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Introduction Current guidelines advise esophagectomy for submucosal esophageal adenocarcinoma (T1b EAC). Data from retrospective studies suggest that endoscopic follow-up (FU) may be a valid alternative in patients without signs of lymph node metastases (LNM) at baseline. Our aim is to evaluate the safety of a watchful waiting strategy with regular endoscopic FU as an alternative in patients treated endoscopically for T1b EAC (NCT03222635). Methods This study, conducted at 19 hospitals in Europe and Australia, aims to include 141 patients with 5-year FU. After endoscopic resection of T1b EAC (R0), patients are re-staged with endoscopic ultrasound (EUS) and CT/PET. Patients (N0M0) undergo strict endoscopic FU with gastroscopy and EUS. CT/PET is repeated after 1 year. The cohort is divided into 'high-risk' (submucosal invasion ≥500um, a/o poorly/undifferentiated tumor (G3–4), a/o lymphovascular invasion (LVI+)) and 'low-risk' (risk features absent). Outcome parameters are 5-year disease specific survival, overall survival, rates of LNM and local recurrence. Results 134 patients (112 men, median age 69) underwent median FU of 22 (IQR 11–35) months: 87 high-risk and 47 low-risk. 6 patients (4% [95%CI 0.2–8.8]) were diagnosed with LNM after median FU of 8 (IQR 5–16) months. 2/6 underwent neoadjuvant chemo(radio)therapy with esophagectomy (ypT0N1M0, ypT0N0M0), 1/6 underwent esophagectomy only (pT0N2M0), 3/6 underwent selective surgical LN resection. 7 patients (5% [95%CI 0.8–9.6] were diagnosed with an intra-luminal tumor recurrence not eligible for endoscopic re-treatment after median FU of 7 (IQR 6–15) months. 2/7 underwent esophagectomy (pT1bN0M0, pTisN0M0), 1/7 had neoadjuvant chemoradiotherapy and esophagectomy (ypT1aN0M0), 3/7 underwent (chemo)radiotherapy only, of which 1 patient eventually died as result of stenosing EAC, 1/7 refused additional treatment. No distant metastases were diagnosed. Five patients died of an EAC-unrelated cause. Five patients discontinued FU due to old age. Two patients were lost to FU. Conclusion The preliminary analysis from our ongoing prospective study suggest that in patients with radically removed high- or low-risk T1b EAC, without LNM at baseline, a strict endoscopic follow-up protocol is feasible and the window for curative therapy remains open for those patients who develop LNM (4%) or a local intra-luminal recurrence (5%) during FU. Most patients demonstrate uneventful FU. [ABSTRACT FROM AUTHOR]

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)