What do you do if you find a Barrett’s? What I like to do is to look very carefully for any suspicious nodularity or stricture at endoscopy and to first biopsy any nodule or stricture. Benign ulcers usually are benign. Then, sample the whole of the Barrett’s esophagus by taking four-quadrant biopsies, as shown with these little x’s, all the way down the Barrett’s esophagus to try to find anything that might be hidden there.

What are we looking for? Well, besides cancer, we are looking for dysplasia, which is a precancerous condition. This is taken from a resection specimen, to get a nicer picture, but this is a Barrett’s, and if you look at this side of this villous-like structure, you will see the obvious goblet cells here. Here, the nuclei are at the base of the cells in order and that is non-dysplastic here. Now, when we look at the other side of this villous structure here, there are more nuclei. The nuclei are above other nuclei; that is, they are stratified. This is low-grade dysplasia; that is non-dysplastic Barrett’s, low-grade dysplasia. The same is true here; this is non-dysplastic here and this is low-grade again. There are too many nuclei here and the nuclei are stratified. This is common and we have found low-grade dysplasia in about a third of our patients and high-grade dysplasia in considerably less than 5%. Here is high-grade dysplasia. On this side you will see lots of nuclei; large, densely-staining nuclei, not much cytoplasm and the nuclei extend up to the lumen surface of the cells. On this side, it is even worse; there is very high-grade dysplasia with malignant-looking cells. These really are cancer cells to look at, but my pathologist colleague tells me that because they actually haven’t broken through the basal lamina, which is there and here, this is by definition high-grade dysplasia and not invasive adenocarcinoma; it is sometimes difficult to tell the difference on a biopsy.

If you were to operate on someone with high-grade dysplasia in different series, anywhere from about 10 to 50% of patients in whom the endoscopist has found Barrett’s high-grade dysplasia and not seen a cancer, cancer is found in 10% to 50% in the resected specimen, depending on how carefully it has been looked for. Some of these patients have a cancer right now; others will get a cancer later.