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    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
      • Vertical length (mm)
    • 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

    • No
    • Yes
      • Dimensions (mm)

    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

    1. 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.
    2. Mapstone NP. Dataset for the histopathological reporting of oesophageal carcinoma, The Royal College of Pathologists, London, 2007.
    3. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    4. Ibrahim NB. ACP. Best Practice No 155. Guidelines for handling oesophageal biopsies and resection specimens and their reporting. J Clin Pathol 2000;53(2):89-94.
    5. Chang F, Deere H, Mahadeva U and George S. Histopathologic examination and reporting of esophageal carcinomas following preoperative neoadjuvant therapy: practical guidelines and current issues. Am J Clin Pathol 2008;129(2):252-262.
    6. Siu KF, Cheung HC and Wong J. Shrinkage of the esophagus after resection for carcinoma. Ann Surg 1986;203(2):173-176.
    7. Lam KY, Ma LT and Wong J. Measurement of extent of spread of oesophageal squamous carcinoma by serial sectioning. J Clin Pathol 1996;49(2):124-129.
    8. 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.
    9. 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. Arch Surg 2009;144(7):618-624.
    10. Dexter SP, Sue-Ling H, McMahon MJ, Quirke P, Mapstone N and Martin IG (2001). Circumferential resection margin involvement: an independent predictor of survival following surgery for oesophageal cancer. Gut 2001;48(5):667-670.
    11. Lagarde SM, ten Kate FJ, Reitsma JB, Busch OR and van Lanschot JJ. Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction. J Clin Oncol 2006;24(26):4347-4355.
    12. Griffiths EA, Brummell Z, Gorthi G, Pritchard SA and Welch IM. Tumor length as a prognostic factor in esophageal malignancy: univariate and multivariate survival analyses. J Surg Oncol 2006;93(4):258-267.
    13. Eloubeidi MA, Desmond R, Arguedas MR, Reed CE and Wilcox CM. Prognostic factors for the survival of patients with esophageal carcinoma in the U.S.: the importance of tumor length and lymph node status. Cancer 2002;95(7):1434-1443.
    14. Holscher AH, Vallbohmer D and Bollschweiler E. Early Barrett's carcinoma of the esophagus. Ann Thorac Cardiovasc Surg 2008;14(6):347-354.

    Jump To

      Oes-gast 1

      Gastro-oesophagectomy with tumour at GOJ

      Oes-gast 2

      Gastro-oesophagectomy

      Oes-gast 3

      Oesophagectomy

      Oes-gast 4

      Gastro-oesophagectomy for dysplasia

      Oes-gast 5

      Gastro-oesophagectomy for tumour

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      22-Mar-2019
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