Diagnostic challenges in the pathologic evaluation of Barrett esophagus

Barrett esophagus represents an unstable epithelium resulting from chronic gastroesophageal reflux disease. Patients with Barrett esophagus routinely undergo endoscopic examination to detect dysplasia and early carcinoma. Although appropriate classification of Barrett esophagus and neoplasia is usually straightforward, persistent esophageal inflammation may induce epithelial changes that mimic, or mask, dysplasia. Recent data also indicate that specific molecular changes occur in nondysplastic Barrett mucosa and herald the development of dysplasia and/or carcinoma.

To describe problematic aspects of biopsy interpretation in tissue samples of the gastroesophageal junction and distal esophagus, including the diagnostic criteria for Barrett esophagus, the importance of the gastric cardia, and pitfalls to the diagnosis of dysplasia. Ancillary studies that have recently emerged as potential adjuncts to the evaluation of patients with Barrett esophagus will be briefly discussed.

A comprehensive review of the relevant literature indexed in PubMed (National Library of Medicine) was performed.

Barrett esophagus is currently defined as the presence of intestinal metaplasia in samples obtained from an endoscopically evident abnormality in the distal esophagus. Diagnosis and grading of dysplasia in mucosal biopsies remain the most reliable method to assess risk for neoplastic progression, but its classification may be hindered by superimposed inflammatory changes and suffers from considerable interobserver variability. Therefore, immunohistochemical studies and molecular assessment for TP53, CDKN2A , and DNA content abnormalities have emerged as potential adjuncts to the detection of dysplasia.