An unusual Barrett's?

This is a C2M4 Barrett's under surveillance
WHAT IS THE LIKELY HISTOLOGY?

■ Non-neoplastic Barrett's

Nodularity within Barrett's is always bad!

■ LGD

Visible nodularity is never truly just LGD

■ HGD/IMca

A good guess but you are missing something!

■ Invasive cancer

Yes! That small ulcer is the spot of invasive cancer!

explanation

Of course you should initially scrutinise the right-hand part of the Barrett's between 12 and 5 O'clock or so. Furthermore, dysplasia is most common in the distal rather than proximal Barrett's. However, in this case the subtle nodularity is situated in the 11 O'clock position. That is why I call this an 'unusual case' of Barrett's

I don't think that LGD is visible endoscopically or possible to recognise even by AI systems.  However, in this case there is a definite nodularity and HGD/IMca seems the most likely diagnosis.   However, worryingly there is a small depression in the centre of the lesion (seen best on NBI) without any crypt pattern at all.  That is the location of the poor differentiation and invasion below the muscular mucosa.  Furthermore, biopsies revealed LVI and the patient subsequently had chemoradiotherapy (CRT). CRT is a great option in elderly patients but I do worry when young patients opt for CRT. This is because they are at high risk of developing further lesions and they have decades of life expectancy ahead of them for this to happen.  The ultimate staging was T1b, N0 disease. I've attached a reminder about TNM staging because it's easy to forget it unless you see it every day! 

​One final point, why did I lump HGD and IMca together?  Simply because histologically, it's very difficult and perhaps impossible to distinguish the two.  Furthermore, there is no need to distinguish the two entities. Both are treated endoscopically!  

This used to be one of the sticks that surgeons beat me with when I started to propose endoscopic resection for small nodules which biopsies had reported HGD.  They would say rubbish like: "I remember doing an oesophagectomy for a patient with dysplasia and afterwards the histopathologists REPORTED CAAAAANCEEER !!!!" 

Thank God, those guys have retired!