How should I sign it out? Problematic scenarios in Barrett's Esophagus

According to American College of Gastroenterologists (ACG), to make a diagnosis of Barrett's esophagus, the following criteria must be fulfilled:

  1. Extension of salmon-colored mucosa into the tubular esophagus extending at least 1 cm proximal to the gastroesophageal junction - (aka- the biopsy has to state its from the distal esophagus or above, not at the GEJ)

  2. Biopsy confirmation of intestinal metaplasia - (aka- presence of goblet cells)

Note there is NO LENGTH REQUIREMENT of how long the segment must be in order to make the diagnosis within the US. However, across the pond, the British do NOT require the presence of goblet cells, but they DO include a segment length of greater than or equal to 1 cm in order to make a diagnosis.


What's the "FINAL DIAGNOSIS" when...


Below are some examples of how to phrase your report for "Barrett's Esophagus" demonstrating a few of the scenarios that pathologists are commonly faced with. As I am in the US, these examples all assume that you (the pathologist) has found goblet cells in the biopsy specimen, there is no dysplasia or carcinoma, and now you are just figuring out what to put as your "Final Diagnosis".



example: ... the specimen is labeled as "distal esophagus" & the endoscopy report describes a lesion?

  • BARRETT'S ESOPHAGUS

This is your ideal situation and a classic case of how Barrett's esophagus is signed out.



example: ... the endoscopy report says the lesion is less than or equal to 1 cm in length?

  • SPECIALIZED INTESTINAL METAPLASIA OF THE ESOPHAGOGASTRIC JUNCTION



example: ... the specimen is labeled only as "esophagus"; no endoscopy report available?

  • BARRETT ESOPHAGUS; SEE COMMENT

  • COMMENT: The above diagnosis of Barrett esophagus is made due to the presence of goblet cells (intestinal metaplasia) with the assumption that the biopsies were obtained from columnar mucosa in the distal esophagus located at least 1 cm proximal to the top of the gastric folds as per 2016 ACG guidelines.


example ... the specimen is labeled as "gastroesophageal junction"; no endoscopy report available?

  • GASTRIC CARDIAC-TYPE MUCOSA WITH GOBLET CELLS; SEE COMMENT

  • COMMENT: This biopsy shows gastric-type mucosa with scattered goblet cells. The diagnosis in this case depends on the location of this biopsy. If this biopsy was taken from the tubular esophagus at least 1 cm above the gastric folds, it shows Barrett mucosa of the distinctive type. If this biopsy was taken from the gastric cardia, it shows intestinal metaplasia of the gastric cardia.


Other Findings to Report in your

"FINAL DIAGNOSIS"


Note that the above examples simply provide guidance on how to phrase your findings (the presence of goblet cells) depending on the biopsy location and endoscopic findings. It should go without saying, but if a more sinister lesion (dysplasia or invasive carcinoma) is present, it obviously must be mentioned. Check out my post on how to grade BE for details. If the case was signed out exactly as it is written above, there is an implied lack of any sinister findings. Depending on the preferences at your institution (and discussion with your clinicians), you may choose to report it as aforementioned, or you may choose to list out all pertinent negatives (negative for dysplasia or carcinoma).


Keep in mind that clinician's tend to quickly browse through the pathology report, so you want to make sure to deliver the message across using some sort of consistent formatting method. Reporting is not (yet) standardized, but I always format my reports in a way that I place the "worst diagnosis" (most important finding) as a "top-line diagnosis" to ensure the clinician sees it. Then I list all relevant secondary and tertiary findings.


I could go on and on about how to format a report, but I'll save that for a later post...



REFERENCE:


Surgical Pathology 10 (2017) 781–800http://dx.doi.org/10.1016/j.path.2017.07.0021875-9181/17/. 2017 Elsevier Inc. All rights reserved.

The article above truly is fantabulous... check it out!

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