Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 235065

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : EC17 - EC22 Full Version

Immunohistochemical Expression of CDX2 in Gastroesophageal Junction Biopsies: An Emerging Marker for Early Intestinal Differentiation of Barrett’s Metaplasia


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55446.16286
Twisha Adhikari, Vidya Monappa

1. Assistant Professor, Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India. 2. Associate Professor, Department of Pathology, Kasturba Medical College, Manipal, Karnataka, India.

Correspondence Address :
Dr. Twisha Adhikari,
Assistant Professor, Department of Pathology, ASHA Building, IDA Scudder Road,
CMC Hospital, Vellore-632004, Tamil Nadu, India.
E-mail: drtwisha89@gmail.com

Abstract

Introduction: Histological diagnosis of Barrett’s oesophagus (BE) in mucosal biopsies is challenging and affected by multiple factors. Goblet Cells (GCs) are not distributed uniformly in BE and is dependent on sampling probabilities. Furthermore, GC Mimickers (GCM) are potential pitfalls in the diagnosis of Intestinal Metaplasia (IM). Alcian Blue (AB) stain has been extensively used in detection of GC’s although it has the limitation of low specificity with positive staining for GCM. Recently, CDX2 Immunohistochemistry (IHC) is reported to be highly sensitive and specific marker which has shown to identify early intestinal phenotype even in absence of diagnostic GCs and especially pertaining to conditions where characteristic morphological changes are not apparent.

Aim: To study the histomorphology of non neoplastic and neoplastic lesions of the Gastroesophageal Junction (GEJ) in reflux patients and evaluate the diagnostic role of CDX2 IHC versus AB stain in detecting IM.

Materials and Methods: This retrospective study was conducted in Department of Pathology at Kasturba Medical College, Manipal, Karnataka, India, on 55 patients with clinical features of reflux and adequate records of GEJ biopsies, diagnosed over 6 years from January 2012 to August 2018. Clinical presentation, endoscopic findings and histomorphology (18 parameters) were recorded. AB stain and CDX2 (IHC) were performed and evaluated in all cases. A detailed histological evaluation was done for all cases and subsequently, sensitivity, specificity, positive predictive value and negative predictive value of CDX2 IHC to identify early intestinal differentiation was calculated.

Results: Of 55 cases, 28 were BE, 19-Reflux oesophagitis (RE) and 8-adenocarcinoma. Heart burn and chest pain were the most common clinical presentations of BE. Endoscopy of BE predominantly showed hiatus hernia with tongue like projections of the gastric mucosa. Histologically, intraepithelial eosinophils and spongiosis were more common features in RE. Barrett’s oesophagus showed columnar epithelium with multilayering, presence of IM with GC (1-20/crypt) along with sub-squamous buried epithelium and splitting of muscularis mucosa. By IHC, as compared to AB; CDX2 IHC was more sensitive (100% vs 78.2%) and specific (96.5% vs 82.6%) for detecting an intestinal phenotype. The five cases (22%) of BE contained only GCM in the biopsy, were CDX2 negative but showed a false positivity for AB. In BE, CDX2 additionally highlighted positivity in non GC columnar cells which were AB negative. The CDX2 showed diffuse positivity in dysplasia with focal strong to absent expression in adenocarcinoma.

Conclusion: The CDX2 efficiently differentiated between GC and pseudo GC. Its presence in the absence of AB in non GC columnar cells suggests that it effectively detects intestinal phenotypic features even before morphological features are evident.

Keywords

Alcian blue, Barretts oesophagous, Goblet cells, Intestinal metaplasia, Reflux

Reflux of the acidic gastric contents into the oesophagus with resultant irritation of the oesophageal mucosa, causes Gastro-Oesophageal Reflux Disease (GERD). Difficulty in swallowing, burning sensation of throat, belching are features of GERD. Patients with GERD could progress to BE. BE predisposes to cancer development , the incidence of BE to cancer progression has been increasing over the years and was seen to be 0.1-0.4% per year in the recent studies (1). The reflux symptoms might not be present in every patient and they may also have normal endoscopic findings. So, an accurate assessment might be difficult in those cases (2),(3),(4). Hence, a good histopathological analysis is the key for management. Needless to say, histological diagnosis of Barrett’s oesophagus (BE) can be quite challenging. Goblet Cells (GCs) are not distributed uniformly in BE, their proportion varies amongst patients and specimens and biopsy may fail to pick up GCs. The columnar cells which are present in between GCs may look a lot like gastric foveolar cells or intestinal absorptive cells. Goblet Cells Mimickers (GCM) are potential pitfalls in the diagnosis of IM (5),(6),(7),(8),(9),(10),(11),(12). The GCMs can look like GCs with their ample accumulation of mucinous cytoplasm and are called as the pseudo-goblets. The columnar epithelial cells may also contain AB positive acid mucins, even though the intensity of staining is less than that of GCs. In addition, these cells have a tendency to be distributed more diffusely than the true GC, which has a more dispersed distribution (5),(6).

In this respect, CDX2 IHC is a reported highly sensitive and specific marker which has been shown to identify early intestinal phenotype even in absence of diagnostic GCs and especially pertaining to conditions where characteristic morphological changes are not apparent (7),(8).

Study objectives:

• Detailed histomorphological analysis of non neoplastic and neoplastic lesions of GEJ in patients with reflux and to correlate with endoscopic findings;
• Evaluate the diagnostic role of CDX2 IHC in detecting early IM in comparison with AB (pH 2.5); and
• Study CDX2 staining patterns in dysplasia and adenocarcinoma of oesophagus.

Material and Methods

This retrospective study was conducted in Department of Pathology at Kasturba Medical College, Manipal, Karnataka, India, from January 2012 to August 2018. All procedures performed were approved by Institutional Review Board and National Research Ethics Committee (IEC number 595/2016, dated 20/09/2016) in accordance with the 1964 Helsinki declaration and its later amendments. A total of 55 cases with symptoms of reflux and who had adequate GEJ mucosal biopsies were included. The clinical details and endoscopic findings were retrieved from the medical records department. Haematoxylin and Eosin (H&E) sections of mucosal biopsies of all the 55 cases were studied for histomorphological features. AB and CDX2 IHC were subsequently done in all the cases and were studied. For CDX2 IHC, deparaffinised tissue sections were used for DAK-CDX2 (Dako Monoclonal mouse Antihuman CDX2, Ref M3646) and manual staining for AB was done in all the cases.

Inclusion and Exclusion criteria: All cases of reflux with GEJ biopsies were included in the study. Other cases with causes of oesophagitis, squamous cell carcinomas and adenocarcinoma of stomach were excluded from the study.

All cases were studied for the histomorphological features as given in [Supplementary Table-1]. The detailed definitions of the histological variable are provided in [Supplementary Table-2].

Reflux oesophagitis (RE) was diagnosed in the presence of epithelial injury and absence of GCs; and BE was diagnosed in the presence of GCs on H&E stain. The pattern of staining of CDX2 IHC and AB were studied subsequently. CDX2 IHC staining was considered positive when any intensity of nuclear staining was seen. The AB was considered as positive when the cells had any intensity of bluish cytoplasmic staining. CDX2 staining was studied in terms of nuclear expression in GCs and non GCs, along with extent of staining (diffuse>50% of cells/focal <50% of cells). Adenocarcinomas were diagnosed in presence of invasion. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) was derived for AB and CDX2 staining in case of BE, following which the data was compared with other published literature.

Statistical Analysis

Categorical data was expressed as frequency along with percentage n (%). Sensitivity, specificity, PPV and NPV was calculated for CDX2 on comparison with AB. Data processing and statistics were done using Microsoft Excel 2010 version.

Results

There were a total of 55 cases, 19 had reflux oesophagitis, 28 had BE and 8 had adenocarcinomas. The clinical details with endoscopic findings are given in (Table/Fig 1). On endoscopy 62.5% cases showed tongue like projection of salmon colored mucosa above the GEJ which ranged from <5-10 cm length above the GEJ. Two (12.5%) presented as Short Segment Barrett’s oesophagus (SSBE) with tongue like projection of 2 cm above GEJ (Table/Fig 2)a and ultra-SSBE was seen in 1 case (0.06%) with a length of <5 mm above GEJ. An 87.5% cases (14 out of 16) were long segment BE (Table/Fig 2)b. All the above cases with tongue like projections were clinically given the diagnosis of BE.

(Table/Fig 3) summarises the various histomorphologic features along with (Table/Fig 4),(Table/Fig 5),(Table/Fig 6),(Table/Fig 7) showing the various histomorphologic findings in RE and BE including pseudo-GCs. Detailed histopathological changes in both the squamous and columnar component of individual oesophageal biopsies were evaluated in cases of RE and BE.

In the squamous components, RE had more basal zone hyperplasia (100% versus 88%), intraepithelial lymphocytes (95% versus 82.1%), intrapepithelial eosinophils (37% versus 24%) and mucosal ulcerations (37% versus 28%) as compared to BE. In the columnar component, BE had more combined mucous and oxyntic glands beneath crypt epithelium (37% versus 17%).

The inflammation in lamina propria was higher in BE than RE (100% vs 78%). The inflammation in BE consisted primarily of lymphocytes and plasma cells (100% vs 67%). In BE, 25.9% and 29.6% of cases showed isolated neutrophil and eosinophil rich inflammation respectively, which was not observed in any case of 19RE. A 33.3% cases of BE also showed diffuse oedema, whereas oedema was not noted in RE. Presence of GCs, dysplasia (18%) and subsquamous columnar cell nests (50%) were only seen in BE whereas presence of H.pylori was only seen in RE (43%). A splitting of muscularis mucosa was more in RE (53% versus 35.7%) as compared to BE. Out of the eight cases of adenocarcinomas, six were well differentiated and two were moderately differentiated. Two cases (33.3%) were associated with BE while RE did not show any association with carcinoma.

CDX2 and Alcian Blue (AB) Staining in Reflux Oesophagitis (RE) and Barrett’s Oesophagus (BE):

AB was done in 24 cases of BE and CDX2 was done in 23 due to the unavailability of blocks in remaining cases. All the cases of BE were positive for AB in the GCs (100%) and also in 18 cases (75%) where along with GCs, non GCs were also stained (Table/Fig 8). All the cases of RE were negative for AB (Table/Fig 3). The CDX2 was positive in only 18 out of 23 cases (78.2%) of BE (true positive cases), which showed positivity of non GCs more than the GCs (Table/Fig 8). Only one case (0.05%) of RE showed nuclear CDX2 positivity (Table/Fig 9).

After further detailed review, the remaining (CDX2 negative) five cases (5/23) (37%) by histology had only GCMs , surprisingly all of which were AB positive and were thus interpreted to be histologically incompatible with a diagnosis of BE. CDX2 IHC on these five cases was repeatedly negative (Table/Fig 10)a-d. Out of these five cases, two had pseudo-GCs and three had columnar blue cells which had AB positivity in a stretch of the epithelium.

CDX2 staining in dysplasia and adenocarcinoma:

All the cases of dysplasia, both low and high grade had diffuse strong positivity for CDX2 IHC (Table/Fig 11)a,b. In case of Adenocarcinomas, CDX2 was available in six out of eight cases. Out of these six cases, 4/6 was well differentiated and 2/6 was moderately differentiated. Both two negative CDX2 cases (Table/Fig 12)a,b were well differentiated adenocarcinomas. In the well differentiated adenocarcinoma category, only one case showed focal (<50% of tumour cells) positive staining of tumour cells. Overall, as compared to AB, overall CDX2 IHC had a higher sensitivity (100%) and specificity (96.5%) with a PPV of 95% to identify early intestinal phenotype in BE (Table/Fig 13).

Discussion

The BE is a relatively indolent disease and prevalent in 2-7 % of the population (6). The importance of BE lies in its increased potential risk of oesophageal adenocarcinoma. Till date, there exists a considerable amount of controversy regarding the precise histological diagnostic criteria of BE. The American Gastroenterological Association (AGA) emphasise that IM (with ‘GCs’) is essential for diagnosing BE (6). AGA defined BE as “Columnar Metaplasia (CM) of oesophagus that is visible ‘endoscopically’ and confirmed ‘histologically’ (6). It is of the view that IM is the only type of oesophageal columnar epithelium that predisposes to malignancy. In contrast, The British Society of Gastroenterology defines BE as “an oesophagus in which any portion of normal distal squamous epithelial lining , which has been replaced by metaplastic columnar epithelium , clearly visible endoscopically (≥1 cm) above GEJ and confirmed histopathologically by oesophageal biopsy” (6). Hence, by this definition BE requires presence of CM with or without GCs. However, it is important to note that the risk for malignancy in CM is much less when compared to IM with GCs (6).

On endoscopy, BE has been classically reported to present as circumferential migration with tongues of metaplastic epithelium (12). The junction with the squamous epithelial lining of the oesophagus may sometimes appear as a symmetric or asymmetric Z line or columnar mucosa seen alternating with squamous mucosa forming islands (island pattern) (13). An endoscopic diagnosis of BE is given only when salmon colour mucosa extends into tubular oesophagus, extending more than or equal to 1 cm proximal to GEJ, which should also be necessarily confirmed on biopsy (14). In this study, 64.5% cases of BE and also a large portion (20%) cases of RE presented with the classic endoscopic tongue like presentation. This point to considerable overlap and non specificity of endoscopic findings in suspected cases of BE.

Histologically, classical BE biopsies show relatively similar histopathological features as GERD, except for the additional presence of metaplastic columnar epithelium with or without the presence of GCs. Goblet cells (GCs) should be differentiated from GCMs, which have been sometimes noted to be concomitantly in BE biopsies (15). In this regard, histochemical stains cannot distinguish between the two as it stains acidic mucin in both. The AB-positive non GCs are generally found in the gastric pit epithelium. If these AB positive columnar cells are present in the surface epithelium then it is an abnormal finding and are known as “Metaplastic AB positive cells” (16). A distinction between the two lesions is imperative in mucosal biopsies, as one is relatively benign and the other with premalignant potential. In this study, the American system was followed for all the cases of BE which were diagnosed on the basis of presence of GCs.

The presence of IM in a biopsy is also considerably dependent on sampling probability. Harrison R et al., reported the frequency of IM varies from patient to patient, depends on the site and also the number of biopsies taken (15). Khandwalla HE et al., and Sharma P et al., found presence of IM in 29% and 23% of repeat biopsies, which were initially diagnosed to be negative for IM [17,18]. Takubo K et al., also reported that the mucosa immediately adjacent to adenocarcinomas was more frequently of gastric type (71%) rather than intestinal type (22%) (19).

The CDX2 is a homeobox transcription factor and belongs to the caudal related family of CDX homeobox genes which was first found to be expressed in the mouse intestine (20). The expression of CDX2 is seen in adult non neoplastic tissues and is limited to normal intestinal epithelium, normal pancreatic epithelial cells, and gastric and IM. In the gastrointestinal tract,CDX2 is seen to be strongly and diffusely positive in small and large intestinal epithelial cells, including absorptive, goblet, endocrine and Paneth cells (21). It has also been reported that the oesophageal superficial columnar mucosal cells lacking GCs, known as “Columnar blues” can demonstrate positive AB staining, but are consistently CDX2 negative (22). Normal oesophageal and gastric epithelial cells are CDX2 negative. In the oesophagus, CDX2 is expressed in CM with or without IM.

A study suggests that CDX2 positivity is necessary for embryonic intestinal proliferation (22). The CDX2 can also be positive in columnar cells in few of the cases without histological features of IM, hence reflects the ability of CDX2 to detect early intestinal phenotypic features even before the histochemical and morphological features are manifested. The expression of CDX2 proximal to Barrett’s metaplasia suggests that its expression precedes the phenotypic transformation (20).

Another role of CDX2 staining has been reported to help differentiate low and high grade dysplasia in BE. According to various literature, diffuse staining for CDX2 is seen in non dysplastic BE and BE with low grade dysplasia. The intensity of CDX2 staining and percentage of positive cells decreases in BE with high grade dysplasia and adenocarcinoma. This suggests that with tumour progression, cellular differentiation decreases (23).

The CDX2 was performed in 48 cases in the current study. An 18/23 cases of BE, all of which had true GCs had consistent CDX2 positive staining. The remaining five cases were hence interpreted to be falsely diagnosed as BE and had pseudo-GCs, which were CDX2 negative but had AB false positivity. Only a single case with no evidence of IM and diagnosed as RE showed CDX2 positivity in the non GCs.

Phillips RW et al., observed that 77% cases with IM were CDX2 positive and 20% cases without GCs and only showing columnar epithelium was positive for CDX2 (23). Streher SA et al., reported CDX2 positivity in 5% cases of oesophagitis and 62.5% cases with IM (24). Groisman GM et al., observed reported that out of 90 cases with endoscopic diagnosis of BE, 45 showed GCs and 45 did not show (22). All the cases with GCs showed CDX2 strong reactivity in both GCs and the surrounding non GCs columnar cells and 38% cases showed focal CDX2 expression in the columnar cells without any GCs. In this study, all BE cases showed CDX2 expression both in GCs and the non GCs which ranged from diffuse to focal positive. In 56.5% cases CDX2 was expressed only in the GCs and in 17.3% cases CDX2 was expressed in the non GCs. Therefore the results from the present study validated the findings of Groisman GM et al., and it underlined the capability of CDX2 in detection of early intestinal phenotype even before the morphologic changes are apparent (22). Another important finding which was uncovered from this study was that CDX2 expression was more present in the non goblet metaplastic columnar epithelial lining than in the GCs which were similar to the findings in literature emphasising CDX2 as a marker of early intestinal differentiation (25).

The present study found that AB was positive in all the cases of BE with GCs (100%), which were both diffuse and focal positive and it was present in the non GCs in 75% cases. All the cases of RE were negative for AB. The GCMs showed apical positivity and also positivity in the stretch of epithelium for AB stain. All of these GCM were negative for CDX2. Johnson DR et al., similarly observed that out of 108 biopsies of BE, all the cases (100%) were AB positive, but only 102 (94.4%) cases were CDX2 positive (21). They had 43 cases with GCMs, all of which were CDX2 negative but AB positive. Similarly, all the cases of BE in this study, were AB positive but only 18/23 cases (78.2%) of them were CDX2 positive and all the GCM were CDX2 negative but AB positive.

So overall, CDX2 appeared to be a specific immunohistochemical marker for also detection of early precursors of IM/ confirmation of IM/BE in oesophageal small mucosal biopsies. As it is a nuclear transcription factor, it showed an “all or none” phenomenon. In this present study, CDX2 had a better PPV (95%) than AB (78%) , similar to that of Johnson DR et al., where the PPV of CDX2 and AB were 95.6% and 71.5%, respectively (21).

CDX2 Expression in Dysplasia and Oesophageal Adenocarcinoma:

Detection of dysplasia is very important, as progression to adenocarcinoma is a very slow and unpredictable process. Although histomorphology is considered as the gold standard when it comes to the diagnosis of dysplasia, IHC markers like CDX2 do provide an essential contributory help. Lord RV et al., reported eight cases of dysplastic BE and five cases of adenocarcinoma, with diffuse strong CDX2 expression and there was no difference in staining intensity between low grade and high grade dysplasia (8). Hayes S et al., and Phillips RW et al., reported a decrease in CDX2 expression from high grade dysplasia to adenocarcinoma (7),(23). Barros R et al., found that out of four cases of dysplastic BE, three were positive for CDX2 and one was negative, and out of eight cases of adenocarcinoma oesophagus seven were positive and one was negative (25). In this study, all the cases of dysplasia both high grade and low grade showed diffuse strong positivity for CDX2. In cases of adenocarcinoma, 4/6 was CDX2 positive which ranged from diffuse to focal expression. As denoted above, different studies have reported varying results with regards to intensity of CDX2 expression in different grades of dysplasia to adenocarcinoma and therefore further studies are warranted for precise confirmation.

Finally, the present study contained a morphometric detailed histopathological analysis of the squamous and columnar component of the oesophagus: 1) Basal zone hyperplasia; 2) Papillary hyperplasia; and 3) Increased intraepithelial eosinophils/neutrophils were the most predominating histological parameters noted in the squamous component of RE biopsies. On comparison with published literature by Colleypriest BJ et al., and Soucy G et al., the findings of the present study were in concordance (11),(20).

Limitation(s)

Firstly, this was retrospective study which included random 55 patients and could possibly represent a selection bias due to random endoscopic and histopathological evaluation. Secondly, although the study performed a detailed histomorphological and immunohistochemical evaluation, the sample size was limited to 55 cases. This study demonstrates that CDX2 is a marker of intestinal phenotype was seen to be positive in GCs and non GCs, and was more present in the non goblet columnar epithelium, suggesting the fact that it is a marker of early intestinal differentiation which could be missed on H&E and AB stains. With its ability to pick up the early GC precursors/intestinal differentiation may prove to be fruitful in diagnosing more cases of BE than routine H&E. Furthermore, CDX2 expression decreased from dysplasia to adenocarcinoma, suggesting that its expression decreases with decrease in intestinal differentiation and tumour progression.

Conclusion

The CDX2 immunohistochemistry is more sensitive and specific compared to AB in picking up intestinal differentiation and is an effective immunohistochemical marker for detection of early BE. Further studies with large cohort of patients, multi-quadrant gastroeosphageal junction biopsies, CDX2 IHC staining and staining with other IHC’s of intestinal differentiation (SATB2, CDX2) as controls are warranted for validating the diagnostic utility of CDX2 IHC in early diagnosis of BE.

References

1.
Johansson ME, Gustafsson JK, Sjöberg KE, Petersson J, Holm L, Sjövall H, et al. Bacteria penetrate the inner mucus layer before inflammation in the dextran sulfate colitis model. PLoS One. 2010;5(8):e12238. Doi: 10.1371/journal.pone.0012238. PMID: 20805871; PMCID: PMC2923597. [crossref] [PubMed]
2.
Areskog M, Tibbling L, Wranne B. Ooesophageal acid perfusion test as a complement to work test in patients with chest pain. Acta Med Scand. 1977;201(6):559-62. Doi: 10.1111/j.0954-6820.1977.tb15747.x. PMID: 878914. [crossref] [PubMed]
3.
Johnson LF, DeMeester TR, Haggitt RC. Endoscopic signs for gastrooesophageal reflux objectively evaluated. Gastrointest Endosc. 1976;22(3):151-55. Doi: 10.1016/s0016-5107 (76)73731-3. PMID: 2512. [crossref]
4.
Breen KJ, Whelan G. The diagnosis of reflux ooesophagitis: An evaluation of five investigative procedures. Aust N Z J Surg. 1978;48(2):156-61. Doi: 10.1111/j.1445-2197.1978.tb07294.x. PMID: 280318. [crossref] [PubMed]
5.
Voltaggio L, Montgomery EA, Lam-Himlin D. A clinical and histopathologic focus on Barrett oesophagus and Barrett-related dysplasia. Arch Pathol Lab Med. 2011;135(10):1249-60. Doi: 10.5858/arpa.2011-0019-RA. PMID: 21970480. [crossref] [PubMed]
6.
Odze RD, Goldblum JR. Odze and Goldblum Surgical Pathology of the GI Tract, Liver, Biliary Tract, and Pancreas. 3rd edition, Philadelphia, PA :Saunders/Elsevier, 2014.
7.
Hayes S, Ahmed S, Clark P. Immunohistochemical assessment for Cdx2 expression in the Barrett metaplasia-dysplasia-adenocarcinoma sequence. J Clin Pathol. 2011;64 (2):110-13. Doi: 10.1136/jcp.2010.075945. Epub 2010 Nov 23. PMID: 21106545. [crossref] [PubMed]
8.
Lord RV, Brabender J, Wickramasinghe K, DeMeester SR, Holscher A, Schneider PM, et al. Increased CDX2 and decreased PITX1 homeobox gene expression in Barrett’s oesophagus and Barrett’s-associated adenocarcinoma. Surgery. 2005;138(5):924-31. Doi: 10.1016/j.surg.2005.05.007. PMID: 16291394. [crossref] [PubMed]
9.
Mills SE, Greenson JK, Hornick, Jason & Longacre, TA & Reuter, VE. (2015). Sternberg’s diagnostic surgical pathology: Sixth edition.
10.
Forbes GM, Glaser ME, Cullen DJ, Warren JR, Christiansen KJ, Marshall BJ, et al. Duodenal ulcer treated with Helicobacter pylori eradication: Seven-year followup. Lancet. 1994;343(8892):258-60. Doi: 10.1016/s0140-6736 (94)91111-8. PMID: 7905095. [crossref]
11.
Soucy G, Onstad L, Vaughan TL, Odze RD. Histologic Features associated with columnar-lined oesophagus in distal oesophageal and Gastrooesophageal Junction (GEJ) biopsies from GERD patients: A community-based population study. Am J Surg Pathol. 2016;40(6):827-35. Doi: 10.1097/PAS.0000000000000623. PMID: 26927889; PMCID: PMC4864087. [crossref] [PubMed]
12.
Goldblum JR. Current issues in Barrett’s oesophagus and Barrett’s-related dysplasia. Mod Pathol. Pathol. 2015;28 Suppl 1:S01-06. Doi: 10.1038/modpathol.2014.125. PMID: 25560595. [crossref] [PubMed]
13.
El-Zimaity HM, Graham DY. Cytokeratin subsets for distinguishing Barrett’s oesophagus from intestinal metaplasia in the cardia using endoscopic biopsy specimens. Am J Gastroenterol. 2001;96(5):1378-82. Doi: 10.1111/j.1572-0241.2001.03792.x. PMID: 11374671. [crossref] [PubMed]
14.
Shaheen NJ, Falk GW, Iyer PG, Gerson LB; American College of Gastroenterology. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Oesophagus. Am J Gastroenterol. 2016;111(1):30-50;quiz 51. Doi: 10.1038/ajg.2015.322. Epub 2015 Nov 3. Erratum in: Am J Gastroenterol. 2016;111 (7):1077. PMID: 26526079. [crossref] [PubMed]
15.
Harrison R, Perry I, Haddadin W, McDonald S, Bryan R, Abrams K, et al. Detection of intestinal metaplasia in Barrett’s oesophagus: An observational comparator study suggests the need for a minimum of eight biopsies. Am J Gastroenterol. 2007;102 (6):1154-61. Doi: 10.1111/j.1572-0241.2007.01230.x. Epub 2007 Apr 13. PMID: 17433019. [crossref] [PubMed]
16.
Offner FA, Lewin KJ, Weinstein WM. Metaplastic columnar cells in Barrett’s oesophagus: A common and neglected cell type. Hum Pathol. 1996;27(9):885-89. Doi: 10.1016/s0046-8177 (96)90213-0. PMID: 8816881. [crossref]
17.
Khandwalla HE, Graham DY, Kramer JR, Ramsey DJ, Duong N, Green LK, et al. Barrett’s oesophagus suspected at endoscopy but no specialized intestinal metaplasia on biopsy, what’s next? Am J Gastroenterol. 2014;109(2):178-82. Doi: 10.1038/ajg.2013.408. Epub 2013 Dec 17. Erratum in: Am J Gastroenterol. 2014;109 (7):1123. PMID: 24343550; PMCID: PMC4046947. [crossref] [PubMed]
18.
Sharma P, Morales TG, Sampliner RE. Short segment Barrett’s oesophagusthe need for standardization of the definition and of endoscopic criteria. Am J Gastroenterol. 1998;93(7):1033-36. Doi: 10.1111/j.1572-0241.1998.00324.x. PMID: 9672325. [crossref] [PubMed]
19.
Takubo K, Aida J, Naomoto Y, Sawabe M, Arai T, Shiraishi H, et al. Cardiac rather than intestinal-type background in endoscopic resection specimens of minute Barrett adenocarcinoma. Hum Pathol. 2009;40(1):65-74. Doi: 10.1016/j.humpath.2008.06.008. Epub 2008 Aug 27. PMID: 18755496. [crossref] [PubMed]
20.
Colleypriest BJ, Farrant JM, Slack JM, Tosh D. The role of Cdx2 in Barrett’s metaplasia. Biochem Soc Trans. 2010;38(2):364-69. Doi: 10.1042/BST0380364. PMID: 20298184. [crossref] [PubMed]
21.
Johnson DR, Abdelbaqui M, Tahmasbi M, Mayer Z, Lee HW, Malafa MP, et al. CDX2 protein expression compared to alcian blue staining in the evaluation of oesophageal intestinal metaplasia. World J Gastroenterol. 2015;21(9):2770-76. Doi: 10.3748/wjg.v21.i9.2770. PMID: 25759548; PMCID: PMC4351230.22. [crossref] [PubMed]
22.
Groisman GM, Amar M, Meir A. Expression of the intestinal marker Cdx2 in the columnar-lined oesophagus with and without intestinal (Barrett’s) metaplasia. Mod Pathol. 2004;17(10):1282-88. Doi: 10.1038/modpathol.3800182. PMID: 15167938. [crossref] [PubMed]
23.
Phillips RW, Frierson HF Jr, Moskaluk CA. Cdx2 as a marker of epithelial intestinal differentiation in the oesophagus. Am J Surg Pathol. 2003;27(11):1442-47. Doi: 10.1097/00000478-200311000-00006. PMID: 14576477. [crossref] [PubMed]
24.
Streher LA, Campos V, da Silva Mazzini G, Binato M, Meurer L, Edelweiss MI, et al. CDX2 overexpression in Barrett’s oesophagus and oesophageal adenocarcinoma. J Cancer Ther. 2014;5:657. [crossref]
25.
Barros R, Pereira D, Callé C, Camilo V, Cunha AI, David L, et al. Dynamics of SOX2 and CDX2 Expression in Barrett’s Mucosa. Dis Markers. 2016;2016:1532791. Doi: 10.1155/2016/1532791. Epub 2016 Sep 27. PMID: 27766003; PMCID: PMC5059566. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/55446.16286

Date of Submission: Feb 09, 2022
Date of Peer Review: Mar 05, 2022
Date of Acceptance: Mar 16, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: Funded by an Internal Grant (IRB Board) from the Institute
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 11, 2022
• Manual Googling: Feb 16, 2022
• iThenticate Software: Mar 09, 2022 (5%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com