title: Columnar islands in Barrett's esophagus: Do they impact Prague C&M criteria and dysplasia grade?
abstract: OBJECTIVE
  The standard for classifying Barrett's metaplasia on endoscopy, the Prague C&M criteria, ignores all islands of metaplastic-appearing tissue. The aims of the present study were to measure the prevalence of columnar islands, quantify their impact on metaplasia extent, and determine if they harbor advanced dysplasia.
  
  
  METHODS
  Data from two prospective patient cohorts were retrospectively analyzed. They included adults who underwent upper endoscopy to evaluate for gastroesophageal reflux disease, Barrett's esophagus (BE), dysplasia, or adenocarcinoma between 2003 and 2012 at tertiary care centers in the USA and Germany. The BE pattern, location, and pathology were examined. The extent of BE as defined by the Prague criteria (disregarding the location of islands) was compared with the complete maximal extent of BE (incorporating the location of islands).
  
  
  RESULTS
  A total of 555 patients underwent endoscopy (mean age 60.1 years, 67.2% male, 91.9% white). Among those patients, 191 (34.4%) showed metaplastic-appearing mucosa in islands. Endoscopically, in 101 (52.9%) cases, islands were proximal to the farthest segment of BE as defined by the Prague M location. Histologically, intestinal metaplasia was confirmed in 60 (58.8%) of the 102 esophagogastroduodenoscopies (EGDs) where islands were biopsied. In 41 (40.2%) cases, the histologically confirmed BE islands extended farther than the maximal segment based on the Prague criteria. Pathology from biopsies of islands either changed the diagnosis or worsened the BE dysplasia grade in 16 (15.7%) of the 102 patients.
  
  
  CONCLUSIONS
  Columnar islands are commonly seen on EGD. The Prague C&M criteria may underestimate the maximal extent of BE and overlook the area of highest dysplasia grade.
authors.affiliation: Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Jeremy A
authors.identifier: http://orcid.org/0000-0003-4435-7178
authors.initials: JA
authors.lastname: Epstein
authors.affiliation: Department of Medicine, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Hilary
authors.initials: H
authors.lastname: Cosby
authors.affiliation: Department of Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Gary W
authors.initials: GW
authors.lastname: Falk
authors.affiliation: Department of Medicine, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Mouen A
authors.initials: MA
authors.lastname: Khashab
authors.affiliation: Helios HSK Clinic, Wiesbaden, Germany.
authors.forename: Ralf
authors.initials: R
authors.lastname: Kiesslich
authors.affiliation: Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Montgomery
authors.affiliation: Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Jean S
authors.initials: JS
authors.lastname: Wang
authors.affiliation: Department of Medicine, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Marcia Irene
authors.initials: MI
authors.lastname: Canto
mesh_terms: D001471:Barrett Esophagus / Q000145:classification* / Q000473:pathology*; D015331:Cohort Studies; D016145:Endoscopy, Digestive System; D000071041:Esophageal Mucosa / Q000473:pathology; D005260:Female; D006801:Humans; D007413:Intestinal Mucosa / Q000473:pathology; D008297:Male; D008679:Metaplasia; D008875:Middle Aged; D012189:Retrospective Studies
keywords: Barrett's esophagus; adenocarcinoma of esophagus; gastroesophageal reflux; gastrointestinal endoscopy