Combined EsophaCap cytology and MUC2 immunohistochemistry for screening of intestinal metaplasia, dysplasia and carcinoma

Figures & data

Figure 1 EsophaCap is an encapsulated sponge (A) attached to a tether (B).

Table 1 Diagnostic categories of esophageal glandular cells in EsophaCap cytology sample

Cytology categories	Criteria for cytological diagnosis	Matched biopsy
Non-diagnostic (ND)	Scant squamous cellularity, extensive bacteria or blood and poor preservation
No or rare columnar cell (NCC)	Normal squamous cells with less than 4 groups glandular cells in cell block	SE or sample error
Columnar cell with no goblet cell (CCNGC)	Large flat, cohesive sheets of glandular cells with distinctly outlined, smooth, sharply defined edges; uniform round or oval nuclei in the basal layer; MUC2 IHC negative	CM
Intestinal metaplasia with no high grade dysplasia (IMNHGD)	Large flat sheets of cells with smooth, sharply defined edges and goblet cells; the uniform round or oval nuclei in the basal layer or focal nuclear stratification and hyperchromasia; goblet cells more ready present in cell block, positive for MUC2 IHC	IM; LGD; ID
Atypical glandular cells (AGC)	Small or large flat sheets of atypical gland cells with nuclear enlargement, uniform, prominent nucleoli, increased N/C ratios, smooth nuclear membranes; fine chromatin, positive MUC2 IHC	LGD, HGD or EAC
Suspicious for EAC (SFEAC)	Rare atypical cells with hyperchromasia, pleomorphism, prominent nucleoli, irregular nuclear contour and thickened membrane, overlapping, loss of polarity, and rare atypical mitoses	HGD/EAC
Esophageal adenocarcinoma (EAC)	Small 3-dimensional clusters of atypical glandular cells with prominent nucleoli, irregular nuclear contours, high N/C ratio, loss of polarity, hyperchromasia, pleomorphism, frequent mitosis and focal necrosis (tumor diathesis), some atypical single cells	EAC

Abbreviations: IM, intestinal metaplasia; CM, columnar cell metaplasia; EAC, esophageal adenocarcinoma; HGD, high-grade dysplasia; ID, indefinite dysplasia; LGD, low-grade dysplasia; SE, squamous epithelium.

Figure 2 Intestinal metaplasia with no high-grade dysplasia (IMNHGD) and columnar cell with no goblet cells (CCNGC) of EsophaCap samples. (A) CCNGC: The specimen consists of multiple squamous cells and one sheet of glandular cells. The glandular cells are well organized. No goblet cells are identified. (B) IMNHGD: The specimen consists of multiple sheets of glandular cells. The glandular cells are well organized. Focal goblet cells are present (arrowhead). (C and E) CCNGC: One columnar cell gland is present in cell block. The columnar cells are negative for MUC2 immunostain; (D and F) IMNHGD: Goblet cells are present in cell block. The goblet cells and adjacent columnar cells are positive for MUC2 immunostain.

Table 2 Number of surgical biopsy and cytology cases with each category

Biopsy Dx	# Cases	Cytology Dx	# Cases
Esophageal adenocarcinoma	29	Esophageal adenocarcinoma	5
High grade dysplasia	20	Suspicious for EAC	7
		Atypical glandular cells	34
Low grade dysplasia/indefinite dysplasia	18/1	Intestinal metaplasia with no high grade dysplasia (IMNHGD)	39
		Intestinal metaplasia	55
Columnar cell metaplasia	7	Columnar cell with no goblet cell (CCNGC)	16
Squamous cell carcinoma	1	Squamous cell carcinoma	1
Squamous dysplasia	1	Atypical squamous cells	1
Squamous epithelium	4	Non-columnar cell metaplasia	34
Total	136		136

Abbreviation: EAC, esophageal adenocarcinoma.

Figure 3 Atypical glandular cells (AGC), suspicious for esophageal adenocarcinoma (SFEAC) and esophageal adenocarcinoma (EAC). (A and B) AGC: The specimen consists of a sheet of glandular cells with increased nuclear size and prominent nucleoli (see arrow). (C and D) SFEAC: The specimen consists of rare cluster of glandular cells with high nuclei/cytoplasm ration, irregular nuclear contour, prominent nucleoli, hyperchromasia and overlapping. (E and F) EAC: The specimen consists of multiple clusters of glandular cells with high nuclei/cytoplasm ration, prominent nucleoli, irregular nuclear contour, hyperchromasia, mitosis (see arrowhead), overlapping and the single cells.

Table 3 Number of glandular cell (GC) clusters in cell block

GC clusters	# Cases	Percentage (%)
>30	30	22.06
20–29	7	5.15
10–19	16	11.76
4–9	32	23.53
0–3	51	37.50
Total	136	100.00

Figure 4 MUC2 immunohistochemical study (IHC) in esophageal tissue microarray (TMA). (A) Columnar cell metaplasia with negative MUC2 immunostain; (B) Barrett’s esophagus with positive MUC2 immunostain; (C) Low-grade dysplasia with positive MUC2 immunostain; (D) High-grade dysplasia with positive MUC2 immunostain; (E) Esophageal adenocarcinoma with negative MUC2 immunostain; (F) Esophageal adenocarcinoma with positive MUC2 immunostain.

Table 4 MUC2 immunohistochemistry in esophageal tissue microarray

Histological Type	Total Cases #	MUC2 positive (%)	MUC2 negative (%)
Adenocarcinoma	109	55 (50.5%)	54 (49.5%)
High-grade dysplasia	8	8 (100%)	0 (0%)
Low-grade dysplasia	31	25 (80.7%)	6 (19.3%)
Intestinal metaplasia	33	33 (100%)	0 (0%)
Columnar cell metaplasia	64	1 (1.6%)	185 (98.4%)
Squamous epithelium	95	0 (0%)	95 (100%)
Squamous cell carcinoma	27	0 (0%)	27 (100%)