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THE TISSUE SYSTEMS PATHOLOGY TEST DETECTED PRESENCE OF MISSED NEOPLASIA IN A PATIENT WITH NON-DYSPLASTIC BARRETT’S ESOPHAGUS
Philip Woodworth
*, Reginald Bell
Institute of Esophageal and Reflux Surgery, Lone Tree, CO
Introduction: Barrett’s esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC) and guidelines recommend endoscopic surveillance of BE to enable early detection and treatment of neoplastic progression. However, practices that rely on clinicopathologic factors are limited in identifying patients who harbor high-grade dysplasia (HGD) or EAC or will progress to HGD/EAC. The tissue systems pathology test (TissueCypher, TSP-9) has been validated to detect missed prevalent HGD/EAC and predict progression to HGD/EAC in BE patients. This case report describes the clinical journey of a patient who received a diagnosis of non-dysplastic (ND)BE and a high-risk result from the TSP-9 test, leading to risk-aligned management with the goal of preventing EAC.
Methods: Data were abstracted from endoscopy, pathology and TSP-9 reports and summarized to describe the clinical journey for a patient in surveillance for NDBE.
Results: A 67-year-old male with a history of chronic gastroesophageal reflux disease (GERD) presented to the foregut surgery center due to uncontrolled GERD symptoms despite proton pump inhibitor use and seeking a second opinion after undergoing esophagogastroduodenoscopy (EGD) at a gastroenterology practice. The patient was a non-smoker, not obese, and had been receiving iron transfusions for chronic anemia of unknown origin. Fundoplication surgery was performed and EGD revealed a large hiatal hernia and Prague criteria C0M1 (Fig. 1A). A biopsy at 42 cm showed no intestinal metaplasia (IM), while a biopsy at 41 cm showed presence of IM without dysplasia consistent with NDBE. The TSP-9 test was ordered to assess the risk of progression to HGD/EAC to help guide management. The patient received a high-risk TSP-9 score of 7.1 with a 17% probability of progression to HGD/EAC within 5 years (Fig. 1B). This level of risk is greater than the risk associated with confirmed low-grade dysplasia (LGD) for which guidelines recommend endoscopic eradication therapy (EET), which led to a management change for this patient with referral back to the gastroenterologist for consideration of EET. The gastroenterologist recommended short interval surveillance and the patient returned to the foregut surgery center 6 months later for EGD to follow up on the high-risk TSP-9 result. Biopsies taken at 42 and 41cm received pathology diagnoses of NDBE and HGD, respectively (Fig 1C). The patient was then referred to a University specialized Barrett’s program for management of HGD.
Conclusions: This patient’s journey demonstrates the ability of TSP-9 to identify presence of prevalent HGD even if it is not directly sampled by forceps biopsies during endoscopy. Whereas current clinical practices failed to identify that this patient was harboring neoplasia, the TSP-9 test identified this patient as high-risk, enabling risk-aligned management with the goal of preventing EAC.
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