Grossing & features to report

Topic Completed: 2 December 2013

Minor changes: 30 March 2021

Copyright: 2003-2021,, Inc.

PubMed Search: Gross esophagectomy specimens

Feriyl Bhaijee, M.D.
Israh Akhtar, M.D.
Page views in 2020: 1,118
Page views in 2021 to date: 972
Cite this page: Bhaijee F, Akhtar I. Grossing & features to report. website. Accessed October 20th, 2021.
Relevant clinical history for esophageal specimens
Grossing - 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
Grossing - 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
Features to report - General
  • Editorial note
  • Lymphomas, well differentiated neuroendocrine (carcinoid) tumors and sarcomas should be reported using separate TNM staging systems or CAP protocols
Features to report - Biopsies
    • Specimen type (procedure)
    • Site of biopsy (if known)
    • Histologic type
    • Histologic grade
    • Microscopic tumor extension
    • Additional findings
Features to report - Endoscopic resection, esophagectomy or esophagogastrectomy
  • Specimen
    • Esophagus
    • Proximal stomach
    • Other (specify)
    • Not specified
  • Procedure
    • Endoscopic resection
    • Esophagectomy
    • Esophagogastrectomy
    • Other (specify)
    • Not specified
  • Tumor site
    • Cervical (proximal) esophagus
    • Midesophagus
      • Upper thoracic esophagus
      • Mid thoracic esophagus
    • Distal (lower thoracic) esophagus
    • Esophagogastric junction (EGJ)
    • Proximal stomach and EGJ
    • Other (specify)
    • Not specified
  • Relationship of tumor to esophagogastric junction (EGJ)
    • Tumor is confined to the tubular esophagus and does not involve the EGJ
    • Tumor midpoint is in the distal esophagus and tumor involves the EGJ
    • Tumor midpoint is at the EGJ
    • Tumor midpoint is in the proximal stomach or cardia and tumor involves the EGJ
    • Not specified
    • Cannot be assessed
    • Distance of tumor center from EGJ (if applicable): __ cm
  • Tumor size
    • Greatest dimension: __ cm
    • Cannot be determined
  • Histologic type
    • Squamous cell carcinoma
    • Adenocarcinoma
    • Adenosquamous carcinoma
    • High grade neuroendocrine carcinoma
      • Large cell neuroendocrine carcinoma
      • Small cell neuroendocrine carcinoma
    • Undifferentiated carcinoma
    • Other (specify)
    • Carcinoma, type cannot be determined
  • Histologic grade
    • Not applicable
    • GX: cannot be assessed
    • G1: well differentiated
    • G2: moderately differentiated
    • G3: poorly differentiated
    • G4: undifferentiated
  • Microscopic tumor extension
    • Cannot be assessed
    • No evidence of primary tumor
    • High grade dysplasia (carcinoma in situ)
    • Tumor invades lamina propria
    • Tumor invades muscularis mucosae
    • Tumor invades submucosal
    • Tumor invades muscularis propria
    • Tumor invades through muscularis propria into periesophageal soft tissue (adventitia)
    • Tumor directly invades adjacent structures (specify)
  • Margins
    • If all margins uninvolved by invasive carcinoma:
      • Distance of invasive carcinoma from closest margin: __ cm
      • Specify margin
    • Proximal / distal margin involved by:
      • Invasive carcinoma
      • Dysplasia
        • Squamous dysplasia: low / high grade
        • Intestinal metaplasia (Barrett esophagus) with dysplasia: low / high grade
      • Intestinal metaplasia (Barrett esophagus) without dysplasia
    • Circumferential (adventitial / deep) margin
      • Cannot be assessed
      • Uninvolved by invasive carcinoma
      • Involved by invasive carcinoma
    • Other margins (specify)
  • Treatment effect (carcinomas treated with neoadjuvant therapy, Dis Esophagus 2006;19:329)
    • No prior treatment
    • Present
      • No residual tumor (complete response, grade 0)
      • Marked response (minimal residual cancer, grade 1)
      • Moderate response (grade 2)
    • No definite response (poor / no response, grade 3)
    • Treatment history not known
  • Lymph vascular invasion
    • Not identified
    • Present
    • Indeterminate
  • Perineural invasion
    • Not identified
    • Present
    • Indeterminant
  • Pathologic staging (pTNM)
    • TNM descriptors
      • m (multiple primary tumors)
      • r (recurrent)
      • y (posttreatment)
    • Primary tumor (pT)
    • Regional lymph nodes (pN)
    • Distant metastasis (pM)
  • Additional pathologic findings
    • None
    • Intestinal metaplasia (Barrett esophagus)
    • Dysplasia: low / high grade
    • Esophagitis
    • Gastritis
    • Other (specify)
  • Ancillary studies (specify)
  • Clinical history
    • Barrett esophagus
    • Other (specify)
    • Not known
  • References: Edge: AJCC Cancer Staging Manual, 7th Edition, 2009, CAP: Cancer Protocol Templates [Accessed 1 February 2018]
Features to report - Optional
Back to top
Image 01 Image 02