Abstract
Barrett’s esophagus (BE) is the only known precursor condition for esophageal adenocarcinoma (EAC). Progression is thought to occur in a stepwise fashion from non-dysplastic BE (NDBE) to low-grade dysplasia (LGD) to high-grade dysplasia (HGD) and finally to EAC. Therefore, regular endoscopic surveillance with biopsies is required for these patients. Dysplasia in BE biopsies is associated with low observer agreement among general pathologists. Expert pathology review of all diagnosis of dysplasia is advised by most BE guidelines. The majority of patients with community LGD will be down-staged after expert review and have a low progression risk. Confirmed LGD has an increased risk of malignant progression, reported up to 9% per patient-year. Since endoscopic management of BE patients depends on the dysplasia grade, expert pathology review leads to a significant impact on the management and outcome of patients Methods Between January 2017 and August 2019, sets of biopsy specimen from 129 dysplastic BE patients were referred from community centers to our tertiary referral center for expert pathology review as a prerequisite for dysplastic BE endoscopic management. These slides and blocks were reassessed by two gastro-intestinal (GI) expert pathologists. Diagnosis were stratified according Vienna Classification supported by p53 immunostaining. In this study, we retrospectively documented the discrepancy between expert and communautary pathologists in grading dysplasia in this selected BE population. LGD was confirmed by expert pathologist in 33/68 patients (49%), 20 patients (29%) were downgraded to NDBE, 5 patients (7%) indefinite for dysplasia (IFD) and 10 patients (15%) were upgraded to HGD, no cancer was missed. HGD was confirmed by expert pathologist in 52/61 patients (85%), downgraded to NDBE in 1 patient (2%) or to LGD in 4 patients (7%) and upgraded to EAC in 4 patients (7%). Discrepancy in BE dysplasia grading between community and tertiary referral centers is still high, especially for LGD. Community diagnosis of LGD is down-staged to NDBE in 49% of the cases after expert GI pathologist review. Therefore, skipping the expert pathology review step in LGD BE patients could lead to overtreat almost half of the patients.
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