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Background: Barrett's esophagus (BE) is a premalignant condition that can progress to adenocarcinoma of the esophagus and gastroesophageal junction. The Prague C and M criteria was established to provide guidelines on the endoscopic characterization of BE through grading of continuous metaplastic extension from the top of the gastric folds. However, we have observed BE patients with metaplastic columnar ‘islands' that would not be classified under the current criteria. The possibility of dysplasia within these islands and the potential for missed lesions during surveillance or through ablative therapy highlights the need for a revision of the Prague criteria. Aim: To identify and characterize Barrett's esophagus patients that develop metaplastic columnar islands and to assess the utility of a descriptive tool used in addition to the Prague criteria Methods: This retrospective review analyzed consecutive patients with BE referred for management of suspected dysplasia. All patients were assessed with endoscopes equipped with high definition white light, and narrow band imaging. All cases were classified using the Prague criteria for BE at a baseline, mapping upper endoscopy with 4 quadrant biopsies taken at 1 cm intervals from the gastroesophageal junction. After the "C" and "M" of the Prague scale were recorded, all additional islands of metaplastic columnar mucosa were mapped. An "I" designation was given to the most proximal island measured from the gastroesophageal junction. The Barrett's segment was represented as a CxMxIx where "x" is the number in cm from the gastroesophageal junction. Biopsied tissue was assessed for dysplasia, which was confirmed by an expert GI pathologist. Patients with and without islands were compared. Results: From June 2012 to October 2014, 73 patients (mean age 66.0, 61male, 12 female) were referred for assessment of potential dysplastic BE. 49 (67%) patients did not have any observed islands (mean age 67.4, range 19-87). 25 (33%) patients (mean age 63.6, range 37-84) had islands of Barrett's tissue; 11 with de novo islands and 14 with islands appearing after endoscopic ablation was administered. In the non-island BE group, the mean and range of C and M were 3.3 (011) and 4.8 (1-12) respectively. In the BE group with islands, the mean and range of C, M and I were 2.5 (0-11), 3.5 (0-10) and 5.2(1-10) respectively. 2 patients in the island BE group had biopsy confirmed intramucosal carcinoma. All patients had regular surveillance with or without ablative therapy. Conclusion: The Prague criteria is well validated for endoscopic description of BE. However, we have observed that many patients assessed for BE have island configurations of Barrett's tissue that fall outside of classic Prague descriptors. The potential risk of missed dysplastic lesions warrants the need for a revision to the Prague Criteria.

Applying proper coding is important for doctors practicing gastroenterology. The coding systems established by various organizations define tumors differently. As a result of changing concepts of tumor classification, there are coding and reimbursement issues following the confirmation of malignant lesions by nationwide cancer screening in patients with intramucosal carcinoma and neuroendocrine tumors of the colorectum. In addition, there have been discrepancies between the views of endoscopists and pathologists regarding tumor coding. The Korean Society of Gastrointestinal Endoscopy held an expert meeting and established a consensus for the coding of intramucosal carcinoma and neuroendocrine tumor of the colorectum.

We read with interest the viewpoint “Gastrointestinal epithelial neoplasia: Vienna revisited” by Dixon ( Gut2002;51:130–1 [OpenUrl][1][Abstract/FREE Full Text][2] ). For many years Western gastrointestinal pathologists have followed the recommendations of British gastrointestinal pathologists. We learned that terms such as carcinoma in situ should be banned from the diagnostic terminology as it could lead to misinterpretation by surgeons and to unnecessary surgical intervention. The Vienna classification1 has introduced new avenues to the understanding of the process of carcinogenesis in the gastrointestinal tract. For some Western pathologists in the Vienna group who also received histopathological training in Japan, the concept of intraepithelial carcinoma (that is, carcinoma in situ) and of intramucosal carcinoma appeared natural. Although during the first day of discussions other Western pathologists appeared reluctant to accept such controversial notions, the discussion became … [1]: {openurl}?query=rft.jtitle%253DGut%26rft.stitle%253DGut%26rft.issn%253D0017-5749%26rft.aulast%253DDixon%26rft.auinit1%253DM%2BF%26rft.volume%253D51%26rft.issue%253D1%26rft.spage%253D130%26rft.epage%253D131%26rft.atitle%253DGastrointestinal%2Bepithelial%2Bneoplasia%253A%2BVienna%2Brevisited%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fgut.51.1.130%26rft_id%253Dinfo%253Apmid%252F12077106%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=gutjnl&resid=51/1/130&atom=%2Fgutjnl%2F52%2F3%2F455.2.atom

Two modern endoscopic techniques are presented with a view to determining the horizontal extent of gastric cancer. They are based on differences in the microvascular structure and density of early gastric cancer compared with those of the non-cancerous background mucosa. One technique requires magnifying endoscopy which can identify microvascular architecture that shows the characteristic findings of carcinoma. The other technique is an image-processing technique which enhances the differences in microvascular structure and density between carcinomatous mucosa and non-carcinomatous mucosa. We demonstrate an example of these techniques applied to an intramucosal carcinoma of a differentiated type, the margin of which could not be determined simply by traditional endoscopy with dye spreading. Magnified observation could detect a demarcation line between the carcinoma and non-carcinomatous mucosa. In addition, the image-processing technique enhanced the contrast of redness between cancerous area and non-cancerous mucosa. Both of these techniques are useful for detecting the precise extent of a carcinoma. The combined application of these techniques should be helpful in determining the precise horizontal extent of early gastric cancer.

Introduction Mucosal neoplasia arising in Barrett’s oesophagus (BE) can be treated with combined radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR). Once there is submucosal invasion the risk of lymph node metastases increases and surgery is favoured. High grade dysplasia (HGD) and intramucosal carcinoma (IMC) arising from the mucosal layer in BE are defined as separate entities in the revised Vienna classification (category 4.1 and 4.4 respectively). Methods We examine prospective data from United Kingdom (UK) registry of patients undergoing RFA/EMR for BE neoplasia over past 5 years to compare outcomes between HGD and IMC patient cohorts. Histological confirmation of HGD or IMC was required on two separate occasions by specialist histopathologists prior to treatment. Before RFA, visible lesions were removed by EMR. Thereafter patients underwent RFA 3 monthly following which biopsies were taken at 12 months for clearance of dysplasia (CR-D) and BE (CR-IM). Twelve month outcomes, frequency of EMR, cancer progression and long term durability in both groups were examined. Results To date 367 patients with HGD and 125 with IMC have been treated. There is no difference in age, sex, baseline BE length between the 2 groups. EMR prior to RFA is far more prevalent in IMC cohort than HGD patients (78 vs. 45%, P Conclusion We report one of the largest series of patients undergoing endoscopic therapy for IMC arising in BE. Patients with IMC are more likely to have visible lesions that require EMR prior to RFA than those with HGD. However, once all visible lesions are removed, there is no statistical difference in clinical outcomes between the cohorts. Minimally invasive endoscopic therapy with RFA/EMR is a safe and effective treatment in patients with IMC. All collaborators of the UK RFA registry are acknowledged for their contributions to this work Disclosure of Interest None Declared.

These are exciting times in the management of Barrett's oesophagus. The emergence of large multicentre consortia, along with new imaging and treatment modalities that utilise ever-improving study design are all welcome developments in the face of the continuing increase in the incidence of oesophageal adenocarcinoma. From a diagnostic, staging and treatment perspective, endoscopic mucosal resection (EMR) has emerged as a critical tool in the management of patients with both high-grade dysplasia and early carcinoma. Tumour staging with EMR is accurate when compared with surgical pathology following oesophagectomy: negative margins on EMR specimens correlate well with absence of residual disease at the time of surgery but submucosal involvement is associated with predictable rates of residual disease and/or lymph node metastases at the time of surgery.1 Furthermore EMR will change the diagnosis in approximately 50% of patients when compared to endoscopic biopsies, given the larger tissue sample available for review by the pathologist.2 Inter-observer agreement among pathologists is improved as well. EMR is clearly a therapeutic option for high-grade dysplasia and intramucosal carcinoma with low risk characteristics that have been well described previously by the Wiesbaden group.3 However, EMR, when used as a standalone therapy for early neoplasia in Barrett's oesophagus, is limited by the subsequent development of metachronous lesions in approximately 21% of patients.4 A number of risk factors for recurrence have been identified with perhaps the most important being the lack of treatment of the residual at risk mucosa.4 There are currently two options to deal with the remaining at risk mucosa: focal EMR accompanied by endoscopic ablation of …

Although numerous studies have assessed the biologic parameters of tumors, measurement of these parameters has had, to date, little impact on histologic diagnosis. Furthermore, analysis of a single parameter is insufficient to evaluate tumor malignant potential. In the present study, cell proliferation, DNA ploidy and p53 product were analyzed to objectify the tumor malignant potential in colorectal adenomas and intramucosal carcinomas. Sixty-one adenomas and 49 intramucosal carcinomas were studied using immunohistochemical analysis of Ki-67 and p53, silver-staining nucleolar organizer region (AgNOR) stain and DNA ploidy in fresh samples. Intramucosal carcinoma exhibited a greater Ki-67-positive rate and AgNOR count than the adenomas, although these parameters varied widely among samples. The incidence of aneuploidy and p53 over-expression in colorectal intramucosal carcinomas was significantly higher than in colorectal adenomas. These results indicate that DNA aneuploidy and p53 accumulation are the most reliable parameters for distinguishing benign and malignant lesions.

The aim of this study was to clarify whether or not the status of gene alteration is heterogeneous in intramucosal carcinoma and homogeneous within invasive carcinoma. We selected 10 colorectal carcinoma cases (1 mucosal, 5 submucosal and 4 advanced carcinomas including 2 cases with lymph node metastasis) and analyzed the p53 gene sequence. Six colorectal cancers in this study showed heterogeneity in p53 mutations in cells from the intramucosal part. In the invasive part of a carcinoma, p53 mutation status was homogeneous intratumorally in all cases. These data indicate that, in regard to p53 gene alterations, colorectal cancers can be composed of various subclones when limited to the mucosa, but clonal selection occurs when one of these subclones commences invasion to the submucosa, generating a monoclonal invasive carcinoma.

Most cases of experimentally induced adenocarcinoma arise in the antral region, in the vicinity of the pylorus of the glandular stomach. In early cases, the tumors appear as round or oval, slightly elevated solitary or multiple lesions 2–4 mm in diameter (Fig. 331). Some cases of intramucosal carcinoma with erosion, located in the level of the mucous membrane, have also been observed. The mean diameter of advanced carcinomas is 5–6 mm (Ohgaki et al. 1983), but tumors 20–30mm in diameter have also been found. Mac-roscopically, three different types can be distinguished: umbilicated or ulcerated tumors with irregular elevated margins; flowerbed-like lesions with a central area of depression; hemispherical or polypous protruded lesions (Saito et al. 1970).

elevated flat lesion with wide pit spreading on the margin of LST and we named it “Skirt”. However, not much is known regarding the differences between rectal LST and colonic LST, and the characteristics of Skirt have not been clarified. Aim: To evaluate retrospectively the clinicopathological characteristics of rectal LST and Skirt. Methods: From February 2006 to April 2012, a total of 663 LST in 612 patients undergoing endoscopic or surgical resection in our hospital were enrolled. LST were classified into the following three groups: granularhomogeneous type (LST-GH), granular-nodular mixed type (LST-GM) and nongranular type (LST-NG). The location was divided into two regions: rectum (from upper rectum to lower rectum) and colon (from cecum to recto-sigmoid colon). The “Skirt” was defined as having three findings: 1) spreading on the margin of LST, 2) hardly elevated lesion and 3) presenting the wide shape pit. We assessed the clinicopathological characteristics of the patient such as age, gender, location, size, tumor type and histological type. Results: A total of 114 LST were located in the rectum (LST-GH: 8 lesions (7%), LST-GM: 87 (76%), LST-NG: 19 (17%)) and 549 LST were located in the colon (LST-GH: 128 lesions (23%), LSTGM: 113 (21%), LST-NG: 308 (56%)). The mean sizes of rectal LST and colonic LST were 40.2 19.7mm and 25.5 13.9mm. The histological types of rectal LST were 21 adenoma (18%), 61 intramucosal carcinoma (54%) and 32 submucosal carcinoma (28%). As for colonic LST, those were 310 (57%), 169 (31%) and 70 (13%). Significant difference was seen in the frequency of LST-GM (p 0.001), large size of tumor (p 0.05), the frequency of carcinoma (p 0.001) between rectal and colonic LST. In contrast, no significant differences in age and gender were seen between rectal and colonic LST. All 21 LST with Skirt were attaching LST-GM lesions. Of the 21 LST, 19 LST were located in the rectum and 2 LST were located in the colon. Rectal LST with Skirt had significantly more female (12/19, p 0.05) and larger tumor size (47.1 17.9mm, p 0.05) than those without Skirt (35/95, 38.9 19.7mm). Conclusions: Rectal LST had significantly more LST-GM, larger tumor size and more cancers in comparison to colonic LST. As for Skirt, rectal LST with Skirt group was characterized with more female and larger tumor size. In the future, further studies need to involve not only clinical pathology but also molecular biology to clarify the significance of Skirt.

Sung Pil Hong, Tae Il Kim, Hyun Gun Kim, Hyun-Soo Kim, Seong-Eun Kim, Kyu Chan Huh, Jeong Eun Shin, Jae Myung Cha, Suck-Ho Lee; Intestinal Tumor Research Group, Korean Association for the Study of the Intestinal Disease Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Soonchunhyang University College of Medicine, Seoul, Yonsei University Wonju College of Medicine, Wonju, Ewha Woman’s University School of Medicine, Seoul, Konyang University College of Medicine, Daejeon, Dankook University College of Medicine, Cheonan, Kyung Hee University School of Medicine, Seoul, Korea

Introduction: Photodynamic Therapy or PDT has been used and validated in the endoscopic treatment of superficial esophagus lesions such as high grade dysplasia (HGD) and/or intramucosal carcinoma. PDT is also currently used as a palliative treatment of non resectable cholangiocarcinomas.

To evaluate endoscopic mucosal resection (EMR) in patients with high-grade dysplasia (HGD) and/or intramucosal cancer (IMC) in Barrett's esophagus (BE).Between June 2000 and December 2003, 39 consecutive patients with HGD (35) and/or IMC (4) underwent EMR. BE30 mm was present in 27 patients. In three patients with short segment BE (25.0%), HGD was detected in a normal appearing BE. Lesions had a mean diameter of 14.8+/-10.3 mm. Mucosal resection was carried out using the cap method.The average size of resections was 19.7+/-9.4 x 14.6+/-8.2 mm. Histopathologic assessment post-resection revealed 5 low-grade dysplasia (LGD) (12.8%), 27 HGD (69.2%), 2 IMC (5.1%), and 5 SMC (-12.8%). EMR changed the pre-treatment diagnosis in 10 patients (25.6%). Three patients with SMC underwent surgery. Histology of the surgical specimen revealed 1 T0N0 and 2 T1N0 lesions. The remaining two patients were cancer free at 32.5 and 45.6 mo, respectively. A metachronous lesion was detected after 25 mo in one patient with HGD. Intra-procedural bleeding, controlled at endoscopy, occurred in four patients (10.3%). After a median follow-up of 34.9 mo, all patients remained in remission.In the medium term, EMR is effective and safe to treat HGD and/or IMC within BE and is a valuable staging method. It could become an alternative to surgery.

As association between Barrett's esophagus and adenocarcinoma of the esophagus is relatively frequent. Survival with adenocarcinoma is generally poor. Routine surveillance endoscopy is suggested with generous biopsy material and brush cytology to detect either high grade dysplasia or intramucosal carcinoma in patients with Barrett's esophagus. Individual cases of high grade dysplasia should be independently confirmed by another pathologist familiar with dysplasia grading. Esophagectomy should be recommended for those patients with high grade dysplasia whose risk for surgery is outweighed by the possible presence or development of cancer.