Two comments. First, the presence of the acute inflammation should make everyone take a step back and consider reactive change. Second, the image doesn't give us a terrific view of the superficial-most epithelium. Maturation from base to surface is an important criterion when considering dysplasia. If this was the biopsy in total, my dx might say "Barrett's esophagus with acute and chronic inflammation" OR "Barrett's esophagus with acute and chronic inflammation, indeterminate for dysplasia."

----Comment by: GIPathDoc on 9/18/2007 9:06:47 AM

Excellent points.

----Comment by: PathDoc15 on 9/19/2007 4:02:28 AM

As a follow up. Barrett's esophagus, negative for dysplasia may have reactive changes and BASAL atypia but shows surface maturation (ie. the N/C ratio decreases and the cells become nonstratified and less hyperchromatic). Barrett's esophagus, idenfinite for dysplasia either shows cytologic atypia and numerous mitosis with a lack of surface maturation in the context of PRONOUNCED inflammation or errosions and ulceration OR inclomplete surface maturation (described above) in the absence of inflammation. Low grade dysplasia shows mild to moderate architectural distoration, nuclear stratification and nuclear enlargement, hyperchromasia, pleomorphism, crowding, dystrophic goblet cells. Most importantly, these changes extend to the top of glands (vs. negative or indeterminate) and POLARITY IS MAINTAINED (vs. high grade). High Grade displasia is like low grade dysplasia with a lack of nuclear polarity (at the surface of crypts). Cribiform architecture of glands, latterally branching and budding crypts and more prominent atypia and pleomorphism characterize high grade dysplasia. LACK OF NUCLEAR POLARITY is perhaps the most helpful (with the greatest interobserver reproducibility) feature in this distinction (low grade vs. high grade). ALWAYS get concensus on high grade dysplasia. In some centers high grade = esophagogestrectomy. The next step is CIS (intramucosal adenocarcinoma) - this is high grade with either infiltrating single tumor cells or dense cribiform back to back glands with angulated infiltrative appearing glands. Often times distinguishing CIS from high grade dysplasia is difficult - this leads to diagnoses like "High grade can not exclude intra mucosal adenocarcinoma" or if there is an ulcer bed sometimes one "can not exclude invasive carcinoma" True invasive carcinoma can be called when desmoplasia is seen. CIS or invasive carcinoma = esophagogastrectomy. Thanks GIPathDoc for keeping me up to date on my dysplasia. BTW. 1 goblet cell = Barrett's.

----Comment by: PathDoc15 on 4/8/2008 4:48:01 PM

Arrow #1 is a goblet cell. Multiple goblet cells are present making the diagnosis of Barrett's esophagus. Arrows #2 and #3 represent some MILD nuclear atypia. Note however, there is a fair amount of inflammation in this biopsy with gland destruction (arrows #4 and #5), so reative atypia is certainly possible. Finally, there remains a small degree of nuclear psuedo stratification and elongation at the tops of the glands shown by arrow #6. If I were to have a do-over on this, I would call it indeterminate (indefinite) for low grade (at best), from this image alone.

----Comment by: PathDoc15 on 4/11/2008 10:21:16 AM