Clinical Use of Tissue Systems Pathology-9 Test for Risk Stratification in Barrett’s Esophagus: A Multidisciplinary Expert Consensus

Background: Endoscopic surveillance of Barrett’s esophagus (BE) aims to detect dysplasia early, but the risk of neoplastic progression in BE is highly variable. Histology, the current gold standard for risk stratification, has limitations that may contribute to the modest impact of surveillance on esophageal adenocarcinoma (EAC) mortality. The Tissue Systems Pathology-9 (TSP-9) test provides personalized prognostic data on progression to high grade dysplasia (HGD) or EAC within 5 years and may improve risk stratification. Methods: The American Foregut Society convened a panel of 10 gastroenterologists and 4 foregut surgeons with BE expertise. The RAND/UCLA Appropriateness Method was used to evaluate the role of TSP-9 across clinical scenarios and BE phenotypes (nondysplastic [NDBE], indefinite for dysplasia [IND], and low-grade dysplasia [LGD]). A literature review informed the scientific basis, rationale and clinical integration of TSP-9. Results: Consensus was reached on 15 statements; 5 did not reach agreement. The panel supported TSP-9 for risk assessment in NDBE, IND, and LGD independent of histology. In NDBE/IND, low-risk scores support guideline-based surveillance. Intermediate risk scores warrant consideration of closer surveillance or endoscopic eradication therapy (EET), while high-risk scores favor closer surveillance or EET. For LGD EET was supported for intermediate or high-risk scores, but no consensus was reached for low-risk scores. TSP-9 was considered useful for identifying prevalent dysplasia and high-risk patients for early intervention. Uncertainty remained regarding performance in erosive esophagitis and relative to expert pathology in IND/LGD. Conclusions: These consensus-based recommendations support the use of TSP-9 to enhance BE risk stratification and guide management.