Résumé
L’adénocarcinome de l’œsophage, la plus importante complication à long terme de l’œsophage de Barrett, connaît un accroissement de fréquence quasi exponentielle dans les pays occidentaux. La dysplasie de haut degré est associée à la biopsie et au cancer invasif dans une très grande proportion de cas et elle est largement considérée comme une indication de l’œsophagectomie. Dès lors, une identification précise des modifications néoplasiques revêt une importance majeure dans la prise en charge des patients porteurs d’un œsophage de Barrett. Bien que les lésions prémalignes de l’épithélium métaplasique puissent présenter des anomalies endoscopiques la muqueuse apparaît souvent entièrement normale à l’examen macroscopique et le diagnostic de dysplasie repose sur des protocoles adaptés de biopsies endoscopiques.
La démonstration histopathologique demeure le standard de référence du diagnostic de dysplasie et jusqu’à, présent, aucune modalité diagnostique n’a donné de signe évident de performance, notamment la cyptopathologie et la biologie moléculaire qui ne semblent présenter aucun avantage par rapport à l’analyse histopathologique. Bien qu’il existe des degrés de convergence interobservateurs moins convaincants pour les stades inférieurs de la dysplasie et malgré l’absence de critères morphologiques parfaitement établis pour la gradation de la dysplasie, le diagnostic histologique de celle-ci semble bien fonctionner en pratique. A l’avenir, la biologie moléculaire et les études spectroscopiques devraient s’ajouter à notre arsenal diagnostique nécessaire à la prise en charge de cette affection qui pose un problème de santé publique de plus en plus embarrassant.
Summary
Adenocarcinoma of the oesophagus, the most important long-term complication of Barrett’s oesophagus, is increasing in an almost exponential fashion in the Western world. High grade dysplasia, on biopsy, is associated with invasive adenocarcinoma in a large proportion of cases and is widely regarded as an indication for oesophagectomy. Therefore the accurate identification of neoplastic change is of critical importance in the management of Barrett’s oesophagus patients. Although pre-malignant lesions in the metaplastic epithelium may show some endoscopic abnormality, the mucosa often appears entirely normal macroscopically and the diagnosis of dysplasia relies on comprehensive endoscopic biopsy protocols.
Histopathological assessment remains the gold standard for the diagnosis of dysplasia and there is no evidence that other potential diagnostic modalities, notably cytopathology and molecular biological methods, have any advantage over histological analysis at this time. Whilst there are less than convincing levels of inter-observer agreement for the lesser grades of dysplasia and fully established morphological criteria for dysplasia grading are not established, the histological diagnosis of dysplasia appears to work well in practice. In the future, molecular and spectroscopic methodology may add to our diagnostic armoury in the management of a disease that is becoming an ever-increasing health dilemma.
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Shepherd, N.A. La dysplasie dans l’œsophage de Barrett. Acta Endosc 30, 123–132 (2000). https://doi.org/10.1007/BF03022279
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DOI: https://doi.org/10.1007/BF03022279
Mots-clés
- adénocarcinome
- biologie moléculaire
- cytologie
- dysplasie
- endoscopie
- épithélium cylindrique œsophagien
- œsophage de Barrett