Grading Dysplasia In Barrett's Esophagus

While Barrett's esophagus can be easily recognized in most cases, grading of dysplasia in Barrett's mucosa is a challenging area of gastrointestinal pathology. While pathologists tend to agree on the extreme ends of the spectrum (negative for dysplasia, high-grade dysplasia/intramucosal adenocarcinoma), there is significant interobserver variability in the middle of the spectrum (indefinite for dysplasia, low-grade dysplasia). Due to this issue, the American College of Gastroenterology recommends that diagnoses of dysplasia in Barrett's be confirmed by a pathologist with experience in gastrointestinal pathology prior to definitive treatment.

The following article, Diagnosis and Management of Barrett-Related Neoplasia in the Modern Era written by Dr. Lysandra Voltaggio and Dr. Elizabeth Montgomery, provides an excellent overview of grading dysplasia in Barrett's esophagus, including variant patterns of dysplasia, use of immunohistochemical stains, and current management considerations.

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Click on each item below to see examples of Barrett's esophagus with various degrees of dysplasia.

Negative for Dysplasia   

Barretts NFD

This example of non-dysplastic Barrett's esophagus shows maturation from the bases of the glands to the surface (the nuclear to cytoplasmic ratio is lower in the surface cells compared to those in the deeper glands). The nuclei have preserved basal polarity and the "4 lines" (foveolar mucin droplets, bases of the mucin vacuoles, cytoplasm below the mucin vacuoles, and nuclei) are seen.

Indefinite for Dysplasia   

3 F

It is difficult to establish strict criteria for this category. We use this term when there are changes that are concerning for dysplasia but do not meet our threshold for a definitive diagnosis. Included in this category are cases with atypia in the deep glands (not meeting our threshold for basal crypt dysplasia) that show surface maturation and cases with significant inflammation that may impart marked reactive atypia.

The mucosa in this case shows some degree of nuclear elongation and the "4-lines" are obscured, raising concern for dysplasia. However, there is also acute inflammation, raising the possibility of marked reparative/regenerative changes. Another feature arguing against dysplasia is lack of a clear transition point between dysplastic and non-dysplastic epithelium. Since the presence or absence of dysplasia was in question, this case was signed out as Barrett's mucosa, indefinite for dysplasia.

Low-Grade Dysplasia   

Barretts with LGD

The left side of the image shows non-dysplastic epithelium, with an abrupt transition to dysplastic epithelium on the right side. The dysplastic epithelium shows lack of maturation from the bases of the glands to the surface and loss of the "4 lines". The nuclei are elongated, hyperchromatic, and crowded. However, the nuclei have preserved polarity (all lined up parallel to each other and perpendicular to the basement membrane) unlike the next example of high-grade dysplasia.

High-Grade Dysplasia   

Barretts with HGD

As in low-grade dysplasia, this example of high-grade dysplasia shows a lack of maturation from the basal aspects of the glands to the surface. However, unlike the low-grade dysplasia example, this biopsy shows rounding and loss of polarity of the nuclei at the surface, characteristic of high-grade dysplasia.

Intramucosal Adenocarcinoma   

Intramucosal adenocarcinoma

This example of intramucosal adenocarcinoma shows the features of high-grade dysplasia discussed previously, as well as complex cribriform architecture, intraluminal necrosis, and glands growing parallel to the surface of the epithelium. The combination of these features supports a diagnosis of intramucosal adenocarcinoma.