Dr maru esophageal adenocarcinoma

Objectives

Barrett's Esophagus and Esophageal Adenocarcinoma-Recent Developments and Challenges Dipen Maru, MD Associate Professor Department of Pathology

Esophageal adenocarcinoma • Rapidly rising incidence (>40% since 1990) due to increase in disease burden

• Poor survival outcome (15% 5 year survival)

• Definition of Barrett's esophagus (BE) • Morphologic approach for dysplasia and intramucosal carcinoma • Review of histologic associated with BE progression • Discuss the non-histology biomarkers • Brief review of prognostic markers of esophageal adenocarcinoma

Esophageal adenocarcinoma • Apprx. 44% of adults in US have GERD at least once a month • Estimated BE prevalence in US: More than 6 million • Obesity-GERD-BE-Dysplasia-Adenocarcinoma sequence • Histology is the gold standard for diagnosis and assessing the risk of adenocarcinoma in clinical practice

Barrett's esophagus

Different Definitions

• Definition: – Columnar epithelial metaplasia of squamous mucosa – Gastric or intestinal type mucosa with >3 cm from GE junction long segment – Intestinal (specialized or distinctive ) type of mucosa for ≤3 cm long segment

• American College of Gastroenterology/German Society of Pathology/French Society of Digestive diseases/Amsterdam working group

Different Definitions

Intestinal Metaplasia

• British Society of Gastroenterology – Does not require intestinal metaplasia • Japanese Groups – Columnar lined epithelium synonymous with BE – Columnar lined epithelium is identified by distal limit of the lower esophageal palisade vessels – Distal 5mm excluded

Columnar mucosa in tubular esophagus with intestinal metaplasia (goblet cell metaplasia) demonstrated by histology

• • • • •

Goblet cells Brush border Villiform architecture Multilayering of the columnar epithelium Alcian Blue PAS stain

Alcian Blue PAS

NonNon-Goblet Cell Columnar Epithelium: Goblet Cells

Cardia type mucosa Pseudogoblet cells Mild architectural changes CDXCDX-2/VILLIN/MUC2/VILLIN/MUC-2 Aneuploid

NonNon-Goblet Cell Columnar Epithelium with Dysplasia ?? Unsampled Intestinal Metaplasia

Barrett's mucosa vs. Cardia intestinal metaplasia Barrett's Esophagus

Cardia Intestinal Metaplasia

Etiology:GERD

? H.pylori or Atrophic Gastritis

Squamous mucosa overlying intestinal Squamous mucosa overlying intestinal metaplasia-Present metaplasia-Absent Intestinal metaplasia with esophageal ducts or submucosal glands-Present

Intestinal metaplasia with esophageal ducts or submucosal glands-Absent

Diffuse intestinal metaplasia-Present

Diffuse intestinal metaplasia-Absent

Incomplete intestinal metaplasiaPresent

Incomplete intestinal metaplasiaAbsent

Focal intestinal metaplasia with predominant cardia type glandsAbsent

Predominant cardia type glands with focal intestinal metaplasia-Present

From Shrivastsva et al American Journal of Surgical Pathology, 2007

Barrett's mucosa vs. Cardia intestinal metaplasia-controversial • No uniform criteria • Need endoscopic correlation • Not accepted by all gastroenterologists and pathologists

Dysplasia-Classification

• IBD study group Negative Indefinite Low-grade dysplasia High-grade dysplasia Adenocarcinoma a Intramucosal carcinoma b Invasive adenoca

•WHO classification

• Vienna classification Negative for neoplasia/dysplasia Indefinite for neoplasia/dysplasia Non-invasive low-grade neoplasia Non-invasive high-grade neoplasia a. High-grade dysplasia b. Non-invasive carcinoma (carcinoma in situ) c. Suspicious for invasive carcinoma Invasive neoplasia a. Intramucosal carcinoma b. Sub mucosal carcinoma or beyond

Biopsy reporting recommendation

Specifying the type of columnar mucosa with specific mention of absence or presence of intestinal metaplasia should be reported in a pathology report

Dysplasia-Diagnostic approach • Appropriate orientation of biopsy • Sqaumocolumnar junction-Higher threshold • Ulceration or acute inflammation-Higher threshold

Dysplasia-Diagnostic approach • Surface maturation: a)Progressive increase in amount of cytoplasmic mucin b)Intact polarity c)Decrease in nuclear size and hyperchromaticity d)Absence of surface mitosis

pHH3 (surrogate marker of mitosis) in BE (A and D) IND (B and E) LGD (C and F)

Goodarzi et. al Modern Pathology, 2009

pHH3 in BEBE-LGDLGD-HGDHGD-Adenocarcinoma

pHH3 in HGD (A and C) Intramucosal ca.

(B and D)

Goodarzi et. al.

Modern Pathology, 2009

Dysplasia-Diagnostic approach • Architectural abnormalities: – Crypt branching, budding, villiform transformation, back to back arrangement – Glands to lamina propria ratio increase – Abrupt transition from atypical/nonatypical epithelium

Dysplasia-Diagnostic approach • Cytologic features: – Mucin depletion, loss/dystrophic goblet cells – Nuclear stratification, nucleomegaly, nucleolar prominence – Loss of polarity, increase N/C ratio, irregular nuclear membrane, hyperchromasia, full thickness nuclear stratification

Maru D. Annals of Diagnostic Pathology, 2009

LGD

LGD

HGD

High Grade dysplasia

HGD

Acute Inflammation with Regenerative Atypia

LGD with acute Inflammation

HGD with acute Inflammation

Basal crypt dysplasia

Basal Crypt Dysplasia

Basal Crypt Dysplasia

Interobserver variations in diagnosis of dysplasia

Guidelines for Surveillance (American Gastroenterology Association 2011)

• Good reproducibility for diagnosis of HGD (k=0.65) • Poor reproducibility for LGD (k=0.32) and indefinite for dysplasia (k=0.15) categories • Poor consensus for HGD vs. Intramucosal carcinoma

• No Dysplasia  Repeat endoscopy in 3-5 years • Low-grade dysplasia  Confirmed by additional pathologist preferably one who is expert in esophageal histopathology  6-12 months

Montgomery et al, Human Pathology 2001 120(7)

AGA guidelines (contd.)

• High-grade dysplasia  Confirmed by additional pathologist preferably one who is expert in esophageal histopathology  In absence of eradication- surveillance at 3months interval  Multifocal HGD-More aggressive treatment  Mucosal abnormalities-endoscopic ultrasound and mucosal resection to exclude cancer

High-grade dysplasia vs. Intramucosal adenocarcinoma • Confluent glandular proliferation with back to back arrangement expanding and overriding the lamina propria • Haphazardly arranged highly dysplastic glands in lamina propria or muscularis mucosa • Single cell infiltration or incomplete glands in a well oriented non ulcerated biopsy • Dirty necrosis in the glandular lumen • Ulceration and true desmoplastic stroma • Reverse maturation

Risk for progression • Presence of high-grade dysplasia • Extent of high-grade dysplasia • High-grade dysplasia with certain endoscopic abnormalities • Low-grade dysplasia with consensus diagnosis of two or three gastrointestinal pathologists

High-grade dysplasia-Risk for progression • Extensive/focal.

– Mayo clinic definition: More than 5 crypts in one biopsy or HGD in more than one biopsy at a time – Cleveland clinic definition: HGD in more than one biopsy at a time • Presence of endoscopic abnormalities associated with dysplasia – Ulcer – Stricture – Nodule/mass/polyp • Clinical features

BE-Progression

DNA Ploidy

• Biomarkers: – Ploidy – P53 (LOH for chromosome 17p) – P16 (LOH for chromosome 9p)` – Aberrant DNA methylation – Sialyl Lewisa, Lewisx, Aspergillus oryzae lectin (AOL)

• Presence of aneuploid population and increase in tetraploid population associated with progression of BE to HGD • Flow cytometry, FISH, and laser scanning cytometry • Need validation in multicenter trial • Unavailability of flow cytometry at smaller health care centers

Aberrant p53 expression by Immunohistochemistry • Mutation leads to abnormal p53 protein with prolong half-life leading to increase number of p53 positive cells • Truncating mutation or epigenetic silencing leads to loss of p53 protein • Limitations: – 10% biopsies for negative for dysplasia are p53+ – Reproducible, easily applicable interpretation guidelines not available

Aberrant DNA Methylation • P16, HPP1, RUNX3 genes methylation • Combination with presence of LGD on histology and length of BE increase likelihood to predict progression to HGD • Three tier (low-intermediate-high) risk system recommended • Need validation in large trial

Early Detection Research Network (National Cancer Institute) 2008 report

Markers for Esophageal Adenocarcinoma (EAC)

Early (T1) EAC- Histologic marker • Histologic markers • Tissue based molecular markers– Her2-Neu overexpression/amplification in Gastric and GE junction adenocarcinoma

• Lymphovascular invasion in early EAC associated with poor outcome • Duplicated muscularis mucosae can overstage pT in EAC • Invasion in to the space between the duplicated muscularis mucosae has similar risk of lymph node metastasis as intramucosal carcinoma

Liu et al. American Journal of Surgical Pathology, 29(8):2005 Estrella J et al. American Journal of Surgical Pathology, 29(8):2011

Duplicated Muscularis Mucosae H&E and Trichrome Stains

T1 EAC invading into the space between the duplicated muscularis mucosae H&E and Trichrome Stains

Univariate Analysis P

T1 EAC with lymphovascular invasion

Depth of Invasion (n=99) Tumor configuration Ulcerative/Flat (n=67) Exophytic (n=32) Tumor differentiation Well (reference) (n=37) Moderate (n=47) Poor (n=15) Lymphovascular Invasion No (reference) (n=76) Yes (n=23) Pathologic tumor stage Mucosa and duplicated MM# (reference) (n=69) Submucosa (n=30) Pathologic tumor stage

0.028

0.57 0.009

1.00 0.72 0.39

0.70 0.01

1.00 0.74 5.37

0.48 0.52

1.00 0.57 1.75

0.002

1.00 6.38

0.001

1.00 6.38

0.022

1.00 3.83

0.62

1.00 1.52

0.70

1.000 0.78

Duplicated MM/submucosa (reference) (n=59) Mucosa (n=40)

Odds Ratio 1.03

Multivariate Analysis Odds P Ratio 0.85 1.00

RFS in patients with EAC invading duplicated MM is similar to intramucosal EAC

Patients with T1 EAC with LVI have shorter RFS then pts. with T1 EAC without LVI

EAC-Advanced Loco regional diseaseHistologic marker Neuroendocrine differentiation in pretreated biopsy is associated with poor outcome

p=0.006

Maru D et al. American Journal of Surgical Pathology, August 2008

Clinical Stage

Median Overall Survival (months)

Loco regional disease (n=17)

28 Âą 13 (Range 8-49)

Systemic disease (n=21)

11 Âą 9 (Range 3-33)

SCNEC

p=0.03

Histology

Median Overall Survival (months)

Pure Neuroendocrine ca. (n=16) 15 Âą 10 (Range 2-43) LCNEC

MIX ADENOCA/NEC

EAC-Advanced Loco regional diseaseHistologic marker In advanced loco-regional disease complete pathologic response and tumor downstaging are associated with better outcome Chirieac et al. Cancer. 2005

Mix Ca. with Neuroendocrine component (n=24)

Chemoradiation-Pathologic response.

Chirieac et al. Cancer.103 (7); 2005

28 Âą 13 (Range 3-49)

Issues specific to the Upper GI Adenocarcinoma

Her2-Neu amplification • Trastuzumab approved by FDA for stage IV gastric and gastroesophageal junction adenocarcinoma • ToGA trial (Bang et al, Lancet 2010;376:687-97) showing benefit in OS in combination with chemotherpay for inoperable locally advanced or metastatic adenocarcinoma

Her2-Neu Immunohistochemistry guidelines for biopsy specimens

• Guidelines are somewhat different than breast cancer • For IHC no requirement of percentage of cells in biopsy specimen and 10% positive cells cut of point in resection specimen • For FISH cut off ratio of Her2-Neu/CEP17 is 2.0 • Heterogeneity within same tumor and between primary and mets are seen not infrequently

Her2-Neu Immunohistochemistry guidelines for resection specimens Staining

Score

Interpretation

Interpretation

No membranous staining of the invasive tumor cells

0

Negative

No membranous staining of the invasive 0 tumor cells

Negative

Faint or barely perceptible membranous staining of < 10% of the invasive tumor cells

0

Negative

Faint or barely perceptible membranous staining of the invasive tumor cells

1

Negative

Faint or barely perceptible membranous staining of > 10% of the invasive tumor cells

1

Negative

Negative

2

Equivocal

Weak or moderate membranous staining of < 10% the invasive tumor cells

1

Weak or moderate membranous staining of the invasive tumor cells

Weak or moderate membranous staining of > 10% the invasive tumor cells

2

Equivoval

Strong complete membranous staining of the invasive tumor cells

3

Positive Strong complete membranous staining of < 10% invasive tumor cells

2

Equivocal

Strong complete membranous staining of > 10% invasive tumor cells

3

Positive

Staining

Score

Heterogeneous Her2/Neu expression/amplification in same tumor

Her2-Neu interpretation in Upper GI Adenocarcinoma • Focal overexpression/amplification

• Difficulty identifying the tumor cells •Technical issues with tissue fixation and processing •Multiple Her2/Neu FISH signals closely packed •Lower expression in poorly differentiated and signet ring cell carcinoma •False negative IHC (~5%)

Conclusions 1. Histologic interpretation by a proficient pathologist-Best predictor of progression of BE to EAC 2. Except for Her2-Neu no biomarkers is ready for routine clinical use in EAC 3. Meticulous gross and microscopic interpretation is critical in identifying predictive and prognostic factors for EAC