8. Barretts Esophagus Flashcards
Barrett’s is characterized by normal esophageal
squamous epithelium that is replaced by metaplastic
columnar mucosa specially
intestinal metaplasia.
Key feature cell in BE
Goblet cells, which have distinct mucous vacuoles,
define intestinal metaplasia and are a feature of BE.
Barrett’s esophagus is a complication of chronic GERD.
• Estimated ____or more of GERD patients have BE
10%
Epithelial dysplasia, considered to be a pre-malignant lesion,
develops in ____to_____ of person/years of BE.
• Dysplasia is classified as low-grade or high-grade on the
basis of morphologic criteria.
0.2% to 1.0%
____ gene probably plays a role as it has been
expressed in 100% of Barrett specimens but not
normal esophagus or stomach.
Cdx
____ expression in normal-appearing squamous
epithelium above specialized intestinal
metaplasia (in Barrett patients) has been
identified .
Cdx2
Cancers in Barrett’s esophagus evolve through a
series of genetic mutations that favor cell growth.
• Abnormalities in____ and _______expression,
have been associated with dysplasia and later
carcinogenesis.
p53
cyclin D1
Molecular studies suggest that Barrett’s epithelium
may be more similar to what type of cancer?
adenocarcinoma
Intramucosal carcinoma or adenocarcinoma is characterized by invasion
of neoplastic epithelial cells into the
lamina propria
Describe the Morphology of BE
BE is recognized as tongues or patches of red,
velvety mucosa extending upward from the GE junction.
• BE metaplastic mucosa alternates with residual
smooth, pale squamous mucosa proximally
What do we need to Dx Barretts?
Diagnosis of BE requires both endoscopic evidence of abnormal mucosa
above the GE junction and histologically documented metaplasia for diagnosis
Who do we commonly see BE in?
What type of screeings are in place for pts with BE?
Typically white adult male between 40-60 years old with long-term reflux
symptoms but BE itself is often completely asymptomatic.
• Periodic endoscopy, with biopsy for detection of dysplasia, is reasonable.
Do most people with BE devo esophageal adenocarcinoma?
NO!
What is the pt population we usually see esophageal adenocarcinoma in?
white middle age male (x 7).
• Incidence is highest in developed western
countries (United States, United Kingdom, Canada, Australia
And The Netherlands).
has esophageal adenocarcinoma gone up or down and what are teh risk factors
increased rapidly since 70s
–Dysplasia in BE
–Tobacco use
–Obesity
–Radiation therapy
• Molecular studies suggest that the progression of
BE to adenocarcinoma occurs over time through
the stepwise acquisition of _______ and _______ changes
genetic and
epigenetic
what chromosomal abnormalities do we see early on in esophageal adenocarcinoma?
p53 abnormalities early on
Additional genetic changes in esophageal adenocarcinoma include amplification of
c-ERB-B2, cyclin D1, and cyclin E genes
Increased epithelial expression of ________ and ________genes suggests that inflammation may also contribute to neoplastic progression in esophageal adenocarcinoma
tumor necrosis factor (TNF)- and nuclear factor (NF)-κB–dependent
What is frequently present near esophageal adenocarcinoma?
BE
Esophageal adenocarcinoma: Early lesions may appear as ________ in otherwise intact mucosa.
• Esophageal adenocarcinoma usually occurs in the _______ of
the esophagus and may invade the adjacent gastric cardia.
flat or raised patches
distal third
Describe the behavior of esophageal adenocarcinoma
Tumors may form large exophytic masses, infiltrate diffusely, or
ulcerate and invade deeply
In microscopic examination, esophageal adenocarcinoma tumors typically produce ______and form _____
mucin
dense glands
occurs in African- American (x 6) male adults (x 4) older than 45 years of age.
SCC typically
Risk factors for Sq Cell Carcinoma
– Alcohol and tobacco use
– Poverty (more common in rural and underdeveloped areas)
– History of caustic esophageal injury
– Achalasia and Plummer-Vinson syndrome
– Frequent consumption of very hot beverages
– Previous radiation therapy
Incidence rates and location of Sq CC
• The incidence of esophageal squamous cell carcinoma can vary by more than 100-
fold between countries.
• The highest incidence countries:
– Asia: Iran, Turkmenistan, China and Hong Kong (Silk Road)
– Elsewhere: Argentina, Brazil, and South Africa
• Majority of esophageal squamous cell
carcinomas in developed world are
partially attributable to
the use of alcohol
and tobacco.
In endemic areas the following risk factors for Sq CC
have been proposed:
– Nutritional deficiencies
– Mutagenic compounds such as those found
in fungus-contaminated foods (polycyclic
hydrocarbons, nitrosamines)
– HPV infection
Where do Sq CC appear and what do they look like early on?
middle third of the esophagus.
appear as small, gray-white plaque-like thickenings.
Growth pattern of Sq CC
Over months to years grow to masses that protrude
into and obstruct the lumen and cuase stricture
• Tumors often spread within the esophageal wall, and may invade
surrounding structures including the respiratory tree or aorta
What does Sq CC look lik on HE?
composed of nests of malignant
cells that partially recapitulate the stratified organization of squamous epithelium
When do people with Sq CC usually get diagnosed?
when they have symptomatic tumors which are generally large at diagnosis and have already invaded the esophageal wall.
Syptoms of Sq CC
- Dysphagia
- Odynophagia (pain on swallowing)
- Obstruction.
• Patients may adjust by altering their diet from
solid to liquid foods and wt loss
Five year survival rates are ___ for patients
with superficial esophageal carcinoma.
75%
Lymph node metastases, are associated with poor prognosis (5 yr of 9%) of Sq CC:
– Upper third of the esophagus favor ____ lymph
nodes
– Middle third favor _____, ______ and ______ nodes
– Lower third spread to _____ and _____ nodes
cervical (upper)
mediastinal, paratracheal, and tracheobronchial (mid)
gastric and celiac (lower)
Symptoms of esophageal adenocarcinoma
– Dysphagia
– Odynophagia
– Progressive weight loss
– Vomiting
Esophageal adenocarcinoma:
Five year survival approximates____ in the patients
with superficial adenocarcinoma. (Only 30% of cases
limited to the mucosa or submucosa.)
Overall five year survival rate is less than ___due to
advanced stage at the time of diagnosis.
80%
25%
