Esophagus
Miscellaneous
Grossing esophagectomy specimens

Author: Feriyl Bhaijee, M.D. (see Authors page)
Editor: Israh Akhtar, M.D.

Revised: 1 February 2018, last major update December 2013

Copyright: (c) 2003-2018, PathologyOutlines.com, Inc.

PubMed Search: Gross esophagectomy specimens

Cite this page: Bhaijee, F. Grossing esophagectomy specimens. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/esophagusgrossing.html. Accessed February 20th, 2018.
Relevant clinical history for esophageal specimens
  • Organ / tissue resected or biopsied
  • Purpose of the procedure
  • Gross appearance of lesions (e.g. mass, ulcer, stricture)
  • Gross appearance of the tissue / lesion sampled
  • Location of biopsies
    • Upper, middle or lower esophagus
    • How many cm from the incisors on EGD
  • Any unusual features of the clinical presentation
    • E.g. history of caustic ingestion
  • Prior surgery / biopsies and results
    • E.g. history of Barrett esophagus
  • Prior malignancy
  • Prior treatment
    • E.g. chemo or radiotherapy
  • Immune compromise
Biopsies
  • Count the number of tissue fragments and describe their color
  • Filter small fragments through tissue paper / biopsy bags
  • Record the aggregate measurement
  • Submit all tissue for processing
Esophagectomies
  • Remove the staple line with scissors
  • Shave the proximal and distal margins (if the tumor is > 2.0 cm from each)
  • Locate the lesion by gently palpating the luminal surface
  • Open the specimen longitudinally
    • Avoid cutting across any palpable lesions
  • Record the length, circumference and wall thickness of the esophagus and attached proximal stomach
  • Record the dimensions of any lesions and their location, with reference to the proximal / distal / deep margins, the squamocolumnar junction (Z line) and the gastroesophageal (GE) junction
    • This should be measured on the fresh specimen due to retraction following excision
    • Z line is the intersection of squamous and glandular mucosa
    • GE junction is the junction of the tubular esophagus and saccular stomach, irrespective of the types of mucosa present
    • Proximal displacement of the Z line above the GE junction suggests Barrett esophagus
  • Photograph lesions (as appropriate)
  • Ink the proximal, distal and deep margins and pin the specimen on a board
    • If the tumor is large, make longitudinal incisions to aid in fixation
  • Fix the specimen in formalin overnight
  • Describe any lesions including:
    • Size
    • Color
    • Configuration (e.g. exophytic, ulcerated, infiltrative)
    • Depth of invasion
    • Location (including relationship to squamocolumnar junction)
    • Percent of circumference involved
    • Luminal diameter at the lesional site
    • Degree of proximal dilatation
  • Describe uninvolved mucosa
    • Normal squamous esophagus: glistening smooth white mucosa
    • Normal glandular stomach: velvety pink / red mucosa with rugal folds
    • Barrett (glandular) mucosa: pale pink / salmon, finely granular, may be discontinuous
  • Adventitial soft tissue / fat should be thoroughly searched and sectioned for lymph nodes
    • Nodes may be very small and close to the esophageal or gastric outer surfaces
  • Submit representative microscopic sections for processing
    • Tumor: one section per cm, including maximal depth of invasion and relation to proximal / distal margins
      • Longitudinal sections preferred
      • If no gross tumor present, submit ulcerated / fibrotic areas
    • Margins: en face sections of proximal / distal margins unless tumor and margin can be demonstrated in perpendicular sections
    • Esophagus and stomach: representative sections of uninvolved areas
    • Other gross lesions (including Barrett esophagus): representative sections
    • Lymph nodes: submit entirely
  • Sample dictation
    • The specimen designated esophagus is received fresh in a container labeled with the patients name and medical record number and consists of an esophagectomy and partial gastrectomy, including esophagus (20.0 cm length x 3.5 cm circumference) with attached proximal stomach (4.0 cm length x 10.0 cm circumference). There is a tan pink, firm, fungating mass (2.5 x 2.0 cm), which invades through the muscularis propria into the adjacent soft tissue. The tumor is 15.0 cm from the proximal resection margin, 2.5 cm from the gastroesophageal junction, 6.5 cm from the distal resection margin and 0.2 cm from the deep resection margin (inked in black). The adjacent esophageal mucosa is tan pink and finely granular from the gastroesophageal junction up to within 10.0 cm of the proximal margin. The remainder of the mucosal surfaces are unremarkable. The attached soft tissue contains four palpable lymph nodes (range 0.3 - 0.5 cm). Gross photographs are taken. Section code:
      • Cassette 1: proximal resection margin, en face, entirely
      • Cassettes 2 - 3: distal resection margin, en face, entirely
      • Cassettes 4 - 5: tumor with deepest extent of invasion (deep margin), longitudinal
      • Cassettes 6 - 7: tumor with adjacent esophageal mucosa, longitudinal, representative
      • Cassette 8: abnormal esophageal mucosa, representative
      • Cassette 9: normal gastric mucosa, representative
      • Cassettes 10 - 11: two lymph nodes each, entirely
Gross differential diagnosis
  • Adenocarcinoma
    • Close to the GE junction
    • Grossly resemble colonic adenocarcinomas
    • Tan / pink, polypoid, variable ulceration
    • May invade the submucosa and undermine proximal / distal normal appearing mucosa
  • Barrett mucosa
    • Pale pink / salmon colored
    • Finely granular
    • Extends proximally from the GE junction
      • May be discontinuous
    • May be associated with adenocarcinoma
  • Leiomyoma
    • Typically arises from muscularis propria
    • Well circumscribed tumor with white pink, whorled cut surfaces
    • Intramural or intraluminal / polypoid
  • Squamous cell carcinoma
    • Occur in upper, middle and lower esophagus
    • Exophytic (intraluminal), infiltrative / ulcerating or circumferential thickening
    • Preoperative radiation may obscure the tumor, due to shallow ulceration, erosion, fibrosis or granular mucosa