Original article
Alimentary tract
Subsquamous Extension of Intestinal Metaplasia Is Detected in 98% of Cases of Neoplastic Barrett's Esophagus

https://doi.org/10.1016/j.cgh.2013.07.013Get rights and content

Background & Aims

Subsquamous intestinal metaplasia (SSIM) has been observed after endotherapy in patients with neoplastic Barrett's esophagus (BE). However, it is not clear whether SSIM occurs in untreated patients. Incompletely eradicated SSIM could provide a source of recurrent disease. We assessed its prevalence in a large cohort of patients who had not received endoscopic therapy.

Methods

Two experienced pathologists analyzed 138 samples of 506 resection specimens found to contain squamous epithelium from 110 patients with neoplastic BE treated by widespread endoscopic mucosal resection (92 men; mean age, 66 years). The maximum extent of SSIM was measured.

Results

Of the 138 samples analyzed, 124 (89.9%) were found to contain SSIM from 108 of the 110 patients (98.2%). The mean length of SSIM was 3.3 mm (range, 0.2-9.6 mm; 25% ≥5 mm); SSIM length correlated with BE length (P < .05). In 83 of 138 samples (60.1%), the SSIM consisted partially or entirely of neoplasias of different grades, with a mean subsquamous extension of 3.3 mm; the extension correlated with grade of neoplasia (P = .0001).

Conclusions

Most patients with BE with neoplasia (of all grades) have subsquamous extension of intestinal metaplasia, including subsquamous extension of lesions at the squamocolumnar junction. Therefore, biopsy and resection of neoplastic BE should extend at least 1 cm into the squamous epithelium.

Section snippets

Methods

Resection specimens gained by widespread EMR from 110 patients (92 men, 18 women; mean age, 66 years) between 2004 and 2010 were included in this retrospective study. Indication for endoscopic resection was BE with suspected or confirmed dysplasia or presumed mucosal carcinoma. Widespread EMR aimed at complete ablation of all BE tissue together with the neoplastic area(s) and in some cases additional thermal methods were done after EMR sessions (details not reported here). Histopathologic

Results

Data of all 110 patients included in this study are shown in Table 1 and Figure 1. Mean age was 66 years; the male:female ratio was 5.11:1. The most severe histologic diagnoses on a per-patient basis included early (T1) cancer in 66, high-grade intraepithelial neoplasia in 15, and low-grade epithelial neoplasia in 3 cases. Barrett length significantly correlated with increasing neoplasia grade, ranging from no neoplasia to T1b cancer (P < .0001). In 26 cases with positive biopsies at other

Discussion

Our study shows an almost regular occurrence of SSIM in patients with (neoplastic) BE. Because our analysis has been designed solely to address the question of subsquamous extension of Barrett epithelium, uses large tissue specimens from widespread EMR extending into the SQE, and includes a substantial number of patients, our findings may be considered of some general impact on BE surveillance and therapy. Our study cannot fully answer the question whether SSIM is a regular event in patients

Acknowledgments

Drs Anders, Lucks, and El-Masry contributed equally to this work.

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    Conflicts of interest The authors disclose no conflicts.

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