1
|
van der Wel MJ, Klaver E, Pouw RE, Brosens LAA, Biermann K, Doukas M, Huysentruyt C, Karrenbeld A, Ten Kate FJW, Kats-Ugurlu G, van der Laan J, van Lijnschoten I, Moll FCP, Offerhaus GJA, Ooms AHAG, Seldenrijk CA, Visser M, Tijssen JG, Meijer SL, Bergman JJGHM. Significant variation in histopathological assessment of endoscopic resections for Barrett's neoplasia suggests need for consensus reporting: propositions for improvement. Dis Esophagus 2021; 34:6294819. [PMID: 34100554 DOI: 10.1093/dote/doab034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/19/2021] [Accepted: 04/27/2021] [Indexed: 12/11/2022]
Abstract
Endoscopic resection (ER) is an important diagnostic step in management of patients with early Barrett's esophagus (BE) neoplasia. Based on ER specimens, an accurate histological diagnosis can be made, which guides further treatment. Based on depth of tumor invasion, differentiation grade, lymphovascular invasion, and margin status, the risk of lymph node metastases and local recurrence is judged to be low enough to justify endoscopic management, or high enough to warrant invasive surgical esophagectomy. Adequate assessment of these histological risk factors is therefore of the utmost importance. Aim of this study was to assess pathologist concordance on these histological features on ER specimens and evaluate causes of discrepancy. Of 62 challenging ER cases, one representative H&E slide and matching desmin and endothelial marker were digitalized and independently assessed by 13 dedicated GI pathologists from 8 Dutch BE expert centers, using an online assessment module. For each histological feature, concordance and discordance were calculated. Clinically relevant discordances were observed for all criteria. Grouping depth of invasion categories according to expanded endoscopic treatment criteria (T1a and T1sm1 vs. T1sm2/3), ≥1 pathologist was discrepant in 21% of cases, increasing to 45% when grouping diagnoses according to the traditional T1a versus T1b classification. For differentiation grade, lymphovascular invasion, and margin status, discordances were substantial with 27%, 42%, and 32% of cases having ≥1 discrepant pathologist, respectively. In conclusion, histological assessment of ER specimens of early BE cancer by dedicated GI pathologists shows significant discordances for all relevant histological features. We present propositions to improve definitions of diagnostic criteria.
Collapse
Affiliation(s)
- M J van der Wel
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Klaver
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - L A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M Doukas
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Huysentruyt
- Department of Pathology, Stichting PAMM, Catharina Hospital, Eindhoven, The Netherlands
| | - A Karrenbeld
- Department of Pathology, University Medical Center Groningen, Groningen, The Netherlands
| | - F J W Ten Kate
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, Groningen, The Netherlands
| | - J van der Laan
- Department of Pathology, Haga Hospital, The Hague, The Netherlands
| | - I van Lijnschoten
- Department of Pathology, Stichting PAMM, Catharina Hospital, Eindhoven, The Netherlands
| | - F C P Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - G J A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A H A G Ooms
- Department of Pathology, Pathan BV, St. Franciscus Gasthuis & Vlietland Hospital, Rotterdam, The Netherlands
| | - C A Seldenrijk
- Department of Pathology, Pathology-DNA, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M Visser
- Department of Pathology, Symbiant BV, Zaans Medical Center, The Netherlands
| | - J G Tijssen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
2
|
van Munster SN, Bergman JJGHM, Pouw RE. Successful endoscopic treatment of Barrett's dysplasia is not just about the destination; it is about the journey. Gastrointest Endosc 2020; 92:551-553. [PMID: 32838905 DOI: 10.1016/j.gie.2020.04.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Cancer Center Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
3
|
Klaver E, van der Wel M, Duits L, Pouw R, Seldenrijk K, Offerhaus J, Visser M, Ten Kate F, Biermann K, Brosens L, Doukas M, Huysentruyt C, Karrenbeld A, Kats-Ugurlu G, van der Laan J, van Lijnschoten I, Moll F, Ooms A, Tijssen J, Meijer S, Bergman J. Performance of gastrointestinal pathologists within a national digital review panel for Barrett's oesophagus in the Netherlands: results of 80 prospective biopsy reviews. J Clin Pathol 2020; 74:48-52. [PMID: 32467320 PMCID: PMC7788478 DOI: 10.1136/jclinpath-2020-206511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/17/2020] [Accepted: 05/01/2020] [Indexed: 11/03/2022]
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.
Collapse
Affiliation(s)
- Esther Klaver
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Myrtle van der Wel
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands.,Department of Pathology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Lucas Duits
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Roos Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Kees Seldenrijk
- Department of Pathology, Pathologie-DNA BV, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Johan Offerhaus
- Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
| | - Mike Visser
- Department of Pathology, Symbiant BV, Alkmaar, The Netherlands
| | - Fiebo Ten Kate
- Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | | | - Michael Doukas
- Department of Pathology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | | | | | | | | | | | - Freek Moll
- Department of Pathology, Isala Klinieken, Zwolle, The Netherlands
| | - Ariadne Ooms
- Department of Pathology, Pathan BV, Sint Franciscus Vlietland Groep, Rotterdam, The Netherlands
| | - Jan Tijssen
- Department of Cardiology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Sybren Meijer
- Department of Pathology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Jacques Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| |
Collapse
|
4
|
van der Wel MJ, Coleman HG, Bergman JJGHM, Jansen M, Meijer SL. Histopathologist features predictive of diagnostic concordance at expert level among a large international sample of pathologists diagnosing Barrett's dysplasia using digital pathology. Gut 2020; 69:811-822. [PMID: 31852770 DOI: 10.1136/gutjnl-2019-318985] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Guidelines mandate expert pathology review of Barrett's oesophagus (BO) biopsies that reveal dysplasia, but there are no evidence-based standards to corroborate expert reviewer status. We investigated BO concordance rates and pathologist features predictive of diagnostic discordance. DESIGN Pathologists (n=51) from over 20 countries assessed 55 digitised BO biopsies from across the diagnostic spectrum, before and after viewing matched p53 labelling. Extensive demographic and clinical experience data were obtained via online questionnaire. Reference diagnoses were obtained from a review panel (n=4) of experienced Barrett's pathologists. RESULTS We recorded over 6000 case diagnoses with matched demographic data. Of 2805 H&E diagnoses, we found excellent concordance (>70%) for non-dysplastic BO and high-grade dysplasia, and intermediate concordance for low-grade dysplasia (42%) and indefinite for dysplasia (23%). Major diagnostic errors were found in 248 diagnoses (8.8%), which reduced to 232 (8.3%) after viewing p53 labelled slides. Demographic variables correlating with diagnostic proficiency were analysed in multivariate analysis, which revealed that at least 5 years of professional experience was protective against major diagnostic error for H&E slide review (OR 0.48, 95% CI 0.31 to 0.74). Working in a non-teaching hospital was associated with increased odds of major diagnostic error (OR 1.76, 95% CI 1.15 to 2.69); however, this was neutralised when pathologists viewed p53 labelled slides. Notably, neither case volume nor self-identifying as an expert predicted diagnostic proficiency. Extrapolating our data to real-world case prevalence suggests that 92.3% of major diagnostic errors are due to overinterpreting non-dysplastic BO. CONCLUSION Our data provide evidence-based criteria for diagnostic proficiency in Barrett's histopathology.
Collapse
Affiliation(s)
| | - Helen G Coleman
- Centre for Public Health, Queens University Belfast, Belfast, UK
| | | | | | - Sybren L Meijer
- Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
5
|
Montgomery E, Arnold CA, Lam-Himlin D, Salimian K, Waters K. Some observations on Barrett esophagus and associated dysplasia. Ann Diagn Pathol 2018; 37:75-82. [PMID: 30312881 DOI: 10.1016/j.anndiagpath.2018.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 09/26/2018] [Indexed: 02/08/2023]
Abstract
Biopsy samples from esophageal columnar metaplasia and dysplasia are commonly encountered in Western pathology practice and knowing a few pitfalls can save both pathologists and patients a great deal of anxiety. Herein we discuss criteria for Barrett esophagus, evaluation of dysplasia, and some pitfalls in reviewing endoscopic mucosal resections. Also included is a summary of suggested follow-up for patients with Barrett esophagus.
Collapse
Affiliation(s)
| | - Christina A Arnold
- Department of Pathology, Ohio State University, United States of America
| | - Dora Lam-Himlin
- Department of Pathology, Mayo Clinic Scottsdale, United States of America
| | - Kevan Salimian
- Department of Pathology, Johns Hopkins University, United States of America
| | - Kevin Waters
- Department of Pathology, Cedars Sinai Health System, United States of America
| |
Collapse
|
6
|
Chapter 2: Role of pathologic confirmation for Barrett′s esophagus and dysplasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
7
|
van der Wel MJ, Duits LC, Pouw RE, Seldenrijk CA, Offerhaus GJA, Visser M, Ten Kate FJ, Biermann K, Brosens LAA, Doukas M, Huysentruyt C, Karrenbeld A, Kats-Ugurlu G, van der Laan JS, van Lijnschoten GI, Moll FCP, Ooms AHAG, van der Valk H, Tijssen JG, Bergman JJ, Meijer SL. Improved diagnostic stratification of digitised Barrett's oesophagus biopsies by p53 immunohistochemical staining. Histopathology 2018; 72:1015-1023. [PMID: 29314176 DOI: 10.1111/his.13462] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/14/2017] [Accepted: 12/29/2017] [Indexed: 12/15/2022]
Abstract
AIMS Interobserver agreement for dysplasia in Barrett's oesophagus (BO) is low, and guidelines advise expert review of dysplastic cases. The aim of this study was to assess the added value of p53 immunohistochemistry (IHC) for the homogeneity within a group of dedicated gastrointestinal (GI) pathologists. METHODS AND RESULTS Sixty-single haematoxylin and eosin (HE) slide referral BO cases [20 low-grade dysplasia (LGD); 20 high-grade dysplasia (HGD); and 20 non-dysplastic BO reference cases] were digitalised and independently assessed twice in random order by 10 dedicated GI pathologists. After a 'wash-out' period, cases were reassessed with the addition of a corresponding p53 IHC slide. Outcomes were: (i) proportion of 'indefinite for dysplasia' (IND) diagnoses; (ii) interobserver agreement; and (iii) diagnostic accuracy as compared with a consensus 'gold standard' diagnosis defined at an earlier stage by five core expert BO pathologists after their assessment of this case set. Addition of p53 IHC decreased the mean proportion of IND diagnoses from 10 of 60 to eight of 60 (P = 0.071). Mean interobserver agreement increased significantly from 0.45 to 0.57 (P = 0.0021). The mean diagnostic accuracy increased significantly from 72% to 82% (P = 0.0072) after p53 IHC addition. CONCLUSION Addition of p53 IHC significantly improves the histological assessment of BO biopsies, even within a group of dedicated GI pathologists. It decreases the proportion of IND diagnoses, and increases interobserver agreement and diagnostic accuracy. This justifies the use of accessory p53 IHC within our upcoming national digital review panel for BO biopsy cases.
Collapse
Affiliation(s)
- Myrtle J van der Wel
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Lucas C Duits
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Cornelis A Seldenrijk
- Department of Pathology, Pathology-DNA, St Antonius Hospital, Nieuwegein, The Netherlands
| | - G J A Offerhaus
- Department of Pathology, University Medical Centre, Utrecht, The Netherlands
| | - Mike Visser
- Department of Pathology, Symbiant BV, Alkmaar, The Netherlands
| | - Fiebo J Ten Kate
- Department of Pathology, University Medical Centre, Utrecht, The Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Michael Doukas
- Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Arend Karrenbeld
- Department of Pathology, Academic Medical Centre, Groningen, The Netherlands
| | - Gursah Kats-Ugurlu
- Department of Pathology, Academic Medical Centre, Groningen, The Netherlands
| | | | | | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Ariadne H A G Ooms
- Department of Pathology, St Fransiscus Vlietland Gasthuis, Pathan BV, Rotterdam, The Netherlands
| | - Hans van der Valk
- Department of Pathology, St Fransiscus Vlietland Gasthuis, Pathan BV, Rotterdam, The Netherlands
| | - Jan G Tijssen
- Department of Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Histological and immunohistochemical characteristics of capsular synovial metaplasias that form around silicone breast implants. Biologia (Bratisl) 2018. [DOI: 10.2478/s11756-018-0024-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
9
|
Triadafilopoulos G, Clarke J, Hawn M. Whole greater than the parts: integrated esophageal centers (IEC) and advanced training in esophageal diseases. Dis Esophagus 2017; 30:1-9. [PMID: 28859396 DOI: 10.1093/dote/dox084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023]
Abstract
An integrated esophageal center (IEC) is a multidisciplinary team with expertise, skill, range, and facilities necessary to achieve optimal outcomes in patients with esophageal diseases efficiently and expeditiously. Within IEC, patients presenting with esophageal symptoms undergo a detailed clinical, functional and structural evaluation of their esophagus prior to implementation of tailored medical, endoscopic or surgical therapy. Serving as a core, the IEC clinical practice also supports research and innovation in esophageal diseases as well as public and physician education. Referrals to the unit may be primary, either from primary care or self-initiated, or secondary from other specialty practices, to reassess patients who have previously failed therapies and to manage complex or complicated cases. The fundamental goals of the IEC are to provide value for patients with esophageal diseases, streamlining complex diagnostic investigations and expediting therapies aiming at reducing costs while improving clinical outcomes, and to accelerate knowledge generation through robust interaction and cross-training across disciplines. The organization of the IEC goes beyond traditional academic and clinical silos and involves a director and administrative team coordinating faculty and fellows from both medical and surgical disciplines and supported by other clinical lines, such as radiology, pathology, etc., while it interfaces with physicians, the public, basic, translational and clinical research groups, and related industry partners.
Collapse
|