Premalignant lesions
Barrett related dysplasia

Topic Completed: 1 April 2013

Revised: 19 March 2020

Copyright: 2003-2019,, Inc.

PubMed Search: Barrett[TIAB] related dysplasia esophagus

Elliot Weisenberg, M.D.
Page views in 2019: 5,316
Page views in 2020 to date: 1,482
Cite this page: Weisenberg E. Barrett related dysplasia. website. Accessed March 31st, 2020.
Definition / general
  • Unequivocally neoplastic epithelium that does not invade lamina propria, associated with Barrett esophagus (BE)
Clinical features
Prognostic factors
  • Low grade dysplasia: antireflux therapy and increased surveillance
  • High grade dysplasia: rebiopsy immediately to rule out missed invasive carcinoma; possibly esophagectomy; recommended to get second opinion on dysplastic biopsies from an experienced GI pathologist
  • Photodynamic therapy: less effective on papillary lesions or distal esophagus lesions (Am J Surg Pathol 2004;28:1466); may cause "buried dysplasia" (Am J Surg Pathol 2007;31:403)
  • Endoscopic mucosal resection: endoluminal therapeutic technique with low morbidity and no mortality; offers improved diagnosis and staging compared with biopsy and ultrasound but resection is often incomplete and there are high rates of persistence / recurrence (Am J Surg Pathol 2005;29:680, Postgrad Med J 2007;83:367)
Gross description
  • Normal appearing or nodule, erosion or polyp
Gross images

Images hosted on other servers:

High grade dysplasia

Dysplasia (grade unspecified)

Microscopic (histologic) description
  • Designate low or high grade based on basal (low grade) or apical orientation (high grade) of nuclei (similar to colon criteria); both grades show mucus depletion and prominent cytoplasmic basophilia
  • Low grade dysplasia: preservation of crypt architecture with minimal distortion, atypical nuclei usually limited to basal half of the crypts; variable hyperchromasia, overlapping cell borders with nuclear crowding and irregular nuclear contours; usually shows maturation towards lumen; abrupt vs gradual transition from typical to atypical epithelium favors dysplasia; diagnose dysplasia cautiously in presence of inflammation; considerable interobserver variability exists in distinguishing no dysplasia from low grade dysplasia / indefinite for dysplasia (Histopathology 2007;50:920)
  • High grade dysplasia: more severe atypia and architectural complexity than low grade dysplasia, often with villiform configuration of mucosal surface, more nuclear pleomorphism and hyperchromatism, often nuclear stratification to crypt luminal surface; often easier to diagnose at low power due to nuclear hyperchromasia
  • Dysplasia limited to basal crypts with surface maturation (crypt dysplasia): uncommon but commonly associated with classic dysplasia and may occur with adenocarcinoma (Am J Surg Pathol 2006;30:423); additional levels are recommended if found in isolation to determine if typical dysplasia or adenocarcinoma may be present
  • Tubular adenoma: dysplasia in a pedunculated lesion, follow up as dysplasia in BE not as a sporatic adenoma
  • Nonadenomatous (foveolar) dysplasia: rare, poorly understood biology and natural history; back to back crypts with high N/C ratio, round to oval irregular nuclei, open chromatin, prominent nucleoli; absence of surface maturation; usually considered high grade dysplasia (Mod Pathol 2010;23:834, Hum Pathol 2013;44:1146)
Microscopic (histologic) images

AFIP images

Low grade dysplasia

Lower half of gland

Upper half of mucosa

Dysplasia in lower half of glands

Dysplasia of surface foveolar epithelium

High grade dysplasia

Marked distortion of glandular architecture

Various images

Dysplastic epithelium replaces Barrett mucosa


Tubular adenoma

Reactive changes

Contributed by Dr. Mark R. Wick

Low grade dysplasia

Metaplasia, high grade dysplasia


Metaplasia with dysplasia

Images hosted on other servers:

Low grade dysplasia

Various images

 High grade dysplasia:

Various images


Various images

Reactive images (click on links)

Positive stains
Differential diagnosis
  • Baseline atypia: glands at base of Barrett mucosa have enlarged, slightly hyperchromatic cells with some stratification and increased mitotic activity but normal surface epithelium
  • Intramucosal adenocarcinoma: neoplastic cells infiltrate into lamina propria, usually as single cells or small clusters
  • Reactive changes: if neutrophils present, be conservative in diagnosing dysplasia; reactive cells have more uniform atypia / less pleomorphism, lower nuclear / cytoplasmic ratio, round and regular nuclear contours, basal nuclei (University of Washington: Pitfalls in the Diagnosis of Dysplasia [Accessed 25 February 2019])
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