A finding at the GOJ

This is the GOJ of a 60 yr old woman with dyspepsia. 
WHAT IS YOUR DIAGNOSIS?

■ Reflux oesophagitis

No this is a nodule not an ulcer!

■ Hyperplastic/reactive nodule

Hyperplastic nodules have villous surface!

■ Unremarkable Barrett's

A nodule within Barrett's is always suspicious!

■ Adenocarcinoma

Absolutely!

■ Squamous cell carcinoma

No abnormal vessel pattern within nearby squamous mucosa!

Explanation

Actually, this patient was on a Barrett's surveillance programme. Five years earlier a small IMca had been removed following which annual surveillance had been reassuring. However, then this lesion was found and referred for removal.  

Histological assessment of the resection fragment reported early invasion into the submucosa (which is 'allowed' provided that the depth of invasion is less than 500 microns (0.5mm).  There was no LVI but unfortunately, there was poor differentiation. Of course, the 'worst' feature to find is probably LVI. Poor differentiation is worrying but less worrying than LVI. The reason for this is that 'poor differentiation' is a rather poorly defined entity.  For example, how many crypts should be involved to call something 'poor differentiation' rather than 'focally poor differentiation'?  

Anyway, the patient was young and ultimately underwent an Ivor-Lewis which confirmed that the EMR had been curative with only some HGD remaining within the residual short stretch of Barrett's.  We urgently need a prospective study following this type of Barrett's patient closely over time with regular EUS and CT to see if we can detect the small number of patients who subsequently turn out to have lymphnode involvement