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Grossing & features to report

Author: Israh Akhtar, M.D.

Editorial Board Member: Aaron R. Huber, D.O.

Deputy Editor-in-Chief: Catherine E. Hagen, M.D.

Last author update: 5 August 2022

Last staff update: 14 September 2023

Copyright: 2003-2024, PathologyOutlines.com, Inc.

PubMed Search: Esophagus gross specimen

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Table of Contents

Cite this page: Akhtar I. Grossing & features to report. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/esophagusgrossing.html. Accessed April 19th, 2024.

Definition / general

This topic describes how to gross esophageal biopsies, esophagectomy specimens and endoscopic mucosal resection specimens
Essential clinical history
Gross differential diagnosis
Features to report in biopsies, esophagectomies and mucosal resections (Arch Pathol Lab Med 2015;139:1446)

Relevant clinical history for esophageal specimens

Organ / tissue resected or biopsied
Indication for the procedure
Endoscopic appearance of lesion / tissue sampled (e.g., mass, ulcer, stricture)
Gross appearance of the organ / lesion / tissue sampled
Location of biopsies:
- Upper (cervical), middle (midthoracic) or lower esophagus (lower thoracic)
- How many centimeters from the incisors on esophagogastroduodenoscopy (EGD)
Relevant clinical and imaging findings (e.g., history of caustic ingestion)
Prior surgery / biopsies and results (e.g., history of Barrett esophagus)
Prior malignancy
Prior treatment (e.g., neoadjuvant therapy, chemo or radiotherapy)
Immune status (e.g., history of HIV, transplant)
References: Pathology Resident Wiki: Gastrointestinal Grossing [Accessed 21 June 2022], Lester: Manual of Surgical Pathology, 3rd Edition, 2010, Gupta: Ace My Path - Gross Dictation Handbook, 1st Edition, 2022, Arch Pathol Lab Med 2015;139:1446

Procedure - biopsies

Biopsies performed for evaluation of heartburn, dysphagia or surveillance of dysplasia in a patient with history of Barrett esophagus
Patient identification: patient name, (last, first) label - designated specimen
Received in formalin / unfixed
Count the number of tissue fragments and describe their color
Filter small fragments through tissue paper / biopsy bags
Record the aggregate measurement or give the range, if multiple pieces
Submit all tissue for processing in 1 cassette, if < 6 pieces
Reference: Arch Pathol Lab Med 2015;139:1446

Procedure - esophagectomies

Esophagectomies are performed with or without proximal stomach for severe dysplasia or for neoplasms; less frequently for strictures
Patient identification: patient name, (last, first) label - designated specimen
Received in formalin / unfixed / fresh for intraoperative consultation
Confirm procedure as esophagectomy or other
Orientation: identify anatomic structures, only esophagus or esophagus and portion of stomach or other; look for any sutures to identify the margins
Remove the staple line with scissors, as close to the staples as possible
Locate the lesion by gently palpating the luminal surface
Open the specimen longitudinally
Avoid cutting across any palpable lesions
Measure the length and diameter or circumference and wall thickness of the esophagus and attached proximal stomach, if present
Describe the mucosa, look for any areas of ulceration, glandular mucosa (pink or tan, appears different from pale squamous mucosa) strictures and tumors and the narrowing of the lumen caused by these lesions
Note 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 fixation
- 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
Describe the external surface and note areas of retraction, induration, perforation by the tumor or any lymph nodes
Photograph lesions (as appropriate)
Ink the proximal, distal and deep (adventitial) margins underneath the tumor, pin the specimen on a board and fix in 10% formalin; if the tumor is large, make longitudinal cuts 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: after fixation cut through the tumor or ulcer to assess the depth of invasion into the esophageal wall
- Location (including relationship to squamocolumnar junction) (see note)
  - Note: tumors that have their epicenter at the gastroesophageal junction and extend no more than 2 cm into the proximal stomach are staged as esophageal, while tumors with an epicenter more than 2 cm into the proximal stomach are staged as primary gastric carcinoma even if the tumor involves the gastroesophageal 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
Reference: Arch Pathol Lab Med 2015;139:1446

Procedure - endoscopic mucosal resections

Indications:
- Barrett esophagus, with or without dysplasia or intramucosal carcinoma
- Lesions that are ≤ 2 cm, well to moderately differentiated and limited to the mucosa or superficial submucosa (Middle East J Dig Dis 2017;9:5, Gastroenterology 2015;149:1599, Endoscopy 2007;39:24)
Procedure:
- Should arrive in the laboratory in a fresh state, with margins oriented by the endoscopist
- Specimen is usually round or oval
- Ink base and lateral mucosal margins with different colors
- Stretch the specimen gently and fix overnight in 10% formalin on a rigid board, with mucosal surface up
- After fixation the specimens should be serially sectioned at 2 - 3 mm intervals parallel to the long axis (not < 2 mm)

Sections to obtain

Submit tumor: 1 section per centimeter, including maximal depth of invasion and relation to proximal / distal margins
- Longitudinal sections preferred
- If no gross tumor present (which is often the case after neoadjuvant therapy of the GE junction tumors), then the entire ulcerated / fibrotic area should be blocked off and submitted
Margins: en face sections of proximal / distal margins unless tumor is < 2 cm from the margin then margin can be best demonstrated in perpendicular sections
Esophagus and stomach: representative sections of uninvolved areas
Other gross lesions (including Barrett esophagus): representative sections
Lymph nodes: submit entirely
For endoscopic mucosal resection (EMR): entire specimen should be submitted in a sequential manner (World J Gastrointest Endosc 2012;4:489)

Tips

If no gross tumor present (which is often the case after neoadjuvant therapy of the GE junction tumors), then the entire ulcerated / fibrotic area should be blocked off and submitted
Examine the specimen for Barrett mucosa, presenting as salmon / pink, granular mucosa (similar to gastric mucosa) above the GE junction, replacing the glistening white squamous mucosa
Tumors that have their epicenter at the gastroesophageal junction and extend no more than 2 cm into the proximal stomach are staged as esophageal, while tumors with an epicenter more than 2 cm into the proximal stomach are staged as primary gastric carcinoma even if the tumor involves the gastroesophageal junction (Amin: AJCC Cancer Staging Manual, 8th Edition, 2017)
15 lymph nodes are recommended for esophageal or GE junction cancer; however, if not found submit entire adventitial tissue for lymph nodes (Ann Surg Oncol 2020;27:1227)
For EMR, immediate pinning and fixing of the specimen helps preserve the size, shape and orientation of the lesion

Diagrams / tables

Images hosted on other servers:

Sections to obtain from esophagectomy specimen

How to obtain sections from margins

Frozen section

Assessment of margins
Assessment of depth of invasion and margin in an EMR (Clin Gastroenterol Hepatol 2006;4:173)
Confirmation of pathology
Volume of cancer cells for tumor banking (Methods Mol Biol 2020;2129:83)

Gross description

Portions of esophagus are usually resected to remove neoplasms and less frequently strictures
After checking the history, indication for the procedure and most recent endoscopic findings, proceed as below

Gross images

Images hosted on other servers:

Esophagectomy with proximal portion of stomach

Esophagectomy specimen status posttreatment

Esophageal endoscopic mucosal resection

Sample gross description report

The specimen designated esophagus is received fresh in a container labeled with the patient's 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
- Cassette 2: distal resection margin, en face
- Cassettes 3 - 4: tumor with deepest extent of invasion and deep margin, longitudinal
- Cassette 5: tumor with adjacent esophageal mucosa, longitudinal, representative
- Cassette 6: tumor with adjacent gastric mucosa, longitudinal
- Cassette 7: abnormal esophageal mucosa, representative
- Cassette 8: normal gastric mucosa, representative
- Cassettes 9 - 10: submit all lymph nodes, entirely

Gross differential diagnosis

Normal esophageal mucosa white, smooth and glistening
Adenocarcinoma:
- Close to the GE junction
- Grossly resemble colonic adenocarcinomas
- Tan / pink, polypoid, central 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
Squamous cell carcinoma:
- Occurs in upper, middle and lower esophagus
- Exophytic (intraluminal), infiltrative / ulcerating or circumferential thickening
- Preoperative radiation therapy given in most cases
- Residual tumor difficult to detect and may be present as shallow ulceration, erosion, fibrosis or granular mucosa
Leiomyoma:
- Typically arises from muscularis propria
- Well circumscribed tumor with white-pink, whorled cut surfaces
- Intramural or intraluminal / polypoid

Features to report - general

Editorial note
Lymphoma (consider the Hodgkin or non-Hodgkin protocol)
Gastrointestinal stromal tumor (consider the GIST protocol)
Non-GIST sarcomas (consider the soft tissue protocol)
Others (report 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
Reference: Arch Pathol Lab Med 2015;139:1446

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
- Mid esophagus:
  - Upper thoracic esophagus
  - Mid thoracic esophagus
- Distal (lower thoracic) esophagus
- Esophagogastric junction (EGJ)
- Proximal stomach and EGJ
- Other (specify)
- Not specified
- Esophagus not otherwise specified
Relationship of tumor to 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
- Adenoid cystic carcinoma
- Mucoepidermoid carcinoma
- Basaloid squamous cell carcinoma
- Spindle cell squamous cell carcinoma
- Verrucous squamous cell carcinoma
- Lymphoepithelioma-like carcinoma
- Mixed squamous cell carcinoma - neuroendocrine carcinoma
- Mixed adenocarcinoma - neuroendocrine carcinoma
- Mixed adenocarcinoma - neuroendocrine tumor
- 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 (Middle East J Dig Dis 2017;9:5):
- If all margins uninvolved by invasive carcinoma, dysplasia and intestinal metaplasia
- Margins examined (proximal, distal, radial, mucosal, deep, others):
  - Distance of invasive carcinoma from closest margin: __ cm
  - Specify closest margin
- Proximal / distal margin involved by:
  - Invasive carcinoma
  - Dysplasia:
    - Squamous dysplasia: low / high grade
    - Intestinal metaplasia (Barrett esophagus) with dysplasia: low grade / 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):
  - Cannot be assessed
  - Uninvolved by invasive carcinoma
  - Involved by invasive carcinoma
- For endoscopic resection specimens only:
  - Mucosal margin:
    - Cannot be assessed
    - Involved by invasive carcinoma
    - Uninvolved by invasive carcinoma
      - Uninvolved by dysplasia
      - Involved by:
        
        Squamous dysplasia: low / high grade
        Intestinal metaplasia (Barrett esophagus) with dysplasia: low grade / high grade
Treatment effect (carcinomas treated with neoadjuvant therapy) (Dis Esophagus 2006;19:329):
- No prior treatment
- Present:
  - No viable cancer cells (complete response, score 0)
  - Single cells or rare small groups of cancer cells (near complete response, score 1)
  - Residual cancer with evident tumor regression (partial response, score 2)
  - No definite response / absent with extensive residual cancer with no evident tumor regression (poor / no response, score 3)
  - Cannot be determined
- Treatment history not known
Lymphovascular invasion:
- Not identified
- Present
- Indeterminate
Perineural invasion:
- Not identified
- Present
- Indeterminant
Regional lymph nodes:
- Lymph node examination required only if lymph nodes present in the specimen
  - No nodes submitted or found
  - Number of lymph nodes involved
  - Number of lymph nodes examined
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)
- Squamous or glandular dysplasia: low grade / high grade
- Esophagitis
- Gastritis
- Other (specify)
Ancillary studies (specify):
- HER2 neu status: for HER2 reporting, CAP gastric HER2 template should be used
Clinical history:
- Barrett esophagus
- Other (specify)
- Not known
References: Edge: AJCC Cancer Staging Manual, 7th Edition, 2009, CAP: Cancer Protocol Templates [Accessed 21 June 2022], CAP: Protocol for the Examination of Specimens from Patients with Carcinoma of the Esophagus [Accessed 21 June 2022], Surg Oncol Clin N Am 2006;15:751

Features to report - optional

Size of largest tumor involvement in metastatic lymph node (Ann Surg Oncol 2002;9:1010, Ann Thorac Surg 2007;83:1265)
Extracapsular lymph node involvement (Am J Surg Pathol 2006;30:171)
Other features (esophagitis, Barrett esophagus, dysplasia, specific types of infection)

Board review style question #1

For esophageal or gastroesophageal junction cancers, what is the number of lymph nodes recommended for pathological evaluation?

At least 5
At least 5 - 10
Not less than 15
No number is required but entire adventitia should be submitted

Board review style answer #1

C. The current evidence supports the goal of obtaining at least 15 lymph nodes for pathological evaluation in both primary esophagectomy and postinduction therapy cases. Earlier, no number was required for esophageal or gastroesophageal cancer. If no lymph node is found, the entire adventitia should submitted (Ann Surg Oncol 2020;27:1227).

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