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Histopathologist features predictive of diagnostic concordance at expert level among a large international sample of pathologists diagnosing Barrett’s dysplasia using digital pathology
  1. Myrtle J van der Wel1,
  2. Helen G Coleman2,
  3. Jacques J G H M Bergman3,
  4. Marnix Jansen4,
  5. Sybren L Meijer1
  6. on behalf of the BOLERO working group
    1. 1 Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
    2. 2 Centre for Public Health, Queens University Belfast, Belfast, UK
    3. 3 Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
    4. 4 Pathology, UCL Cancer Institute, London, UK
    1. Correspondence to Dr Marnix Jansen, Pathology, UCL Cancer Institute, London WC1E 6AG, UK; m.jansen{at}


    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.

    • barrett's oesophagus
    • dysplasia
    • oesophageal cancer
    • health service research

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    • MJ and SLM are shared corresponding and senior authors.

    • Twitter @jansen_marnix

    • MJvdW and HGC contributed equally.

    • Collaborators BOLERO study participants (in alphabetical order): Dr Junko Aida, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan; Dr Rossana Baiocco, General Hospital of Desenzano del Garda, Desenzano, Italy; Dr Camille Boulagnon-Rombi, Université de Reims Champagne-Ardenne, Reims, France; Dr Iva Brcic, Medical University of Graz, Graz, Austria; Dr Lodewijk Brosens, University Medical Center Utrecht, Utrecht, the Netherlands; Dr Fátima Carneiro, IPATIMUP, Porto, Portugal; Dr Gieri Cathomas, Kantonsspital Baselland, Liestal, Switzerland; Dr Denis Chatelain, CHU Amiens-Picardie, Amiens, France; Dr Allison Cluroe, Addenbrooke's Hospital, Cambridge, UK; Dr Parag Dabir, Regional Hospital, Randers, Denmark; Dr Giovanni De Petris, Penrose Hospital, Colorado Springs, USA; Dr Michael Doukas, Erasmus Medical Center, Rotterdam, the Netherlands; Dr Hala El-Zimaity, Toronto General Hospital, Toronto, Canada; Dr Matteo Fassan, University of Padua, Padua, Italy; Dr Roberto Fiocca, University of Genova, Genova, Italy; Dr Jean-François Fléjou, Saint-Antoine Hospital, Paris, France; Dr Alejandro García Varona, Hospital El Bierzo, Leon, Spain; Dr Elvira Gonzalez Obeso, Hospital Clinico Universitario, Valladolid, Spain; Dr Heike Grabsch, (1) Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK, and (2) Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, NL; Dr Federica Grillo, University of Genova, Genova, Italy; Dr Barbara Gruber, Patologia Bariloche, San Carlos de Bariloche, Argentina; Dr Laura Guerra Pastrian, University Hospital La Paz, Madrid, Spain; Dr Anne Hoorens, University Hospital Gent, Gent, Belgium; Dr Marnix Jansen, University College Hospital, London, UK; Dr Katerina Kamaradova, Charles University Hospital, Hradec Kralove, Czech Republic; Dr Ryoji Kushima, Shiga University of Medical Science, Shiga, Japan; Dr Cord Langner, Medical University of Graz, Graz, Austria; Dr Rupert Langer, University of Bern, Bern, Switzerland; Dr Felix Lasitschka, Universitätsklinikum Heidelberg, Heidelberg, Germany; Dr Ester Lörinc, University Hospital Lund and Malmö, Lund, Sweden; Dr Luca Mastracci, University of Genova, Genova, Italy; Dr Damian McManus, Belfast HSC Trust, Belfast, UK; Dr Sybren Meijer, Academic Medical Center, Amsterdam, the Netherlands; Dr Carmen Mendez, University Hospital La Paz, Madrid, Spain; Dr Anya Milne, Diakonessenhuis, Utrecht, the Netherlands; Dr Miriam Mitchison, University College Hospital, London, UK; Dr Masoud Mireskandari, Jena University Hospital, Jena, Germany; Dr Elizabeth Montgomery, Johns Hopkins Medical Institute, Baltimore, USA; Dr Cian Muldoon, St James’s Hospital, Dublin, Ireland; Dr Maria O’Donovan, Cambridge Cancer Centre, Cambridge, UK; Dr Rob Odze, Brigham and Women’s Hospital, Boston, USA; Dr Johan Offerhaus, University Medical Centre Utrecht, the Netherlands; Dr Gabriel Olmedilla, University Hospital La Paz, Madrid, Spain; Dr John Pauli, The Prince Charles Hospital, Brisbane, Australia; Dr Rachel S van der Post, Radboud university medical centre, Nijmegen, the Netherlands; Dr Bob Riddell, Mount Sinai Hospital, Toronto, Canada; Dr Ari Ristimaki, Haartman Institute, Helsinki, Finland; Dr Ana Rodriguez, University Hospital La Paz, Madrid, Spain; Dr Manual Rodriguez-Justo, University College Hospital, London, UK; Dr Shigeki Sekine, National Cancer Center Hospital, Tokyo, Japan; Dr Kees Seldenrijk, St Antonius Hospital, Nieuwegein, the Netherlands; Dr Tulio Souza, Hospital Aliança, Salvador, Brazil; Dr Matt Stachler, Brigham and Women’s Hospital, Boston, USA; Dr Michael Vieth, Klinikum Bayreuth, Bayreuth, Germany; Dr Vincenzo Villanacci, Spedali Civili di Brescia, Brescia, Italy; Dr Rhonda Yantiss, Weill Cornell Medical College, New York, USA.

    • Contributors Study concept and design: MJvdW, MJ, SLM. Acquisition of data: MJvdW, MJ, SLM. Analysis and interpretation of data: MJvdW, HGC. Drafting of the manuscript: MJvdW, HGC, MJ, SLM. Critical revision of the manuscript: MJvdW, HGC, JJGHMB, MJ SLM. Study supervision: SLM, MJ.

    • Funding This study was funded by Cancer Research UK and Dutch Cancer Society.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval This study used anonymised, archived, formalin-fixed, paraffin-embedded material and did not require approval from the relevant institutional ethics committee under applicable local regulatory law (‘Code of conduct’, FEDERA).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.