Brigham and Women's Hospital, Boston, MA 02115, USA.
Am J Surg Pathol. 2011 Jan;35(1):45-54. doi: 10.1097/PAS.0b013e3181ffdd14.
Recent morphologic and molecular evidence suggests that dysplasia in Barrett esophagus (BE) begins in the bases of the crypts [crypt dysplasia (CD)] and progresses with time to involve the upper portions of the crypts and surface epithelium. The aim of this study was to evaluate the criteria and reproducibility of diagnosing CD among 6 gastrointestinal pathologists, all with research interest in BE. Six gastrointestinal pathologists evaluated 2 clinical study sets, the first consisting of 40 BE cases [BE: 10, CD: 9, low-grade dysplasia (LGD): 10, high-grade dysplasia (HGD); 9, and intramucosal adenocarcinoma; 2] and the second consisting of 63 cases (BE: 16, CD: 15, LGD: 15, HGD: 15, and intramucosal adenocarcinoma: 2), at least 4 months apart. In between evaluations, all of the pathologists met at 1 hospital (consensus conference) to review the areas of disagreement and establish more objective criteria. Overall, the level of agreement for all cases was moderate (κ=0.44), and the level of agreement did not change significantly after evaluation of the second study set. The highest levels of agreement were obtained for lesions at the low and high end of the spectrum (BE without dysplasia and HGD). Overall, the degree of agreement for CD was moderate after both the first and second study set review (κ=0.44 and 0.46, respectively). However, the degree of agreement for CD was higher than that obtained for LGD in both study sets. In the first study set, 4 or more pathologists agreed with the original CD diagnosis in 78% of cases, and this value did not change significantly after review of the second study set. The observers agreed that characteristic features of CD include the presence of unequivocal dysplastic cells, similar in appearance to traditional LGD, involving any part, or all of the length, of the crypt in the absence of intercrypt surface epithelial involvement. Rare cases of CD may show high-grade cytologic features composed of markedly enlarged nuclei with increased nuclear/cytoplasmic ratio, eosinophilic cytoplasm, irregular nuclear membranes, and loss of polarity. The findings in this study suggest that CD can be diagnosed reliably with a moderate level of interobserver agreement. Long-term and multi-institutional studies should be carried out to further determine the biological and clinical significance and natural history of CD in patients with BE.
最近的形态学和分子证据表明，巴雷特食管（BE）中的发育不良始于隐窝底部（隐窝发育不良（CD）），并随着时间的推移进展为隐窝上部和表面上皮受累。本研究的目的是评估 6 位对 BE 研究感兴趣的胃肠病理学家在诊断 CD 方面的标准和可重复性。6 位胃肠病理学家评估了 2 个临床研究集，第一个研究集包括 40 例 BE 病例[BE：10 例，CD：9 例，低级别上皮内瘤变（LGD）：10 例，高级别上皮内瘤变（HGD）：9 例和黏膜内腺癌；2 例]，第二个研究集包括 63 例（BE：16 例，CD：15 例，LGD：15 例，HGD：15 例和黏膜内腺癌：2 例），两次评估至少相隔 4 个月。在评估之间，所有病理学家都在 1 家医院（共识会议）会面，以审查意见不一致的领域，并制定更客观的标准。总体而言，所有病例的一致性水平为中度（κ=0.44），并且在评估第二个研究集后，一致性水平没有显著变化。在疾病谱的高低端获得了最高水平的一致性（无发育不良的 BE 和 HGD）。总体而言，在第一个和第二个研究集评估后，CD 的一致性程度均为中度（κ=0.44 和 0.46）。但是，在两个研究集中，CD 的一致性程度均高于 LGD。在第一个研究集中，4 名或更多病理学家在 78％的病例中同意原始 CD 诊断，并且在审查第二个研究集后，该值没有明显变化。观察者一致认为，CD 的特征性特征包括存在明确的异型细胞，其外观类似于传统的 LGD，涉及隐窝的任何部分或全长，而不存在隐窝间表面上皮受累。罕见的 CD 病例可能表现出高级别细胞学特征，包括细胞核明显增大，核/细胞质比例增加，嗜酸性细胞质，不规则核膜和极性丧失。本研究的结果表明，CD 可以通过中等程度的观察者间一致性可靠地诊断。应进行长期和多机构研究，以进一步确定 BE 患者中 CD 的生物学和临床意义以及自然史。
