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Grading
Dysplasia in Barrett's Esophagus
Images For Pathologists: Based
on a Large National
Study
Centered at Johns Hopkins
Follow-Up Images
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[Click
on image for larger size.]
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Figure
15.
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This
case was submitted as Barrett's esophagus with no dysplasia and, on blind
review received 23 "votes" of no dysplasia and a single vote of indefinite
for dysplasia. The patient is without progression at 48 months. |
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Figure
16.
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Submitting
diagnosis: No dysplasia. Blind review results: 13 "no dysplasia", 6 indefinite,
5 low-grade dysplasia. No progression at 36 months. |
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Figure
17.
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This
case was submitted as an example of atypia indefinite for dysplasia. On
blind review, there were 12 "votes" for no dysplasia, 11 for indefinite,
and 1 for low-grade dysplasia. The patient has not progressed at 35 months. |
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Figure
18.
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This
case was submitted as indefinite for dysplasia. There were a range of
diagnostic opinions on blind review: 8 of no dysplasia, 8 of atypia indefinite
for dysplasia, 7 of low-grade dysplasia, and 1 of high-grade dysplasia.
Invasive carcinoma was detected at 55 months. |
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Figure
19.
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This
case was submitted with a diagnosis of low-grade dysplasia and received
blind votes as follows: 10 - no dysplasia, 3 - atypia indefinite for dysplasia,
10 - low-grade dysplasia, 1- high-grade dysplasia. No carcinoma was detected
in 60 months of follow-up. |
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Figure
20.
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This
case was submitted as an example of low-grade dysplasia and graded blindly
with 9 votes of no dysplasia, 7 of indefinite, and 8 of low-grade dysplasia.
Invasive carcinoma was subsequently detected in this patient although
the interval was not known. |
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Figure
21.
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Submitted
as an example of high-grade dysplasia, this case caused diagnostic difficulty
on blind review and had ulcerated zones. Diagnoses on blind review: No
dysplasia - 3, indefinite - 3, low-grade dysplasia - 2, high-grade dysplasia
- 9, invasive carcinoma - 1. An invasive carcinoma was resected at 2 months
and the patient was dead of metastatic disease at 24 months. This case
is also depicted in Figure 9. |
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Figure
22.
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As
in the case of "Indefinite for dysplasia", there was little consensus
surrounding the interpretation of Intramucosal carcinoma. The term "Intramucosal
carcinoma" is applied to the earliest invasive carcinomas, i.e. lesions
that invade through the basement membrane and infiltrate the lamina propria
but not the muscularis mucosae. The superficial nature of mucosal biospies
obviously limits the ability to distinguish such lesions from deeply invasive
ones. Distinction from high-grade dysplasia is also subjective, although
identification of syncytial arrangements of cells and complex glandular
budding is believed to reflect early invasion (before desmoplasia becomes
well-developed). The case depicted here may represent such a situation.
Diagnoses: High-Grade - 5, Intramucosal carcinoma - 17, Frankly Invasive
carcinoma - 2. Consensus - Intramucosal carcinoma. |
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Figure
23.
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A majority
(13) of observervations were of no dysplasia on this biopsy although there
were 8 interpretations of indefinite and 3 of low-grade dysplasia. The
patient had no progression on follow-up. |
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Figure
24.
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There
was no consensus on this case which was submitted as "Barrett's esophagus
with inflammation", although the patient was without progression at 36
months. The diagnoses on blind review: No dysplasia - 8, indefinite -
8, low-grade dysplasia - 7, high-grade dysplasia 1. |
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Figure
25.
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This
case met criteria for a consensus diagnosis of atypia indefinite for dysplasia
but was interpreted by the submitting pathologist as high-grade dysplasia.
An invasive adenocarcinoma was resected at 2 months and the patient died
of other causes at 12 months. This lesion was ulcerated and markedly inflamed.
The submitting pathologist diagnosed the case in the context of a history
of a mass lesion with T3N1 characteristics on endoscopic ultrasound. Opinions
on this case: No dysplasia - 3, atypia indefinite for dysplasia - 14,
low-grade dysplasia - 2, high-grade dysplasia - 3. |
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Figure
26.
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A majority
of votes were for "indefinite" on this case, as was the submitting diagnosis.
The patient has not progressed in 50 months. Opinions rendered: no dysplasia
- 7, indefinite for dysplasia - 14, low-grade dysplasia - 3. |
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Figure
27.
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Thirteen
votes were for low-grade dysplasia on this case, 8 for indefinite, and
3 for no dysplasia. The submitting diagnosis was indefinite for dysplasia.
There was no progression at 17 months. |
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Figure
28.
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Both
the submitting and consensus diagnoses were low-grade dysplasia for this
lesion. There were 18 votes for low-grade dysplasia, 1 for no dysplasia,
1 for indefinite, and 4 for high-grade dysplasia. The patient had not
progressed at 48 months. |
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Figure
29.
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The
submitting and consensus diagnoses were high-grade dysplasia for this
lesion but invasive carcinoma was resected at 7 months. Although there
were 18 opinions of high-grade dysplasia on blind review, there were 4
additional ones of low-grade dysplasia and 2 of intramucosal carcinoma. |
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Figure
30.
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This
case was submitted as high-grade dysplasia, but the majority of votes
were for intramucosal carcinoma (high-grade dysplasia-7, intramucosal
carcinoma - 15, frankly invasive carcinoma - 2). Intramucosal carcinoma
was resected at 1 month and the patient remains disease-free at 83 months. |
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Figure
31.
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This
was submitted as an example of intramucosal carcinoma and the majority
of observers regarded as frankly invasive carcinoma on blind review (high-grade
dysplasia - 1, intramiucosal carcinoma - 5, frankly invasive carcinoma
- 18). The patient was dead of metastatic esophageal adenocarcinoma at
12 months. |
