8. Barretts Esophagus

Question 1

Barrett’s is characterized by normal esophageal
squamous epithelium that is replaced by metaplastic
columnar mucosa specially

Answer 1

intestinal metaplasia.

Question 2

Key feature cell in BE

Answer 2

Goblet cells, which have distinct mucous vacuoles,
define intestinal metaplasia and are a feature of BE.

Question 3

Barrett’s esophagus is a complication of chronic GERD.
• Estimated ____or more of GERD patients have BE

Answer 3

10%

Question 4

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.

Answer 4

0.2% to 1.0%

Question 5

____ gene probably plays a role as it has been
expressed in 100% of Barrett specimens but not
normal esophagus or stomach.

Answer 5

Cdx

Question 6

____ expression in normal-appearing squamous
epithelium above specialized intestinal
metaplasia (in Barrett patients) has been
identified .

Answer 6

Cdx2

Question 7

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.

Answer 7

p53

cyclin D1

Question 8

Molecular studies suggest that Barrett’s epithelium
may be more similar to what type of cancer?

Answer 8

adenocarcinoma

Question 9

Intramucosal carcinoma or adenocarcinoma is characterized by invasion
of neoplastic epithelial cells into the

Answer 9

lamina propria

Question 10

Describe the Morphology of BE

Answer 10

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

Question 11

What do we need to Dx Barretts?

Answer 11

Diagnosis of BE requires both endoscopic evidence of abnormal mucosa
above the GE junction and histologically documented metaplasia for diagnosis

Question 12

Who do we commonly see BE in?

What type of screeings are in place for pts with BE?

Answer 12

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.

Question 13

Do most people with BE devo esophageal adenocarcinoma?

Answer 13

NO!

Question 14

What is the pt population we usually see esophageal adenocarcinoma in?

Answer 14

white middle age male (x 7).
• Incidence is highest in developed western
countries (United States, United Kingdom, Canada, Australia
And The Netherlands).

Question 15

has esophageal adenocarcinoma gone up or down and what are teh risk factors

Answer 15

increased rapidly since 70s

–Dysplasia in BE
–Tobacco use
–Obesity
–Radiation therapy

Question 16

• Molecular studies suggest that the progression of
BE to adenocarcinoma occurs over time through
the stepwise acquisition of _______ and _______ changes

Answer 16

genetic and
epigenetic

Question 17

what chromosomal abnormalities do we see early on in esophageal adenocarcinoma?

Answer 17

p53 abnormalities early on

Question 18

Additional genetic changes in esophageal adenocarcinoma include amplification of

Answer 18

c-ERB-B2, cyclin D1, and cyclin E genes

Question 19

Increased epithelial expression of ________ and ________genes suggests that inflammation may also contribute to neoplastic progression in esophageal adenocarcinoma

Answer 19

tumor necrosis factor (TNF)- and nuclear factor (NF)-κB–dependent

Question 20

What is frequently present near esophageal adenocarcinoma?

Answer 20

BE

Question 21

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.

Answer 21

flat or raised patches

distal third

Question 22

Describe the behavior of esophageal adenocarcinoma

Answer 22

Tumors may form large exophytic masses, infiltrate diffusely, or
ulcerate and invade deeply

Question 23

In microscopic examination, esophageal adenocarcinoma tumors typically produce ______and form _____

Answer 23

mucin

dense glands

Question 24

occurs in African- American (x 6) male adults (x 4) older than 45 years of age.

Answer 24

SCC typically

Question 25

Risk factors for Sq Cell Carcinoma

Answer 25

– 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

Question 26

Incidence rates and location of Sq CC

Answer 26

• 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

Question 27

• Majority of esophageal squamous cell
carcinomas in developed world are
partially attributable to

Answer 27

the use of alcohol
and tobacco.

Question 28

In endemic areas the following risk factors for Sq CC
have been proposed:

Answer 28

– Nutritional deficiencies
– Mutagenic compounds such as those found
in fungus-contaminated foods (polycyclic
hydrocarbons, nitrosamines)
– HPV infection

Question 29

Where do Sq CC appear and what do they look like early on?

Answer 29

middle third of the esophagus.
appear as small, gray-white plaque-like thickenings.

Question 30

Growth pattern of Sq CC

Answer 30

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

Question 31

What does Sq CC look lik on HE?

Answer 31

composed of nests of malignant
cells that partially recapitulate the stratified organization of squamous epithelium

Question 33

When do people with Sq CC usually get diagnosed?

Answer 33

when they have symptomatic tumors which are generally large at diagnosis and have already invaded the esophageal wall.

Question 34

Syptoms of Sq CC

Answer 34

1. Dysphagia
2. Odynophagia (pain on swallowing)
3. Obstruction.
   • Patients may adjust by altering their diet from
   solid to liquid foods and wt loss

Question 35

Five year survival rates are ___ for patients
with superficial esophageal carcinoma.

Answer 35

75%

Question 36

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

Answer 36

cervical (upper)

mediastinal, paratracheal, and tracheobronchial (mid)

gastric and celiac (lower)

Question 37

Symptoms of esophageal adenocarcinoma

Answer 37

– Dysphagia
– Odynophagia
– Progressive weight loss
– Vomiting

Question 38

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.

Answer 38

80%

25%