ENDOSCOPIC RESECTION (ER)
OF THE OESOPHAGUS AND
GASTRO-OESOPHAGEAL
JUNCTION.
STRUCTURED REPORTING
PROTOCOL
(1st Edition 2013)
Core Document versions:
•
•
AJCC Cancer Staging Manual 7th edition (including errata corrected with
5th reprint 10th Aug 2010).
World Health Organization Classification of Tumours Pathology and
Genetics of Tumours of the Digestive System, 2010, 4th edition
i
ISBN: 978-1-74187-716-8
Publications number (SHPN): (CI) 120057
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o
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o
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First published: February 2013, 1st Edition (Version 1.0)
ii
Disclaimer
The Royal College of Pathologists of Australasia ("College") has developed these
protocols as an educational tool to assist pathologists in reporting of relevant
information for specific cancers. While each protocol includes “standards” and
“guidelines” which are indicators of ‘minimum requirements’ and
‘recommendations’, the protocols are a first edition and have not been through a
full cycle of use, review and refinement. Therefore, in this edition, the inclusion of
“standards” and “guidelines” in each document are provided as an indication of
the opinion of the relevant expert authoring group, but should not be regarded as
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The College makes all reasonable efforts to ensure the quality and accuracy of the
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iii
Contents
Scope ........................................................................................................ v
Abbreviations ............................................................................................ 6
Definitions................................................................................................. 7
Introduction ............................................................................................ 10
Authority and development ..................................................................... 13
1
Pre-analytical ................................................................................ 16
2
Specimen handling and macroscopic findings ............................... 18
3
Microscopic findings ...................................................................... 23
4
Ancillary studies findings .............................................................. 32
5
Synthesis and overview ................................................................ 35
6
Structured checklist ...................................................................... 36
7
Formatting of pathology reports ................................................... 51
Appendix 1
Pathology request information and surgical
handling procedures ................................................. 52
Appendix 2
Guidelines for formatting of a pathology report ....... 59
Appendix 3
Example of a pathology report ................................. 60
Appendix 4
WHO Classificationa of oesophageal tumours ........... 62
References .............................................................................................. 64
iv
Scope
This protocol contains standards and guidelines for the preparation of structured
reports relating to endoscopic resection (ER) of pre-malignant and malignant
lesions of the oesophagus and gastro-oesophageal junction. Endoscopic resection
is the term used to describe the endoscopic removal of mucosal and superficial
submucosal confined neoplastic lesions either by Endoscopic Submucosal
Dissection (ESD) techniques (en-bloc resection) or by the previously termed
Endoscopic Mucosal Resection (EMR) techniques (piecemeal for lesions > 2cm).
Given that the submucosa is commonly included in EMR resection specimens
Endoscopic Resection (ER) is the preferred term to encompass specimens
resected by both methods.
Endoscopic biopsy specimens are excluded. Surgically resected specimens are
covered in a separate document.
Structured reporting aims to improve the completeness and usability of pathology
reports for clinicians, and in particular to guide clinical decision making. The
protocol provides a framework for reporting of any oesophageal and gastrooesophageal junction ER specimens, whether as a minimum data set or fully
comprehensive report. This approach also allows easy extraction of relevant
information for cancer registries and for clinical, translational and basic research.
The structured report allows flexibility in the report, including the provision of any
appropriate additional information as free text.
v
Abbreviations
AJCC
ER
ESD
GOJ
PBS
RCPA
TNM
UICC
WHO
American Joint Committee on Cancer
Endoscopic Resection
Endoscopic Submucosal Dissection
Gastro-oesophageal junction
Pharmaceutical Benefits Scheme
Royal College of Pathologists of Australasia
tumour-node-metastasis
International Union Against Cancer
World Health Organization
6
Definitions
The table below provides definitions for general or technical terms used in this
protocol. Readers should take particular note of the definitions for ‘standard’,
‘guideline’ and ‘commentary’, because these form the basis of the protocol.
Ancillary
study
An ancillary study is any pathology investigation that may form
part of a cancer pathology report but is not part of routine
histological assessment.
Clinical
information
Patient information required to inform pathological assessment,
usually provided with the specimen request form, also referred
to as “pre-test information”.
Commentary
Commentary is text, diagrams or photographs that clarify the
standards (see below) and guidelines (see below), provide
examples and help with interpretation, where necessary (not
every standard or guideline has commentary).
Commentary is used to:
•
define the way an item should be reported, to foster
reproducibility
•
explain why an item is included (e.g. how does the item
assist with clinical management or prognosis of the
specific cancer).
•
cite published evidence in support of the standard or
guideline
•
state any exceptions to a standard or guideline.
In this document, commentary is prefixed with ‘CS’ (for
commentary on a standard) or ‘CG’ (for commentary on a
guideline), numbered to be consistent with the relevant
standard or guideline, and with sequential alphabetic lettering
within each set of commentaries (eg CS1.01a, CG2.05b).
General
commentary
General commentary is text that is not associated with a
specific standard or guideline. It is used:
•
to provide a brief introduction to a chapter, if necessary
•
for items that are not standards or guidelines but are
included in the protocol as items of potential
importance, for which there is currently insufficient
evidence to recommend their inclusion. (Note: in future
reviews of protocols, such items may be reclassified as
either standards or guidelines, in line with diagnostic
and prognostic advances, following evidentiary review).
7
Guideline
Guidelines are recommendations; they are not mandatory, as
indicated by the use of the word ‘should’. Guidelines cover
items that are not essential for clinical management, staging or
prognosis of a cancer, but are recommended.
Guidelines include key observational and interpretative findings
that are fundamental to the diagnosis and conclusion. Such
findings are essential from a clinical governance perspective,
because they provide a clear, evidentiary decision-making trail.
Guidelines are not used for research items.
In this document, guidelines are prefixed with ‘G’ and
numbered consecutively within each chapter (eg G1.10).
Macroscopic
findings
Measurements or assessment of a biopsy specimen made by
the unaided eye.
Microscopic
findings
In this document, the term ‘microscopic findings’ refers to
histo-morphological assessment.
Predictive
factor
A predictive factor is a measurement that is associated with
response or lack of response to a particular therapy.
Prognostic
factor
A prognostic factor is a measurement that is associated with
clinical outcome in the absence of therapy or with the
application of a standard therapy. It can be thought of as a
measure of the natural history of the disease.
Standard
Standards are mandatory, as indicated by the use of the term
‘must’. Their use is reserved for core items essential for the
clinical management, staging or prognosis of the cancer and
key information (including observations and interpretation)
which is fundamental to the diagnosis and conclusion. These
elements must be recorded and at the discretion of the
pathologist included in the pathology report according to the
needs of the recipient of the report.
The summation of all standards represents the minimum
dataset for the cancer.
In this document, standards are prefixed with ‘S’ and
numbered consecutively within each chapter (eg S1.02).
Structured
report
A report format which utilises standard headings, definitions
and nomenclature with required information.
Synoptic
report
A structured report in condensed form (as a synopsis or
precis).
8
Synthesis
Synthesis is the process in which two or more pre-existing
elements are combined, resulting in the formation of
something new.
The Oxford dictionary defines synthesis as “the combination of
components or elements to form a connected whole”.
In the context of structured pathology reporting, synthesis
represents the integration and interpretation of information
from two or more modalities to derive new information.
9
Introduction
Oesophageal and Gastro-oesophageal Junction Cancer
The College of American Pathologists (CAP), Association of Directors of Anatomic and
Surgical Pathology (ADASP) and the Royal College of Pathologists (United Kingdom)
have recently published protocols for the reporting of oesophageal cancer. 1-3 There
are no specifically dedicated protocols relating to the handling and reporting of
specimens from the oesophagus removed using ER techniques.
Endoscopic resections are performed as diagnostic staging and therapeutic
procedures. Results may determine further management and treatment of a variety
of precursor lesions and early cancers (T1N0). This has now become the standard of
care in Japan.4-6
In some western centres the experience of handling specimens of endoscopic
resections may be limited, however given the significant advantages of ER in contrast
with oesophagectomy with respect to the associated morbidity and mortality, these
techniques are rapidly being adopted and therefore pathologists are more likely to
encounter these specimens.
Endoscopic resections are usually performed subsequent to a diagnosis of high-grade
intraepithelial neoplasia (dysplasia), early malignancy (T1N0) or nodular lesions with
any grade of intraepithelial neoplasia.7 Although there is no universal consensus, the
term "intraepithelial neoplasia" (IEN) is preferred over the term dysplasia to
encompass all non-invasive neoplasia, whether based on traditional morphological
features or on clonal/molecular abnormalities in the absence of the traditional
morphological abnormalities.8
The application of a standardised protocol by pathologist for handling, grossing, and
assessing ER specimens is critical for consistent accurate diagnosis thereby enabling
appropriate clinical decision-making. All specimens provided by ER techniques should
be handled and reported as surgical specimens paying particular attention to
maintenance of proper orientation, meticulous macroscopic examination, accurate
lesion mapping and appropriate morphologic diagnosis. This publication aims to fulfil
this need by incorporating available relevant evidence-based information and
collective opinions from an expert multidisciplinary group. The intention is to provide
pathologists with a minimum dataset and guidelines that are comprehensive and easy
to use. It is hoped that this will help the clinicians to manage the patients optimally.
Given this background, structured reporting of endoscopic resections of premalignant lesions and early cancers of the oesophagus and gastro-oesophageal
junction aims at "guiding/teaching" to ensure that reporting is up to a desired
standard, "enhancing" the practice of pathology with regards to these lesions,
"inducing" the clinicians to undertake appropriate management and "promoting"
relevant advanced research in Australia.
Importance of histopathological reporting
The role of the histopathologist in reporting endoscopic resections is to confirm the
endoscopic abnormality and to provide information that would enable clinicians to
decide on further management and staging of the lesion. Thus, the outcomes of
endoscopic resections should include a report that would confirm or modify the pre10
procedure diagnosis with information about (1) the presence or absence of
intraepithelial neoplasia/dysplasia and the severity (2) the presence or absence of
malignancy, and if malignancy is present, (3) the degree of differentiation, (4) the
status of the margins (lateral and deep), ie. completeness of excision, (5) the depth
of invasion and (6) the status of vascular invasion, especially in cases with
submucosal invasion (stage T1b). There is evidence that the degree of
differentiation, the depth of invasion and lympho-vascular invasion seen in
endoscopic resection specimens, may be predictors of lymph node metastasis and
therefore indicate the need for surgical management as definitive therapy.9-10
Technical issues and artefacts such as haemorrhage, electro-diathermy effect, and
poor preparation of specimens with shrinkage that would hamper accurate histologic
interpretation should be conveyed to the clinicians for the purpose of quality
improvement.
Benefits of structured reporting
It is not uncommon to find inconsistencies in pathology reports within single
institutions, across organisations, states and countries. The single most effective way
to overcome this situation is to create a standardised reporting system that will
ensure that key pathological features necessary for patient management and
prognostication are included. It is also desirable to document important features in a
systematic fashion for the purposes of audits, tumour registries and research.
Design of this protocol
This protocol defines the relevant information to be assessed and recorded in a
pathology report for lesions of the oesophagus and gastro-oesophageal junction
removed by ER. Mandatory elements (standards) are differentiated from those that
are not mandatory but represent best practice (guidelines). Also, items suited to tick
boxes are distinguished from more complex elements requiring free text or narrative.
The structure provided in the following chapters, headings and subheadings describe
the elements of information and their groupings, but does not necessarily represent
the format of either a pathology report or a checklist. These and the structured
pathology request form (Appendix 1) are templates that represent information from
this protocol, organised and formatted differently to suit different purposes.
11
Key documentation
•
Guidelines for Authors of Structured Cancer Pathology Reporting Protocols11
•
The Pathology Request-Test-Report Cycle — Guidelines for Requesters and
Pathology Provider12
•
WHO Classification of tumours, Pathology and Genetics of Tumours of the
Digestive System, 2010, 4th edition8
•
AJCC Cancer Staging Manual, 7th edition, 201013
•
The Paris endoscopic classification of superficial neoplastic lesions: esophagus,
stomach, and colon14
Updates since last edition
Not applicable
12
Authority and development
This section provides details of the committee involved in developing this protocol
and the process by which it was developed.
Protocol developers
This protocol was developed by an expert committee, with assistance from relevant
stakeholders.
Expert committee
Clinical Prof Priyanthi Kumarasinghe (Chair and lead author), Pathologist
Dr Ian Brown, Pathologist
Dr Amanda Charlton, Pathologist
Clin A/Prof Bastiaan de Boer, Pathologist
A/Prof Robert Eckstein, Pathologist
Dr Krishna Epari, Surgeon
Dr Anthony Gill, Pathologist
Prof Alfred Lam, Pathologist
Prof Gregory Lauwers, Pathologist
Dr Cathy Streutker, Pathologist
Dr Spiro Raftopoulos, Gastroenterologist
Prof Michael Bourke, Gastroenterologist
A/Prof Timothy Price, Medical Oncologist
International Liaison
Dr Mary K Washington, Chair of the Gastrointestinal Tumors Cancer Committee,
College of American Pathologists.
Acknowledgements
The oesophageal tumour expert committee wish to thank all the pathologists and
clinicians who contributed to the discussion around this document.
13
Stakeholders
ACT Health
Anatomical Pathology Advisory Committee (APAC)
Australian Association of Pathology Practices Inc (AAPP)
Australian Cancer Network
Australian Commission on Safety and Quality in Health Care
Cancer Australia
Cancer Control New Zealand
Cancer Council ACT
Cancer Council NSW
Cancer Council Queensland
Cancer Council SA
Cancer Council Tasmania
Cancer Council Victoria
Cancer Council Western Australia
Cancer Institute NSW
Cancer Services Advisory Committee (CanSAC)
Cancer specific expert groups – engaged in the development of the protocols
Cancer Voices
Clinical Oncology Society of Australia (COSA)
Colorectal Cancer Research Consortium
Department of Health and Ageing
Gastroenterological Society of Australia GESA
Grampians Integrated Cancer Services (GICS)
Health Informatics Society of Australia (HISA)
Independent Review Group of Pathologists
Medical Software Industry Association (MSIA)
National Breast and Ovarian Cancer Centre (NBOCC)
National Coalition of Public Pathology (NCOPP)
National E-Health Transition Authority (NEHTA)
National Pathology Accreditation Advisory Council (NPAAC)
National Round Table Working Party for Structured Pathology Reporting of Cancer.
New Zealand Guidelines Group (NZGG)
14
New Zealand Ministry of Health
New Zealand Society of Gastroenterology (NZSG)
NSW Department of Health
Peter MacCallum Cancer Institute
Queensland Cooperative Oncology Group (QCOG)
Representatives from laboratories specialising in anatomical pathology across
Australia
Royal Australasian College of Physicians (RACP)
Southern Cancer Network, Christchurch, New Zealand
Southern Melbourne Integrated Cancer Service (SMICS)
Standards Australia
The Medical Oncology Group of Australia
The Royal Australasian College of Surgeons (RACS)
The Royal Australian and New Zealand College of Radiologists (RANZCR)
The Royal Australian College of General Practitioners (RACGP)
The Royal College of Pathologists of Australasia (RCPA)
Victorian Cooperative Oncology Group (VCOG)
Western Australia Clinical Oncology Group (WACOG)
Secretariat
Meagan Judge, Royal College of Pathologists of Australasia.
Development process
This protocol has been developed following the nine-step process set out in
Guidelines for Authors of Structured Cancer Pathology Reporting Protocols.11
Where no reference is provided, the authority is the consensus of the expert group.
15
1
Pre-analytical
This chapter relates to information that should be recorded on receipt of the
specimen in the laboratory.
The pathologist is reliant on the quality of information received from the clinicians or
requestor. Some of this information may be received in generic pathology request
forms, however, the additional information required by the pathologist specifically for
the reporting of endoscopic resections is outlined in Appendix 1 which also includes a
standardised request information sheet that may be useful in obtaining all relevant
information from the requestor.
Surgical handling procedures affect the quality of the specimen and recommendations
for appropriate surgical handling are included in Appendix 1.
S1.01
S1.02
All demographic information provided on the request form and
with the specimen must be recorded.
CS1.01a
The Royal College of Pathologists of Australasia (RCPA) The
Pathology Request-Test-Report Cycle — Guidelines for
Requesters and Pathology Providers must be adhered to.15
This document specifies the minimum information to be
provided by the requesting clinician for any pathology test.
CS1.01b
The patient’s ethnicity must be recorded, if known. In
particular whether the patient is of Aboriginal or Torres
Strait islander origin. This is in support of a government
initiative to monitor the health of indigenous Australians
particularly in relation to cancer.
CS1.01c
The patient’s health identifiers may include the patient’s
Medical Record Number as well as a national health number
such as a patient’s Medicare number (Australia), Individual
Healthcare Identifier (IHI) (Australia) or the National
Healthcare Identifier (New Zealand).
All clinical information as documented on the request form must
be recorded verbatim.
CS1.02a
The request information may be recorded as a single text
(narrative) field or it may be recorded atomically.
S1.03
The pathology accession number of the specimen must be
recorded.
S1.04
The principal clinician involved in the patient’s care and
responsible for investigating the patient must be recorded.
CS1.04a
The requesting clinician (identified under S1.01) may be
the doctor who performs the surgery or biopsy, and may
not be the person with overall responsibility for
investigating and managing the patient. Identification of
the principal clinician is essential, to ensure that
pathological and clinical information is communicated
16
effectively.
CS1.04b
Knowledge of the clinical presentation is an essential part
of the WHO classification yet it may not be available for a
number of reasons:
• The clinical assessment and staging may be
incomplete at the time of endoscopic resection
• The pathology request is often authored by the
clinician performing the endoscopic resection rather
than the clinician who is investigating and managing
the patient
• The identity of this clinician is often not indicated on
the pathology request form
In practice therefore, it is important in such cases that the
reporting pathologist should be able to communicate with
the managing clinician for clarification.
S1.05
The proceduralist’s identity and contact details must be
recorded.
G1.01
Any clinical information received in other communications from the
requestor or other clinician should be recorded together with the source
of that information.
17
2 Specimen handling and macroscopic
findings
This chapter relates to the procedures required after the information has been
handed over from the requesting clinician and the specimen has been received in the
laboratory.
Specimen handling

Generally the entire ER specimen is subjected to microscopic
examination and it is unwise to procure tissue samples for tissue banking
or research purposes except under exceptional circumstances. As a
safeguard, research use of any part of the specimen should be put on
hold until the diagnostic process is complete.

The number of endoscopic resections (ERs) separately received
and/or in each container should be matched with the labelling
and information provided on the request form and submitted
separately as appropriate. The specimen(s) must be handled in a
systematic and thorough fashion to ensure completeness and
accuracy of pathological data.
•
Specimen reception: Specimens are best received with the
mucosa upward pinned on a cork board or similar firm base in the
endoscopic suite. If not this should be done in the laboratory
immediately on receipt of specimen. (Refer to Figure SH1 below).
18
Figure SH1
•
Specimen measurement, fixation and orientation:
Immediate pinning and fixing of the specimen help to preserve
the tissue size, shape, and orientation. They are best fixed for at
least 12 hours in formalin. After fixation, the surgical margins
(lateral and deep) must be appropriately inked. Where
orientation is required, the endoscopist should use the designation
of O (oral) and A (anal) or P (proximal) and D (distal) marked on
the board. In this situation it is necessary for the pathologists to
specifically indicate the respective ends of the specimens. This will
allow the endoscopist to be informed of the area that may require
further resection. Care must be taken to orient the sections such
that the circumferential (lateral) surgical margins are assessed,
either “en bloc” or in cross sections, depending on the size of the
specimen. A photograph will be helpful for mapping the
lesion/margins and to document the macroscopic appearance of
the lesion for comparison with the endoscopic impression (refer to
Appendix 1 and Figure A1).
•
A photograph, with a ruler in place, may be taken after removal of
the pins.
•
Specimen dissection: The specimen must be entirely submitted
in sequential sections after ensuring the best possible orientation
and routinely processed, cut and stained with hematoxylin and
19
eosin. The specimen is cut into 2-3 mm (not less than 2 mm)
parallel slices from one end to the other. If the specimen is
oriented it can be cut along the oral/anal plane. The plane can be
modified according to the margin of interest. The slices are
serially placed into the cassettes starting with the first slice. No
more than 4 slices are placed into 1 cassette. Circumferential
(lateral) surgical margins are assessed, either “en bloc” or in cross
section, depending on the size of the specimen. The first slice
may be inverted to allow the margin to be sectioned first during
histological evaluation (Refer to figure SH2). Larger/ longer
cassettes may be used if the facility is available.
20
Figure SH2
Mucosal slices
Macroscopic findings
S2.01
All linear measurements are in SI units, unless explicitly
stated.
S2.02
The specimen dimensions and maximum size of any visible
lesion(s) must be recorded.
CS2.02a
The specimen and any visible lesion(s) are measured in 2
dimensions. Note that the resected specimens tend to
shrink considerably both before and after fixation, making
measurements shorter than in vivo.
If there are multiple specimens, dimensions should be
given for each.
G2.01
The gross appearance of the lesion(s) should be recorded.
S2.03
The distance from the lesion (if identifiable) to the nearest
margin (cut edge) must be recorded.
S2.04
The nature and site of all blocks must be recorded.
CS2.04a
A diagram or photograph showing the serial slices and a
key to the blocks taken may be helpful. (See figure SH2
21
above).
G2.02
A descriptive or narrative field should be provided to record any
macroscopic information that is not recorded in the above standards
and guidelines, and that would normally form part of the macroscopic
description.
CG2.02a
The traditional macroscopic narrative recorded at the time
of specimen dissection is often reported separately from
the cancer dataset. Although this remains an option, it is
recommended that macroscopic information be recorded
within the overall structure of this protocol.
CG2.03b
Much of the information recorded in a traditional
macroscopic narrative is covered in the standards and
guidelines above and in many cases, no further description
is required.
22
3
Microscopic findings
This section relates to purely histological (morphological) assessment. Information
derived from multiple investigational modalities, or from two or more chapters, is
described in Chapter 5.
S3.01
The type of mucosa and tissue layers present must be
recorded.
CS3.01a
Options include:
•
Mucosa (M)
o
Glandular
o
Squamous
o
Mixed
•
Muscularis mucosae (MM)
•
Submucosa (SM)
Refer to Figure S3.01 below.
CS3.01b
A comment should be made if muscularis mucosae is
duplicated. Although attempts have been made to grade
the extent this may not be practical in all cases.16
Submucosa is identified by the presence of large calibre
thick walled vessels.
CS3.01c
Muscularis propria may be present in some specimens. If
muscularis propria is seen it may suggest that perforation
has occurred.
23
Figure S3.01
S3.02
Tissue layers
The type of lesion(s) present must be recorded.
CS3.02a
These types are:
1. No carcinoma or Intraepithelial neoplasia (IEN)
2. Indefinite for IEN/ Dysplasia
3. IEN/Dysplasia
4. Carcinoma
S3.03
CS3.02b
A comment should be made if neoplastic elements are
present in a sub-squamous location.
CS3.02c
IF IEN, complete S3.03 – S3.04.
CS3.02d
If carcinoma, complete S3.05 – S3.09, G3.01, G3.02
The histologic type of the intraepithelial neoplasia
(IEN)/dysplasia must be recorded if present.
CS3.03a
The histologic types will be either:
•
Squamous
•
Glandular
24
S3.04
The histologic grade of the intraepithelial neoplasia
(IEN)/dysplasia must be recorded if present.
CS3.04a
For intraepithelial neoplasia(IEN)/dysplasia the histologic
grade will be:
•
Low
•
High
•
Indefinite
WHO guidelines should be used.
CS3.04b
S3.05
Atypia that raises concern but not diagnostic of dysplasia
(IEN) is labelled “Indefinite for dysplasia” (IDD) in the
tubular gut.8,17 This can be due to technical and/or
interpretative difficulties. The form of dysplasia that is
being recognised as crypt dysplasia where the dysplastic
changes are confined to the crypts without surface
involvement is likely to be called IDD by some.18-20
Although it is generally believed the worrisome atypia
raises the possibility of a low grade lesion in practice, there
may be features that may raise the possibility of a high
grade lesion. This situation may arise in particular with
increasing recognition of different morphological types of
dysplasia associated with Barrett disease. Therefore it is
prudent that the degree of uncertainty is correctly
conveyed to the clinician. There is insufficient data
regarding the biological potential of the diagnosis of IDD.20
Currently there are no strict guidelines regarding the
management of these lesions.
If carcinoma, the histologic type must be recorded.
CS3.05a
Record the histologic type according to the WHO
classification8:
•
Squamous cell carcinoma
•
Adenocarcinoma
•
Adenoid cystic carcinoma
•
Adenosquamous carcinoma
•
Basaloid squamous cell carcinoma
•
Mucoepidermoid carcinoma
•
Spindle cell (squamous) carcinoma
•
Verrucous (squamous) carcinoma
•
Undifferentiated carcinoma
25
S3.06
If carcinoma, the histologic grade must be recorded.
CS3.06a
CS3.06b
G3.01
•
G1 Well differentiated
•
G2 Moderately differentiated
•
G3 Poorly differentiated
•
G4 Undifferentiated – stage grouping as G3
squamous.
It is important to document the presence of poorly and
undifferentiated components as this might influence the
decision for surgery.21
This may be recorded as one of the following:
•
Intestinal
•
Gastric
•
Mixed/hybrid
Immunohistochemical stains may be useful to suggest a
phenotype (refer to chapter 4).
If carcinoma, the tumour size must be specified.
CS3.07a
Size must be recorded in maximal dimension for each
tumour identified.
If carcinoma, the depth of invasion must be recorded.
CS3.08a
S3.09
GX Grade cannot be assessed – stage grouping as
G1
23
CG3.01b
S3.08
•
If adenocarcinoma, the phenotype of the tumour may be recorded.22CG3.01a
S3.07
The tumour should receive a histological grade a based on
the AJCC classification13:
The depth of invasion should be recorded according to the
AJCC13:
•
Cannot be assessed
•
T1a – tumour invades lamina propria or muscularis
mucosae
•
T1b - Tumour invades submucosa
If adenocarcinoma or squamous cell carcinoma, an additional
level of detail on depth of invasion must be recorded.
a
Used with the permission of the American Joint Committee on Cancer (AJCC),
Chicago, Illinois. The original source for this material is the AJCC Cancer Staging
Manual, Seventh Edition (2010) published by Springer Science and Business Media
LLC, www.springerlink.com.
26
CS3.09a
There is evidence that depth of tumour invasion provides
additional information about the need for surgical
management and/or other forms of therapy as definitive
treatment.9,10,21,24 There are 2 methods to further subdivide
the depth of invasion. The method, AJCC or Stolte should
be recorded in the report.
CS3.09b
The first is based on recommendations by AJCC on the
subdivisions of the mucosa and as described by Hölscher et
al.9 This system subdivides both mucosal invasion (T1a)
and submucosal invasion (T1b) into 3 levels (see Figure
CS3.09b below). This system is applicable to both
squamous and adenocarcinomas.
In the AJCC, T1a is sub-divided as M1-M3
•
m1 - In situ
•
m2 - into the lamina propria
•
m3 – into the muscularis mucosae
T1b is sub-divided as SM1-3
This division may be difficult and essentially depends on
the amount of submucosa included in the specimen.
Division of submucosal invasion will not be applicable to
lesions that are T1a. When there is submucosal invasion in
an ER specimen subdivision may not be accurate as the full
thickness of the submucosa is often not included.
•
sm1 – superficial 1/3 submucosa
•
sm2 – intermediate one third of submucosa
•
sm3 – outer one third of submucosa
27
Figure: CS3.09b
CS3.09c
Early carcinoma: Depth of tumour infiltration (3
mucosal tiers)
The second is a 4 tiered system recommended by Stolte25
and others to assess mucosal invasion of adenocarcinomas
(see figure CS3.09c (i) below). Their recommendations
take into account the duplication of muscularis mucosae
that occurs in columnar lined mucosa and Barrett
oesophagus (see figure CS3.09c (ii) below). The duplicated
muscularis mucosae shows an inner layer of muscularis
mucosae, which is identified immediately deep to the
lamina propria, and an outer layer of muscularis mucosae,
that lies immediately superficial to the submucosa. The
space between the duplicated muscularis mucosae is loose
connective tissue and thin-walled vessels (capillaries).
Large-calibre, thick-walled blood vessels such as large
arteries are not seen in this space in between the inner and
outer layers of muscularis mucosa.26,27,16,24,28
They draw a distinction between the different levels of
invasion within the duplicated muscularis mucosa as there
is emerging evidence that this may correlate with a
difference in the behaviour of T1a adenocarcinomas.29
More importantly it is important to appreciate the presence
of duplicated and distorted muscularis mucosa in these
lesions to avoid misinterpretation of muscle invasion.
In Stolte, T1a is sub-divided as M1-M3
•
m1 - into the lamina propria
28
•
m2 - into the superficial/inner muscularis mucosae
•
m3 - into the space between the layers of the
muscularis mucosae
•
m4 - into the outer/true muscularis mucosae
T1b subdivision is similar to AJCC based system.
Figure: CS3.09c (i)
Early carcinoma: Depth of tumour infiltration (4
mucosal tiers)
29
Figure: CS3.09c (ii)
Duplication of muscularis mucosae
S3.10
If carcinoma, the presence or absence of vascular space
invasion in small (lymphatic and capillary) and large (vein and
artery) calibre vessels must be recorded.
G3.02
If carcinoma, the presence or absence of perineural invasion should be
recorded.
G3.03
The presence or absence of tumour budding should be recorded.
CG3.03a
Tumour budding can be defined as the presence of single
cells or small groups of less than 5 undifferentiated cells at
the invasive front of the carcinoma. More than 5 tumour
buds per square mm has been proposed as a high rate of
tumour budding.
There is early evidence suggesting that tumour budding
may represent an adverse prognostic indicator. However,
at the current time there is insufficient evidence to support
its routine reporting and it should be considered optional as
well as investigational.30-31
S3.11
The margin status must be recorded.
CS3.11a
Record whether the deep and lateral margins are involved
or not involved by:
1. Carcinoma
30
2. IEN/Dysplasia
If not involved, record the distance of tumour to the
closest margin (in mm) in either case where appropriate.
CS3.11b
S3.12
The presence or absence of other pathologies must be
specified.
CS3.12a
G3.04
If multiple specimens are submitted, the deep and lateral
margin status should be assessed as above if the
specimens are oriented and the margin status has been
requested by the surgeon. Lateral margin status may not
be required in some specimens and this decision needs
clear communication between the pathologists and the
endoscopist.
Other pathologies may include:
•
IEN in cases of carcinoma
•
Ulceration
•
Scar formation
•
Columnar metaplasia
•
Goblet cells
•
Infection
•
Foreign body
•
Other changes related to previous treatment
•
Other neoplasms eg granular cell tumours
•
Other (specify)
Any additional relevant microscopic comments should be recorded.
31
4
G4.01
Ancillary studies findings
The results of any ancillary tests performed should be recorded.
CG4.01a
Ancillary tests have been used to support the diagnosis of
intraepithelial neoplasia (IEN)/dysplasia or carcinoma at
the discretion of the pathologist. At this point in time there
is limited evidence for their utility.
CG4.01b
Immunohistochemical stains may be performed to identify
phenotypes. MUC2, CD10, villin and CDX2 are known to be
positive in intestinal phenotype and MUC5AC and MUC6 in
gastric phenotypes.22-23,32-33 The significance of this has not
been determined.
CG4.01c
Ancillary tests may be used to add additional information
or confirmation e.g. D2 40, CD 34, CD31 to assess lymphovascular invasion.
CG4.01d
Her 2 over expression is reported in approximately 15 25% of gastric/gastro-oesophageal junction (GOJ)
adenocarcinomas in Western countries including Australia
(range 2-45% for GOJ and 9-60% for oesophagus).34,35
Trastuzumab-based therapy offers a significant survival
advantage for patients with HER2 overexpressing locally
advanced, recurrent or metastatic gastric/gastrooesophageal adenocarcinomas compared to conventional
therapy alone. The efficacy for low stage, non-metastatic
GOJ or EAC is currently unknown.
CG4.01e
At present, no specific ancillary tests are routinely
recommended for oesophageal tumour classification. In the
case of occasional poorly differentiated carcinoma, mucin
stains (positive, albeit often focal, in adenocarcinoma),
high molecular weight cytokeratin (eg CK5/6; positive in
SCC) and p63 and/or p40 (ΔNp63) (positive in SCC) may
help distinguish SCC from adenocarcinoma and basaloid
squamous carcinoma from adenoid cystic carcinoma.
Spindle cell (squamous) carcinoma will express
cytokeratin, aiding distinction from primary sarcomas and
melanoma.
32
Table G4.01: Morphologic and immunohistochemical features of dysplasia
Pattern of
dysplasia
Intestinal
(adenomatous)
Morphologic
features
- Columnar cells
- Hyperchromatic,
pencillate,
stratified nuclei
See figure G4.01(i)
- Dense eosinophilic
cytoplasm
Gastric foveolar
- Cuboidal to
(non adenomatous)
columnar cells with
pale clear to light
See figure G4.01(ii)
eosinophilic
cytoplasm
- Hyperchromatic
round to oval
nuclei
- Prominent nucleoli
if high grade
- Cytological
Hybrid
features
intermediate
between the above
patterns
- Or an intimate
admixture of both
- Resembling
Serrated
colorectal serrated
lesions
- Poorly
characterised at
present
- Closely packed
Pyloric gland
tubules lined by
cuboidal to
columnar
epithelium with
pale to eosinophilic
ground glass
cytoplasm
- Round basal nuclei
- Nucleoli easily
visible
MUC2
MUC5ac
MUC6
CDX-2
Villin
CD10
+
±
-
+
+
+
-
+
rare
-
-
-
±
+
±
±
±
±
?(+)
?(+)
?
?(+)
?
?
-
+
(surface)
+
-
-
-
33
Figure G4.01(i)
H&E
MUC2
Figure G4.01(ii)
Intestinal panel
CDX-2
VILLIN
Gastric foveolar panel
H&E
CDX-2
MUC5ac
VILLIN
34
5
Synthesis and overview
Information that is synthesised from multiple modalities and therefore cannot reside
solely in any one of the preceding chapters is described here.
By definition, synthetic elements are inferential rather than observational, often
representing high-level information that is likely to form part of the report ‘Summary’
or ‘Diagnosis’ section in the final formatted report.
Overarching case comment is synthesis in narrative format. Although it may not
necessarily be required in any given report, the provision of the facility for
overarching commentary in a cancer report is essential.
G5.01
The ‘Diagnostic summary’ section of the final formatted report should
include:
•
Type of lesion (S3.02)
o
o
G5.02
If carcinoma record:

Histologic type

Histologic grade

Depth of invasion

Margin Status

Vascular invasion

Presence of other pathologies
If IEN record:

Histologic grade

Margin status

Presence of other pathologies
A field for free text or narrative in which the reporting pathologist can
give overarching case comment must be provided.
CG5.02a
CG5.02b
This field may be used, for example, to:
•
list any relevant ancillary tests
•
document any noteworthy adverse gross and/or
histological features
•
express any diagnostic subtlety or nuance that is
beyond synoptic capture
•
document further consultation or results still
pending.
Use of this field is at the discretion of the reporting
pathologist.
35
6
Structured checklist
The following checklist includes the standards and guidelines for this protocol which
must be considered when reporting, in the simplest possible form. The summation of
all “Standards” is equivalent to the “Minimum Data Set” for oesophageal tumours. For
emphasis, standards (mandatory elements) are formatted in bold font.
S6.01
The structured checklist provided below may be modified as
required but with the following restrictions:
a. All standards and their respective naming conventions,
definitions and value lists must be adhered to.
b. Guidelines are not mandatory but are recommendations and
where used, must follow the naming conventions, definitions
and value lists given in the protocol.
G6.01
G6.02
The order of
according to
described in
Reporting of
CG6.01a
Where the LIS allows dissociation between data entry and
report format, the structured checklist is usually best
formatted to follow pathologist workflow. In this situation,
the elements of synthesis or conclusions are necessarily at
the end. The report format is then optimised independently
by the LIS.
CG6.01b
Where the LIS does not allow dissociation between data
entry and report format, (for example where only a single
text field is provided for the report), pathologists may elect
to create a checklist in the format of the final report. In this
situation, communication with the clinician takes precedence
and the checklist design is according to principles given in
Chapter 7.
Where the checklist is used as a report template (see G6.01), the
principles in Chapter 7 and Appendix 2 apply.
CG6.02a
G6.03
information and design of the checklist may be varied
the laboratory information system (LIS) capabilities and as
Functional Requirements for Structured Pathology
Cancer Protocols.36
All extraneous information, tick boxes and unused values
should be deleted.
Additional comment may be added to an individual response where
necessary to describe any uncertainty or nuance in the selection of a
prescribed response in the checklist. Additional comment is not required
where the prescribed response is adequate.
36
Values in italics are conditional on previous responses.
Values in all caps are headings with sub values.
S/G
Item description
Response type
Conditional
Clinical information and surgical handling
S1.01
Demographic information
provided
S1.02
Clinical information provided
on request form
Text
OR
Structured entry as below:
Tumour morphology
Multi select value list (select all that apply):
•
•
Polypoid
o
0-Ip (protruded, pedunculated)
o
0-Is (protruded, sessile; >2.5mm
above baseline)
Non-Polypoid
o
0-IIa (superficial, elevated; <
2.5mm above baseline)
o
0-IIb (flat)
o
0-IIc (superficial shallow,
depressed)
o
0-III (excavated/ulcerated)
37
S/G
Item description
Response type
Conditional
Lesion type
Single selection value list:
If focal, record the site and
location of the lesion as well as
the distal extent and proximal
extent.
Site(s) of the lesion
Location
Distal extent
•
Focal lesion
•
Non-focal lesion
Multi select value list (select all that apply):
•
cervical oesophagus
•
upper thoracic
•
middle thoracic
•
lower thoracic
•
gastro-oesophageal junction
Text: (describe using a clock face orientation)
Numeric: ___cm
Note
This is the most distal extent of the lesion from
the incisors
Proximal extent
Numeric: ___cm
Note
This is the most proximal extent of the lesion
38
S/G
Item description
Response type
Conditional
from the incisors
Type of procedure
Single selection value list:
Details
•
Endoscopic Resection (ER)
•
Endoscopic Submucosal Dissection (ESD)
•
Other
Text
Existence of local residual
neoplasia
Text
Previous pathological
diagnosis
Text
S1.03
Pathology accession number
Alpha-numeric
S1.04
Principal clinician caring for
the patient
Text
S1.05
Proceduralist’s name &
contact details
Text
G1.01
Additional information
Text
Macroscopic findings
39
If other, please specify details
S/G
Item description
Response type
Conditional
S2.02
Specimen dimensions
Numeric: ___x___mm
Notes:
1. length x width
2. Specimen dimensions should be repeated
for each specimen received.
Maximum lesion size
Numeric: ___x___mm
OR
No macroscopically visible lesions
Notes:
1. length x width
2. Lesion size should be repeated for each
visible lesion noted.
G2.01
Gross appearance of lesion(s)
Text
S2.03
Distance of lesion from
closest margin
Numeric: ___mm
OR
Not identifiable
S2.04
Nature and site of all blocks
Text
40
If macroscopically visible lesions
then consider reporting G2.01
and report S2.03.
S/G
Item description
Response type
G2.02
Other macroscopic comment
Text
Conditional
Microscopic findings
S3.01
Tissue layers present
Multi select value list (select all that apply):
•
S3.02
Type of lesion
Mucosa
o
Squamous
o
Glandular
o
Glandular & squamous
•
Muscularis mucosae
•
Submucosa
•
Muscularis propria
Single selection value list:
1. No carcinoma and Intraepithelial neoplasia
(IEN)
If carcinoma, complete S3.05S3.10 and consider G3.01 and
G3.02
2. Indefinite for IEN/ Dysplasia
If IEN complete S3.03 – S3.04.
3.
Intraepithelial neoplasia(IEN)/Dysplasia
4. Carcinoma
Neoplastic elements in sub-
Text
41
If Carcinoma or IEN, record
whether the neoplastic
elements are in a sub-squamous
location.
S/G
Item description
Response type
Conditional
Single selection value list:
Conditional on IEN/dysplasia
being recorded in S3.02.
squamous location?
S3.03
S3.04
S3.05
S3.06
Histological type IEN/dysplasia
Histological grade IEN/dysplasia
Histologic type - carcinoma
Histologic grade-carcinoma
•
Squamous
•
Glandular
Single selection value list:
•
Low
•
High
•
Indefinite
Single selection value list:
•
Squamous cell carcinoma
•
Adenocarcinoma
•
Adenoid cystic carcinoma
•
Adenosquamous carcinoma
•
Basaloid squamous cell carcinoma
•
Mucoepidermoid carcinoma
•
Spindle cell (squamous) carcinoma
•
Verrucous (squamous) carcinoma
•
Undifferentiated carcinoma
Single selection value list:
42
Conditional on IEN/dysplasia
being recorded in S3.02.
Conditional on carcinoma being
recorded in S3.02.
Conditional on carcinoma being
S/G
G3.01
S3.07
Item description
Phenotype
Tumour size
Response type
Conditional
recorded in S3.02.
•
Not applicable
•
GX Grade cannot be assessed
•
G1 Well differentiated
•
G2 Moderately differentiated
•
G3 Poorly differentiated
•
G4 Undifferentiated
Single selection value list:
•
Intestinal
•
Gastric
•
Mixed/hybrid
Numeric: ___mm
Conditional on adenocarcinoma
being recorded in S3.02.
Conditional on carcinoma being
recorded in S3.02.
Notes:
1. Maximum dimension
2. Tumour size should be repeated for each
tumour noted.
S3.08
Depth of invasion
Single selection value list:
•
Cannot be assessed
•
T1a – tumour invades lamina propria or
muscularis mucosae
•
T1b - Tumour invades submucosa
43
Conditional on carcinoma being
recorded in S3.02.
S/G
Item description
Response type
Conditional
S3.09
Additional detail - depth of
invasion
Note: 1 or both of the below subdivisions
may be reported.
Conditional on adenocarcinoma
or squamous cell carcinoma
being recorded in S3.02.
3-tiered (AJCC)
4-tiered (Stolte)
Single selection value list:
•
m1 - In situ
•
m2 - into the lamina propria
•
m3 – into the muscularis mucosae
•
sm1 – superficial 1/3 submucosa
•
sm2 – intermediate one third of
submucosa
•
sm3 – outer one third of submucosa
Single selection value list:
•
m1 - into the lamina propria
•
m2 - into the superficial/inner muscularis
mucosae
•
m3 - into the space between the layers of
the muscularis mucosae
•
m4 - into the outer/true muscularis
mucosae
44
Conditional on adenocarcinoma
or squamous cell carcinoma
being recorded in S3.02.
S/G
Item description
Response type
Conditional
S3.10
Lymphatic and capillary
space invasion
Single selection value list:
Conditional on carcinoma being
recorded in S3.02.
Vein and artery space
invasion
G3.02
G3.03
S3.11
Perineural invasion
Tumour budding
SURGICAL MARGIN STATUS
•
Absent
•
Present
Single selection value list:
•
Absent
•
Present
Single selection value list:
•
Absent
•
Present
Single selection value list:
•
Absent
•
Present
Note
If multiple specimens are submitted, the deep
and lateral margin status should be assessed for
each specimen if the specimens are oriented and
the margin status has been requested by the
endoscopist.
45
Conditional on carcinoma being
recorded in S3.02.
S/G
Item description
Response type
Conditional
Deep margin
Single selection value list:
If involved, specify what it is
“involved by”.
•
Involved
•
Not involved
If not involved, record the
distance of tumour to closest
margin
Involved by
Single selection value list:
1. Carcinoma
2. IEN/Dysplasia
3. Both Carcinoma and IEN/Dysplasia
Distance to closest margin
Lateral margin
Numeric: ___mm
Single selection value list:
•
Involved
•
Not involved
If involved, specify what it is
“involved by”.
If not involved, record the
distance of tumour to closest
margin
46
S/G
Item description
Involved by
Response type
Conditional
Single selection value list:
1. Carcinoma
2. IEN/Dysplasia
3. Both Carcinoma and IEN/Dysplasia
Distance to closest margin
Numeric: ___mm
OR
Not applicable
S3.12
Other pathologies
Single selection value list:
•
IEN in cases of carcinoma
•
Ulceration
•
Scar formation
•
Columnar metaplasia
•
Goblet cells
•
Infection
•
Foreign body
•
Other changes related to previous
treatment
•
Other neoplasms eg granular cell tumours
47
If ‘other’, record details
S/G
Item description
Response type
•
Details
G3.04
Other microscopic comment
Conditional
Other (specify)
Text
Text
Ancillary test findings
G4.01
ANCILLARY TESTS
Performed
Test type eg IHC, MUC etc
Single selection value list:
•
No
•
Yes
Text
If IHC, record the antibodies
Note: Test result type, result and interpretive
comment will need to repeat for each ancillary
test performed.
Antibodies
If yes, record test type
List (as applicable) all:
•
Positive antibodies
•
Negative antibodies
•
Equivocal antibodies
48
S/G
Item description
Response type
Result
Conditional
Text
Note: Test result type, result and interpretive
comment will need to repeat for each other
ancillary test performed.
Interpretive comment
Text
Note: Test result type, result and interpretive
comment will need to repeat for each other
ancillary test performed.
Synthesis and overview
G5.01
Diagnostic summary
Text
Include:
• Type of lesion (S3.02)
o If carcinoma record:

Histologic type

Histologic grade

Depth of invasion

Margin status

Vascular invasion

Presence of other
49
S/G
Item description
Response type
Conditional
pathologies
o If IEN record:
G5.02

Histologic grade

Margin status

Presence of other
pathologies
Overarching comment
Text
50
7
Formatting of pathology reports
Good formatting of the pathology report is essential for optimising communication
with the clinician, and will be an important contributor to the success of cancer
reporting protocols. The report should be formatted to provide information clearly
and unambiguously to the treating doctors, and should be organised with their
use of the report in mind. In this sense, the report differs from the structured
checklist, which is organised with the pathologists’ workflow as a priority.
Uniformity in the format as well as in the data items of cancer reports between
laboratories makes it easier for treating doctors to understand the reports; it is
therefore seen as an important element of the systematic reporting of cancer. For
guidance on formatting pathology reports, please refer to Appendix 2.
51
Appendix 1
Pathology request
information and surgical handling
procedures
This appendix describes the information that should be collected before the
pathology test. Some of this information can be provided on generic pathology
request forms; any additional information required specifically for the reporting of
cancers of the Oesophagus and Gastro-oesophageal Junction may be provided by
the clinician on a separate request information sheet. An example request
information sheet is included below. Elements which are in bold text are those
which pathologists consider to be required information. Those in non-bold text are
recommended.
Also included in this appendix are the procedures that are recommended before
handover of specimens to the laboratory.
Patient information

Adequate demographic and request information should be
provided with the specimen.
•
•

Items relevant to cancer reporting protocols include:
•
patient name
•
date of birth
•
sex
•
identification and contact details of requesting doctor
•
date of request
The patient’s ethnicity should be recorded, if known. In particular
whether the patient is of aboriginal or Torres Strait islander origin.
This is in support of a government initiative to monitor the health
of indigenous Australians particularly in relation to cancer.
The patient’s health identifiers should be provided.
•
The patient’s health identifiers may include the patient’s Medical
Record Number as well as a national health number such as a
patient’s Medicare number (Australia), Individual Healthcare
Identifier (IHI) (Australia) or the National Healthcare Identifier
(New Zealand).
Clinical Information

The endoscopic tumour morphology should be recorded in accordance
with the Paris Classification of superficial neoplastic lesions.14
•
This information is best attained at time of gastroscopy by the
requesting clinician.
52
•
Select all that apply:
•
•
Polypoid
o
0-Ip (protruded, pedunculated)
o
0-Is (protruded, sessile; >2.5mm above baseline)
Non-Polypoid
o
0-IIa (superficial, elevated; < 2.5mm above
baseline)
o
0-IIb (flat)
o
0-IIc (superficial shallow, depressed)
o
0-III (excavated/ulcerated)
Refer to Figures A1(i) and (ii) below.
Refer to Figures A2(i), (ii) and (iii) below for examples of common
endoscopic lesions.
53
Figure A1 (i)
Neoplastic lesions with “superficial” morphology
Figure A1 (ii)
Schematic representation of the major variants of type 0
neoplastic lesions of the digestive tract.
The major variants of type 0 neoplastic lesions of the digestive tract:
polypoid (lp and ls), non-polypoid (IIa, IIb and IIc), non-polypoid and
excavated (III). Terminology as proposed in a consensus macroscopic
14
description of superficial neoplastic lesions.
54
Figure A2
(i)
0-IIb
1A
1B
1C
1A 0-IIb(flat)15mm lesion in the 9 o’clock position within a C1M3 Barrett segment.
1B The lesion was removed en-bloc.
1C A hemi-circumferential resection of the Barrett segment has been performed
using the Duette system. Histology showed high-grade intraepithelial
neoplasia/dysplasia.
Figure A2
(ii)
0-IIb+c
2A
2B
2C
2A 20mm 0-IIb+c (flat with depressed areas) lesion in the 3 o’clock position
2B The edges of the lesion are marked
2C The lesion has been completely excised with the uninvolved Barrett beneath
removed to the level of the Gastro-Oesophageal Junction. All markers placed
have been removed confirming complete macroscopic resection. Histology
showed intramucosal cancer with free lateral and deep margins.
Figure A2
3A
(iii)
0-IIa+c
3B
3C
3A Overview of a 0-IIa+c lesion in the 2 o’clock position within a C1 M3 segment
3B Close up of a 0-IIa+c lesion
3C Complete excision by EMR using the Duette system. Histology showed
intramucosal cancer with free lateral and deep margins
55
3A
3B
3C

For focal lesions the location/site should be recorded.
•

•
cervical oesophagus
•
upper thoracic
•
middle thoracic
•
lower thoracic
•
gastro-oesophageal junction
•
Location should also be described in a neutral position using a
clock face orientation.
•
Lesion distance above the gastric fold (distal extent) and distance
below the incisors (proximal extent) should be recorded by the
proceduralist.
•
Accurate recording of the site will facilitate future follow-up.
The type of endoscopic procedure should be recorded.
•

Choose from the following list (select all that apply):
Choose from one of the following:
•
Endoscopic Resection (ER)
•
Endoscopic Submucosal Dissection (ESD)
•
Other (specify)
The Proceduralist’s opinion on the existence of local residual neoplasia
following the operative procedure should be recorded.
•
This item relates to the overall completeness of resection of the
tumour, including evidence of residual disease at resection
margins or within regions in which resection has not been
attempted. It allows for residual tumour status (R) to be assessed.

Any previous pathological diagnosis should be recorded if known.

Any additional relevant information should be recorded.
•
There should be a free text field so that the referring doctor can
add anything that is not addressed by the above points, such as
previous cancers, risk factors, investigations, treatments and
family history.
56
Specimen handling

The specimen must be pinned out using stainless-steel pins along
the periphery and fixed in 10% formalin (at least 10 volumes of
formalin per approximate volume of specimen).
•

This is best done in the procedure room following specimen
retrieval. If not, the specimen should be sent fresh to the
pathology department for immediate pinning and fixation.
The specimen must be capable of orientation if the status of
specific margins is critical in determining the need for further
resection or surgery and the extent required.
•
Where orientation is required, the endoscopists should use the
designation of O (oral) and A (anal) or P (proximal) /D (distal)
marked on the board. This will allow the endoscopist to be
informed of the area that may require further resection.
57
Example Request Information Sheet
The above Request Information Sheet is published to the RCPA website.
58
Appendix 2
Guidelines for formatting of
a pathology report
Layout
Headings and spaces should be used to indicate subsections of the report, and
heading hierarchies should be used where the LIS allows it. Heading hierarchies
may be defined by a combination of case, font size, style and, if necessary,
indentation.
•
Grouping like data elements under headings and using ‘white space’
assists in rapid transfer of information.37
Descriptive titles and headings should be consistent across the protocol, checklist
and report.
When reporting on different tumour types, similar layout of headings and blocks
of data should be used, and this layout should be maintained over time.
•
Consistent positioning speeds data transfer and, over time, may reduce
the need for field descriptions or headings, thus reducing unnecessary
information or ‘clutter’.
Within any given subsection, information density should be optimised to assist in
data assimilation and recall.
•
•
•
Configuring reports in such a way that they ‘chunk’ data elements into a
single unit will help to improve recall for the clinician.37
‘Clutter’ should be reduced to a minimum.37 Thus, information that is not
part of the protocol (e.g. billing information, Snomed codes, etc) should
not appear on the reports or should be minimized.
Injudicious use of formatting elements (e.g. too much bold, underlining or
use of footnotes) constitutes clutter and may distract the reader from the
key information.
Where a structured report checklist is used as a template for the actual report,
any values provided in the checklist but not applying to the case in question must
be deleted from the formatted report.
Reports should be formatted with an understanding of the potential for the
information to mutate or be degraded as the report is transferred from the LIS to
other health information systems.
As a report is transferred between systems:
•
•
•
•
text characteristics such as font type, size, bold, italics and colour are
often lost
tables are likely to be corrupted as vertical alignment of text is lost when
fixed font widths of the LIS are rendered as proportional fonts on screen or
in print
spaces, tabs and blank lines may be stripped from the report, disrupting
the formatting
supplementary reports may merge into the initial report.
59
Appendix 3
Example of a pathology report
60
61
Appendix 4
WHO Classificationa of
oesophageal tumours
Epithelial tumours
Premalignant lesions
Squamous
Intraepithelial neoplasia (dysplasia), low grade
Intraepithelial neoplasia (dysplasia), high grade
8077/0*
8077/2
Glandular
Dysplasia (intraepithelial neoplasia), low grade
Dysplasia (intraepithelial neoplasia), high grade
8148/0*
8148/2
Carcinoma
Squamous cell carcinoma
Adenocarcinoma
Adenoid cystic carcinoma
Adenosquamous carcinoma
Basaloid squamous cell carcinoma
Mucoepidermoid carcinoma
Spindle cell (squamous) carcinoma
Verrucous (squamous) carcinoma
Undifferentiated carcinoma
8070/3
8140/3
8200/3
8560/3
8083/3
8430/3
8074/3
8051/3
8020/3
Neuroendocrine neoplasmsb
Neuroendocrine tumour (NET)
NET G1 (carcinoid)
NET G2
Neuroendocrine carcinoma (NEC)
Large cell NEC
Small cell NEC
Mixed adenoneuroendocrine carcinoma
8240/3
8249/3
8246/3
8013/3
8041/3
8244/3
Mesenchymal tumours
Granular cell tumour
Haemangioma
Leiomyoma
Lipoma
Gastrointestinal stromal tumour
Kaposi sarcoma
Leiomyosarcoma
Melanoma
Rhabdomyosarcoma
Synovial sarcoma
9580/0
9120/0
8890/0
8850/0
8936/1
9140/3
8890/3
8720/3
8900/3
9040/3
62
Lymphomas
Secondary tumours
a
b
*
The morphology code of the International Classification of Diseases for
Oncology (ICD-O). Behaviour is coded /0 for benign tumours, /1 for
unspecified, borderline or uncertain behaviour, /2 for carcinoma in situ and
grade III intraepithelial neoplasia, and /3 for malignant tumours.
The classification is modified from the previous (third) edition of the WHO
classification of tumours taking into account changes in our understanding of
those lesions. In the case of neuroendocrine neoplasms, the classification has
been simplified to be of more practical utility in morphological classification.
These new codes were approved by the IARC/WHO Committee for ICD-O at its
meeting in March 2010.
63
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