) <0.001 Velvet mucosa segment length meann + SD (cm) 3,5 + 2,9 2,0 + 1,7 2,9 + 2,6 0.018 Prevalence of preneoplastic/neoplastic lesions 30 (14.6%) 0 (0%) 30 (9.0%) <0.001

  16. Cost - Effectiveness N° Barrett N° Early Neopl. COST EFFECTIVENESS

  17. Cost - Effectiveness N° Barrett N° Early Neopl. COST EFFECTIVENESS

  18. Barrett’s Esophagus: the Histology Report ENDOSCOPY HISTOLOGY DIAGNOSIS

  19. MorphologyisSUGGESTIVE of INTESTINAL METAPLASIA of the CARDIA Normal o irregular Z line MorphologyisDIAGNOSTIC for BARRETT’s ESOPHAGUS with INTESTINAL METAPLASIA SSBE >0,5-1 cm Samples of INTESTINAL epithelium MorphologyisDIAGNOSTIC for BARRETT’s ESOPHAGUS with INTESTINAL METAPLASIA LSBE

  20. MorphologyisSUGGESTIVE of SITE-APPROPRIATEgastric mucosa Normal o irregular Z line BE cannot be defined/confirmedbased on histology alone SSBE >0,5-1 cm Samples of CARDIAL epithelium MorphologyisDIAGNOSTIC for BARRETT’s ESOPHAGUS withoutintestinal metaplasia LSBE

  21. The findingisSUGGESTIVE of HIATUS HERNIA distalesophagus Samples of OXYNTIC mucosa The findingisDIAGNOSTIC for ECTOPIA (inlet patch) proximalesophagus

  22. UNA DIAGNOSI FACILE……… CHE RICHIEDE UN APPROCCIO CLINICO-PATOLOGICO CORRETTO

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