Editorial

Adenocarcinoma in Barrett's esophagus: A new epidemic?

Handling and pathological examination of endoscopic resections of early Barrett's cancer is very important since it provides the basis for deciding whether subsequent surgical treatment is necessary or not. It is recommended that (i) the resected specimens should be unfolded and pinned to a cork mat; (ii) the margins of resection should be identified by marking with Indian ink, and (iii) the entire specimen must be strip-sectioned and embedded prior to histological evaluation.

For the histological evaluation the following information is needed: (i) depth of infiltration, differentiated as m1–m4 and sm1–sm3; (ii) evaluation of the resection margins, lateral and deep (R0/R1); (iii) degree of differentiation (G1–G4) and (iv) invasion of lymphatic or blood vessels.

Current information in the literature regarding the risk for regional lymphogenic metastatic spread identify ‘low risk’ as G1/G2, m1–m4 (possibly sm1 absent further risk factors), L0, V0, R0 and ‘high risk’ as G3/G4, sm2, sm3, L1, V1.

Patients with esophageal high-grade dysplasia or mucosal esophageal cancer can be successfully treated by endoscopy. We performed a systematic review of the literature to determine whether endoscopic ultrasound (EUS) correctly predicts the T-stage of early esophageal cancers, compared with pathology specimens obtained by using endoscopic mucosal resection (EMR) or surgery.

Standard systematic review methods were used to perform reference searches, determine eligibility, abstract data, and analyze data. When possible, individual patient-level data were abstracted, in addition to publication-level aggregate data.

Twelve studies had sufficient information to abstract and review for quality; 8 had individual patient-level data (n = 132). Compared with surgical or EMR pathology staging, EUS had T-stage concordance of 65%, including all studies (n = 12), but only 56% concordance when limited to individual patient-level data. Factors such as initial biopsy pathology (high-grade dysplasia vs early-stage cancer) did not appear to affect the concordance of staging between EUS and EMR/surgical staging.

EUS is not sufficiently accurate in determining the T-stage of high-grade dysplasias or superficial adenocarcinomas; other means of staging, such as EMR, should be used.

This review presents the pathological features of Barrett's oesophagus, with an emphasis on the role of pathologists in the diagnosis, surveillance and treatment of the disease. The diagnosis of Barrett's oesophagus is based both on endoscopy and histology. The surveillance of patients relies on systematic biopsy sampling, looking for dysplasia – intraepithelial neoplasia. Well established classifications of dysplasia are now used by pathologists, but there remain problems with this marker. Therefore, many alternative biomarkers have been proposed, that remain of limited interest in daily practice, including DNA-ploidy, proliferation markers, and p53 abnormalities. Endoscopic improvements already allow a better selection of biopsies, and it may be that new technologies will allow ‘virtual biopsies’. The role of pathologists is now extended to the evaluation of new therapeutic modalities of early neoplastic lesions in Barrett's oesophagus, especially endoscopic mucosal resection.