Our understanding of Barrett’s esophagus has undergone considerable change since the influential British surgeon, Dr. Norman Barrett, first described this condition over half a century ago. Advances have occurred in the definition of Barrett’s esophagus, the pathologic and clinical diagnostic criteria, and its management. The main problems in Barrett’s esophagus from the viewpoint of pathology continue to revolve around: 1) the over-diagnosis of Barrett’s esophagus itself, and 2) the over-diagnosis of high-grade dysplasia in Barrett’s esophagus. These are serious matters that result not only in inappropriate and lifelong cancer surveillance but also unwarranted invasive therapy, including even unwarranted esophagectomy. Management options for Barrett’s esophagus with high-grade dysplasia are rapidly expanding from surgery alone. Alternatives now include endoscopic ablative therapy, endoscopic mucosal resection, and expanded use of continued biopsy surveillance. Whereas the diagnostic threshold to pursue esophagectomy formerly rested upon the pathologist’s ability to reliably diagnose high-grade dysplasia from lesser grade lesions, the newer non-surgical options are starting to push the esophagectomy diagnostic threshold to the level of carcinoma. The remainder of this discussion considers these aspects of Barrett’s neoplasia in detail, along with the means to achieve reliable and accurate diagnoses upon which rational management decisions can be made.
Originally presented on February 13, 2015 in Park City, Utah.
Mary Bronner, MD
Division Chief, Anatomic Pathology and Oncology, ARUP Laboratories
Dr. Carl R. Kjeldsberg Endowed Chair in Pathology, University of Utah School of Medicine
Professor of Pathology, University of Utah School of Medicine
Dr. Bronner is the division chief of the Anatomic Pathology and Oncology divisions at ARUP and Carl R. Kjeldsberg presidential endowed professor of pathology at the University of Utah School of Medicine. Dr. Bronner received her MD from the University of Pennsylvania and completed her pathology residency training and chief residency at the Hospital of the University of Pennsylvania in Philadelphia. Dr. Bronner’s honors include her election as president of the GI Pathology Society, election as council member of the United States and Canadian Academy of Pathology, and, in 2005, the award of the Arthur Purdy Stout Prize, recognizing her work as a surgical pathologist under the age of 45 whose research publications have had a major impact on diagnostic pathology.
Dr. Bronner is an editorial journal board member for Human Pathology, The American Journal of Surgical Pathology, and Modern Pathology. She has served as an investigator on numerous NIH and foundation grants over the course of her career and has published over 100 peer-reviewed articles and numerous book chapters. Her research interests include molecular biomarkers for the early detection and prevention of gastrointestinal cancers arising in chronic inflammatory disorders of the intestine, stomach, liver, and pancreas, which together make up the most important causes of human cancer worldwide.
After this presentation, participants will be able to:
- Understand the definition of Barrett’s esophagus and the reasons for the two-fold diagnostic criteria.
- Describe the reason that Barrett’s esophagus is overdiagnosed.
- Understand the most reliable criteria for distinguishing Barrett’s low-grade dysplasia from high-grade dysplasia.
- Explain what has happened to the management options for Barrett’s with high-grade dysplasia and how this has changed the significant diagnostic thresholds for pathologists.
University of Utah School of Medicine, Department of Pathology, and ARUP Laboratories