Oesophagus and gastro-oesophageal junction
Background
Oesophagus may be resected with proximal stomach for severe dysplasia and Barrett's oesophagus with adenocarcinoma. Squamous cell carcinomas may also be resected often after adjunctive chemotherapy.1-3
Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.
- No
- Non-routine fixation (not formalin), describe.
- Yes
- Special studies required, describe.
- Ensure samples are taken prior to fixation.
- Not performed
- Performed, describe type and result
- Frozen section
- Other, describe
See general information for more detail on specimen handling procedures.
Inspect the specimen and dictate a macroscopic description.
External Inspection
Orientate and identify proximal and distal aspects of the specimen.
Record additional orientation or designation provided by operating clinician:
- Absent
- Present
- Method of designation (e.g. suture, incision)
- Featured denoted
Photograph the intact specimen.
Describe the following features of the specimen:1-14
Procedure
Record as stated by the clinician.
- Pharyngolaryngo-oesophagectomy
- Oesophago-gastrectomy
- Oesophagectomy
- Other, specify
Anatomical components included (more than one may apply) and dimensions (mm)
Describe and measure the anatomical components present. Measurements are usually taken post-fixation.
- Pharynx
- Oesophagus
- Length of tubular oesophagus (mm)
- Stomach
- Length of greater curve (mm)
- Length of lesser curve (mm)
- Cardia
- Fundus
- Body
- Pylorus
- Other, specify
The length of the oesophagus will shrink by one quarter to one third without pinning.6,7
Specimen integrity
- Intact
- Opened or disrupted, describe
Describe the presence of any tears or defects in the oesophageal adventitia or muscularis propria, particularly in specimens taken after neoadjuvant therapy.5
Dissection
Paint the oesophageal circumferential resection margin with ink.
Two methods can be used to prepare the specimen for fixation depending on tumour location:
Circumferential tumours
Open longitudinally to the edge of the tumour and insert a “wick” of formalin-soaked paper towel, then once fixed “breadloaf” section the specimen. See anterior resection diagram in the colorectal tumour protocol
Non circumferential tumours
Open longitudinally avoiding the tumour and pin flat on a corkboard to fix in formalin.
Dissect the perioesophageal fat and look for lymph nodes.12,13
Internal Inspection
Describe the internal appearance including the following items:1-14
Tumour
- Not discernible
- Present
- Number; if more than one tumour, designate and describe each tumour separately
Tumour site
- Cervical oesophagus
- Upper thoracic
- Middle thoracic
- Lower thoracic
- Gastro-oesophageal junction (GOJ)
Distances from GOJ (mm)
- Mid-point of tumour to GOJ
- Distal edge of tumour to GOJ
The gastro-oesophageal junction occurs where tubular oesophagus meets wider opening stomach sac usually identified by the upper limit of gastric rugal folds (squamo-columnar junction Z line). However where chronic reflux has led to development of glandular epithelium in the oesophagus (Barrett's oesophagus) or tumour obscures this landmark, the junction can be identified as the highest point of the peritoneal reflection on the serosal surface.1 Gastric cardiac carcinomas involving the oesophagus are more adequately staged as gastric cancers.8 Where tumour >50mm from gastro-oesophageal junction refer to instructions for gastrectomy.
Tumour size (mm)
- Greatest dimension
- Other dimensions
- Maximum tumour thickness
Tumour appearance
- Polypoid
- Ulcer
- Thickening
- Other, specify
Distance from surgical margins (mm)
- Proximal
- Distal
- Circumferential9,10
Involvement of other attached structures, if applicable
- Specify
- Distance to surgical margin(s)/anatomical surface (mm)
Barrett’s mucosa14
- Present
- Not identified
- Not applicable
Lymph nodes
- Retrieved from resection specimen
- Describe site(s)
- Number retrieved
Separately submitted
- For each container, record specimen number and designation
- Collective size of tissue in three dimensions (mm)
- Number of grossly identified lymph nodes submitted
- Maximum diameter of each (mm)
Donuts
Note photographs taken, diagrams recorded and markings used for identification.
Processing
Dissect the specimen further & submit sections for processing according to the diagrams provided.
Submit representative sections of:
- Tumour, at least four blocks including:
- Deepest point of invasion
- Tumour to closest circumferential margin or non-peritonealised margin and gastric serosa if applicable
- Interface of tumour with adjacent mucosa
- Gastro-oesophageal junction and squamocolumnar junction
- Uninvolved stomach (if present) and oesophagus
- Proximal resection margin, perpendicular to margin
- Distal resection margin, perpendicular to margin
Neoadjuvant specimens can be difficult to assess macroscopically. Look for central oedematous, fibrous areas that are indicative of the tumour bed of the original tumour.1.5
On dissection, thickening or fibrosis may be evident in the submucosa & muscularis propria.1,5
Structured reporting protocol recommendation: "In cases of intramucosal carcinoma or high grade intraepithelial neoplasia there may be little or no gross abnormality. In such cases, clinical and radiological data regarding tumour location should be obtained to guide sampling. Extensive sampling of the tumour site may be required, with examination of blocks at multiple levels. Preoperative chemotherapy may result in the shrinkage or complete loss of macroscopic abnormality. In the absence of macroscopic tumour, clinical and radiologic data regarding tumour location is used to localise sampling. Following slicing, thickening or fibrosis in the submucosa and muscularis propria may indicate the site of previous tumour. If no carcinoma is found in the initial blocks, then examine three further levels of each block. If there is still no carcinoma found, then in most cases, embedding of the whole site is required before a complete response to neoadjuvant therapy can be reported."1
Submit representative sections guided by clinical/radiological data.
Extensive sampling of the area may be required to demonstrate dysplasia.
Drawing the blocks taken on a printed photograph of the opened specimen is recommended.
After taking blocks pack the specimen in such a way so that it can be easily reconstructed if more blocks need to be taken.
Record details of each cassette.
An illustrated block key similar to those below may be useful.
Block allocation key
|
Cassette id
|
Site
|
No. of pieces
|
|
A
|
Proximal margin
|
|
|
B
|
Distal margin
|
|
|
C-D
|
Tumour (point of deepest penetration) with composite block to closest circumferential margin
|
|
|
E-F
|
Proximal and distal tumour interface
|
|
|
G
|
Background proximal
|
|
|
H
|
Background distal
|
|
|
Cassette id
|
Site
|
No. of pieces
|
|
A
|
Proximal margin
|
|
|
B
|
Distal margin
|
|
|
C-D
|
Tumour (point of deepest penetration) with composite block to closest circumferential margin |
|
|
E-F
|
Proximal and distal tumour interface
|
|
|
G
|
Background proximal
|
|
|
H
|
Gastro-oesophageal junction
|
|
|
Cassette id
|
Site
|
No. of pieces
|
|
A
|
Proximal margin
|
|
|
B
|
Distal margin
|
|
|
C-F
|
Area of dysplasia/Barrett’s including biopsy site (if present)
|
|
|
G-H
|
Gastro-oesophageal junction
|
|
Acknowledgements
Prof Priyanthi Kumarasinghe for her contribution in reviewing and editing this protocol.
References
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Kumarasinghe P, Brown I, Charlton A, de Boer B, Eckstein R, Epari K, Lam A, Lauwers G, Raftopoulos S and Price T.
Tumours of the oesophagus and gastro-oesophageal junction structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2013.
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Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
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Ibrahim NB. ACP. Best Practice No 155. Guidelines for handling oesophageal biopsies and resection specimens and their reporting.
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Am J Clin Pathol 2008;129(2):252-262.
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Huang Q, Shi J, Feng A, Fan X, Zhang L, Mashimo H, Cohen D and Lauwers G. Gastric cardiac carcinomas involving the esophagus are more adequately staged as gastric cancers by the 7th edition of the American Joint Commission on Cancer Staging System.
Mod Pathol 2011;24(1):138-146.
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Deeter M, Dorer R, Kuppusamy MK, Koehler RP and Low DE (2009). Assessment of criteria and clinical significance of circumferential resection margins in esophageal cancer.
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