Interobserver reproducibility in pathologist interpretation of columnar-lined esophagus

Abstract

Confirmation of endoscopically suspected esophageal metaplasia (ESEM) requires histology, but confusion in the histological definition of columnar-lined esophagus (CLE) is a longstanding problem. The aim of this study is to evaluate interpathologist variability in the interpretation of CLE. Thirty pathologists were invited to review three ten-case sets of CLE biopsies. In the first set, the cases were provided with descriptive endoscopy only; in the second and the third sets, ESEM extent using Prague criteria was provided. Moreover, participants were required to refer to a diagnostic chart for evaluation of the third set. Agreement was statistically assessed using Randolph's free-marginal multirater kappa. While substantial agreement in recognizing columnar epithelium (K = 0.76) was recorded, the overall concordance in clinico-pathological diagnosis was low (K = 0.38). The overall concordance rate improved from the first (K = 0.27) to the second (K = 0.40) and third step (K = 0.46). Agreement was substantial when diagnosing Barrett's esophagus (BE) with intestinal metaplasia or inlet patch (K = 0.65 and K = 0.89), respectively, in the third step, while major problems in interpretation of CLE were observed when only cardia/cardia-oxyntic atrophic-type epithelium was present (K = 0.05-0.29). In conclusion, precise endoscopic description and the use of a diagnostic chart increased consistency in CLE interpretation of esophageal biopsies. Agreement was substantial for some diagnostic categories (BE with intestinal metaplasia and inlet patch) with a well-defined clinical profile. Interpretation of cases with cardia/cardia-oxyntic atrophic-type epithelium, with or without ESEM, was least consistent, which reflects lack of clarity of definition and results in variable management of this entity.

Prevalence and risk factors for Barrett’s esophagus in Taiwan

“…Furthermore, the esophageal biopsy specimens were interpreted by eight pathologists. Mastracci et al[42] revealed that the overall agreement rate of the diagnostic category of “BE with IM” between pathologists is moderate, with a K value of 0.599. This phenomenon might also be one of the confounding factors responsible for the different detection rates between ESEM and BE.…”

The importance of a second opinion in the diagnosis of Barrett’s esophagus: a “real life” study

“…This aspect is not usually mentioned in the literature, and studies have mainly focused on recognition of intestinal metaplasia in BE (30) or dysplasia in BE (20,31,32). A recent study evaluating inter-pathologist variability in the interpretation of columnar-lined esophagus showed a poor/ fair concordance rate (K = 0.17, CI 0.16-0.19) in identifying possible BE without intestinal metaplasia (33). Once again, the agreement was greater between gastrointestinal pathologists than in other general pathologists.…”

Gastro-esophageal reflux disease and Barrett’s esophagus: an overview with an histologic diagnostic approach

“…An Italian study, evaluated both the inter-observer agreement in type of epithelium recognition (oxyntic/cardia versus intestinal) and more importantly on diagnostic category assignation. While agreement for diagnosis of BE had a moderate-substantial agreement rate among participants (overall K = 0.60 95% CI 0.58-0.62) major problems arose when interpreting columnar epithelium in an irregular z-line 32 . This perfectly describes the frequent and diffuse problems faced by practicing pathologists in esophageal biopsy assessment, and therefore in BE diagnosis.…”

“…The term histologic squamo-columnar junction (SCJ) or Z-line refers to the transition between esophageal stratified squamous epithelium and columnar epithelium. It can be identified both by endoscopists (due to the white color of the squamous epithelium compared to the pinkish color of columnar epithelium) and by pathologists who easily identify the histologic transition between squamous and columnar epithelium 32 . As a rule, GEJ and SCJ coincide in normal subjects but a dis-alignment of the SCJ up to 1 cm proximally to GEJ is also seen.…”