The Columnar Lined Esophagus: aspects on the assessment of dysplasia and on the relationship with the esophageal submucosal glands

Columnar metaplasia, where columnar epithelium replaces the normal squamous epithelium in esophagus, is considered to be a precancerous condition in which the development of adenocarcinoma can be followed through various grades of dysplasia. The interpretation of these histological changes is subjective and suffers from considerable inter-observer variation among pathologists. In study I, we devised and tested two clinically applicable methods for immunohistochemical assessment of p53 and Ki67 as surrogate dysplasia markers. Using these methods, the inter-observer agreement improved substantially from mean k value 0.24 for H&E evaluation to 0.71 and 0.52 for p53 and Ki67 evaluations, respectively. There was a correlation between severity of dysplasia, p53 over-expression and shift of the proliferation zone towards the mucosal surface. We conclude that our methods are reproducible and associated with less inter-observer variation than morphologic dysplasia grading, and that p53 and Ki67 are useful supplementary prognostic markers. The origin of columnar metaplasia in esophagus is debated. The submucosal glands have been proposed as a stem cell source, but studies of the human esophageal glands are rare. In studies II – IV, we conducted comparative and descriptive analyses of the distribution and morphology of the submucosal glands in patients with columnar metaplasia in esophagus. We have shown that there is an accumulation of submucosal glands beneath the transformation-zones between squamous and columnar mucosa, and that the submucosal glands in the columnar lined part of esophagus are hyperplastic. There are overlapping immunophenotypes between the submucosal gland unit, the columnar metaplasia and the transformation-zones for the markers CK17, CK4 and lysozyme. We propose that the submucosal glands are the esophageal counterparts of skin adnexa as a source of re-epithelialization, and conclude that in esophagus both neosquamous islands and columnar metaplasia originate in the submucosal gland unit

Hyperplasia of the Submucosal Glands of the Columnar Lined Oesophagus.

To evaluate the presence of multilayered epithelium (ME) and to compare the distribution, size and morphology of the oesophageal submucosal glands (SMG) beneath reflux exposed metaplastic columnar mucosa with those of normal squamous epithelium in patients with columnar lined oesophagus (CLO)

Submucosal glands in the columnar-lined oesophagus: evidence of an association with metaplasia and neosquamous epithelium.

Aim: A multipotential stem cell, possibly located in the submucosal gland ducts, has been suggested as the origin of metaplastic mucosa in the oesophagus. The topographic distribution of these glands and their excretory ducts (SMG) within the columnar lined oesophagus (CLO) is largely unknown. The aim of this study was to examine the distribution of SMG in relation to the type of overlying epithelium in patients with CLO. Methods and results: Seven oesophageal resection specimens were examined histologically in toto. The median frequency of SMG was similar in the metaplastic segments (0.12 SMG/mm) and the normal squamous segments (0.10 SMG/mm). Within the metaplastic segments, the median frequency of SMG beneath the squamous islands was significantly higher than that observed under the columnar lined parts (0.22 versus 0.08 SMG/mm, P = 0.046), There was a strong accumulation of SMG at the squamo-columnar transition zones (0.53 SMG/mm), which was significantly greater than that found in the columnar and squamous parts (P = 0.001 and 0.002, respectively). Conclusions: The relative accumulation of SMG beneath squamous islands and the squamo-columnar junctions within the metaplastic segment supports the hypothesis that both metaplastic columnar mucosa and neosquamous epithelium originate from a progenitor in the SMG

Ki67 and p53 immunohistochemistry reduces interobserver variation in assessment of Barrett's oesophagus.

Aims: To devise clinically applicable methods for assessing p53 and Ki67 immunohistochemical (IHC) reactivity in Barrett's oesophagus (BE) and to compare the interobserver agreement between these methods and routine haematoxylin and eosin (H&E) evaluation. Methods and results: One hundred and fifteen biopsies diagnosed as BE, selected from the files of the University Hospital MAS, Malmö, were re-evaluated for dysplasia by three pathologists. For IHC analysis areas with the most prominent positivity were evaluated. The mean of p53+ epithelial nuclei/high-power field (HPF) was obtained by counting between 1 and 5 HPFs/biopsy. A proliferation quotient (PQ) was obtained by dividing the number of Ki67+ epithelial nuclei in the upper half by the lower half of the mucosa, using two HPFs. Mean κ values were 0.24, 0.71 and 0.52 for H&E, p53 and Ki67 evaluations, respectively. There was a correlation between increasing severity of dysplasia, IHC measurable overexpression of p53 and shift of the mucosal proliferation zone towards the surface, measured as PQ. Conclusions: The described methods for p53 and Ki67 evaluation are more reproducible than routine H&E evaluation of BE. Furthermore, the IHC methods correlate with the severity of dysplasia and are useful supplementary prognostic markers

Standard protocol for assessment of colon cancer improves the quality of pathology.

Aim: Tumour stage is the most important prognostic factor in colon cancer. The aim of this study was to examine the impact on the quality of pathology by the use of a standardized PAD protocol. Method: A standardized PAD protocol for colorectal cancer was developed and all patients subjected to colon resection due to adenocarcinomas between 2004 and 2006 were analyzed concerning lymph node status, circumferential resection margin (CRM), intravascular and perineural growth. Moreover, usage of the PAD protocol and whether a pathologist or biomedicine analytic technician (BMA) performed the lymph node dissection was noted and also if the surgical procedure was elective or acute. Results: During the study period 302 colon resections were carried out. The standard protocol was employed in 68% of the cases varying from 0-100% between pathologists. The median number of investigated lymph nodes was 16 ± 11. When the lymph node dissection was performed by a BMA, significantly more lymph nodes were examined; 22 ± 15 and 14 ± 9 respectively (p<0.01). There was a positive correlation between application of the standard protocol and the number of analyzed lymph nodes (<0.05). Comments on CRM, perineural growth and intravascular growth were also significantly more frequent when the protocol was used. Emergency surgery did not influence the handling of the specimens. Conclusion: Minor efforts in terms of a standard protocol for pathology and specimen dissection by BMAs, leading to an increased quality of the PAD-report may also improve long term outcome for patients

Value of Fecal Calprotectin as a Biomarker for Juvenile Polyps in Children Investigated with Colonoscopy.

The clinical presentation of colonic juvenile polyps with abdominal discomfort and occult rectal bleedings make them difficult to recognize. The aim was to report the clinical features of colonic juvenile polyps in children referred to colonoscopy and evaluate fecal calprotectin (FCP) as a screening biomarker for their diagnosis

Screening Detects a High Proportion of Celiac Disease in Young HLA-genotyped Children.

BACKGROUND AND AIMS:: Celiac disease is associated with tissue transglutaminase autoantibodies (tTGAb) and the human leukocyte antigen (HLA)-risk alleles DQB1*02 and DQB1*0302. The aim was to estimate the proportion of undiagnosed celiac disease in children with HLA risk at 3 years of age. PATIENTS AND METHODS:: From a population-based HLA-DQ screening study of newborns born between June 2001 and August 2004 in the southern part of Sweden, 6206 children with HLA-risk alleles were identified and asked to participate at a mean 3.3 +/- 0.4 years of age. As controls, 7654 children with HLA-nonrisk alleles were asked to participate. In all, 1620 (26.1%) children with HLA risk and 1815 (23.7%) controls were screened for tTGAb using radioligand-binding assays. Celiac disease was established by intestinal biopsy in children with a confirmed positive tTGAb test. RESULTS:: Twenty-three children reported already having clinically diagnosed celiac disease and did not participate further. In children with HLA-risk genotypes, 73 of 1620 (4.5%, 95% CI 3.5%-5.5%) were tTGAb-positive compared with none of 1815 from the controls (P < 0.0001). Seventy-one children underwent biopsy (1 refused biopsy and 1 biopsy failed), of whom 56 of 1618 (3.5%, 95% CI 2.6%-4.4%) had damaged intestinal mucosa classified as celiac disease. The ratio between clinically and screening detected celiac disease in this study was 1:2.4 (23:56). CONCLUSIONS:: The proportion of clinically undetected celiac disease may be particularly high among 3-year-old children with HLA-DQB1*02 and DQB1*0302 in Sweden, where these 2 HLA-risk alleles frequently occur

Low expression of CysLT(1)R and high expression of CysLT(2)R mediate good prognosis in colorectal cancer

Colorectal cancer is the third most common cancer type in the western world. in search of new treatment possibilities, the inflammation mediators, know as cysteinyl leukotrienes (CysLTs), have been shown to regulate intestinal epithelial cell survival and proliferation via the CysLT(1)R, and cell differentiation via the CysLT(2)R. These results prompted us to investigate the significance of CysLT(1)R and CysLT(2)R expression in colorectal cancer tissue for patient survival. The CysLT(1)R, CysLT(2)R, beta-catenin and Bcl-xL protein expression levels were evaluated by immunohistochemistry in a tissue microarray of 329 colorectal patients. We found that high nuclear expression of CysLT(1)R is associated with a poor prognosis, whereas high nuclear expression of CysLT(2)R is associated with a good prognosis. We also observed that patients with colorectal tumours characterised by high CysLT(1)R but low CysLT(2)R nuclear expression had the lowest survival expectancy, whereas patients with colorectal tumours characterised by low CysLT(1)R but high CysLT(2)R nuclear expression had the best survival expectancy. Interestingly, beta-catenin as a single prognostic marker did not exhibit any prognostic value. However, in patients with tumours characterised by a high CysLT(1)R nuclear expression, an elevated beta-catenin nuclear expression had a significantly prognostic value. In conclusion these data indicate that nuclear expressions of CysLTRs are potential prognostic indicators of colorectal cancer. (C) 2009 Elsevier Ltd. All rights reserved

Autoantibodies Against Soluble and Immobilized Human Recombinant Tissue Transglutaminase in Children with Celiac Disease.

Objectives: The conformation of tissue transglutaminase might influence the performance of immunoassays to detect autoantibodies from patients with celiac disease. The present study investigated how the exposure of tissue transglutaminase kept in a liquid phase and fixed to a solid support affected the binding of immunoglobulin (Ig)A and IgG autoantibodies in children with untreated and treated celiac disease. Methods: Included were 73 untreated celiac disease children, 50 controls and 80 children with treated celiac disease. IgA and IgG antitissue transglutaminase were measured with solid phase enzyme-linked immunoassay (ELISA) and liquid phase radioligand binding assays. For IgG antitissue transglutaminase detection with radioligand binding assays antihuman IgG and protein A were used. IgA endomysial autoantibodies were measured by indirect immunofluorescence. Results: Both ELISA and radioligand binding assays detected IgA antitissue transglutaminase in 65 of 73 untreated celiac disease children and in 2 of 50 controls. One additional control child was detected with radioligand binding assays. Endomysial autoantibodies were present in 62 of 73 celiac disease children and in 2 of 50 controls. IgG antitissue transglutaminase was detected with both ELISA and radioligand binding assays in 40 of 73 untreated celiac disease children and in 2 of 50 controls. Radioligand binding assays using protein A detected 20 of 73 additional untreated celiac disease children and one control child with increased IgG antitissue transglutaminase. In treated celiac disease children, 21 of 80 were IgA antitissue transglutaminase positive with radioligand binding assays, 3 of 80 with ELISA, whereas none had endomysial autoantibodies. Conclusions: No qualitative differences between radioligand binding assays and ELISA in IgA or IgG antitissue transglutaminase binding from untreated celiac disease children was demonstrated. However, discrepancies in the binding of IgA antitissue transglutaminase from a subgroup of treated celiac disease children indicated that alterations of tissue transglutaminase might occur on fixation of the antigen. Protein A used for radioligand binding assays seemed not to assess IgG autoantibodies exclusively. IgA antitissue transglutaminase detection in screening of childhood celiac disease can be performed either by ELISA or radioligand binding assays because the two assays are interchangeable