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Nieuwenhuis EA, van Munster SN, Meijer SL, Brosens LAA, Jansen M, Weusten BLAM, Alvarez Herrero L, Alkhalaf A, Schenk E, Schoon EJ, Curvers WL, Koch AD, van de Ven SEM, Verheij EPD, Nagengast WB, Westerhof J, Houben MHMG, Tang T, Bergman JJGHM, Pouw RE, Ooms A, Huysentruyt C, ten Kate F, Moll F, Kats-Ugurlu G, van Lijnschoten I, van de Laan J, Offerhaus J, Biermann K, Seldenrijk K, Brosens L, Meijer S, Doukas M. Analysis of metastases rates during follow-up after endoscopic resection of early "high-risk" esophageal adenocarcinoma. Gastrointest Endosc 2022; 96:237-247.e3. [PMID: 35288149 DOI: 10.1016/j.gie.2022.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/04/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS After endoscopic resection (ER) of early esophageal adenocarcinoma (EAC), the optimal management of patients with high-risk histologic features for lymph node metastases (ie, submucosal invasion, poor differentiation grade, or lymphovascular invasion) remains unclear. We aimed to evaluate outcomes of endoscopic follow-up after ER for high-risk EAC. METHODS For this retrospective cohort study, data were collected from all Dutch patients managed with endoscopic follow-up (endoscopy, EUS) after ER for high-risk EAC between 2008 and 2019. We distinguished 3 groups: intramucosal cancers with high-risk features, submucosal cancers with low-risk features, and submucosal cancers with high-risk features. The primary outcome was the annual risk for metastases during follow-up, stratified for baseline histology. RESULTS One hundred twenty patients met the selection criteria. Median follow-up was 29 months (interquartile range, 15-48). Metastases were observed in 5 of 25 (annual risk, 6.9%; 95% confidence interval [CI], 3.0-15) high-risk intramucosal cancers, 1 of 55 (annual risk, .7%; 95% CI, 0-4.0) low-risk submucosal cancers, and 3 of 40 (annual risk, 3.0%; 95% CI, 0-7.0) high-risk submucosal cancers. CONCLUSIONS Whereas the annual metastasis rate for high-risk submucosal EAC (3.0%) was somewhat lower than expected in comparison with previous reported percentages, the annual metastasis rate of 6.9% for high-risk intramucosal EAC is new and worrisome. This calls for further prospective studies and suggests that strict follow-up of this small subgroup is warranted until prospective data are available.
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Affiliation(s)
- Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marnix Jansen
- Department of Pathology, UCL Cancer Institute and University College London Hospital, NHS Trust, London, UK
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Ed Schenk
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands; Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands, (12)Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Thjon Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
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2
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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3
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van der Wel MJ, Klaver E, Duits LC, Pouw RE, Seldenrijk CA, Offerhaus G, Visser M, Ten Kate F, Biermann K, Brosens L, Doukas M, Huysentruyt C, Karrenbeld A, Kats-Ugurlu G, van der Laan JS, van Lijnschoten G, Moll F, Ooms A, Tijssen JG, Bergman J, Meijer SL. Adherence to pre-set benchmark quality criteria to qualify as expert assessor of dysplasia in Barrett's esophagus biopsies - towards digital review of Barrett's esophagus. United European Gastroenterol J 2019; 7:889-896. [PMID: 31428413 PMCID: PMC6683647 DOI: 10.1177/2050640619853441] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/07/2019] [Indexed: 12/20/2022] Open
Abstract
Background Dysplasia assessment of Barrett’s esophagus biopsies is associated with low
observer agreement; guidelines advise expert review. We have developed a
web-based review panel for dysplastic Barrett’s esophagus biopsies. Objective The purpose of this study was to test if 10 gastrointestinal pathologists
working at Dutch Barrett’s esophagus expert centres met pre-set benchmark
scores for quality criteria. Methods Ten gastrointestinal pathologists twice assessed 60 digitalized Barrett’s
esophagus cases, enriched for dysplasia; then randomised (7520 assessments).
We tested predefined benchmark quality criteria: (a) percentage of
‘indefinite for dysplasia’ diagnoses, benchmark score ≤14% for all cases,
≤16% for dysplastic subset, (b) intra-observer agreement; benchmark score
≥0.66/≥0.39, (c) percentage agreement with ‘gold standard diagnosis’;
benchmark score ≥82%/≥73%, (d) proportion of cases with high-grade dysplasia
underdiagnosed as non-dysplastic Barrett’s esophagus; benchmark score ≤1/78
(≤1.28%) assessments for dysplastic subset. Results Gastrointestinal pathologists had seven years’ Barrett’s
esophagus-experience, handling seven Barrett’s esophagus-cases weekly. Three
met stringent benchmark scores; all cases and dysplastic subset, three met
extended benchmark scores. Four pathologists lacked one quality criterion to
meet benchmark scores. Conclusion Predefined benchmark scores for expert assessment of Barrett’s esophagus
dysplasia biopsies are stringent and met by some gastrointestinal
pathologists. The majority of assessors however, only showed limited
deviation from benchmark scores. We expect further training with group
discussions will lead to adherence of all participating gastrointestinal
pathologists to quality criteria, and therefore eligible to join the review
panel.
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Affiliation(s)
- M J van der Wel
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - E Klaver
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - L C Duits
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - C A Seldenrijk
- Department of Pathology, Pathology-DNA BV, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Gja Offerhaus
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - M Visser
- Department of Pathology, Symbiant BV, Zaans Medical Center, Zaandam, the Netherlands
| | - Fjw Ten Kate
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - K Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laa Brosens
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - M Doukas
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Huysentruyt
- Department of Pathology, Stichting PAMM, Eindhoven, The Netherlands
| | - A Karrenbeld
- Department of Pathology, Academic Medical Center Groningen, Groningen, The Netherlands
| | - G Kats-Ugurlu
- Department of Pathology, Academic Medical Center Groningen, Groningen, The Netherlands
| | - J S van der Laan
- Department of Pathology, Haga Hospital, The Hague, The Netherlands
| | | | - Fcp Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Ahag Ooms
- Department of Pathology, Pathan BV, St. Fransiscus Vlietland Hospital, Rotterdam, the Netherlands
| | - J G Tijssen
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jjghm Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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4
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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