Dysplasia and early neoplasia in Barrett's oesophagus

Over the last 20–30 years, oesophageal adenocarcinoma has increased six-fold in the west, the majority complicating Barrett's. The greatest risk is associated with higher grades of dysplasia. Although there is ongoing research into molecular alterations, which may be helpful in predicting progression to cancer, the main predictive indicator remains the histological identification and grade of dysplasia. Significant inter and intraobserver variability in the diagnosis of dysplasia is well documented and atypia can be seen in other settings including inflammation. Given the screening and management implications for the patient, a robust diagnosis is essential, such that agreement between two pathologists with an interest in gastrointestinal pathology is of paramount importance, together with regular communication between pathologists and clinicians.This article reviews the literature and attempts to address some of the areas of diagnostic difficulty.