#GIpath Hi all, in this thread I’ll post 5 cases of Barrett’s esophagus, question dysplasia. Polls added, take a vote. Leave a comment too, if you’d like. Will post my thoughts over the weekend.
Assume a generic history (50 year old, Barrett’s surveillance, no hx dysplasia)

Case 1:

Case 1 poll:

Case 2:

Case 2 poll:

Case 3:

Case 3 poll:

Case 4:

Case 4 poll:

Case 5:

Case 5 poll:

See how your vote compares to the audience. Welcome any input.
@MFeelyDO @MariaWesterhoff @SingJamieD @dr_mobarki @CArnold_GI @Dr_Brian_Cox @Chucktowndoc @jake_bledsoe @MELanocyteMD @ALBoothMD @IHC_guy @KMirza

1. @Dr_Brian_Cox @cebulka26 @MELanocyteMD @IUraizee3MD @MFeelyDO @skipocytes @jake_bledsoe @CArnold_GI @IHC_guy @ALBoothMD @dr_mobarki et al Thanks all very much for the responses, it was awesome to get so much participation w voting. Was worried Barrett’s dysplasia....

2. ...Might not be super exciting. A random comment for those in training (also this is from the perspective of a non-academic community pathologist, so my perspective might be different from those in academics): figuring out weird tumors is cool, and rewarding, but...

3. Usually these cases end up with the correct diagnosis (or in gray area cases, with a reasonable diagnosis allowing for appropriate patient care). This is through some combination of extensive IHC, review with colleagues, or send out consultation

4. ... and for most of us, these cases are minority. More important to practice? Being thorough, conscientious, and leaving “no stone unturned” with the routine everyday cases. Something doesn’t seem quite right? Get levels. Show someone. Call the clinician.

5. “if you have an itch, scratch it”. Thats what the good ones do .

Case 1: agree that this is a fairly straightforward low grade dysplasia. Looks like a colonic adenoma? It’s probably LGD! (Hyperchromatic, stratified nuclei at surface, maintained polarity).

Case 2: Most called HGD. This case was actually originally called ‘indefinite’. I was asked to review by the GI to clarify between dysplasia or reactive.

Not sure what prompted the IFD diagnosis... as @CArnold_GI discussed in her #capvirtualpath talk, the columnar/squamous transition isn’t a good area to look for dysplasia (it’s always a little atypical there, black arrow)

But to me those complex irregular glands deeper in the mucosa & slightly odd (?desmoplastic) stroma were bad ju-ju (red arrow)

I leveled it (pics shown)
Dx on consultation: adenocarcinoma, at least intramucosal.
Lesson 1: easy to get caught up looking at maturation (which is important), don’t forget to look at the base
Lesson 2: get levels if considering dysplasia!!

Case 3: Agree with the majority to call this negative for dysplasia. Some hyperchromasia, but not as the surface. Dr. Waters, @Voltaggiol, and @LizMontgomeryMD ‘s “four lines” are intact at the surface, reassuring for benignancy. Ref: https://pubmed.ncbi.nlm.nih.gov/30234520/ 

Couple pics with the lines applied to this case:

Following this rule will help reduce your “indefinites” to “negatives”, and is based on great evidence. Often these are cases with surface nuclear stratification (?tangential embedding vs dysplasia). Goblet cells may disrupt lines (it’s Barrett’s after all!) ignore these areas

Case 4: Agree with the majority to call this intramucosal carcinoma. Was actually some discrepancy in the department (HGD, HGD suspicious for ca, or intramucosal ca). I must have been in a bad mood that day because i just wanted to call it intramucosal ca!

Note intraluminal necrosis (black arrow), small angulated glands (blue arrows), focal open nuclei with prominent nucleoli (red arrows). These all suggest a transition from dysplasia to invasion.

As cyto folks ( @doc_kartik , @skokiejeeters ) will tell you, nucleoli can be kind of jerks (can be prominent in reactive and invasive processes), but in the context of these other findings, they’re more evidence of cancer.

Case 5: Tricky one, but agree with the plurality to call this low grade dysplasia. Wanted to show it because I thought it had some features of foveolar type dysplasia, which can be more subtle.

Note abundant foveolar type mucin (black arrows) + lack of goblet cells (at least this field, were present focally in other areas)

Is there dysplasia? Look at the red arrows here: base of this crypt looks similar to the surface (ie, lack of maturation). Four lines are not intact. See the blue arrow: some atypical hyperchromatic nuclei are present. Not much inflammation.

A bit more subtle than case #1, but I would call this low grade dysplasia.