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Adam S
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Quote Adam S Replybullet Topic: Pathology Report
    Posted: 31 Jan 2018 at 11:46pm
I received a pathology report subsequent to an upper endoscopy, and was hoping that someone on the forum could offer some clarification about the findings.  The physician performing the endoscopy initially reported a finding of Barrett's Esophagus:  10mm lesion at 41cm.  However, the pathology report indicated : Reflux Esophagitis; negative for Complete Intestinal Metaplasia and Dysplasia on Multiple Levels."

After receiving this report the physician met with me and told me that his initial finding of Barrett's was incorrect.  Obviously, this was welcomed information to me  I began taking a PPI and was told that I did not need follow-up endoscopy.

After doing some research about Barrett's, metaplasia, and related issues, I found that the current thinking about Barrett's appears to be that the presence of incomplete metaplasia is the hallmark of a Barrett's diagnosis, and that complete metaplasia is generally not associated with Barrett's.  I contacted the physician who did the endoscopy and asked him about this, but he was not able to give an adequate explanation.  He seemed to believe that that the possible progression was from incomplete metaplasia to complete metaplasia, to dysplasia, to carcinoma. 

What I gathered from my reading was that incomplete metaplasia and complete metaplasia are two distinct lesions, and that the possible progression was rather incomplete metaplasia (i.e., Barrett's), dysplasia, carcinoma.  There did appear to be a possible relationship between complete metaplasia and Barrett's, but the concensus appeared to be that this was statistically insignificant compared to the relationship between incomplete metaplasia and Barrett's.

if my conclusions are correct, the pathology report does not appear to be adequate, since it does not mention whether incomplete metaplasia was present.  If, in fact, incomplete metaplasia is the hallmark of Barrett's that is what I would primarily be interested in.  It seems odd to me that the report mentions the absence of dysplasia and the absence of complete metaplasia, as if the two are distinctly related, but does not included any mention of incomplete metaplasia.

I apologize for the length of this message, but I do hope that someone on the forum might be able offer some clarification.  Thank you in advance.

Regards,

Adam S
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steveb8189
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Quote steveb8189 Replybullet Posted: 01 Feb 2018 at 9:58am
Hi Adam and welcome to the site. Your question is very similar to a few that have been recently asked by people worried about their diagnosis. I suggest you have a read of Chris's reply to Allan on this thread - the first reply on the 5th page:

http://www.barrettscampaign.org.uk/forum/forum_posts.asp?TID=1544&KW=goblet&PN=5

I think you sound to be in a similar position to him
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Adam S
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Quote Adam S Replybullet Posted: 01 Feb 2018 at 3:18pm
Steve,
Thank you for your kind reply.  As you note, and as I suspected, the technical definition of Barrett's is different in the U.S. and the U.K.  I gather from reading the posting you recommended that the "gastric or cardial" metaplasia mentioned in the posting is what I referred to as "complete metaplasia", as differentiated from "incomplete metaplasia" ( i.e., an incomplete form of intestinal metaplasia, often referred to as "specialized intestinal metaplasia").

As noted in the posting, it appears that in the U.S. a finding of gastric mucosa in the esophagus does not warrant a diagnosis of Barrett's, whereas is the U.K. it would.  Although my pathology report might warrant a diagnosis of Barrett's in the U.K. my primary concern is the confusing nature of the pathology report itself. 

I seems to me that since a diagnosis of Barrett's in the U.S. requires a finding of incomplete intestinal metaplasia, and especially since the endoscopist's finding prior to the pathology report diagnosed Barrett's, the pathologist would be looking for incomplete intestinal metaplasia (the type associated with Barrett's in the U.S.).  Since the pathologist only mentions the absence of complete intestinal metaplasia, one is left to wonder about the presence of imcomplete intestinal metaplasia. 

The thought has crossed my mind that the pathologist, in error, noted "complete" when he should have noted "incomplete", or that the transcriber produced an error.  At this point, I am going to attempt speaking directly with the pathologist, although given the nature of our health care system, this may be difficult to accomplish.

Thank you again for your comments.

Regards,

Adam S
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steveb8189
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Quote steveb8189 Replybullet Posted: 02 Feb 2018 at 2:56pm
Hi Adam
I am not an expert but I would have read your report to mean the opposite to your latest post

The report says you don't have Intestinal Metaplasia but given something was visible it is likely you have gastric mucosa - or what is sometimes also described as goblet cells or a columnar epithelium.

Therefore I would say you have Barretts on the US definition but not the UK one.
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Adam S
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Quote Adam S Replybullet Posted: 02 Feb 2018 at 10:01pm
Steve,
Thanks for the reply.  I actually spoke with the pathologist at length yesterday.  He noted that the language he used in the pathology report should be interpreted as negative for a finding of Barrett's because there was no finding of specialized intestinal metaplasia, i.e., SIM.  Apparently, SIM is required for a Barrett's diagnosis in the U.S.

 He also noted that in the U.K. the findings would result in a Barrett's diagnosis, because of the presence of cardiac intestinal metaplasia.  I have to admit this is still rather confusing to me since my understanding is that cardiac intestinal metaplasia is also referred to as "complete metaplasia", whereas SIM is also referred to as "incomplete metaplasia".  I asked the pathologist about this distinction, and he appeared to agree with me; however, his report notes the absence of complete intestinal metaplasia, so it does appear contradictory.

I pointed this out to him, but he reiterated his initial finding that his language in the report should be taken as a negative for Barrett's as understood in the U.S.   He also stated that there is a good deal of confusion in regard to Barrett's diagnoses among doctors as well as pathologists.

At any rate, he concluded that, whether or not one would determine a diagnosis of Barrett's (depending upon location or personal inclination), the pathology findings suggest a very low risk, because of the small size of the lesion (10mm), and the fact that the report was negative for SIM as well as dysplasia.

I think the best approach at this point is to have a follow-up endoscopy within the next year and see what results.

Regards,

Adam S




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steveb8189
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Quote steveb8189 Replybullet Posted: 03 Feb 2018 at 12:00pm
The standard process in the UK is a follow up within 12 months and if SIM is still not found then to consider discharging.

Sounds like you're in a good position anyway :)
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