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      Performance of gastrointestinal pathologists within a national digital review panel for Barrett’s oesophagus in the Netherlands: results of 80 prospective biopsy reviews

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          Abstract

          Aims

          The histopathological diagnosis of low-grade dysplasia (LGD) in Barrett’s oesophagus (BO) is associated with poor interobserver agreement and guidelines dictate expert review. To facilitate nationwide expert review in the Netherlands, a web-based digital review panel has been set up, which currently consists of eight ‘core’ pathologists. The aim of this study was to evaluate if other pathologists from the Dutch BO expert centres qualify for the expert panel by assessing their performance in 80 consecutive LGD reviews submitted to the panel.

          Methods

          Pathologists independently assessed digital slides in two phases. Both phases consisted of 40 cases, with a group discussion after phase I. For all cases, a previous consensus diagnosis made by five core pathologists was available, which was used as reference. The following criteria were used: (1) percentage of ‘indefinite for dysplasia’ diagnoses, (2) percentage agreement with consensus diagnosis and (3) proportion of cases with a consensus diagnosis of dysplasia underdiagnosed as non-dysplastic. Benchmarks were based on scores of the core pathologists.

          Results

          After phase I, 1/7 pathologists met the benchmark score for all quality criteria, yet three pathologists only marginally failed the agreement with consensus diagnosis (score 68.3%, benchmark 69%). After a group discussion and phase II, 5/6 remaining aspirant panel members qualified with all scores within the benchmark range.

          Conclusions

          The Dutch BO review panel now consists of 14 pathologists, who—after structured assessments and group discussions—can be considered homogeneous in their review of biopsies with LGD.

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          Most cited references15

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          ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus.

          Nicholas J. Shaheen, Gary W. Falk, Prasad Iyer … (2016)
          Barrett's esophagus (BE) is among the most common conditions encountered by the gastroenterologist. In this document, the American College of Gastroenterology updates its guidance for the best practices in caring for these patients. These guidelines continue to endorse screening of high-risk patients for BE; however, routine screening is limited to men with reflux symptoms and multiple other risk factors. Acknowledging recent data on the low risk of malignant progression in patients with nondysplastic BE, endoscopic surveillance intervals are attenuated in this population; patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Neither routine use of biomarker panels nor advanced endoscopic imaging techniques (beyond high-definition endoscopy) is recommended at this time. Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma. Based on recent level 1 evidence, endoscopic ablative therapy is also recommended for patients with BE and low-grade dysplasia, although endoscopic surveillance continues to be an acceptable alternative. Given the relatively common recurrence of BE after ablation, we suggest postablation endoscopic surveillance intervals. Although many of the recommendations provided are based on weak evidence or expert opinion, this document provides a pragmatic framework for the care of the patient with BE.
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            Endoscopic management of Barrett's esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

            Bas Weusten, Raf Bisschops, Emanuel Coron … (2017)
            Current practices for the management of Barrett's esophagus (BE) vary across Europe, as several national European guidelines exist. This Position Statement from the European Society of Gastrointestinal Endoscopy (ESGE) is an attempt to homogenize recommendations and, hence, patient management according to the best scientific evidence and other considerations (e.g. health policy). A Working Group developed consensus statements, using the existing national guidelines as a starting point and considering new evidence in the literature. The Position Statement wishes to contribute to a more cost-effective approach to the care of patients with BE by reducing the number of surveillance endoscopies for patients with a low risk of malignant progression and centralizing care in expert centers for those with high progression rates.Main statements MS1 The diagnosis of BE is made if the distal esophagus is lined with columnar epithelium with a minimum length of 1 cm (tongues or circular) containing specialized intestinal metaplasia at histopathological examination. MS2 The ESGE recommends varying surveillance intervals for different BE lengths. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance is advised. For BE ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. Patients with limited life expectancy and advanced age should be discharged from endoscopic surveillance. MS3 The diagnosis of any degree of dysplasia (including "indefinite for dysplasia") in BE requires confirmation by an expert gastrointestinal pathologist. MS4 Patients with visible lesions in BE diagnosed as dysplasia or early cancer should be referred to a BE expert center. All visible abnormalities, regardless of the degree of dysplasia, should be removed by means of endoscopic resection techniques in order to obtain optimal histopathological staging MS5 All patients with a BE ≥ 10 cm, a confirmed diagnosis of low grade dysplasia, high grade dysplasia (HGD), or early cancer should be referred to a BE expert center for surveillance and/or treatment. BE expert centers should meet the following criteria: annual case load of ≥10 new patients undergoing endoscopic treatment for HGD or early carcinoma per BE expert endoscopist; endoscopic and histological care provided by endoscopists and pathologists who have followed additional training; at least 30 supervised endoscopic resection and 30 endoscopic ablation procedures to acquire competence in technical skills, management pathways, and complications; multidisciplinary meetings with gastroenterologists, surgeons, oncologists, and pathologists to discuss patients with Barrett's neoplasia; access to experienced esophageal surgery; and all BE patients registered prospectively in a database.
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              Low-grade dysplasia in Barrett's esophagus: overdiagnosed and underestimated.

              Anton-H-J Naber, Brenda Elzer, Pieter Scholten … (2010)
              Published data on the natural history of low-grade dysplasia (LGD) in Barrett's esophagus (BE) are inconsistent and difficult to interpret. We investigated the natural history of LGD in a large community-based cohort of BE patients after reviewing the original histological diagnosis by an expert panel of pathologists. Histopathology reports of all patients diagnosed with LGD between 2000 and 2006 in six non-university hospitals were reviewed by two expert pathologists. This panel diagnosis was subsequently compared with the histological outcome during prospective endoscopic follow-up. A diagnosis of LGD was made in 147 patients. After pathology review, 85% of the patients were downstaged to non-dysplastic BE (NDBE) or to indefinite for dysplasia. In only 15% of the patients was the initial diagnosis LGD. Endoscopic follow-up was carried out in 83.6% of patients, with a mean follow-up of 51.1 months. For patients with a consensus diagnosis of LGD, the cumulative risk of progressing to high-grade dysplasia or carcinoma (HGD or Ca) was 85.0% in 109.1 months compared with 4.6% in 107.4 months for patients downstaged to NDBE (P<0.0001). The incidence rate of HGD or Ca was 13.4% per patient per year for patients in whom the diagnosis of LGD was confirmed. For patients downstaged to NDBE, the corresponding incidence rate was 0.49%. LGD in BE is an overdiagnosed and yet underestimated entity in general practice. Patients diagnosed with LGD should undergo an expert pathology review to purify this group. In case the diagnosis of LGD is confirmed, patients should undergo strict endoscopic follow-up or should be considered for endoscopic ablation therapy.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Clin Pathol
                Journal ID (iso-abbrev): J Clin Pathol
                Journal ID (hwp): jclinpath
                Journal ID (publisher-id): jcp
                Title: Journal of Clinical Pathology
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Print): 0021-9746
                ISSN (Electronic): 1472-4146
                Publication date (Print): January 2021
                Publication date (Electronic): 28 May 2020
                Volume: 74
                Issue: 1
                Pages: 48-52
                Affiliations
                [1 ] departmentDepartment of Gastroenterology and Hepatology , Amsterdam UMC – Locatie AMC , Amsterdam, The Netherlands
                [2 ] departmentDepartment of Pathology , Amsterdam UMC – Locatie AMC , Amsterdam, The Netherlands
                [3 ] departmentDepartment of Pathology, Pathologie-DNA BV , Sint Antonius Hospital , Nieuwegein, The Netherlands
                [4 ] departmentDepartment of Pathology , UMC Utrecht , Utrecht, The Netherlands
                [5 ] departmentDepartment of Pathology , Symbiant BV , Alkmaar, The Netherlands
                [6 ] departmentDepartment of Pathology , Erasmus Medical Center , Rotterdam, Zuid-Holland, The Netherlands
                [7 ] departmentDepartment of Pathology , Stichting PAMM , Eindhoven, The Netherlands
                [8 ] departmentDepartment of Pathology , UMCG , Groningen, The Netherlands
                [9 ] departmentDepartment of Pathology , Haga Hospital , Den Haag, The Netherlands
                [10 ] departmentDepartment of Pathology , Isala Klinieken , Zwolle, The Netherlands
                [11 ] departmentDepartment of Pathology, Pathan BV , Sint Franciscus Vlietland Groep , Rotterdam, The Netherlands
                [12 ] departmentDepartment of Cardiology , Amsterdam UMC – Locatie AMC , Amsterdam, The Netherlands
                Author notes
                [Correspondence to ] Esther Klaver, Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam 1105 AZ, Netherlands; e.klaver@ 123456amsterdamumc.nl
                Author information
                http://orcid.org/0000-0003-4981-7540
                http://orcid.org/0000-0001-5825-3236
                http://orcid.org/0000-0003-1341-8994
                http://orcid.org/0000-0002-3518-2305
                Article
                Publisher ID: jclinpath-2020-206511
                DOI: 10.1136/jclinpath-2020-206511
                PMC ID: 7788478
                PubMed ID: 32467320
                SO-VID: d69ff9f2-fd52-4533-aefa-ff8c34793dd6
                Copyright © © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 13 February 2020
                Date revision received : 17 April 2020
                Date accepted : 01 May 2020
                Categories
                Subject: Original Research
                Subject: 1506
                Custom metadata
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                ScienceOpen disciplines: Pathology
                Keywords: barrett's oesophagus,digital pathology,quality assurance
                Data availability:
                ScienceOpen disciplines: Pathology
                Keywords: barrett's oesophagus, digital pathology, quality assurance

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