SM_135b: Pathology of Esophageal Disorders

Question 1

Normal esophagus is lined by ____

Answer 1

Normal esophagus is lined by stratified squamous epithelium

Question 2

Z-line at junction of stomach and esophagus is the point at which ____

Answer 2

Z-line at junction of stomach and esophagus is the point at which squamous mucosa becomes columnar

Question 3

Esophagus is lined by ____

Answer 3

Esophagus is lined by stratified squamous epithelium

Question 4

____ is an inflammatory process due to reflux of gastric or duodenal contents into esophagus secondary to failure of anti-reflux mechanisms

Answer 4

GERD is an inflammatory process due to reflux of gastric or duodenal contents into esophagus secondary to failure of anti-reflux mechanisms

Question 5

Describe endoscopic findings of reflux esophagitis

Answer 5

Reflux esophagitis endoscopic findings

• Hypereremia or erythema
• Patches resembling leukoplakia

Question 6

Describe histological findings of reflux esophagitis

Answer 6

Reflux esophagitis histological findings (primarily in distal esophagus)

• Basal cell hyperplasia
• Vascular congestion and extension of vascular papillae to the top half of the overall thickness
• Mixed inflammatory cell infiltrate (eosinophils, lymphocytes, and few neutrophils unless there is erosion / ulceration)
• Ballooning of squamous cells (increased water content)

Question 7

This is ____ in ____

Answer 7

This is basal cell hyperplasia in reflux esophagitis

Question 8

This is ____ in ____

Answer 8

This is vascular congestion in reflux esophagitis

Question 9

This is ____ in ____

Answer 9

This is intraepithelial eosinophils and lymphocytes (squiggles) in reflux esophagitis

Question 10

These are ____ in ____

Answer 10

These are intraepithelial lymphocytes (squiggles) in reflux esophagitis

Question 11

These are ____ in ____

Answer 11

These are balloon cells in reflux esophagitis

Question 12

Complications of reflux esophagitis include ____, ____, and ____

Answer 12

Complications of reflux esophagitis include erosion / ulceration, strictures, and Barrett’s esophagus

• Strictures: from fibrosis secondary to ulceration

Question 13

____ is loss of superficial epithelium down to muscularis mucosa, while ____ is loss of superficial epithelium above muscularis mucosa

Answer 13

Ulceration is loss of superficial epithelium down to muscularis mucosa, while erosion is loss of superficial epithelium above muscularis mucosa

Question 14

____ is a chronic immune / antigen-mediated esophageal disease characterized by esophageal dysfunction and eosinophil-predominant inflammation

Answer 14

Eosinophilic esophagitis is a chronic immune / antigen-mediated esophageal disease characterized by esophageal dysfunction and eosinophil-predominant inflammation

Question 15

Eosinophilic esophagitis is most likely associated with ____, involves the ____ and ____, and is most prevalent in ____

Answer 15

Eosinophilic esophagitis is most likely associated with allergy, involves the proximal and distal esophagus, and is mostprevalent in children/teenagers

Question 16

Eosinophilic esophagitis endoscopic findings include ____, ____, ____, and ____

Answer 16

Eosinophilic esophagitis endoscopic findings include furrows, rings, strictures, and white patches / plaques

Question 17

Describe histology of eosinophilic esophagitis

Answer 17

Eosinophilic esophagitis histology

• Prominent intraepithelial eosinophils
• Eosinophilic microabscesses (clusters of multiple eosinophils) often with large clusters near the surface
• Increased intraepithelial lymphocytes
• Basal cell hyperplasia
• Fibrosis in the lamina propria

Question 18

These are ____ in ____

Answer 18

These are intraepithelial eosinophils in eosinophilic esophagitis

Question 19

These are ____ and ____ in ____

Answer 19

These are eosinophilic microabscesses and increased intraepithelial lymphocytes in eosinophilic esophagitis

Question 20

This is ____ in ____

Answer 20

This is lamina propria fibrosis in eosinophilic esophagitis

Question 21

_____ is conversion of normal squamous epithelium of the esophagus into metaplastic columnar epithelium

Answer 21

Barrett’s esophagus is conversion of normal squamous epithelium of the esophagus into metaplastic columnar epithelium

• Endoscopically recognizable columnar (mucinous) metaplasia of the esophageal mucosa that is confirmed pathologically to contain intestinal metaplasia

Question 22

Barrett’s esophagus endoscopic findings are ____

Answer 22

Barrett’s esophagus endoscopic findings are salmon pink “gastric type” mucosa in the squamous-lined esophagus

(salmon pink is all proximal to gastroesophageal junction)

Question 23

Biopsy of Barrett’s esophagus shows ____

Answer 23

Biopsy of Barrett’s esophagus shows some goblet cells in a background of gastric-type mucin cells

Question 24

Columnar mucinous metaplasia is ____

Answer 24

Columnar mucinous metaplasia is everything with mucin

Question 25

Intestinal metaplasia is ____

Answer 25

Intestinal metaplasia is goblet cells specifically

Question 26

Describe pathogenesis of Barrett’s esophagus

Answer 26

Barrett’s esophagus pathogenesis

1. Chronic GERD
2. Inflammation and ulceration of esophageal sqamous mucosa
3. If persistant and recurrent, leads to columnar / mucinous metaplasia which may or may not have intestinal metaplasia (goblet cells)

Question 28

Development of ____ in Barrett’s esophagus follows a ____ sequence that is characterized by the accumulation of multiple genetic and epigenetic alterations, many of which occur befor ehte onset of morphologic dysplasia

Answer 28

Development of adenocarcinoma in Barrett’s esophagus follows a metaplasia - dysplasia - carcinoma sequence that is characterized by the accumulation of multiple genetic and epigenetic alterations, many of which occur befor ehte onset of morphologic dysplasia

Question 29

Cancer surveillance in Barrett’s esophagus involves ____ and ____

Answer 29

Cancer surveillance in Barrett’s esophagus involves repeat biopsies b/c incidence of cancer is high and following of patients with biopsies positive for dysplasia

Question 30

Describe low-grade dysplasia

Answer 30

Low-grade dysplasia

• Epithelial cell nuceli typically elongated, crowded, and hyperchromatic
• Dysplastic cells usually mucin depleted and show a marked decrease in goblet cell differention

Question 31

This is ____

Answer 31

This is low-grade dysplasia (Barrett’s esophagus)

Question 32

Describe high-grade dysplasia / carcinoma in situ

Answer 32

High-grade dysplasia / carcinoma in situ

• Overall architecture shows more crypt complexity: cribriforming, variability in size and shape of crypts, and extensive branching
• Cytologically, epithelium shows nuclear stratification, loss of polarity, pleomorphism, enlarged nucleoli, and increased atypical mitotic activity
• As in low-grade dysplasia, mucin depletion and decrease in / abscence of goblet cell and differentiation of high-grade dysplasia

Question 33

This is ___

Answer 33

This is high-grade dysplasia / carcinoma in situ

Question 34

Descrine invasive adenocarcinoma

Answer 34

Invasive adenocarcinoma

• Same nuclear features of high-grade dyplasia / carcinoma in situ except invading into tissue
• Almost always distal esophagus and may extend into stomach, arising as a consequence of Barrett’s esophagus
• 15-25% have amplification of oncogene c-ERB-B2 (Her2)

Question 35

This is ____

Answer 35

This is invasive adenocarcinoma

Question 36

___ is defined as a malignant epithelial tumor with glandular differentiation, most common in the distal esophagus

Answer 36

Adenocarcinoma is defined as a malignant epithelial tumor with glandular differentiation, most common in the distal esophagus

• Majority of cases arise from the Barrett mucosa

Question 37

This is a ____ characteristic of ____

Answer 37

This is a polypoid lesion characteristic of adenocarcinoma

Question 38

____ is the most common esophageal malignancy worldwide but not in the US

Answer 38

Squamous cell carcinoma is the most common esophageal malignancy worldwide but not in the US

• Etiology is multifactorial

Question 39

Describe pathogenesis of esophageal carcinoma

Answer 39

Esophageal carcinoma pathogenesis

1. Normal w/ low/short exposure to carcinogens
2. Esophagitis
3. Atrophy w/ high/prolonged exposure to carcinogens
4. Cancer

Question 40

Cytologic changes in squamous cell carcinoma include ____, ____, ____, and ____

Answer 40

Cytologic changes in squamous cell carcinoma include nuclear hyperchromasia, pleomorphism, increased nucleus:cytoplas, and increased mitotic rate

Question 41

This is ____

Answer 41

This is squamous cell carcinoma in situ

Question 42

This is ____

Answer 42

This is invasive squamous cell carcinoma

Question 43

Gross pathology of esophageal carcinoma is ____, ____, ____, and ____

Answer 43

Gross pathology of esophageal carcinoma is gross, stenosing, nodular, ulcerated, and lobulated

Question 44

Squamous cell carcinomas typically invade ____

Answer 44

Squamous cell carcinomas typically invade vertically through the esophageal wall and spread to involve contiguous organs such as the trachea, aorta, and pericardium

(60% of patients have regional lymph node metastases)