Case 68
- Wangpan Shi
- Mar 13
- 1 min read
A 56-year-old male presented with postprandial pain and an lesion at GE junction was found.
What's the diagnosis:
A: Intestinal metaplasia with reactive atypia
B: Intestinal metaplasia with low grade dysplasia
C: Intestinal metaplasia with high grade dysplasia
D: Intramucosal adenocarcinoma
Answer
The correct answer is C.
Dysplasia in the gastrointestinal tract is most commonly classified as intestinal or foveolar (gastric-type) dysplasia, with rare cases showing a serrated growth pattern. A mixture of both types is not uncommon. Intestinal dysplasia features columnar cells with goblet and enterocyte-like cells, while foveolar dysplasia is characterized by mucin-rich columnar cells with few or no goblet cells.
Dysplasia is classified as negative, indefinite, or positive (low-grade or high-grade), following either the Reid system (1988) or the modified Vienna classification.
Low-grade dysplasia (LGD): Displays nuclear elongation, enlargement, hyperchromasia, and stratification while maintaining nuclear polarity. Goblet cells decrease with increasing dysplasia grade.
High-grade dysplasia (HGD): Shows significant cytological and architectural atypia, including enlarged nuclei, nuclear pleomorphism, full-thickness nuclear stratification, and increased mitoses. Features such as gland crowding, cribriforming, and intraluminal necrosis are common.
Foveolar dysplasia lacks goblet cells, instead showing prominent mucin-rich columnar cells with round to oval nuclei. In high-grade foveolar dysplasia, nuclear size increases, irregular nuclear contours appear, and mitotic activity rises.
Crypt dysplasia, an early-stage dysplasia confined to crypt bases, is most often low-grade, though high-grade changes may occur.
Immunohistochemistry (p53, AMACR, IMP3) can aid in distinguishing dysplasia from non-dysplastic epithelium but has limitations, as normal p53 expression does not rule out dysplasia.
Author: Wangpan Jackson Shi, MD
Case credit: UCSD Pathology
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