TUMOURS 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
ISBN: 978-1-74187-710-6
Publications number (SHPN): (CI) 120056
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In regard to Chapter 6 of the Protocol - the checklist:
o
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o
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o
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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
definitive or as widely accepted peer professional opinion. The use of these
standards and guidelines is subject to the clinician’s judgement in each individual
case.
The College makes all reasonable efforts to ensure the quality and accuracy of the
protocols and to update the protocols regularly. However subject to any
warranties, terms or conditions which may be implied by law and which cannot be
excluded, the protocols are provided on an "as is" basis. The College does not
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to date. The protocols do not constitute medical or professional advice. Users
should obtain appropriate medical or professional advice, or where appropriately
qualified, exercise their own professional judgement relevant to their own
particular circumstances. Users are responsible for evaluating the suitability,
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iii
Contents
Scope ................................................................................................................. v
Abbreviations .................................................................................................... vi
Definitions ........................................................................................................ vii
Introduction .......................................................................................................1
Authority and development ................................................................................4
1
Pre-analytical ...........................................................................................7
2
Specimen handling and macroscopic findings ..........................................9
3
Microscopic findings ............................................................................... 19
4
Ancillary studies findings ....................................................................... 23
5
Synthesis and overview.......................................................................... 29
6
Structured checklist ............................................................................... 37
7
Formatting of pathology reports ............................................................ 57
Appendix 1
Pathology request information and surgical
handling procedures........................................................... 58
Appendix 2
Guidelines for formatting of a pathology report ................67
Appendix 3
Example of a pathology report .......................................... 68
Appendix 4
WHO Classificationa of oesophageal tumours ....................70
References ....................................................................................................... 72
iv
Scope
This protocol contains standards and guidelines for the preparation of structured
reports for oesophageal and gastro-oesophageal junctional carcinomas.
Oesophagectomy and oesophago-gastrectomy specimens are included in this
document and a separate protocol is available for reporting endoscopic
resections. Endoscopic biopsy specimens are excluded. Structured reporting aims
to improve the completeness and usability of pathology reports for clinicians, and
in particular to improve decision support for cancer treatment. The protocol
provides a framework for reporting of any oesophageal and gastro-oesophageal
junctional (GOJ) carcinomas 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.
However the structured report allows flexibility in the report to reflect the
inherent issues of oesophageal and gastro-oesophageal junctional carcinomas
with an allowance to include any appropriate additional information as free text.
The report will allow optional elements for reporting relevant
immunohistochemical and molecular results.
v
Abbreviations
AJCC
American Joint Committee on Cancer
OAC
Oesophageal adenocarcinoma
GOJ
Gastro-oesophageal junction
PBS
Pharmaceutical Benefits Scheme
RCPA
Royal College of Pathologists of Australasia
SCC
Squamous cell carcinoma
TNM
tumour-node-metastasis
UICC
International Union Against Cancer
WHO
World Health Organization
vi
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
Guideline
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).
Guidelines are recommendations; they are not mandatory, as
indicated by the use of the word ‘should’. Guidelines cover items
vii
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 histomorphological 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).
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
viii
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.
ix
Introduction
Oesophageal and Gastro-oesophageal Junction Cancer
Oesophagectomy and oesophagogastrectomy specimens include all types of
oesophageal carcinomas and carcinomas that straddle the junction of the
oesophagus and the proximal stomach. The classification of gastro-oesophageal
junctional (GOJ) carcinomas is difficult in practice. The AJCC guide includes the
GOJ tumours and those of proximal 5cm stomach that extend into the GOJ in the
group of oesophageal adenocarcinoma (OAC) and GOJ cancers.1 Separate stage
groupings have been recommended for squamous and adenocarcinomas. It is
likely that some tumours that originate in the proximal stomach present as
gastro-oesophageal junctional cancers, and will be reported using the protocol
below.
Oesophageal and gastro-oesophageal junctional (GOJ) carcinoma can be of either
squamous or glandular type. There are differences with regards to geographic
distribution, epidemiology, aetiology and prognosis for these two histological
subtypes. In developed nations the incidence and the prevalence of oesophageal,
gastro-oesophageal junctional and proximal cardiac adenocarcinomas have been
on the rise during the last decades. The incidence was considered to be highest in
the UK, Australia, the Netherlands and the USA. In Asia and Africa OAC was
considered uncommon but an increase has been reported lately.2
Oesophageal cancer is number 8 on the list of most common cancers worldwide
and the sixth most common cause of death from cancer.3
In Australia oesophageal cancer is the 9th most common cancer and one of the
top 10 causes of cancer mortality in males.4 Alcohol and smoking are risk factors
for many cancers. In Australia in 2001, cancers attributed to excessive alcohol
consumption accounted for 3.2% and those attributed to smoking for 12.0% of all
new cases. Oesophageal cancer is high up in the list of such cancers.4
Barrett oesophagus has been singled out as the most important risk factor for
OAC. Chronic gastro-oesophageal reflux disease predisposes to Barrett
oesophagus. Adenocarcinomas of the GOJ share many characteristics with those
of the distal oesophagus in countries where distal oesophageal adenocarcinomas
are more common. However there appear to be geographical variations whereby
in some Asian countries GOJ cancers have more similarities with proximal cardiac
cancers than distal oesophageal cancers.5
While using the same protocol for this entire group of malignancies it is
important to recognize that there are inherent biological differences within the
group especially with regards to location and the type of cancer.
Importance of histopathological reporting
The role of the histopathologist in the management of OAC and GOJ carcinomas is
to produce an accurate histological assessment that will inform clinicians about
prognosis and the need for additional treatment. The most common types of
1
specimens encountered include oesophagogastrectomy, oesophagectomy and
endoscopic resections (a separate protocol is available).
Survival is dependent mainly on disease stage. Pathological assessment of
surgical resection specimens should include salient features of OAC and GOJ
carcinomas that are important for staging such as tumour type, depth of invasion
and lymph node involvement.6 Similar to rectal carcinomas, oesophageal cancers
have shown an increased risk of both local and systemic recurrences consequent
to incomplete resections.7-8 Several studies have demonstrated that a negative
circumferential margin is associated with improved survival.9-10
Given the fact that the only curative treatment for oesophageal and GOJ cancer is
complete surgical resection of the primary tumour, it is imperative that all above
relevant information and adequacy of surgical margins is provided in the report.
Recently it has been established that certain molecular markers such as HER2
play an important role in target therapy for GOJ cancers. Herceptin therapy has
shown a significant survival benefit for HER2 over-expressed,
advanced/metastatic GOJ cancers.11 Currently pathologists may be expected to
report on HER2 status of GOJ cancers upon request by clinicians.
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
for the purposes of audits, tumour registries and research in a systematic fashion.
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 OAC.12-14 These
protocols by themselves or with modifications to suit local needs have been used
in recent years in Australia and New Zealand. A uniform modified protocol
prepared in agreement with all parties involved in patient management is
needed to cater for local requirements. This publication aims to fulfil this need
incorporating relevant, currently available evidence-based information and
collective suggestions and expert opinions of a 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.
The structured report aims at "guiding/teaching" to ensure that reporting is up to
a desired standard, "enhancing" the practice of pathology with regards to
oesophageal cancer, "inducing" the clinicians to undertake appropriate
management and "promoting" advanced oesophageal and GOJ cancer research in
Australia.
2
Design of this protocol
This protocol defines the relevant information to be assessed and recorded in a
pathology report for tumours of the oesophagus and gastro-oesophageal junction.
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 (Chapter 7) or a
checklist (Chapter 6). 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.
It should be noted that if the resection specimen contains two or more primary
carcinomas (as indicated by the term ‘synchronous carcinomas’ on the reporting
checklist) then a separate reporting checklist must be completed for each primary
carcinoma.
Key documentation
•
Guidelines for Authors of Structured Cancer Pathology Reporting
Protocols15
•
The Pathology Request-Test-Report Cycle — Guidelines for Requesters and
Pathology Provider16
•
WHO Classification of tumours, Pathology and Genetics of Tumours of the
Digestive System, 2010, 4th edition17
•
AJCC Cancer Staging Manual, 7th edition, 20101
Changes since the last edition
Not applicable.
3
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
A/Prof Bastiaan deBoer, Pathologist
A/Prof Robert Eckstein, Pathologist
Dr Krishna Epari, Surgeon
Dr Anthony Gill, Pathologist
Prof Alfred Lam, Pathologist
Prof Gregory Lauwers, Pathologist
Dr Spiro Raftopoulos, 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 and gastro-oesophageal junction tumour expert committee wish
to thank all the pathologists and clinicians who contributed to the discussion
around this document.
4
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)
Department of Health and Ageing
Gastroenterological Society of Australia GESA
Grampians Integrated Cancer Services (GICS)
Independent Review Group of Pathologists
Health Informatics Society of Australia (HISA)
Medical Software Industry Association (MSIA)
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)
New Zealand Ministry of Health
New Zealand Society of Gastroenterology (NZSG)
NSW Department of Health
5
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.15
Where no reference is provided, the authority is the consensus of the expert
group.
6
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 cancers of the Oesophagus and Gastrooesophageal Junction is outlined in Appendix 1. Appendix 1 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.18
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 effectively.
7
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 biopsy
• The pathology request is often authored by the
clinician performing the biopsy 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 surgeon’s name 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.
8
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

Pathologists may be asked to provide tissue samples from fresh
specimens for tissue banking or research purposes. The decision to
provide tissue should only be made when the pathologist is sure that the
diagnostic process including the measurement of maximum depth of
invasion and other important parameters that influence patient prognosis
and management will not be compromised. As a safeguard, research use
of the specimen may be put on hold until the diagnostic process is
complete so that the specimen can be retrieved.

The specimen must be handled in a systematic and thorough
fashion to ensure completeness and accuracy of pathological
data.
•
Specimen reception: specimens are best received without delay
either fresh or in formalin. This allows optimal orientation and
sampling of non-fixed tissue e.g. tumour bank, research. Where
receipt of fresh specimen is impractical, the specimen should be
sent in an adequate volume of formalin (approximately 10 times
greater than the tissue volume) depending on local approach.19
•
Specimen measurement and fixation: generally the specimen
should be pinned out on corkboard, measurements of length taken
(see Specimen Inspection below), and then fully fixed in an
adequate volume of formalin (generally overnight) before
dissection and block-taking. In cases where the specimen is not
opened initially, a “wick” inserted into the lumen will aid fixation.
•
Specimen inspection: the external aspect should be inspected for
any visible tumour prior to inking of the entire circumferential
margin. The nature and extent of any peri-oesophageal tissue
should be described. Any surgical tears or defects should be
recorded. The length of the tubular oesophagus, and of any
included stomach, along the greater and lesser curvatures, should
be recorded, if not previously recorded prior to fixation.
•
Specimen dissection: there are 2 recommended methods of
opening the oesophagus:
1. If, by inspection and palpation, the tumour is not
circumferential, the oesophagus can be opened longitudinally with
scissors, taking care to avoid cutting into the tumour. This allows
better assessment of the mucosal surface of the tumour and
9
oesophagus.
2. If, by inspection and palpation, the tumour is circumferential, it
should be “bread-sliced” transversely, similar to the method used
for rectal cancers. This gives better assessment of the
circumferential margin. For further details see Figure S2.11 below.
3. A photograph of the specimen is recommended

All lymph nodes must be harvested and examined histologically.
•
In completely resected carcinomas, lymph node status is the most
important independent prognostic indicator.20-22,23
•
Regional lymph nodes include supraclavicular nodes, upper
paratracheal nodes, posterior mediastinal nodes, lower paratracheal
nodes, aortopulmonary nodes, anterior mediastinal nodes,
subcarinal nodes, middle paraoesophageal nodes, lower
paraoesophageal nodes, pulmonary ligament nodes,
tracheobronchial nodes, diaphragmatic nodes, paracardial nodes,
left gastric nodes, common hepatic nodes, splenic nodes and
coeliac nodes.
Other lymph node groups are non-regional nodes.
•
Individually labelled lymph nodes should be reported separately.
•
Lymph nodes may be more difficult to locate following
chemoradiotherapy.
10
Figure SH1
Lymph node map for oesophageal cancer.*
1 Supraclavicular zone
8L Lower paraesophageal
2R Right Upper Paratracheal
9 Pulmonary ligament
2L Left Upper Paratracheal
10R Right tracheobronchial
3P Posterior mediastinal
10L Left tracheobronchial
4R Right Lower Paratracheal
15 Diaphragmatic
4L Left Lower Paratracheal
16 Paracardial
5 Aortopulmonary
17 Left gastric
6 Anterior mediastinal
18 Common hepatic
7 Subcarinal
19 Splenic
8M Middle paraesophageal
20 Celiac
*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, Sixth Edition (2002) published by Springer Science and Business Media
LLC, www.springerlink.com.
11
Macroscopic findings
S2.01
The type of resection must be recorded.
CS2.01a
Options include:
•
Pharyngolaryngo-oesophagectomy
•
Oesophagectomy
•
Oesophago-gastrectomy
•
Other (specify)
S2.02
All linear measurements are in SI units, unless explicitly
stated.
S2.03
The specimen dimensions must be recorded.
CS2.03a
Record the length of the tubular oesophagus, and the
stomach, along the greater curve if present (see Specimen
Inspection in Specimen Handling above). The stomach can
be recognised by the presence of rugal folds on the
mucosal surface, and serosa on the outer surface.
Note that the resected oesophagus shrinks considerably
both before and after fixation, making measurements
shorter than in vivo measurements.24 For the purposes of
this protocol it is generally expected that measurements
will be made after fixation.
S2.04
The tumour site (location) must be recorded.
CS2.04a
It is often not feasible for the pathologist to identify the
level of the tumour within the oesophagus without
information from the surgeon.
The pathologist must record the distance of the proximal
edge of the tumour from the proximal end of the
specimen.
For tumours located entirely within the oesophagus, the
distance between the distal edge of the tumour and the
gastro-oesophageal junction must be recorded (see
CS2.04c).
For tumours straddling the gastro-oesophageal junction,
the distance of the midpoint of the tumour from the
gastro-oesophageal junction must be recorded. This, in
conjunction with the overall length of the tumour, will
determine whether the tumour is classified and staged
using this protocol or the RCPA gastric cancer protocol.
CS2.04b
Tumours having their midpoint within 5cm of the gastrooesophageal junction, the so-called gastric “cardia”, that
extend into the oesophagus (macroscopically or
microscopically) are staged using the oesophageal cancer
protocol; see figure S2.04.
12
CS2.04c
Figure S2.04
S2.05
G2.01
Stage as oesophageal carcinoma
The maximum tumour dimension must be recorded
CS2.05a
Tumour size is based on macroscopic assessment,
confirmed or amended on microscopy. This is of particular
relevance where the macroscopic size may be difficult to
assess, such as after chemoradiotherapy and in cases of
diffuse carcinoma.
CS2.05b
Maximum tumour length has been shown to correlate with
survival.23,25
The maximum tumour thickness may be recorded.
CG2.01a
G2.02
The gastro-oesophageal junction can be identified as the
point where the tubular oesophagus meets the upper limit
of the gastric rugal folds. If this mucosal landmark is
obscured by extensive tumour involvement or columnar
lined oesophagus, the junction can be located at the
highest point of the peritoneal reflection on the serosal
surface of the stomach.
Tumour thickness is based on macroscopic assessment,
confirmed or amended on microscopy.
The gross appearance of the tumour should be recorded.
13
S2.06
CG2.02a
An attempt should be made to assess whether the tumour
is restricted to mucosa, muscularis propria, or involves the
adventitia or serosa.
CG2.02b
Prior chemoradiotherapy or endoscopic resection may
result in scarring and loss of grossly recognisable tumour.
The distance from the tumour to the nearest proximal or distal
margin (cut end) must be recorded.
CS2.06a
S2.07
S2.08
Tumour distance to margins is based on macroscopic
assessment, confirmed or amended on microscopy. This is
of particular relevance where the macroscopic size may be
difficult to assess, such as after chemoradiotherapy and in
cases of diffuse carcinoma.
The distance of the tumour from the circumferential margin of
the oesophagus must be recorded.
CS2.07a
The distance is used as a guide to subsequent microscopic
assessment.
CS2.07b
Tumour involving the circumferential resection margin by
gross examination is classified as R2.
Involvement of any adjacent structures must be recorded.
CS2.08a
Involvement of pleura, pericardium, diaphragm, gastric
serosa, or other adjacent structures, upstages oesophageal
carcinoma to T4. Refer to Figure S2.08 below.
14
Figure S2.08 Anatomic cancer classification for oesophageal cancer.
Anatomic cancer classification is by depth of cancer invasion (T) and regional
lymph node classification (N), defined by absence (N0) or presence (N1) of
cancer-positive lymph nodes. Distant metastasis (M) not illustrated.26 Reproduced
with permission.
S2.09
The presence or absence of Barrett mucosa must be recorded.
CS2.09a
Glandular mucosa can usually be distinguished from
squamous mucosa by naked eye inspection.
CS2.09b
Thickening, congestion and superficial ulceration within the
glandular or squamous mucosa may be due to dysplasia or
in situ carcinoma.
CS2.09c
The presence of Barrett mucosa should be confirmed by
microscopy.
G2.03
The length of Barrett mucosa within the tubular oesophagus should be
recorded.
S2.10
Additional specimens such as labelled lymph nodes/donuts
must be recorded.
S2.11
The nature and site of all blocks must be recorded.
CS2.11a
A diagram or photograph showing the sites of blocks taken
15
may be helpful.
CS2.11b
Proximal and distal resection margins should be sampled,
usually parallel to the cut edge. If the tumour is very close
to the margin, perpendicular slices can aid microscopic
measurement.
The central part of the tumour is cut in serial 3mm slices,
and the slices laid out sequentially (figure S2.11). Select
blocks of tumour to show the greatest depth of invasion,
and tumour closest to the circumferential (radial) margin.
Sample gastric serosa if close to the tumour.
Take blocks to show involvement of other tissues/organs if
present on the specimen, eg pleura.
CS2.11c
At the proximal and distal ends of the tumour, take
perpendicular blocks. This will help to show the relation of
the tumour to neoplastic precursors such as Barrett
oesophagus, and glandular or squamous dysplasia.
CS2.11d
Unless obliterated by tumour, sample the squamoglandular
junction and the junction of tubular oesophagus and
stomach, to assess for Barrett oesophagus.
CS2.11e
Take a sample of uninvolved oesophagus and stomach
above and below the tumour to assess for tumour
precursors such as Barrett oesophagus, glandular and
squamous dysplasia, and Helicobacter pylori infection.
CS2.11f
In cases of intramucosal carcinoma or high grade
intraepithelial neoplasia there may be little or no gross
abnormality. In such cases, clinical and radiological data
regarding tumour location should be obtained to guide
sampling. Extensive sampling of the tumour site may be
required, with examination of blocks at multiple levels
(figure S2.11).
CS2.11g
Preoperative chemotherapy may result in the shrinkage or
complete loss of macroscopic abnormality.27 In the absence
of macroscopic tumour, clinical and radiologic data
regarding tumour location is used to localise sampling.
Following slicing, thickening or fibrosis in the submucosa
and muscularis propria may indicate the site of previous
tumour.
If no carcinoma is found in the initial blocks, then examine
three further levels of each block. If there is still no
carcinoma found, then in most cases, embedding of the
whole site is required before a complete response to
neoadjuvant therapy can be reported.
CS2.11h
All macroscopically uninvolved nodes should be completely
embedded. Macroscopically involved nodes require only
one slice embedded for confirmation.
16
Figure S2.11
Recommended blocks for histology in resected
oesophageal neoplasms
Recommended blocks for histology in resected oesophageal neoplasms. (A)
Oesophagectomy specimen. (B) Oesophago-gastrectomy specimen containing
tumour above the gastro-oesophageal junction. (C) Oesophago-gastrectomy
specimen containing tumour at the gastro-oesophageal junction. (D) Resected
specimen for high grade dysplasia/in situ carcinoma. Shaded blocks represent the
recommended minimum number to be sampled (A) and (C).28 Reproduced with
permission.
G2.04
A descriptive or narrative field should be provided to record any
macroscopic information that is not recorded in the above standards
17
and guidelines, and that would normally form part of the macroscopic
description.
CG2.04a
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.
CG2.04b
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.
18
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
Tumour location must be recorded.
CS3.01a
The tumour location should be explicitly recorded after
microscopic confirmation as the confirmed location after
microscopic examination may be different to the
macroscopic impression. In the AJCC classification tumours
“arising in the stomach <5cm from the gastro-oesophageal
junction and crossing the gastro-oesophageal junction are
staged using the TNM system for oesophageal
adenocarcinoma”. In the event that the location on
microscopic evaluation involves the oesophagus, even
when not obvious macroscopically, then the cancer is
reported using the oesophageal cancer structured report if
they are within the 5cm of the proximal stomach
("cardia").
By adhering to the AJCC classification1, it is recognised that
there will be tumours that are present in the proximal
stomach, which appear to be of gastric origin (eg
unassociated with Barrett oesophagus and predominantly
located in the stomach), will be somewhat artificially placed
into the category of tumours of the “oesophagus and
gastro-oesophageal junction”. Such tumours are reported
using the protocol for oesophageal cancer. Nevertheless, in
reporting such tumours it is recommended that the
likelihood that such tumours may have arisen within the
stomach is recorded.
S3.02
Histological tumour type must be recorded.
CS3.02a
The histological type of the tumour should be recorded
based on the current WHO classification.17
These types are:
•
Squamous cell carcinoma
•
Adenocarcinoma
•
Adenoid cystic carcinoma
•
Adenosquamous carcinoma
•
Basaloid squamous cell carcinoma
•
Mucoepidermoid carcinoma
•
Spindle cell (squamous) carcinoma
19
CS3.02b
S3.03
•
Verrucous (squamous) carcinoma
•
Undifferentiated carcinoma
The revised TNM staging system for oesophageal
carcinomas incorporates tumour grade and histologic type
in the stage groupings. Mixed histologic types, such as
adenosquamous carcinomas, are staged using the
squamous cell carcinoma stage grouping.
Histologic grade must be recorded.
CS3.03a
The tumour should receive a histological grade a based on
the AJCC classification1:
•
Grade X Grade cannot be assessed – stage grouping
as G1
•
Grade 1 Well differentiated
•
Grade 2 Moderately differentiated
•
Grade 3 Poorly differentiated
•
Grade 4 Undifferentiated – stage grouping as G3
squamous
For adenocarcinomas:
•
Grade 1 – is comprised of greater than 95% of
tumour composed of glands.
•
Grade 2 - 50% to 95% of tumour composed of
glands
•
Grade 3 - 49% or less of tumour composed of
glands.
Glandular structures are absent in undifferentiated
tumours.17
CS3.03b
Mucoepidermoid carcinoma and adenoid cystic carcinoma
of the oesophagus are not graded.
Signet-ring cell carcinoma is classified as grade 3.
Small cell carcinoma and undifferentiated carcinoma are
classified as grade 4.
G3.01
The pattern of growth should 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.
20
CG3.01a
The pattern of growth should be recorded as either:
1. Expanding: Tumour cells grow en masse by expansion
resulting in tumour nodules, or
2. Infiltrating: Tumour cells penetrate individually and
widely resulting in diffuse infiltration of the oesophagus.
S3.04
Tumour size must be specified.
CS3.04a
S3.05
A final estimate of the maximum dimension of the tumour
is given based on both the macroscopic and histological
findings.
The depth of invasion must be recorded.
CS3.05a
The level of invasion relative to the anatomical layers of
the oesophagus (lamina propria, muscularis mucosae,
submucosa, muscularis propria and adventitial connective
tissue) must be recorded. (Refer to Figure S2.08).
S3.06
The presence or absence of peritoneal involvement must be
recorded.
S3.07
The presence or absence of pleural involvement must be
recorded.
S3.08
The presence or absence of vascular space invasion in small
(lymphatic and capillary) and large (vein and artery) caliber
vessels as well as perineural growth must be recorded.
G3.02
The presence or absence of tumour budding may be recorded.
CG3.02a
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
investigational.29
S3.09
The degree of regression after preoperative chemoradiation
must be recorded.
CS3.09a
The following schema, though based on a study originally
applied to rectal cancer, is recommended by the College of
American Pathologists1 as is the same as that endorsed by
the RCPA for gastric carcinoma. In the absence of other
widely used schemas, the following grading system is
recommended.
Grade 0: Complete Response – No viable cancer cells
Grade 1: Moderate response - Single cells or small
21
groups of cancer cells
Grade 2: Minimal response – Residual cancer outgrown by
fibrosis
Grade 3: Absent response – Minimal or no tumour kill;
extensive residual cancer.
S3.10
The distance of carcinoma from the proximal, distal and
radial/circumferential margins must be recorded.
CS3.10a
For most oesophageal cancers, the radial margin of the
oesophagus will commonly be the closest margin. Away
from the gastro-oesophageal junction, the only
radial/circumferential margins are the lesser omental
ligaments and the greater omental resection margin.
CS3.10b
If the tumour shows microscopic involvement of the
excision margin (R1 resection) this should be explicitly
stated. Otherwise the distance of the tumour from the
resection margin (circumferential and end margins both)
should be stated.
G3.03
If submitted, state whether the donut is involved by tumour or not.
S3.11
The number of lymph nodes involved and the total number
received must be recorded.
S3.12
CS3.11a
Record the number of lymph nodes from the main
resection specimen, and the regional nodes from each
separately labelled specimen should be recorded.
CS3.11b
According to the AJCC1, a “tumour nodule with smooth
contour in regional node area” is classified as a positive
node. Note that similar nodules on the peritoneal surface
are considered M1.
The presence or absence of Barrett mucosa, squamous or
glandular dysplasia, gastritis, eosinophilic oesophagitis or
other pathologies must be specified.
CS3.12a
G3.04
If Barrett mucosa or dysplasia involves a margin this
should be stated. The estimated distance of dysplasia from
the closest margin should be stated.
Any additional relevant microscopic comments should be recorded.
22
4
Ancillary studies findings
Ancillary investigations in tumours of the gastro-oesophageal junction or
oesophagus can potentially serve the following purposes: 1) to predict response
to medical therapy; 2) to aid tumour classification; 3) to detect a genetic
aetiology for the cancer; 4) to provide prognostic information; and 5) to establish
the presence or absence of an infectious co-factor.
G4.01
The results of any ancillary tests performed should be incorporated
into the pathology report.
CG4.01a
Therapeutic guidance
Surgical resection has long been the first line of treatment
for oesophageal cancer, however, local recurrence rates
approach 60% and a ‘surgery alone’ approach is only
recommended for non cervical T1 lesions. The addition of
adjuvant radiotherapy and chemotherapy is recommended
for all other cases30. Targeted therapy is currently being
investigated as an addition to these regimes and for the
treatment of metastatic disease.
Of the potential targets trialled to date, epithelial growth
factor receptor - EGFR (Her1 and Her2) and vascular
endothelial growth factor - VEGF surface receptor
antagonists have shown the most promise.
a.
Her 2 (EGFR-2)10,28-30
Her 2 over expression is reported in approximately 15 25% of gastric/gastro-oesophageal junction (GOJ)
adenocarcinomas in Western countries including in
Australia (range 2-45% for gastric/GOJ and 9-60% for
oesophagus).11,31 The 2010 ToGA study found that
trastuzumab-based therapy offered a significant survival
advantage for patients with HER2 overexpressing locally
advanced, recurrent or metastatic gastric and gastrooesophageal junctional adenocarcinomas compared to
conventional therapy alone. Currently the relevance in true
oesophageal adenocarcinomas and squamous carcinomas
is unclear. However it is likely that pathologists will be
required to determine the Her 2 status in biopsy or
resection material in GOJ and gastric cancers as well as in
metastatic sites. Currently immunohistochemistry (IHC)
and in-situ hybridisation (ISH) testing is performed
concurrently in an accredited laboratory in Australia to
select the patients who are eligible for trastuzumab based
treatment. National guidelines for testing and criteria for
negative and positive HER2 status in gastric/GOJ cancers
are based on the current scientific evidence and both local
and international expert opinions.32-33
It should be noted methods/interpretation of HER-2
positivity for gastric/GOJ cancers differs importantly from
that for breast cancer, and that application of breast cancer
23
scoring will significantly under-report the proportion of
HER-2 positive oesophagitis gastric cancer.34 Hence a
modified IHC scoring and ISH cut-off levels are adopted.35
In Australia a positive HER2 result requires a combination
of IHC2+ or a IHC3+ score and a positive ISH result. The
high level of heterogeneity noted in these cancers has
resulted in many difficulties in interpretation of results.
Table G4.01 (i) below is a guide to assess protein
expression by IHC. Figure G4.01 (iii) shows an example of
HER2 gene amplification by silver in situ hybridisation
(SISH) and heterogeneity.
b.
EGFR -1
Over expression of EGFR -1 is found in 1/3 to 2/3 of
oesophageal adenocarcinoma and squamous cell
carcinoma (SCC). To date, clinical trials using the EGFR-1
antagonist, cetuximab, have revealed varied results. At
this stage, assessment of EGFR-1 expression is not
warranted.
c.
VEGF
VEGF is over expressed in 30 – 60% of oesophageal
adenocarcinoma. Over expression is associated with higher
tumour stage and poorer survival.36 In non selected
patients, the VEGF antagonist bevacizumab has shown
promising results when added to multimodality treatment.
At this time, assessment of VEGF status is not required.
d.
Others
Other molecular targets undergoing clinical trial and/or
being considered for clinical trial and potentially requiring
assessment of protein expression by pathologists include:
other EGFRs, cyclooxygenase-2 (COX-2), mammalian
target of rapamycin (mTOR), heat shock protein 90
(Hsp90), and PI3K/Akt, matrix metalloproteinases, insulinlike growth factor receptor (IGFR) and regulators of the
cell cycle e.g. cyclins and nuclear factor κβ.
There is evidence that high levels of microsatellite
instability predict a poor response to alkylating
chemotherapy in colorectal carcinoma, however, there is
conflicting data in oesophageal adenocarcinoma and MSI
testing (or mismatch repair marker
immunohistochemistry) is not warranted at this stage.37
CG4.01b
Aid to tumour classification
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) and
p63 and/or p40 (ΔNp63) (positive in SCC) may help
distinguish SCC from adenocarcinoma and basaloid
24
squamous carcinoma from adenoid cystic carcinoma.
Spindle cell (squamous) carcinoma will express
cytokeratin, aiding distinction from primary sarcomas and
melanoma.
Immunohistochemical stains may be performed to identify
phenotypes. MUC2, CD10 and CDX2 are known to be
positive in intestinal phenotype and MUC5AC and MUC6 in
gastric phenotypes. The significance of this has not been
determined.38-39
CG4.01c
Detection of inherited cases
Familial cases of oesophageal cancer are uncommon. In
many cases an underlying genetic disease is already
evident (eg Tylosis or achalasia predisposing to
oesophageal SCC). The approximately 5% of oesophageal
adenocarcinomas that arise on the basis of microsatellite
instability, are due to sporadic hypermethylation related
silencing of MLH-1 gene and do not represent Lynch
syndrome.37 Because of the rarity of genetically defined
predisposing conditions, ancillary investigation is not
required.
CG4.01d
Prognostic markers40
Most data exists for oesophageal adenocarcinoma and has
found that expression or identification of the following
markers to predict survival - Epidermal growth factor
receptors (1 and 2 - Her2/neu): Transforming growth
factor (TGF α and β1); P53, Ki-67, Cyclin dependent kinase
inhibitor 1 (p21); B-cell lymphoma 2 (bcl-2);
Cyclooxygenase-2 (COX-2); Nuclear factor-κB (NF-κB);
Vascular endothelial growth factor (VEGF); Tissue inhibitor
of metalloproteinase (TIMP) and microsatellite instability
(MSI). At present, routine testing for all or any of these
markers is not warranted.
Several studies have investigated the prognostic utility of
whole genome expression array profiling and micro RNA
expression profiling in oesophageal cancer. Either or both
techniques have potential future utility in prediction of
patient survival, prediction of response to preoperative
therapy and to guide therapy.
For Squamous cell carcinoma, apart from staging, Ki-67
appears to be able to stratify the patients into prognostic
groups.41 However, this method has not been widely used.
CG4.01e
Infectious co-factor
There is considerable data on the role of HPV infection in
the development of oesophageal SCC. Some of this is
conflicting, however, it appears that identification of HPV is
uncommon in western countries (<5%) but may be more
frequent (30-50%) in high oesophageal SCC prevalence
25
regions such as in parts of China.42 The presence of HPV
does not correspond to a particular morphology. It is
currently unknown whether HPV detection and/or p16
expression will predict radiotherapy response as it does for
upper aerodigestive tract SCC. At this stage routine
evaluation of HPV status and/or p16 is not required.
26
Table G4.01 (i)
Score
Surgical
specimen
HER2 scoring (immunohistochemistry) table
Biopsy specimen
HER2
status
(protein
overexpression)
No reactivity or
membranous
reactivity in <10%
of tumour cells
No reactivity or no
membranous
reactivity in any
tumour cell
0
Faint/barely
perceptible
membranous
reactivity
in ≥ 10% of
tumour cells; cells
are reactive only
in part of their
membrane
Tumour cell cluster
with a faint/barely
perceptible
membranous
reactivity
irrespective of
percentage of
tumour cells stained
1+ Negative
Weak to moderate
complete,
basolateral or
lateral
membranous
reactivity in ≥
10% of tumour
cells
Tumour cell cluster
with a weak to
moderate complete,
basolateral or
lateral membranous
reactivity
irrespective of
percentage of
tumour cells stained
2+ Equivocal
Strong complete,
basolateral or
lateral
membranous
reactivity in ≥
10% of tumour
cells
Tumour cell cluster
with a strong
complete,
basolateral or lateral
membranous
reactivity
irrespective of
percentage of
tumour cells stained
3+ Positive
27
Negative
Figure G4.01 (ii)
IHC for HER2 demonstrating heterogeneous patterns
Score 3+
Left score 1+
Right score 3+
Mix of scores
1+, 2+ and 3+
3
1
1
0
3
28
Figure G4.01 (iii) HER2 gene amplification by SISH on the right half of
the tumour in contrast to non-amplification on the left half. This example
also highlights HER2 heterogeneity.
29
Table G4.01 (iv) Morphologic and immunohistochemical features of
dysplasia
Pattern of
dysplasia
Intestinal
(adenomatous)
Morphologic
features
- Columnar cells
- Hyperchromatic,
pencillate,
stratified nuclei
See figure G4.01(iv)
- Dense eosinophilic
cytoplasm
Gastric foveolar
- Cuboidal to
(non adenomatous)
columnar cells with
pale clear to light
See figure G4.01(v)
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)
+
-
-
-
30
Figure G4.01(v)
H&E
Intestinal panel
CDX-2
MUC2
Figure G4.01(vi)
VILLIN
Gastric foveolar panel
H&E
CDX-2
MUC5ac
VILLIN
31
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. For example.
tumour stage is synthesised from multiple classes of information – clinical,
macroscopic and microscopic.
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.
S5.01
The tumour stage and stage grouping must be recorded,
incorporating clinical and pathological data, based on the
TNM staging system of the AJCC Cancer Staging Manual (7th
Edition).1 (See Tables S5.01a, b, c and d below.)
Table S5.01a
AJCC primary tumour definitions for tumours of the
oesophagus and oesophagogastric junction. b
Primary Tumour (T)**
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
Tis
High grade dysplasia***
T1
Tumour invades lamina propria, muscularis mucosae, or
submucosa
T1a
Tumour invades lamina propria or muscularis mucosae
T1b
Tumour invades submucosa
T2
Tumour invades muscularis propria
T3
Tumour invades adventitia
T4
Tumour invades adjacent structures
T4a
Resectable tumour invading pleura, pericardium, or diaphragm
T4b
Unresectable tumour invading other adjacent structures, such
as aorta, vertebral body, trachea etc
** (1) At least maximal dimension of the tumour must be
recorded and (2) multiple tumours require the T(m) suffix.
*** High grade dysplasia includes all noninvasive neoplastic
epithelia that was formerly called carcinoma in-situ, a
diagnosis that is no longer used for columnar mucosae
anywhere in the gastrointestinal tract.
Table S5.01b
AJCC regional lymph node classifications for tumours of
b
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.
32
the oesophagus and oesophagogastric junction. c
Regional Lymph Nodes (N)*
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis in 1-2 regional lymph nodes
N2
Metastasis in 3-6 regional lymph nodes
N3
Metastasis in seven or more regional lymph
nodes
* Number must be recorded for the total number of regional
nodes sampled and total number of reported nodes with
metastasis.
Table S5.01c
AJCC distant metastasis classifications for tumours of the
oesophagus and oesophagogastric junction.c
Distant Metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
NOTE that the designation "MX" has been dropped from the 7th
edition of the AJCC/UICC TNM system.
The terminology pM1 (distant metastases present) can only be
used by pathologists on the basis of pathological assessment of
a relevant tissue sample.
The pathologist may not be in possession either of the clinical
information that indicates a cM1 stage or of specimens received
from other procedures that indicate a pM1 stage. In such
situations pM staging may not be reported.
Thus there must be a recognition that staging based on
examination of the resection specimen may not reflect the stage
of disease in the patient.
This can be indicated in the “synthesis and diagnostic summary”
section of the report by including a statement such as: Note:
the staging given is based on examination of the specimens
received. Stage IV cannot normally be assigned on these
examinations.
Note that positive peritoneal cytology is classified as M1. Often
this is separately reported. Positive cytology would change the
stage group to stage IV. This information if available should be
indicated in the report preferably as a comment.
Table S5.01d
AJCC/UICC pathological stage grouping for tumours of
the oesophagus and oesophagogastric junction.c
c
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.
33
Anatomic Stage/Prognostic Groups
Squamous cell carcinoma*
Stage
T
N
M
Grade
Tumour Location **
O
Tis
N0
M0
1, X
Any
IA
T1
N0
M0
1, X
Any
IB
T1
N0
M0
2-3
Any
T2-3
N0
M0
1, X
Lower, X
T2-3
N0
M0
1, X
Upper, middle
T2-3
N0
M0
2-3
Lower, X
T2-3
N0
M0
2-3
Upper, middle
T1-2
N1
M0
Any
Any
T1-2
N2
M0
Any
Any
T3
N1
M0
Any
Any
T4a
N0
M0
Any
Any
IIIB
T3
N2
M0
Any
Any
IIIC
T4a
N1-2
M0
Any
Any
T4b
Any
M0
Any
Any
Any
N3
M0
Any
Any
Any
Any
M1
Any
Any
IIA
IIB
IIIA
IV
*
Or mixed histology including a squamous component or NOS.
**
Location of the primary cancer is defined by the position of the upper
(proximal) edge of the tumour in the oesophagus.
34
Adenocarcinoma
Stage
T
N
M
Grade
O
Tis (HGD*)
N0
M0
1, X
IA
T1
N0
M0
1-2, X
IB
T1
N0
M0
3
T2
N0
M0
1-2, X
IIA
T2
N0
M0
3
IIB
T3
N0
M0
Any
T1-2
N1
M0
Any
T1-2
N2
M0
Any
T3
N1
M0
Any
T4a
N0
M0
Any
IIIB
T3
N2
M0
Any
IIIC
T4a
N1-2
M0
Any
T4b
Any
M0
Any
Any
N3
M0
Any
Any
Any
M1
Any
IIIA
IV
*HGD, high grade dysplasia.
S5.02
The year of publication and edition of the cancer staging system
used in S5.01 must be included in the report.
G5.01
The ‘Diagnostic summary’ section of the final formatted report should
include:
G5.02
o
Tumour location
o
Histologic type
o
Tumour grade
o
Tumour size
o
Lymph nodes
o
Stage
o
Involved or close margins (includes tumour less than 1mm from
margin)
A field for free text or narrative in which the reporting pathologist can
give overarching case comment must be provided.
CG5.02a
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
35
pending.
CG5.02b
Use of this field is at the discretion of the reporting
pathologist.
36
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.43
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.
37
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 location
Operative procedure
Multi select value list (select all that apply):
•
cervical oesophagus
•
upper thoracic
•
middle thoracic
•
lower thoracic
•
gastro-oesophageal junction
Single selection value list:
•
Pharyngolaryngo-oesophagectomy
•
Oesophagectomy
•
Oesophago-gastrectomy
•
Other
38
If other, record the details.
S/G
Item description
Response type
Details
Operative method of oesophagogastrectomy
Extent of lymphadenectomy
Preoperative therapy
Text
Single selection value list:
•
3 Stage (eg McKeown)
•
2 Stage (eg Ivor-Lewis)
•
1 Stage (eg Sweet)
•
Trans-hiatal
Single selection value list:
•
Three field
•
Two field
•
Two field (Infra-carinal)
•
Conservative
Single selection value list:
Type
Involvement of adjacent
Conditional
•
Administered
•
Not administered
Single selection value list:
•
Preoperative chemotherapy
•
Preoperative radiotherapy
•
Preoperative chemoradiotherapy
Text
39
If administered, record type
S/G
Item description
Response type
Conditional
Single selection value list:
If present, provide details
organs
Distant metastases
Details
Existence of residual cancer
New primary cancer or
recurrence
•
Absent
•
Present
Text
Single selection value list:
•
Absent
•
Present (R2)
Single selection value list:
•
New primary
•
Recurrence – regional
•
Recurrence - distant
S1.03
Pathology accession number
Alpha-numeric
S1.04
Principal clinician caring for
the patient
Text
S1.05
Surgeon’s name & contact
details
Text
G1.01
Additional information
Text
Macroscopic findings
40
S/G
Item description
Response type
Conditional
S2.01
Type of resection
Single selection value list:
If other, record the details.
Details
S2.03
S2.04
•
Pharyngolaryngo-oesophagectomy
•
Oesophagectomy
•
Oesophago-gastrectomy
•
Other
Text
Length of tubular
oesophagus
Numeric: ___mm
Length of greater curve
stomach (if present)
Numeric: ___mm
Tumour site
Multi select value list (select all that apply):
•
cervical oesophagus
•
upper thoracic
•
middle thoracic
•
lower thoracic
•
gastro-oesophageal junction
Proximal edge of tumour to
proximal end of specimen
Numeric: ___mm
Distal edge of tumour to
gastro-oesophageal junction
Numeric: ___mm
41
S/G
Item description
Response type
Conditional
Midpoint of tumour to
gastro-oesophageal junction
Numeric: ___mm
Conditional on gastrooesophageal junction being
selected above.
S2.05
Maximum tumour dimension
Numeric: ___mm
G2.01
Maximum tumour thickness
Numeric: ___mm
G2.02
Gross appearance of tumour
Text
S2.06
Distance of tumour to
nearest proximal or distal
margin (cut end)
Numeric: ___mm
OR
Not identifiable
OR
Involved
S2.07
Distance of tumour to
circumferential margin
Numeric: ___mm
OR
Not identifiable
OR
Involved
S2.08
Involvement of adjacent
structures
Not involved
If other, provide details
OR
Multi select value list (select all that apply):
42
S/G
Item description
Response type
Details
S2.09
Barrett mucosa
Conditional
•
Pleura
•
Peritoneum
•
Pericardium
•
Diaphragm
•
Aorta
•
Carotid vessels
•
Azygos vein
•
Trachea
•
Left or right main bronchus
•
Vertebral body
•
Perioesophageal tissue
•
Other
Text
Single selection value list:
•
Absent
•
Present
If present, consider G2.03
G2.03
Length of Barrett mucosa
Numeric: ___mm
Conditional on the presence
of Barrett mucosa in S2.09
S2.10
Additional specimens
Single selection value list:
If submitted, describe
•
Not submitted
43
S/G
Item description
Response type
•
Description
Conditional
Submitted
Text
S2.11
Nature and site of all blocks
Text
G2.04
Other macroscopic comment
Text
Microscopic findings
S3.01
S3.02
Tumour location
Histologic type
Multi select value list (select all that apply):
•
cervical oesophagus
•
upper thoracic
•
middle thoracic
•
lower thoracic
•
gastro-oesophageal junction
Single selection value list:
•
Squamous cell carcinoma
•
Adenocarcinoma
•
Adenoid cystic carcinoma
•
Adenosquamous carcinoma
44
If other, record details
S/G
Item description
Response type
Details
S3.03
Histologic grade
Conditional
•
Basaloid squamous cell carcinoma
•
Mucoepidermoid carcinoma
•
Spindle cell (squamous) carcinoma
•
Verrucous (squamous) carcinoma
•
Undifferentiated carcinoma
•
Other
Text
If Adenocarcinoma (from S3.02):
Single selection value list:
•
Grade X Grade cannot be assessed
•
Grade 1 Well differentiated (greater than 95% of
tumour composed of glands).
•
Grade 2 Moderately differentiated (50% to 95%
of tumour composed of glands)
•
Grade 3 Poorly differentiated (49% or less of
tumour composed of glands).
•
Grade 4 Undifferentiated
If Squamous cell carcinoma, adenosquamous
carcinoma, basaloid squamous cell carcinoma,
Spindle cell (squamous) carcinoma and Verrucous
(squamous) carcinoma (from S3.02):
45
Conditional on
Adenocarcinoma, Squamous
cell carcinoma,
adenosquamous carcinoma,
basaloid squamous cell
carcinoma, Spindle cell
(squamous) carcinoma and
Verrucous (squamous)
carcinoma being selected in
S3.02.
S/G
Item description
Response type
Conditional
Single selection value list:
•
Grade X
•
Grade 1 Well differentiated
•
Grade 2 Moderately differentiated
•
Grade 3 Poorly differentiated
•
Grade 4 Undifferentiated
Note
1. Grade X tumours are grouped as grade 1
carcinomas.
2. Mucoepidermoid carcinoma and adenoid cystic
carcinoma of the oesophagus are not graded.
3. If small cell carcinomas OR undifferentiated
carcinoma record grade as 4. Signet-ring cell
carcinoma is classified as grade 3.
G3.01
Pattern of growth
Single selection value list:
•
Expanding
•
Infiltrating
S3.04
Maximum tumour dimension
Numeric: ___mm
S3.05
Depth of invasion
Single selection value list:
•
lamina propria
46
S/G
S3.06
S3.07
S3.08
Item description
Peritoneal involvement
Pleural involvement
Lymphatic and capillary
space invasion
Vein and artery space
invasion
Perineural invasion
G3.02
Tumour budding
Response type
Conditional
•
muscularis mucosae
•
submucosa
•
muscularis propria
•
adventitial connective tissue
Single selection value list:
•
Absent
•
Present
Single selection value list:
•
Absent
•
Present
Single selection value list:
•
Absent
•
Present
Single selection value list:
•
Absent
•
Present
Single selection value list:
•
Absent
•
Present
Single selection value list:
47
S/G
S3.09
S3.10
Item description
Degree of regression (AJCC)
Response type
•
Absent
•
Present
Conditional
Single selection value list:
•
Grade 0: Complete Response – No viable cancer
cells
•
Grade 1: Moderate response - Single cells or
small groups of cancer cells
•
Grade 2: Minimal response – Residual cancer
outgrown by fibrosis
•
Grade 3: Absent response – Minimal or no
tumour kill; extensive residual cancer
SURGICAL MARGIN STATUS
Distance of carcinoma to
proximal margin
Numeric: ___mm
OR
Involved (R1)
Distance of carcinoma to
distal margin
Numeric: ___mm
OR
Involved (R1)
48
S/G
Item description
Response type
Distance of carcinoma to
radial/circumferential
margin
Numeric: ___mm
Conditional
OR
Involved (R1)
G3.03
S3.11
Donut
Single selection value list:
•
Not involved
•
Involved
LYMPH NODE STATUS
Main resection specimen
Numeric: Number of LN’s
AND
If positive, record the number
of positive nodes.
Single selection value list:
Number of positive nodes
Separately labelled
specimen(s)
•
Negative
•
Positive
Numeric: ___
Text: record site as per labelling
AND
Numeric: Number of LN’s
49
If positive, record the number
of positive nodes.
S/G
Item description
Response type
Conditional
AND
Single selection value list:
•
Negative
•
Positive
Notes:
Note that the number of Lymph Nodes and whether any
are positive will need to be repeated for each separately
labelled specimen received.
Number of positive nodes
Numeric: ___
Note:
Note that the number of positive Lymph Nodes will need
to be repeated for each site received with positive
nodes.
S3.12
Other pathologies
Multi select value list (select all that apply):
•
Barrett mucosa
•
Squamous or glandular dysplasia
•
Gastritis
•
Eosinophilic oesophagitis
•
Other
50
If ‘other’, record details
If Barrett mucosa or dysplasia
record margin involvement
If dysplasia, record the
distance of dysplasia to
closest margin
S/G
Item description
Response type
Details
Margin involvement
Distance of dysplasia to
closest margin
G3.04
Other microscopic comment
Conditional
Text
Single selection value list:
•
Involved
•
Not involved
Numeric: ___mm
Text
Ancillary test findings
G4.01
ANCILLARY TESTS
Performed
Test type eg IHC, MUC etc
Single selection value list:
•
No
•
Yes
Text
If yes, record test type
If IHC, record the antibodies
Note: Test result type, result and interpretive comment
will need to repeat for each ancillary test performed.
51
S/G
Item description
Response type
Antibodies
Result
Conditional
List (as applicable) all:
•
Positive antibodies
•
Negative antibodies
•
Equivocal antibodies
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
S5.01
AJCC TUMOUR STAGING
Primary tumour category
Single selection value list:
TX
T0
Tis
T1
T1a
Primary tumour cannot be assessed
No evidence of primary tumour
High grade dysplasia***
Tumour invades lamina propria, muscularis
mucosae, or submucosa
Tumour invades lamina propria or muscularis
52
S/G
Item description
Response type
T1b
T2
T3
T4
T4a
T4b
Conditional
mucosae
Tumour invades submucosa
Tumour invades muscularis propria
Tumour invades adventitia
Tumour invades adjacent structures
Resectable tumour invading pleura, pericardium,
or diaphragm
Unresectable tumour invading other adjacent
structures, such as aorta, vertebral body, trachea
etc
Note
(1) At least maximal dimension of the tumour must be
recorded and (2) multiple tumours require the
T(m) suffix.
*** High grade dysplasia includes all noninvasive
neoplastic epithelia that was formerly called
carcinoma in-situ, a diagnosis that is no longer
used for columnar mucosae anywhere in the
gastrointestinal tract.
Regional lymph node
Single selection value list:
NX
N0
N1
N2
N3
Regional lymph nodes cannot be assessed
No regional lymph node metastasis
Metastasis in 1-2 regional lymph nodes
Metastasis in 3-6 regional lymph nodes
Metastasis in seven or more regional lymph nodes
53
S/G
Item description
Response type
Conditional
Note
*
Distant metastasis
Single selection value list:
M0
M1
Pathological stage grouping
Number must be recorded for the total number of
regional nodes sampled and total number of
reported nodes with metastasis.
No distant metastasis
Distant metastasis
For Squamous cell carcinoma:
Single selection value list:
Stage
O
IA
IB
IIA
IIB
IIIA
IIIB
T
N
M
Grade
Tumour
Location **
Tis (HGD)
T1
T1
T2-3
T2-3
T2-3
T2-3
T1-2
T1-2
T3
T4a
T3
N0
N0
N0
N0
N0
N0
N0
N1
N2
N1
N0
N2
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
1, X
1, X
2-3
1, X
1, X
2-3
2-3
Any
Any
Any
Any
Any
Any
Any
Any
Lower,
Upper,
Lower,
Upper,
Any
Any
Any
Any
Any
54
X
middle
X
middle
S/G
Item description
Response type
IIIC
IV
T4a
T4b
Any
Any
Conditional
N1-2
Any
N3
Any
M0
M0
M0
M1
Any
Any
Any
Any
Any
Any
Any
Any
Note
* Or mixed histology including a squamous
component or NOS.
** Location of the primary cancer is defined by the
position of the upper (proximal) edge of the tumour
in the oesophagus.
For Adenocarcinoma
Single selection value list:
Stage
O
IA
IB
IIA
IIB
IIIA
T
Tis (HGD*)
T1
T1
T2
T2
T3
T1-2
T1-2
T3
N
N0
N0
N0
N0
N0
N0
N1
N2
N1
55
M
M0
M0
M0
M0
M0
M0
M0
M0
M0
Grade
1, X
1-2, X
3
1-2, X
3
Any
Any
Any
Any
S/G
Item description
Response type
Conditional
T4a
N0
T3
N2
T4a
N1-2
T4b
Any
Any
N3
IV
Any
Any
*HGD, high grade dysplasia.
IIIB
IIIC
S5.02
G5.01
Year and edition of staging
system
Diagnostic summary
Numeric: year
AND
Text: Edition eg 1st, 2nd etc
Text
Include:
o
Tumour location
G5.02
o
Histologic type
o
Tumour grade
o
Maximum tumour
dimension
o
Lymph nodes
o
Stage
o
Involved or close margins
(includes tumour less than
1mm from margin)
Overarching comment
Text
56
M0
M0
M0
M0
M0
M1
Any
Any
Any
Any
Any
Any
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.
57
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 tumour location/site should be recorded.
•
Select all that apply:
•
cervical oesophagus
58
•
upper thoracic
•
middle thoracic
•
lower thoracic
•
gastro-oesophageal junction
Refer to Figure A1 below.
•
Cancers whose midpoint is in the lower thoracic oesophagus, GOJ
or within the proximal 5cm of the stomach (cardia) that extend
into the GOJ or oesophagus are staged as carcinoma of the
oesophagus. (Refer to Figure S2.04). All other cancers with a
midpoint in the stomach lying more than 5cm distal to the GOJ or
those within 5cm of the GOJ but not extending into the GOJ or
oesophagus are staged using the gastric (non-GOJ) cancer staging
system.1
•
It should be noted that true gastric proximal (cardia) tumours
are rare; most involve the GOJ and should therefore be staged
using the oesophageal cancer staging system.1
Figure A1
Anatomy of oesophageal cancer primary site
Anatomy of oesophageal cancer primary site, including typical endoscopic
measurements of each region measured from the incisors. Exact measurements
are dependent on body size and height.
59
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.

The type of operation or procedure should be recorded.
•

•
Pharyngolaryngo-oesophagectomy
•
Oesophagectomy
•
Oesophago-gastrectomy
•
Other (specify)
The operative method of the oesophago-gastrectomy may be recorded.
•

Choose from one of the following:
Choose from one of the following:
•
3 Stage (eg McKeown)
•
2 Stage (eg Ivor-Lewis)
•
1 Stage (eg Sweet)
•
Trans-hiatal
The extent of lymphadenectomy should be recorded.44
•
There is a general lack of uniformity as to what the term
lymphadenectomy in oesophageal cancer surgery means. For the
purposes of this protocol the definitions provided by Jamieson et
al44 will be used:
Radical lymphadenectomy procedures
i.
Three-field lymphadenectomy with lymph node resection
encompassing upper abdominal (D2), inferior, middle, and
superior mediastinal lymph nodes, and inferior cervical
nodes.
ii.
Two-field lymphadenectomy, which is the same as the
above with the exception of removal of the cervical nodes.
iii.
Infracarinal 2-field lymphadenectomy which omits both
cervical lymph nodes and a formal superior mediastinal
nodal dissection.
Conservative lymphadenectomy in which only the nodes in
direct proximity to the tumour, the oesophagus, and upper
stomach are removed.
•
Choose from one of the following:
•
Three field
•
Two field
•
Two field (Infra-carinal)
60
•

If preoperative therapy has been administered, this should be recorded.
•


•
Preoperative chemotherapy
•
Preoperative radiotherapy
•
Preoperative chemoradiotherapy
Involvement of adjacent organs, either resected or not resected,
is required for assessment of the tumour (T) stage. Unless
obvious, the area of involvement should be marked with a suture
or other marker.
The presence of any distant metastases should be recorded.
•
The reporting of metastatic deposits, either resected or not
resected, is required for assessment of the metastatic (M) stage
of the tumour. The sites of such deposits should be stated.
•
Additional specimens taken eg peritoneal nodules, liver biopsy,
other etc should be labelled and recorded separately.
•
The presence of positive peritoneal cytology is classified as
metastatic disease. This information should be provided to the
reporting pathologist, in part because the diagnosis may have
been made at a different laboratory.
The Surgeon’s opinion on the existence of local residual cancer
following the operative procedure should be recorded.
•

Choose from one of the following:
The involvement of adjacent organs should be recorded.
•

Conservative
This item relates to the overall completeness of resection of the
tumour, including evidence of macroscopic residual disease at
surgical margins or within regions in which resection has not been
attempted (R2). It allows for residual tumour status (R) to be
reported by the pathologist following microscopic assessment of
the surgical margins. Residual microscopic disease is reported as
R1.
Record if this is a new primary cancer or a recurrence of a
previous cancer, if known.
•
The term recurrence defines the reappearance or metastasis of
cancer (of the same histology) after a disease free period.
Recurrence should be classified as regional (local) recurrence or
distant metastasis. Regional (local) recurrence refers to the
recurrence of cancer cells at the same site as the original
(primary) tumour or the regional lymph nodes. Distant metastasis
refers to the spread of cancer of the same histologic type as the
original (primary) tumour to distant organs or distant lymph
nodes.
61
•

This information will provide an opportunity for previous reports to
be reviewed during the reporting process, which may provide
valuable information to the pathologist. This information also has
implications for recording cancer incidence and evidence based
research.
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.
Surgical handling

The specimen must be capable of orientation if the status of
specific surgical margins is critical in determining the need for,
or extent of, further surgery.
•


The specimen should be sent to the laboratory in the fresh state
without delay where possible.
•
The laboratory should be informed if the specimen is likely to be
received outside normal working hours.
•
Where a specimen is unable to be received by the laboratory (eg
outside normal working hours), it should be opened by the
surgeon, contents drained, and placed in an adequate volume of
formalin based solution.
The specimen should be sent to the laboratory intact where possible.
•

Where there are no anatomical landmarks, specimen orientation
may be indicated with marking sutures or other techniques. If a
specimen is orientated, the orientation should be indicated on the
specimen request form (this may be facilitated by the use of a
diagram).
When a specimen needs to be opened eg to confirm adequate
surgical margins or tumour localisation, the specimen should be
opened by a single longitudinal incision and should avoid cutting
through tumour if at all possible.
Lymph nodes must be labelled clearly, identifying the site.
•
Lymph nodes taken separately from the resection specimen must
be labelled as to site. (Refer to Figure A2 below).
62
Figure A2
Lymph node map for oesophageal cancer.*
_
1 Supraclavicular zone
8L Lower paraesophageal
2R Right Upper Paratracheal
9 Pulmonary ligament
2L Left Upper Paratracheal
10R Right tracheobronchial
3P Posterior mediastinal
10L Left tracheobronchial
4R Right Lower Paratracheal
15 Diaphragmatic
4L Left Lower Paratracheal
16 Paracardial
5 Aortopulmonary
17 Left gastric
6 Anterior mediastinal
18 Common hepatic
7 Subcarinal
19 Splenic
8M Middle paraesophageal
20 Celiac
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, Sixth Edition (2002) published by Springer Science and Business Media
LLC, www.springerlink.com.
63

Any other additional tissue eg donut, must be labelled clearly,
identifying the site.
64
Example Request Information Sheet
65
The above Request Information Sheet is published to the RCPA website.
66
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.39
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.39
‘Clutter’ should be reduced to a minimum.45 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.
67
Appendix 3
Example of a pathology report
68
69
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
9580/0
9120/0
8890/0
8850/0
8936/1
9140/3
8890/3
70
Melanoma
Rhabdomyosarcoma
Synovial sarcoma
8720/3
8900/3
9040/3
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.
71
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