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Esophagus

, Volume 14, Issue 1, pp 1–36 | Cite as

Japanese Classification of Esophageal Cancer, 11th Edition: part I

  • Japan Esophageal SocietyEmail author
Open Access
Special Article

Keywords

Esophageal Cancer Endoscopic Submucosal Dissection Endoscopic Resection Esophagogastric Junction Japanese Classification 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
President
Hisahiro Matsubara

Chiba University

Former President
Nobutoshi Ando

Tokyo Dental University

English Edition Committee, Chairman
Hisahiro Matsubara

Chiba University

English Edition Committee Members
Kenji Nemoto

Yamagata University

Naohisa Yahagi

Keio University

Soji Ozawa

Tokai University

Yoshiaki Kajiyama

Juntendo University

Tatsuyuki Kawano

Tokyo Medical and Dental University

Tomio Arai

Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology

Yuji Tachimori

National Cancer Center Hospital

Shoji Natsugoe

Kagoshima University

Kumiko Momma

Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital

Yasuyuki Seto

Tokyo University

Yuichiro Doki

Osaka University

English Edition Supervisor
Hiromasa Fujita

Fukuoka Wajiro Hospital

Editorial Assistants
Yasunori Akutsu

Chiba University

Japanese Edition Committee, Chairman
Hisahiro Matsubara

Chiba University

Japanese Edition Committee Members
Kenji Nemoto

Yamagata University

Naohisa Yahagi

Keio University

Soji Ozawa

Tokai University

Yoshiaki Kajiyama

Juntendo University

Tatsuyuki Kawano

Tokyo Medical and Dental University

Tomio Arai

Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology

Yuji Tachimori

National Cancer Center Hospital

Shoji Natsugoe

Kagoshima University

Kumiko Momma

Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital

Yasuyuki Seto

Tokyo University

Yuichiro Doki

Osaka University

Pathological Research Committee, Chairman
Tomio Arai

Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology

Pathological Research Committee Members
Yasuo Ohkura

Kyorin University

Shingo Ishiguro

PCL Japan

Hiroshi Kawachi

The Cancer Institute Hospital of Japanese Foundation for Cancer Research

Kaiyo Takubo

Tokyo Metropolitan Institute of Gerontology

Masamitsu Unakami

Watari Hospital

Takashi Yao

Juntendo University

Suguru Yonezawa

Kagoshima University

Tetsuo Nemoto

Toho University

Endoscopy Research Committee, Chairman
Tuneo Oyama

Saku Central Hospital

Endoscopy Research Committee Members
Kumiko Momma

Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital

Tai Omori

Kawasaki Municipal Ida Hospital

Tatsuyuki Kawano

Tokyo Medical and Dental University

Hideo Shimada

Tokai University Oiso Hospital

Manabu Takeuchi

Nagaoka Red Cross Hospital

Ken Haruma

Kawasaki Medical School

Ryu Ishihara

Osaka Medical Center for Cancer and Cardiovascular Diseases

Akio Yanagisawa

Kyoto Prefectural University of Medicine

Ryoji Kushima

Shiga University of Medical Science

Contents

Preface

General principles of this edition

Abbreviations

Part I General rules

  1. 1.
    Purpose, object, and methods of descriptions
    1. 1.1.

      Purpose

       
    2. 1.2.

      Object

       
    3. 1.3.
      Methods of descriptions
      1. 1.3.1.

        Principles of descriptions and abbreviations

         
       
     
  2. 2.
    Clinical aspects
    1. 2.1.
      Description of primary tumor
      1. 2.1.1.

        Number of primary tumors, size and circumferential location

         
      2. 2.1.2.

        Tumor location

         
      3. 2.1.3.

        Macroscopic tumor type

         
      4. 2.1.4.

        Depth of tumor invasion (T)

         
       
    2. 2.2.
      Metastatic lesions from esophageal cancerMetastatic lesions from esophageal cancer
      1. 2.2.1.

        Lymph node metastasis

         
      2. 2.2.2.

        Distant organ metastasis (M)

         
       
    3. 2.3.

      Stage

       
    4. 2.4.

      Multiple primary cancers

       
     
  3. 3.
    Surgical aspects
    1. 3.1.

      Handling of the resected specimen

       
    2. 3.2.
      Description of surgical findings and macroscopic findings of primary tumor
      1. 3.2.1.

        Tumor size

         
      2. 3.2.2.

        Distance from surgical margin to the tumor

         
      3. 3.2.3.

        Macroscopic tumor type

         
      4. 3.2.4.

        Surgical margin

         
      5. 3.2.5.

        RM: Radial margin

         
       
    3. 3.3.
      Intramural metastasis and multiple cancers of the esophagus
      1. 3.3.1.

        IM: Intramural metastasis

         
      2. 3.3.2.

        Multiple cancers of the esophagus

         
       
    4. 3.4.
      Lymph nodes
      1. 3.4.1.

        Preparation of resected lymph nodes for pathological examination

         
      2. 3.4.2.

        Grading of lymph node metastasis (N)

         
      3. 3.4.3.

        Lymph node dissection (D)

         
       
    5. 3.5.

      Distant organ metastasis (M)

       
    6. 3.6.

      Residual tumor (R)

       
    7. 3.7.

      Curativity (Cur)

       
     
  4. 4.
    Pathological findings
    1. 4.1.

      Handling of the surgically resected specimens

       
    2. 4.2.
      Description of pathological findings
      1. 4.2.1.

        Histological classification

         
      2. 4.2.2.

        Depth of tumor invasion (pT)

         
      3. 4.2.3.

        Infiltrative growth pattern (INF)

         
      4. 4.2.4.

        Vascular invasion (ly/v)

         
      5. 4.2.5.

        Intramural metastasis (pIM)

         
      6. 4.2.6.

        Distance from surgical margin

         
      7. 4.2.7.

        Multiple primary cancers

         
      8. 4.2.8.

        Others

         
      9. 4.2.9.

        Pathological criteria for the effects of radiation and/or chemotherapy

         
       
    3. 4.3.

      Lymph node metastasis (pN)

       
    4. 4.4.

      Distant organ metastasis (pM)

       
    5. 4.5.

      Residual tumor (pR)

       
    6. 4.6.

      Curativity (pCur)

       
     
  5. 5.
    Endoscopic treatment
    1. 5.1.

      Handling of specimens resected endoscopically

       
    2. 5.2.
      Description of macroscopic findings and endoscopic findings
      1. 5.2.1

        Number of tumors and number of resected specimens

         
      2. 5.2.2

        Size of resected specimen and size of tumor lesion (for each lesion)

         
      3. 5.2.3

        Tumor types

         
      4. 5.2.4

        Macroscopic findings

         
      5. 5.2.5.

        Clinical assessment of residual tumor

         
       
    3. 5.3.

      Preparation for pathological examination

       
    4. 5.4.
      Description of pathological findings
      1. 5.4.1.

        Pathological diagnosis

         
      2. 5.4.2.

        Depth of tumor invasion (pT)

         
      3. 5.4.3.

        Resection margin

         
      4. 5.4.4.

        Infiltrative growth pattern (INF)

         
      5. 5.4.5.

        Vascular invasion (ly/v)

         
      6. 5.4.6.

        Report of pathological findings

         
       
    5. 5.5.

      Residual tumor (pR)

       
    6. 5.6.

      Curativity (pCur)

       
     
  6. 6.
    Barrett esophagus and adenocarcinoma in Barrett esophagus
    1. 6.1.
      Definition and description methods for Barrett mucosa, Barrett esophagus and adenocarcinoma in Barrett esophagus
      1. 6.1.1.

        Definition of the esophagogastric junction (EGJ)

         
      2. 6.1.2.

        Barrett mucosa

         
      3. 6.1.3.

        Barrett esophagus

         
      4. 6.1.4.

        Adenocarcinoma in Barrett esophagus

         
       
    2. 6.2.

      Tumor location

       
    3. 6.3.
      Description of tumors
      1. 6.3.1.

        Primary tumor

         
      2. 6.3.2.

        Intramural metastasis (IM)

         
      3. 6.3.3

        Lymph node metastasis (N)

         
      4. 6.3.4.

        Distant organ metastasis (M)

         
       
    4. 6.4.

      Stage

       
     
  7. 7
    Treatment
    1. 7.1.
      Endoscopic treatment
      1. 7.1.1.

        Endoscopic resection: ER

         
      2. 7.1.2.

        Other endoscopic treatment

         
       
    2. 7.2.
      Surgical treatments
      1. 7.2.1.

        Resection and reconstruction procedures

         
      2. 7.2.2.

        Conservative/palliative procedure

         
       
    3. 7.3.
      Stenting
      1. 7.3.1.

        Esophageal stents

         
      2. 7.3.2.

        Tracheobronchial stents

         
      3. 7.3.3.

        Aortic stents

         
       
    4. 7.4.
      Common issues for radiotherapy and chemotherapy
      1. 7.4.1.

        Disease status

         
      2. 7.4.2.

        Aim of treatment

         
      3. 7.4.3.

        Reasons for definitive radiotherapy

         
       
    5. 7.5.
      Radiotherapy (RT)
      1. 7.5.1.

        Clinical target volume (CTV)

         
      2. 7.5.2.

        Methods of radiotherapy

         
      3. 7.5.3.

        External beam radiotherapy

         
      4. 7.5.4.

        Intraluminal irradiation

         
      5. 7.5.5.

        Completion of treatment

         
      6. 7.5.6.

        Reasons for treatment cessation

         
       
    6. 7.6.
      Chemotherapy (CT)
      1. 7.6.1.

        Agents

         
      2. 7.6.2.

        Administration routes

         
      3. 7.6.3.

        Administration procedures

         
      4. 7.6.4.

        Administration doses

         
      5. 7.6.5.

        Administration schedules

         
      6. 7.6.6.

        Duration of administration

         
      7. 7.6.7.

        Total administration dose

         
      8. 7.6.8.

        Reasons for treatment cessation

         
      9. 7.6.9.

        Adverse events

         
       
    7. 7.7.
      Multi-modality treatment
      1. 7.7.1.

        Combination of endoscopic treatment and surgery, radiotherapy, chemoradiotherapy or chemotherapy

         
      2. 7.7.2

        Chemoradiotherapy (CRT)

         
       
    8. 7.8.

      Hyperthermia (HT)

       
    9. 7.9.

      Immunotherapy (IT)

       
     
  8. 8.
    Results of treatment
    1. 8.1.

      Total number of patients

       
    2. 8.2.

      Multiple primary cancers

       
    3. 8.3.

      Main treatment and adjuvant therapy

       
    4. 8.4.
      Total number of patients treated, and number and ratio of patients treated with each procedure
      1. 8.4.1.

        Patients operated

         
      2. 8.4.2.

        Patients with endoscopic treatment

         
      3. 8.4.3.

        Patients with chemotherapy and/or radiotherapy

         
       
    5. 8.5.

      Operative mortality

       
    6. 8.6.

      Hospital mortality

       
    7. 8.7.
      Long-term outcome
      1. 8.7.1.

        Alive or dead

         
      2. 8.7.2.

        Recurrence

         
       
    8. 8.8.
      Long-term outcomes and prognosis, especially survival rate
      1. 8.8.1.

        Analysis of survival rates

         
      2. 8.8.2.

        Period and rate of esophageal preservation

         
       
    9. 8.9.
      Terminology related to survival period
      1. 8.9.1.

        Survival time

         
      2. 8.9.2.

        Overall survival (OS)

         
      3. 8.9.3.

        Median survival time (MST)

         
      4. 8.9.4.

        Survival rate

         
      5. 8.9.5.

        Progression-free survival (PFS), time to progression (TTP)

         
      6. 8.9.6.

        Relapse-free survival, recurrence-free survival (RFS)

         
      7. 8.9.7.

        Disease-free survival (DFS)

         
      8. 8.9.8.

        Time to treatment failure (TTF)

         
      9. 8.9.9.

        Response duration

         
      10. 8.9.10.

        Complete response duration

         
       
     

Preface to the 11th Edition

Eight years after the publication of the 10th edition in 2007, the 11th edition of the Japanese Classification of Esophageal Cancer has now been published. During this period, supplements to the 10th edition involving the revision of “disease typing” and terminology were published in 2008; in addition, following the adoption of criteria for the diagnosis of lesions located at the gastroesophageal junction that was made in cooperation with the Japanese Gastric Cancer Association, a 7-page leaflet was attached to this Classification in September 2013. The present revision was aimed at ensuring consistency with other general rules for surgical and pathological studies on cancer as far as possible, reflecting the latest advances in the diagnosis and treatment of esophageal cancer in Japan and providing a set of rules that are easier to use and that facilitate improvements in treatment outcomes. During this revision, we attempted to secure consistency with the UICC’s TNM classification as far as possible. However, this attempt was skipped for the N classification, since the current edition (7th) of the TNM classification does not reflect the nationwide registry data of the Japan Esophageal Society and because the rules for studies on supraclavicular lymph nodes are completely different between our classification and the N classification. This is a significant issue that will need to be addressed in the next revision.

Using nationwide registry data, the effects of regional lymph node excision were reviewed from the viewpoints of lymph node metastasis and the survival rate. As a result, the lymph node groupings were modified (T4 was subdivided into two subtypes, similar to the TNM classification). Following recent advances and the spread of endoscopic treatment, findings from endoscopic treatment have now been incorporated into the description methods, and the exclusion of cancer from intraepithelial neoplasms has been clarified. This revised edition has been prepared as a result of numerous discussions among committee members. Although there are still some questions to be discussed, we wish to take this opportunity to thank the considerable efforts made by the individual committee members.

October, 2015

General principles of this edition

  1. 1.

    Following the spread of endoscopic treatment, findings from endoscopic treatment (e) have been added to the methods used to describe findings.

     
  2. 2.

    The criteria for the diagnosis of lesions located at the gastroesophageal junction, which have been jointly adopted by the Japanese Gastric Cancer Association, have been added to the main text.

     
  3. 3.

    Regarding the depth of tumor invasion, the subgroup T1b- has been added to the subgroup T1b, similar to that for T1a, and the subgroup T4 has been further subdivided into T4a and T4b so as to be consistent with the UICC’s TNM classification.

     
  4. 4.

    Regarding lymph nodes, No. 112ao has been divided into the esophageal side and the dorsal side. Furthermore, to secure consistency with the general rules for surgical and pathological studies on gastric cancer, No. 3 has been divided into No. 3a and No. 3b.

     
  5. 5.

    Regarding lymph node grouping, modifications have been made to Ut (Group 3 only), Mt/Lt (Groups 1, 2, 3), and Ae (Groups 2, 3). In accordance with the revision of the criteria for the diagnosis of lesions located at the gastroesophageal junction, the same lymph node classification as that used for Ae will now be applied to cancer of the gastroesophageal junction.

     
  6. 6.

    Regarding the stage of cancer, T1aN1 is now classified as Stage II, as is the case with T1bN1. T4a up to N3 is now classified as Stage III. T4b, beginning with N0, is now classified as Stage IVa.

     
  7. 7.

    Regarding the extent of residual cancer, classification into R1 based on macroscopic findings is now avoided, consistent with the general rules for surgical and pathological studies on colorectal cancer.

     
  8. 8.

    Regarding histopathological findings, it has now been made clear that carcinoma in situ is not to be included among neoplasms within the squamous epithelium. The extent of differentiation of both squamous cell carcinoma and adenocarcinoma is now described as “well differentiated” or a similar expression, omitting any description of type. Endocrine cell neoplasm is now called neuroendocrine tumor, consistent with the WHO classification. Also, concerning extralymph node metastasis, the expression “tumor nodule” has been adopted, consistent with the general rules for surgical and pathological studies on colorectal cancer. Vascular invasion in specimens collected during endoscopic treatment is now rated as (−) or (+), consistent with the method used for gastric cancer.

     
  9. 9.

    The TNM classification adopted for the revised classification has been switched to the Japanese translation of the TNM classification, 7th edition.

     
  10. 10.

    Regarding the number of lymph node metastases, the conventional rule for the correction of grouping according to the number of metastases was too complex and was not used frequently. This rule has been deleted from the revised edition.

     
  11. 11.

    The endoscope pictures have been replaced with clearer ones.

     
  12. 12.

    Regarding the extents and borders of the lymph nodes, not only schematic figures, but also actual CT images have been provided to simplify understanding, accompanied by the presentation of features that will also be useful for radiotherapy.

     

Abbreviations

AD

Adventitia

Ae

Abdominal esophagus

AI

Invasion to the adjacent structures

APC

Argon plasma coagulation

B

Tracheal bifurcation

c

Clinical findings

Ce

Cervical esophagus

CR

Complete response

CRT

Chemoradiotherapy

CT

Chemotherapy

CTV

Clinical target volume

Cur

Curativity

D

Lymph node dissection

DFS

Disease-free survival

DM

Distal margin

DMM

Deep muscularis mucosae

E

Esophagus

EG

Tumor located in the esophageal side

EGJ

Esophagogastric junction

EMR

Endoscopic mucosal resection

EP

Epithelium [p. 41, 74]

ER

Endoscopic resection

ESD

Endoscopic submucosal dissection

EVG

Elastica van Gieson staining

f

Final findings

G

Stomach

GE

Tumor located in the gastric side

GIST

Gastrointestinal stromal tumor

H

Esophageal hiatus

HM

Horizontal margin

HT

Hyperthermia

IM

Intramural metastasis

INF

Infiltrative growth pattern

IR/SD

Incomplete response/stable disease

IT

Immunotherapy

LN

Lymph node

LPM

Lamina propria mucosae

LSBE

Long segment Barrett esophagus

Laser

Laser therapy

Lt

Lower thoracic esophagus

Ly

Lymphatic invasion

ly/v

Lymphatic invasion or venous invasion

M

Distant organ metastasis

MCT

Microwave coagulation therapy

MFH

Malignant fibrous histiocytoma

MM

Muscularis mucosae

MP

Muscularis propria

MST

Median survival time

Mt

Middle thoracic esophagus

N

Lymph node metastasis

O

Esophageal orifice

OS

Overall survival

p

Pathological findings

PD

Progressive disease

PDT

Photodynamic therapy

PFS

Progression-free survival

Ph

Pharynx

PM

Proximal margin

PR

Partial response

R

Residual tumor

RECIST

Response Evaluation Criteria in Solid Tumors

RFS

Relapse/recurrence-free survival

RM

Radial margin

RT

Radiotherapy

s

Surgical findings

S

Superior margin of the sternum

SCE

Specialized columnar epithelium

SCJ

Squamocolumnar junction

SD

Stable disease

SM

Submucosa

SMM

Superficial muscularis mucosae

SSBE

Short segment Barrett esophagus

T

Depth of tumor invasion

Te

Thoracic esophagus

Tis

Carcinoma in situ

TT

Thermotherapy

TTF

Time to treatment failure

TTP

Time to progression

Ut

Upper thoracic esophagus

v

Venous invasion

VB

Victoria blue staining

VM

Vertical margin [p. 39]

X

Cannot be assessed [p. 2]

Terminology of the lymph nodes

R

Right

L

Left

sm

Submandibular

spf

Superficial

ac

Accessory

tr

Tracheal

up

Upper

mid

Middle

rec

Recurrent nerve

tb

Tracheobronchial

pre

Pretracheal

ao

Paraaortic

pul

Pulmonary ligament

Number of the lymph nodes

a: 1–3, b: 4–7, c: ≧8

Part I

General rules

1. Purpose, object, and methods of descriptions

1.1. Purpose

“The Guidelines for the Clinical and Pathologic Studies on Carcinoma of the Esophagus” was originally published in 1969 by the Japanese Society for Esophageal Diseases. Since then, the Society has changed its name in 2003 to become the Japan Esophageal Society, and has published the “Japanese Classification of Esophageal Cancer” in Japanese with some revisions to keep up to date with treatment results and to provide a standard nomenclature. To promote the international use of the Guidelines and the Classification, the Society is publishing this handbook in English entitled “The Japanese Classification of Esophageal Cancer”.

1.2. Object

The term esophageal cancer in the Japanese Classification refers to cancer originating in the esophagus, and cancer metastatic to the esophagus is excluded. All primary malignant tumors in the esophagus should be described according to the Japanese Classification.

1.3. Methods of descriptions

1.3.1. Principles of descriptions and abbreviations

Findings are recorded using upper-case letters T (depth of tumor invasion), N (lymph node metastasis) and M (distant organ metastasis). The extent of each finding is expressed by Arabic numerals following each upper-case letter. “X” is used in unknown cases. Five categories of findings, namely Clinical, Endoscopic treatment, Surgical, Pathological, and Final findings, are identified using the lower case “c”, “e”, “s”, “p”, and “f”, respectively, before each upper-case letter. The “f” of Final findings can be omitted (Tables 1-1, 1-2). Checklists for descriptions of the Japanese Classification of Esophageal Cancer are shown in the following tables (Tables 1-3, 1-4).
Table 1-1

Principles of description

Clinical findings (c)

Endoscopic treatment findings (e)

Surgical findings (s)

Pathological findings (p)

Final findings (f)

Physical examination

Diagnostic imaging

Xray, Endoscopy (NBI magnification, Iodine staining, EUS etc.), CT, MRI, PET etc.

Biopsy and Cytology

Biochemical and Biological examinations

Others (genetic studies etc.)

Operative findings

Macroscopic examination of the resected specimens

Operative findings

Intraoperative diagnostic imaging

Frozen sections

Macroscopic examination of the resected specimens

Pathological examination of materials obtained by surgical or endoscopic resection

Comprehensive findings based on clinical, surgical and pathological findings

Note

Note: In cases in which any findings are modified by combined treatment, findings should be recorded as the estimated most advanced condition throughout the treatment

Tracheal invasion was observed from clinical findings; cT4, cN2, cM0, cStage IVa

As the tumor responded to chemoradiotherapy, surgery was performed; CRT-sT3, sN2, sM0, sStage III

Although the tumor completely responded to chemoradiotherapy on pathological findings, metastasis to Group 3 lymph nodes was observed; CRT-pT0 (T3), pN3, sM0, pStage III

Final findings; (f) T4, (f) N3, (f) M0, (f) Stage IVa

Table 1-2

Description methods

 

Clinical findings

Endoscopic treatment findings

Surgical findings

Pathological findings

Final findings

Depth of tumor invasion

cT

eT

sT

pT

(f) T

Lymph node metastasis

cN

sN

pN

(f) N

Distant organ metastasis

cM

sM

pM

(f) M

Intramural metastasis

cIM

eIM

sIM

pIM

(f) IM

Stage

cStage

eStage

sStage

pStage

(f) Stage

Proximal margin

sPM

pPM

(f) PM

Distal margin

sDM

pDM

(f) DM

Radial margin

sRM

pRM

(f) RM

Horizontal margin (EMR/ESD)

eHM

sHM

pHM

(f) HM

Vertical margin (EMR/ESD)

eVM

sVM

pVM

(f) VM

    

Residual tumor

eR

sR

pR

(f) R

Curativity

eCur

sCur

pCur

(f) Cur

Findings modified by treatment methods other than surgery are abbreviated as follows: RT radiotherapy, CT chemotherapy, CRT chemoradiotherapy, EMR endoscopic mucosal resection, ESD endoscopic submucosal dissection, laser laser therapy, PDT photodynamic therapy

Table 1-3

Checklist for descriptions of the Japanese Classification of Esophageal Cancer (surgically treated cases)

Tumor location: Ce, Ut, Mt, Lt, Ae

Size: maximum length (mm) and orthogonally oriented maximum width (mm)

Macroscopic tumor type:

 Type 0, Type 1, Type 2, Type 3, Type 4, Type 5, Combined type, Others

 Subclassification for superficial cancers: 0-I(0-Ip, 0-Is), 0-II(0-IIa, 0-IIb, 0-IIc), 0-III

Histological type: squamous cell carcinoma, basaloid (-squamous) carcinoma, carcinosarcoma, adenocarcinoma, Barrett's adenocarcinoma, adenosquamous carcinoma, mucoepidermoid carcinoma, adenoid cystic carcinoma, neuroendocrine cell tumor, undifferentiated carcinoma, other carcinomas, non-epithelial malignant tumors, GIST, malignant melanoma

Depth of tumor invasion: pTX, pT0, pT1a (EP, LPM, MM), pT1b (SM1, SM2, SM3), pT2, pT3, pT4

Pattern of infiltration: INFa, INFb, INFc

Lymphatic invasion: ly0, ly1, ly2, ly3

Venous invasion: v0, v1, v2, v3

Intramural metastasis: pIMX, pIM0, pIM1

Involvement of resection margins

 Proximal margin: pPMX, pPM0, pPM1

 Distal margin: pDMX, pDM0, pDM1

 Radial margin: pRMX, pRM0, pRM1

Multiple primary cancers: absent, present (number)

Lymph node metastasis: pNX, pN0, pN1, pN2, pN3, pN4

 Number of positive nodes (No. of lymph node stations with positive nodes)

Distant metastasis: M0, M1

Residual tumor: pRX, pR0, pR1, pR2

Histological curativity: pCurA, pCurB, pCurC

Distant organ metastasis: MX, M0, M1; Intramural gastric metastasis: pIM1-St

Therapeutic efficacy: No data, Grade 0, Grade 1a, Grade 1b, Grade 2, Grade 3

Curativity: Cur A, Cur B, Cur C

Table 1-4

Checklist for descriptions of the Japanese Classification of Esophageal Cancer (endoscopically treated cases)

Macroscopic findings

 Tumor location: Ce, Ut, Mt, Lt, Ae

 Macroscopic tumor type: Type 0-I, Type 0-IIa, Type 0-IIb, Type 0-IIc, Type 0-III, combined type, others

 Size of specimen: length (mm), width (mm)

 Size of tumor: length (mm), width (mm)

 Resection: en bloc resection, piecemeal resection

 Piecemeal resection: number of specimens

 Horizontal margin: HMX, HM0, HM1

 Vertical margin: VMX, VM0, VM1

 Multiple lesions: present, absent

Histological findings

Histological type: squamous cell carcinoma, basaloid (-squamous) carcinoma, carcinosarcoma, adenocarcinoma, Barrett's adenocarcinoma, adenosquamous carcinoma, mucoepidermoid carcinoma, adenoid cystic carcinoma, neuroendocrine cell tumor, undifferentiated carcinoma, other carcinomas, non-epithelial malignant tumors, GIST, malignant melanoma

 Depth of tumor invasion: pTX, pT0, pT1a (EP, LPM, MM), T1b (SM1, SM2, SM3)

 Pattern of infiltration: INFa, INFb, INFc

 Lymphatic invasion: ly (−), ly (+)

 Venous invasion: v (−), v (+)

 Size of tumor: length (mm) × width (mm)

 Horizontal margin: pHMX, pHM0, pHM1

 Vertical margin: pVMX, pVM0, pVM1

 Residual tumor: pRX, pR0, pR1, pR2

 Curativity: pCur A, pCur B, pCur C

The order of clinicopathological description is:

Tumor location (in addition to describing the distance from the incisor), circumferential extent, tumor length, macroscopic tumor type, histological type (when identified), depth of tumor invasion, lymph node metastasis, distant organ metastasis and stage.

e.g.: Mt (31–36 cm), 1/2 of circumference and on anterior wall, 5 cm, Type 2, moderately differentiated squamous cell carcinoma, pT3, pN2, sM0, fStage III.

The order of pathological description is:

Tumor location, tumor length, macroscopic tumor type, histological type, depth of tumor invasion, pattern of infiltration, lymphatic invasion, venous invasion, intramural metastasis, involvement of the resection margins (proximal margin, distal margin, and radial margin), multiple primary cancers, effects of radiation and/or anticancer chemotherapy, lymph node metastasis, distant organ metastasis, and stage.

e.g.: Mt, 5 cm, Type 2, moderately differentiated squamous cell carcinoma, pT3, INFa, ly1, v1, IM0, pPM0, pDM0, pRM0, multiple primary carcinomas (present, two lesions), CRT-grade 2, pN1 (2/30), sM0, fStage III.

2. Clinical aspects

2.1. Description of primary tumor

2.1.1. Number of primary tumors, size and circumferential location

Maximum length (mm) and orthogonally oriented maximum width (mm), center of circumferential extent, and circumferential ratio of the tumor to the entire esophagus should be described. In addition, the methods used for diagnosis, such as barium X-ray, endoscopy and EUS, should be recorded.

2.1.2. Tumor location

2.1.2.1. Anatomical definition of the esophagus

The esophagus is defined anatomically from the esophageal orifice to the esophagogastric junction. The esophageal orifice is at the lower margin of the cricoid cartilage. The identification of the esophagogastric junction (EGJ) will be described later.

2.1.2.2. Anatomical regions (subsites) of the esophagus

The esophagus lies between the hypopharynx and stomach, and can be anatomically divided into the following portions; cervical esophagus (Ce), thoracic esophagus (Te) and abdominal esophagus (Ae). The zone of the esophagogastric junction is divided into the esophageal side (E) and gastric side (G) (Fig. 1-1).Note
Fig. 1-1

Tumor location. O esophageal orifice, S superior margin of the sternum, B tracheal bifurcation, D diaphragm, EGJ esophagogastric junction, H esophageal hiatus

Cervical esophagus (Ce): This extends from the esophageal orifice to the sternal notch.

Thoracic esophagus (Te): From the sternal notch to the superior margin of the esophageal hiatus.

Upper thoracic esophagus (Ut): From the sternal notch to the tracheal bifurcation.

Middle thoracic esophagus (Mt): The proximal half of the two equal portions between the tracheal bifurcation and the esophagogastric junction.

Lower thoracic esophagus (Lt): The thoracic part of the distal half of the two equal portions between the tracheal bifurcation and the esophagogastric junction.

Abdominal esophagus (Ae): The abdominal part of the distal half of the two equal portions between the tracheal bifurcation and the esophagogastric junction (from the superior margin of the esophageal hiatus to the esophagogastric junction).
  • Note: The zone of the esophagogastric junction is defined as the region between 2 cm in esophagus and 2 cm in the stomach from the esophagogastric junction. The abdominal esophagus is included in this zone.

2.1.2.3. Principles of description of tumor location

Describe the tumor location identified by examinations according to the following order of priority: barium X-ray, CT, and endoscopic measurements. Include the distance from the incisor in addition to the tumor location. When the tumor location is uncertain because examinations other than endoscopy have yet to be performed, describe only the distance from the incisor.

When the tumor extends continuously in more than one portion of the esophagus, the main tumor location is that with the deepest tumor invasion. If it is difficult to determine the site of deepest tumor invasion, the portion at the central point of the tumor can be recorded as the main tumor location.

In the case of multiple primary lesions, the locations of the lesions are described in the order of depth of tumor invasion. The deepest lesion is described first. If it is difficult to determine the order of the depth, the description order depends on the size of the area occupied by the lesion. The largest lesion is described first.

e.g.: MtLt, LtAeG.

2.1.3. Macroscopic tumor type

2.1.3.1. Principles of tumor type classification

The tumor type classification is based on the macroscopic findings. Radiological and endoscopic classifications are based on the macroscopic classification.

Tumors in which invasion is macroscopically diagnosed to be limited to within the submucosa are classified as superficial type, while tumors in which invasion is diagnosed to extend to the muscularis propria or beyond are classified as advanced type. The superficial type has the prefix ‘0’ and is classified into 0-I, 0-II or 0-III. The advanced type is divided into 4 categories: 1, 2, 3, or 4. When a tumor cannot be classified into any of the 5 (0–4) categories or their combinations, it is classified as 5.

2.1.3.2. Macroscopic classification (Fig. 1-2)Note 1
Fig. 1-2

Macroscopic classification (Type 0–4)

  1. Type 0

    Superficial type

     
  2. Type 1

    Protruding type

     
  3. Type 2

    Ulcerative and localized type

     
  4. Type 3

    Ulcerative and infiltrative type

     
  5. Type 4

    Diffusely infiltrative type

     
  6. Type 5
    Unclassifiable type
    1. Type 5a

      Unclassifiable type without treatment

       
    2. Type 5b

      Unclassifiable type after treatmentNotes 1, 2

       
     
  • Note 1: The macroscopic tumor type before chemotherapy and/or radiotherapy is described. Previous treatment is indicated. Cases with minor changes following treatment and which fit the macroscopic tumor type(s) are classified as type 1–4 and cases of major changes are designated as unclassifiable type.

  • Note 2: Any former treatment(s) is mentioned before the macroscopic tumor type. e.g.: CT-3, CRT-5b, EMR-0-IIc

2.1.3.3. Subclassification of superficial type (type 0)
  1. Type 0-I
    Superficial and protruding type
    1. Type 0-Ip

      Pedunculated type

       
    2. Type 0-Is

      Sessile (broad based) type

       
     
  2. Type 0-II
    Superficial and flat type
    1. Type 0-IIa

      Slightly elevated type

       
    2. Type 0-IIb

      Flat type

       
    3. Type 0-IIc

      Slightly depressed type

       
     
  3. Type 0-III

    Superficial and excavated type

     

Other notations

  • Note 1: Combined type: When multiple macroscopic tumor types are mixed in one lesion, it is called a combined type. The wider type is described first and types are connected with +. Double quotation marks (“”) are placed around the macroscopic tumor type that has the deepest tumor invasion. In this case, the main macroscopic tumor type is the deepest one. However, when an advanced type is mixed with a superficial type, the advanced type is described first and double quotation marks are unnecessary.

    e.g.: 0-IIc+“0-Is”, 3+0-IIc.

  • Note 2: Superficial spreading type: superficial type 0-II in which the maximal length of the tumor extends 5 cm or more longitudinally. It may be noted additionally in the macroscopic tumor type.

[Reference]

Japanese Society for Esophageal Diseases. Guidelines for the Clinical and Pathologic Studies on Carcinoma of the Esophagus (in Japanese). 8th ed. Kanehara Shuppan, Tokyo, 1992; 34.

2.1.4. Depth of tumor invasion (T)
  1. TX

    Depth of tumor invasion cannot be assessed

     
  2. T0

    No evidence of primary tumor

     
  3. T1a
    Tumor invades mucosaNote 1(Fig 1-3)
    1. T1a-EP

      Carcinoma in situ (Tis)

       
    2. T1a-LPM

      Tumor invades lamina propria mucosae (LPM)

       
    3. T1a-MM

      Tumor invades muscularis mucosae (MM)

       
     
  4. T1b
    Tumor invades submucosa (SM)Notes 2, 3, 4
    1. T1b-SM1

      Tumor invades the upper third of the submucosal layer

       
    2. T1b-SM2

      Tumor invades the middle third of the submucosal layer

       
    3. T1b-SM3

      Tumor invades the lower third of the submucosal layer

       
     
  5. T2

    Tumor invades muscularis propria (MP)

     
  6. T3

    Tumor invades adventitia (AD)

     
  7. T4
    Tumor invades adjacent structures (AI)Notes 5, 7
    • T4a Pleura, pericardium, diaphragm, lung, thoracic duct, azygos vein, nerve.

    • T4b Aorta (great artery), trachea, bronchus, pulmonary vein, pulmonary artery, vertebral body.

     
Fig. 1-3

Subclassification for superficial cancer (modified from the guidelines for esophageal cancer treatment)

  • Note 1: Early esophageal cancer: T1a can be designated as early cancer of the esophagus regardless of the presence or absence of lymph node or distant organ metastasis. e.g.: early esophageal cancer: T1aNxMx.

  • Note 2: Superficial esophageal cancer: T1a and T1b are designated as superficial cancer regardless of lymph node or distant organ metastasis.

    e.g.: superficial esophageal cancer: T1NxMx

  • Note 3: Formerly used subclassification of superficial type generally corresponds to the following.

    M1: T1a-EP, M2: T1a-LPM, M3: T1a-MM, SM1: T1b-SM1, SM 2: T1b-SM2, SM 3: T1b-SM3

  • Note 4: In endoscopically resected specimens, a tumor invading the submucosa to a depth of 200 μm or less from the lamina muscularis mucosae is classified as T1b-SM1, while a tumor extending more than 200 μm is classified as T1b-SM2, since the distance of the submucosal layer is unknown.

  • Note 5: Invaded organs such as the pericardium, aorta, vena cava, trachea, lung, diaphragm, thoracic duct, recurrent laryngeal nerve, azygos vein should be recorded.

    e.g.: T4a (lung).

  • Note 6: When a metastatic lymph node additionally invades a surrounding organ other than the esophagus, it should be classified as T4 and recorded as “T4 (metastatic node number-invaded organ)”.

    e.g.: T4b (No.112aoA-Aorta).

2.2. Metastatic lesions from esophageal cancer

2.2.1. Lymph node metastasis

2.2.1.1. Naming and numbers of lymph node stations

The names and numbers of lymph nodes are defined as shown in Table 1-5 and Fig. 1-4. The stations of cervical and thoracic lymph nodes are shown in Figs. 1-5, 1-6 and 1-7. The names and numbers of abdominal lymph node stations are defined in the Japanese Classification of Gastric Carcinoma (Table 1-5).
Fig. 1-4

Station numbers of regional lymph nodes

Fig. 1-5

Superficial cervical lymph nodes

Fig. 1-6

Deep cervical lymph nodes

Fig. 1-7

Tracheobronchial lymph nodes (right view of the trachea) (posterior view of the trachea)

Table 1-5

Numbers and naming of regional lymph nodes

(1) Cervical lymph nodes* (Figs. 1-4, 1-5, 1-6)

 No. 100

Superficial lymph nodes of the neck

  No. 100spf

Superficial cervical lymph nodes

  No. 100sm

Submandibular lymph nodes

  No. 100tr

Cervical pretracheal lymph nodes

  No. 100ac

Accessory nerve lymph nodes

 No. 101

Cervical paraesophageal lymph nodes

 No. 102

Deep cervical lymph nodes

  No. 102up

Upper deep cervical lymph nodes

  No. 102mid

Middle deep cervical lymph nodes

 No. 103

Peripharyngeal lymph nodes

 No. 104

Supraclavicular lymph nodes

(2) Thoracic lymph nodes (Figs. 1-4, 1-7)

 

 No. 105

Upper thoracic paraesophageal lymph nodes

 No. 106

Thoracic paratracheal lymph nodes

  No. 106rec

Recurrent nerve lymph nodes

  No. 106recL

Left recurrent nerve lymph nodes

  No. 106recR

Right recurrent nerve lymph nodes

  No. 106pre

Pretracheal lymph nodes

  No. 106tb

Tracheobronchial lymph nodes

  No. 106tbL

Left tracheobronchial lymph nodes

  No. 106tbR

Right tracheobronchial lymph nodes

 No. 107

Subcarinal lymph nodes

 No. 108

Middle thoracic paraesophageal lymph nodes

 No. 109

Main bronchus lymph nodes

  No. 109L

Left main bronchus lymph nodes

  No. 109R

Right main bronchus lymph nodes

 No. 110

Lower thoracic paraesophageal lymph nodes

 No. 111

Supradiaphragmatic lymph nodes

 No. 112

Posterior mediastinal lymph nodes

  No. 112aoA

Anterior thoracic paraaortic lymph nodes

  No. 112aoP

Posterior thoracic paraaortic lymph nodes

  No. 112pul

Pulmonary ligament lymph nodes

 No. 113

Ligamentum arteriosum lymph nodes (Botallo lymph nodes)

 No. 114

Anterior mediastinal lymph nodes

(3) Abdominal lymph nodes (Fig. 1-4)

 No. 1

Right paracardial lymph nodes

 No. 2

Left paracardial lymph nodes

 No. 3a

Lesser curvature Lymph nodes along the branches of the left gastric artery

 No. 3b

Lesser curvature Lymph nodes along the 2nd branches and distal part of the right gastric artery

 No. 4

Lymph nodes along the greater curvature

  No. 4sa

Lymph nodes along the short gastric vessels

  No. 4sb

Lymph nodes along the left gastroepiploic artery

 No. 4d

Lymph nodes along the right gastroepiploic artery

 No. 5

Suprapyloric lymph nodes

 No. 6

Infrapyloric lymph nodes

 No. 7

Lymph nodes along the left gastric artery

 No. 8a

Lymph nodes along the common hepatic artery (anterosuperior group)

 No. 8p

Lymph nodes along the common hepatic artery (Posterior group)

 No. 9

Lymph nodes along the celiac artery

 No. 10

Lymph nodes at the splenic hilum

 No. 11

Lymph nodes along the splenic artery

  No. 11p

Lymph nodes along the proximal splenic artery

  No. 11d

Lymph nodes along the distal splenic artery

 No. 12

Lymph nodes in the hepatoduodenal ligament

 No. 13

Lymph nodes on the posterior surface of the pancreatic head

 No. 14

Lymph nodes along the superior mesenteric vessels

  No. 14A

Lymph nodes along the superior mesenteric artery

  No. 14V

Lymph nodes along the superior mesenteric vein

 No. 15

Lymph nodes along the middle colic artery

 No. 16

Lymph nodes around the abdominal aorta

  No. 16a1

Lymph nodes in the aortic hiatus

  No. 16a2

Lymph nodes around the abdominal aorta (from the upper margin of the celiac trunk to the lower margin of the left renal vein)

  No. 16b1

Lymph nodes around the abdominal aorta (from the lower margin of the left renal vein to the upper margin of the inferior mesenteric artery)

  No. 16b2

Lymph nodes around the abdominal aorta (from the upper margin of the inferior mesenteric artery to the aortic bifurcation)

 No. 17

Lymph nodes on the anterior surface of the pancreatic head

 No. 18

Lymph nodes along the inferior margin of the pancreas

 No. 19

Infradiaphragmatic lymph nodes

 No. 20

Lymph nodes in the esophageal hiatus of the diaphragm

The left side (L) and the right side (R) should be distinguished for 101, 102, 104, 106rec, 106tb, 109, and 112pul

  • Note: The number of lymph node stations should be recorded using “No.” plus a number.

    e.g.: No.106recR.

[Reference]

Japanese Gastric Cancer Association. Japanese Classification of Gastric Carcinoma. 14th ed. Kanehara Shuppan, Tokyo, 2010.

2.2.1.2. Lymph node groups

Lymph node groups are defined according to the location of the tumor as shown in Table 1-6, Figs. 1-8, 1-9, 1-10, 1-11 and 1-12.
Fig. 1-8

Lymph node groups for tumors located in Ce

Fig. 1-9

Lymph node groups of tumors located in Ut

Fig. 1-10

Lymph node groups for tumors located in Mt

Fig. 1-11

Lymph node groups for tumors located in Lt

Fig. 1-12

Lymph node groups for tumors located in Ae (EG)

Table 1-6

Lymph node groups according to the location of the tumor

Tumor location

Group 1 (N1)

Group 2 (N2)

Group 3 (N3)

Cervical Ce

101, 106reca

102, 104, 105a

100

Upper thoracic Ut

101, 105, 106rec

104, 106tbL, 107, 108, 109

102mid, 106pre, 106tbR, 110, 112aoA, 112pul, 1, 2, 3a, 7, 20

Middle thoracic Mt

106rec, 108, 1, 2, 3a

101, 104, 105, 107, 109, 110, 112aoA, 112pul, 7, 9, 20

106tbL

Lower thoracic Lt

110, 1, 2, 3a, 7, 20

101, 106rec, 107, 108, 109, 112aoA, 112pul, 9

104, 105, 106tbL, 111, 8a, 11p

Abdominal Ae

110, 1, 2, 3a, 7, 20

111, 112aoA, 112pul, 8a, 9, 11p, 19

106rec, 107, 108, 109, 11d

Nodes other than N1 through N3 are expressed as N4

aLimited to the area which can be dissected from the cervical incision

  • Note: In deciding the lymph node group of multiple esophageal cancers and widely extending esophageal cancer, the location of the deepest tumor invasion takes precedence in documentation.

2.2.1.3. Grading of lymph node metastasis (N)
NX

Lymph node metastasis cannot be assessed

N0

No lymph node metastasis

N1

Metastasis involving only Group 1 lymph nodes

N2

Metastasis to Group 2 lymph nodes, regardless of involvement of Group 1 lymph nodes

N3

Metastasis to Group 3 lymph nodes, regardless of involvement of Group 1 or 2 lymph nodes

N4

Metastasis to distant (Group 4) lymph nodes, regardless of whether any other group(s) of regional lymph nodes are involved or not

  • Note: Extralymph node metastasis (tumor nodule) is included within N.

2.2.2. Distant organ metastasis (M)
MX

Distant organ metastasis cannot be assessed

M0

No distant organ metastasis

M1

Distant organ metastasis

  • Note 1: Organs with metastasis should be recorded in parentheses.

    e.g.: M1 (lung), M1 (liver, stomach).

  • Note 2: Pleural, peritoneal, and pericardial dissemination should be recorded as M1.

2.3. Stage (Table 1-7)
Table 1-7

Stage

T4a pleura, pericardium, diaphragm, lung, thoracic duct, azygos vein, nerve

T4b aorta (large vessel), trachea, bronchus, pulmonary vein, pulmonary artery, vertebra

The stage should be recorded based on the following TNM stage classification.

e.g.: T2N2M0, Stage III.

2.4. Multiple primary cancers

Multiple primary cancers of the esophagus:

The term “multiple primary cancers of the esophagus” is used to refer to the presence of two or more primary esophageal cancers.
  • Note: Descriptions of the locations of multiple primary cancers of the esophagus should be made according to the order of the depth of tumor invasion (deeper to shallower), inserting “/” between the abbreviations for the location of each lesion; the total number of lesions should also be recorded in parentheses.

    e.g.: MtUt/Lt/Lt (3 lesions).

Multi-organ primary cancers including the esophagus:

The term “multi-organ primary cancers including the esophagus” is used to refer to the presence of one or more primary malignant diseases other than esophageal cancer in a patient with primary esophageal cancer.

Multiple primary cancers including the esophagus:

The term “multiple primary cancers including the esophagus” indicates the concept combining both “multiple primary cancers of the esophagus” and “multi-organ primary cancers including the esophagus”.
  • Note 1: In cases with multi-organ primary cancers including the esophagus, organs other than the esophagus should be specified in parentheses.

  • Note 2: Whether the multiplicity is synchronous or metachronous should be recorded.

    e.g.: Multi-organ primary cancers: stomach (synchronous).

3. Surgical aspects

3.1. Handling of the resected specimen

The resected esophagus should be cut and opened along the longitudinal line on the side opposite to the lesion. The opened esophagus should be gently stretched longitudinally and fixed so that the length of the specimen becomes similar to its size in vivo. The specimen should be treated with iodine solution after fixation in order to accurately describe the macroscopic findings. This is particularly important in superficial carcinoma. Photographic recording is recommended for both fresh and fixed specimens.

3.2. Description of surgical findings and macroscopic findings of primary tumor

Operative findings should be identified in the record putting “s” in front of each factor.

e.g.: sT2, sStageII.

3.2.1. Tumor size (Fig. 1-13)
Fig. 13

Tumor size and the distance from resection margin to tumor. a Greatest longitudinal dimension (mm). b Greatest transverse dimension (mm)

The greatest longitudinal dimension in millimeters and the greatest transverse (at 90° to the longitudinal tumor axis) dimension in millimeters: a × b (mm)

3.2.2. Distance from surgical margin to the tumor (Fig. 1-13 )

Proximal (oral) margin (PM) (mm)

Distal (anal) margin (DM) (mm)

3.2.3. Macroscopic tumor type

The macroscopic appearance of tumors before and after fixation can be different. Under such circumstances, the macroscopic tumor type should be described according to pre-fixation observations, and the pathological tumor type should be described based on the post-fixation findings. Pathological tumor types can be classified referring to the cross-sectional observation. Macroscopic tumor types should be determined regardless of microscopic depth of tumor invasion.
  • Note: The presence of preoperative chemotherapy and radiotherapy should be recorded with the macroscopic tumor type.

3.2.4. Surgical margin

3.2.4.1. PM: Proximal (oral) margin
PMX

Proximal margin cannot be assessed

PM0

No evidence of tumor invasion

PM1

Tumor invasion

3.2.4.2. DM: Distal (anal) margin
DMX

Distal margin cannot be assessed

DM0

No evidence of tumor invasion

DM1

Tumor invasion

  • Note: The distance from the resection margin to tumor should be recorded in millimeters for PM0 and DM0 specimens.

3.2.5. RM: Radial margin
RMX

Radial margin cannot be assessed

RM0

No evidence of tumor invasion

RM1

Tumor invasion

  • Note: The radial margin is the surgical margin in the radial direction, i.e., the outer surface of the surgical dissection plane.

3.3. Intramural metastasis and multiple cancers in the esophagus

3.3.1. IM: Intramural metastasis

Metastatic lesions in the esophageal, pharyngeal, or gastric wall macroscopically (clearly) separate from the primary tumor should be recorded as IM, and the number of such lesions should be described.
IMX

Intramural metastasis cannot be assessed

IM0

No intramural metastasis

IM1

Intramural metastasis

  • Note: IM in the gastric wall should be recorded as “IM1-St”. It is classified as organ metastasis (M1).

3.3.2. Multiple cancers of the esophagus

Multiple cancers are two or more primary cancer lesions separate from each other. Multiple cancers and IM should be clearly differentiated in the description.

3.4. Lymph nodes

3.4.1. Preparation of resected lymph nodes for pathological examination

Surgically dissected lymph nodes are classified according to the definition of regional lymph nodes, given individual names or numbers and sent to pathologists. The lymph nodes dissected en bloc with the esophagus should be isolated from the specimen before fixation.

3.4.2. Grading of lymph node metastasis (N)

The surgical diagnosis of the grading of lymph node metastasis (sN) should be made comprehensively with intraoperative findings of macroscopic observation, imaging examinations, immediate pathological diagnosis with frozen section, and macroscopic findings obtained during postoperative preparation.

3.4.3. Lymph node dissection (D)

3.4.3.1. Field of lymph node dissection

Three-field dissection

Dissection of cervical, thoracic and abdominal lymph nodes through cervical, thoracic and abdominal approaches, respectivelyNote

Two-field dissection

Dissection of thoracic and abdominal lymph nodes through thoracic and abdominal approaches, respectively.

Dissection of cervical and abdominal lymph nodes through cervical and abdominal approaches, respectively.

Dissection of cervical and thoracic lymph nodes through cervical and thoracic approaches, respectively.

One-field dissection

Dissection of a single field of cervical, thoracic and abdominal lymph nodes through cervical, thoracic or abdominal approaches, respectively.

  • Note: The term “three-field dissection” should not be applied when only the cervical paraesophageal nodes (101R, 101 L) are dissected in the neck.

3.4.3.2. Extent of lymph node dissection (D)
DX

Extent of lymph node dissection cannot be assessed.

D0

No or incomplete dissection of Group-1 lymph nodes.

D1

Complete dissection of Group-1 lymph nodes, but no or incomplete dissection of Group-2 lymph nodes.

D2

Complete dissection of Group-1 and Group-2 lymph nodes, but no or incomplete dissection of Group-3 lymph nodes.

D3

Complete dissection of Group-1, Group-2 and Group-3 lymph nodes

3.5. Distant organ metastasis (M)

Surgical findings of distant organ metastasis (sM) should be determined through comprehensive consideration of operative macroscopic findings, intraoperative imaging examinations such as intraoperative ultrasound examination, macroscopic observation of resected specimen, and intraoperative immediate pathological diagnosis with frozen section. Whether the distant organ metastasis was resected or not should be recorded.

3.6. Residual tumor (R) Note 1 (Fig. 1-14)
RX

Presence of residual tumor cannot be assessed.

R0

No residual tumor.

R1

Microscopic residual tumorNote 2

R2

Macroscopic residual tumorNote 3

  • Note 1: The postoperative state of both primary tumor and metastatic lesions should be evaluated.

  • Note 2: This refers to the presence of a tumor on the surgical margin of the resected specimen that was identified upon microscopic examination.

  • Note 3: This refers to a macroscopically obvious residual tumor.

3.7. Curativity (Cur) (Table 1-8)
Table 1-8

Surgical curativity

 

Stage

N and D

PM, DM, RM

R

Cur A

Stage 0, I, II, III

D > N

PM0, DM0, RM0

R0

Cur B

Neither Cur A nor Cur C

Cur C

Residual tumor assessed by surgical (macroscopic) findings, R2

Cur A

Complete removal of the tumor is strongly believed.

sStage 0–III, and sR0, and sD > sN

Cur B

Neither Cur A nor Cur C R1.

sStage IVa, sStage IVb or sD≦sN, but R0 was achieved with resection of a T4b tumor or complete removal of metastatic tumor (M1) or lymph nodes.

Cur C

Residual tumor.

R2, i.e., M1 evident residual tumor in distant organ(s) (M1), lymph nodes, or surgical margin(s) (PM1, DM1, RM1).

Fig. 1-14

Curativity

4. Pathological findings

4.1. Handling of the surgically resected specimens (Fig. 1-15)

Before cutting the resected esophagus, the formalin-fixed specimen should be treated with iodine solution to confirm the unstained area. Rinsing the sample with tap water for at least 1 h can result in a good staining condition. To increase the contrast between stained and unstained areas, the sample should be treated with a relatively low concentration (0.1–0.5%) of iodine solution for a long time.

The resected specimen should be cut parallel along the long axis of the esophagus. Whole step sections are made in superficial type cancer. One representative section of an advanced tumor at the site of deepest invasion, parallel or perpendicular to the esophagus should be blocked and used for microscopic examination. Schemas or photographs of the sites of cut sections should be preserved.

4.2. Description of pathological findings

The p (pathology) mark is prefixed to the pathological findings except for vascular invasion as follows.

e.g.: p0-Is, pType 2, pT2, pStagedII.

4.2.1. Histological classification
Fig. 1-15

How to cut surgically resected specimens

4.2.1.1. Benign epithelial neoplasmsNote 1

  1. 1.

    Squamous cell papilloma

     
  2. 2.

    Adenoma

     
  3. 3.

    Others

     

4.2.1.2. Intraepithelial neoplasiasNote 2–7

  1. 1.

    Squamous intraepithelial neoplasia

     

4.2.1.3. Malignant epithelial neoplasms

  1. 1.
    Squamous cell carcinoma
    1. a.

      Well differentiated

       
    2. b.

      Moderately differentiated

       
    3. c.

      Poorly differentiated

       
     
  2. 2.

    Basaloid (-squamous) carcinoma

     
  3. 3.

    Carcinosarcoma

     
  4. 4.
    Adenocarcinoma
    1. a.

      Well differentiated

       
    2. b.

      Moderately differentiated

       
    3. c.

      Poorly differentiated

       
     
  5. 5.

    Adenosquamous carcinoma

     
  6. 6.

    Mucoepidermoid carcinoma

     
  7. 7.

    Adenoid cystic carcinoma

     
  8. 8.
    Neuroendocrine cell tumorNote 8
    1. a.

      Neuroendocrine tumor (NET) G1 or G2

       
    2. b.

      Neuroendocrine carcinoma

       
     
  9. 9.

    Undifferentiated carcinoma

     
  10. 10.

    Others

     

4.2.1.4. Non-epithelial tumors

  1. 1.

    Smooth muscle tumor

     
  2. 2.

    Gastrointestinal stromal tumor (GIST)

     
  3. 3.
    Neurogenic tumor
    • Schwannoma, neurofibroma, granular cell tumor.

     
  4. 4.
    Others
    • Hemangioma, lymphangioma, lipoma, etc.

     

4.2.1.5. Lymphoid tumors

The definition is according to the WHO classification.

[Reference]

Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, fourth edition. IARC, Lyon, 2008.

4.2.1.6. Other malignant tumors

  1. 1.

    Malignant melanoma

     
  2. 2.

    Others

     

4.2.1.7. Tumor-like lesions

Ectopic gastric mucosa

Heterotopic sebaceous gland

Cowden disease

Glycogenic acanthosis

Fibrovascular polyp
  • Note 1: Squamous papilloma is not a true neoplasia, but reactive hyperplasia.

  • Note 2: Adenocarcinoma and a tumor-like lesion arising from Barrett mucosa are excluded. The classification of adenocarcinoma in Barrett esophagus is the same as that in the Japanese Classification of Gastric Carcinoma.

  • Note 3: According to the WHO classification, high-grade intraepithelial neoplasia cannot be diagnosed as carcinoma because of the absence of invasion. In the 11th edition, however, intraepithelial squamous cell carcinoma (pT1a-EP carcinoma) or squamous cell carcinoma in situ can be diagnosed when cellular and structural atypia are sufficient to suggest malignancy. The 10th edition mentioned that low-grade intraepithelial neoplasia might contain basal-type squamous cell carcinoma. When such lesions are distributed in the lower half of the epithelium and are sufficiently atypical to suggest malignancy, the lesion can be diagnosed as squamous cell carcinoma according to the classification of the 11th edition.

  • Note 4: Most “squamous intraepithelial neoplasias” according to the definition of the 11th edition are endoscopically or macroscopically recognized as a “small unstained or tan-stained area”. The lesion may be solitary or multiple.

  • Note 5: According to the definition of the 11th edition, intraepithelial neoplastic lesion without atypia sufficient to suggest malignancy is termed as squamous intraepithelial neoplasia. Thus, intraepithelial neoplasia does not include squamous cell carcinoma in situ. Please be careful to note the differences in the definitions of intraepithelial neoplasia between the 10th and 11th editions. A two-tier subclassification of intraepithelial neoplasia (low grade and high grade) is not used in the 11th edition. In making a diagnosis of intraepithelial neoplasia based on a biopsy specimen, the inclusion of one of the following comments is recommended: “follow-up is needed”, “re-biopsy after a short time period should be recommended”, or “immediate re-biopsy is strongly recommended because of suspicious carcinoma”.

  • Note 6: When the determination of a biopsy specimen as “neoplastic” or “reactive” is difficult, the specimen should not be diagnosed as “intraepithelial neoplasia”, but rather as “atypical epithelium” or “atypical epithelium, indefinite for neoplasia”. For clinicians, the inclusion of instructions such as the need for a re-biopsy is recommended.

  • Note 7: Squamous cell carcinoma, which is limited to within the epithelial layer without invasion, is different from squamous intraepithelial neoplasia. Squamous cell carcinoma in situ is equal to squamous cell carcinoma with a depth of pT1a-EP.

  • Note 8: Neuroendocrine tumor and neuroendocrine carcinoma are formally classified as carcinoid tumor and endocrine cell carcinoma, respectively. These terms have been adopted according to the WHO classification. In Japan, however, “endocrine cell carcinoma” is considered to be the correct term, since endocrine cells in the gastrointestinal tract originate from gastrointestinal stem cells.

4.2.2. Depth of tumor invasion (pT) Note 1–7

  • Note 1: Intraductal spreading of cancer is categorized as pT1a-EP, and if the tumor invades beyond the duct of the esophageal gland, the depth of tumor invasion is defined as the layer presenting extraductal invasion of cancer.

  • Note 2: The vertical depth of submucosal invasion is measured from the muscularis mucosae, and the depth is recorded in parentheses.

    e.g.: pT1b-SM2 (400 μm).

  • Note 3: The depth of tumor invasion is defined histologically as the point of deepest direct invasion by the primary tumor. Vascular invasion within the confines of the primary tumor should be regarded as the depth of direct tumor invasion. However, when vascular invasion is found outside the confines of the primary tumor, the depth of such invasion should be specified in parentheses after the depth of direct invasion. For example, when a primary tumor has invaded into the submucosa (pT1b) but lymphatic invasion is found in the muscularis propria outside the main tumor, this is designated as pT1b (ly-T2).

  • Note 4: Cancer that has macroscopically invaded adjacent organ(s) (sT4) and histologically diagnosed malignant tissue recognized on the surgical radial margin (pRM1) are categorized as pT4.

  • Note 5: Direct invasion of tumor from lymph node metastasis to the adjacent organ(s) is categorized as pT4.

    e.g.: Direct invasion from No.108 lymph node metastasis to the lung: pN1 (108-lung) T4a

  • Note 6: In determining the depth of invasion of an advanced cancer after preoperative treatment, both the depth of invasion by residual tumor and the estimated depth of tumor invasion prior to treatment should be considered. The type of adjuvant therapy (RT-, CT-, CRT-, EMR-), depth of invasion by the residual tumor, and estimated depth of tumor invasion prior to treatment should be specified in the given order, with the last item in parentheses. e.g.: RT-pT1b (T4).

  • Note 7: If no residual tumor is found in an entire specimen after preoperative treatment, the designation should be pT0, and its stage is recognized as the same as T1a.

    e.g.: CRT-pT0 (T3), N0, M0, CRT-pStage 0.

4.2.3. Infiltrative growth pattern (INF)

The growth and infiltrative pattern of tumor can be classified into one of the following three types, with regard to the predominant pattern observed at tumor margins.
INFa (expansive type)

Expansive growth of tumor nests with a well-demarcated border from surrounding tissue.

INFb (intermediate type)

Intermediate growth pattern, between INFa and INFc.

INFc (infiltrative type)

Infiltrative growth of tumor nests with an ill-defined border from surrounding tissue.

4.2.4. Vascular invasion (ly/v) Note 1

  • Note 1: Indefinite for determination of lymphatic or venous invasion is described as ly/v.

4.2.4.1. Lymphatic invasion (ly)Note 1
ly0

None

ly1

Slight

ly2

Moderate

ly3

SevereNotes 2–3

  • Note 1: Examination using immunohistochemical staining with an anti-D2-40 antibody should be described. e.g.: ly1 (D2-40).

  • Note 2: Carcinomatous lymphangiosis in distant organ(s) is categorized as M1.

  • Note 3: A tumor mass found in the thoracic duct is described as positive lymphatic invasion.

4.2.4.2. Venous invasion (v)Note 1
v0

None

v1

Slight

v2

Moderate

v3

Severe

  • Note 1: Examination by elastic fiber staining methods should be described.

    e.g.: v1 (Elastica van Gieson), v2 (Victoria blue).

4.2.5. Intramural metastasis (pIM)

4.2.6. Distance from Surgical margin

4.2.6.1. Proximal and distal margin (pPM, pDM)Note

  • Note: The distance from surgical margin to tumor edge in pPM0 or pDM0 is measured in histological specimens (mm).

4.2.6.2. Radial margin (pRM)

4.2.7. Multiple primary cancers

Present (number of lesions).

Absent.
  • Note: A lesion with a histological type different from that of the main tumor or an isolated lesion with an intraepithelial component is recognized as another primary cancer, and the patient is classified as having multiple primary cancers.

4.2.8. Others

  1. 1.

    Metastatic or invasive cancer from other organs.

     
  2. 2.
    Co-existing tumor.
    • Leiomyoma, etc.

     
  3. 3.

    Other non-neoplastic lesions.

     

Barrett esophagus, Achalasia, etc.

4.2.9. Pathological criteria for the effects of radiation and/or chemotherapy (Fig. 1-16 )
Fig. 1-16

Histological efficacy of chemotherapy and/or radiotherapy

In cases of preoperative radiation and/or chemotherapy, the radiation dose and method of administration, type and dose of chemotherapy, and time interval between preoperative therapy and surgical resection of the tumor are described. In cases of preoperative treatment, all the specimens in which the primary tumor is macroscopically possibly present should be examined histologically.
  • Grade 0: ineffective
    • No recognizable cytological or histological therapeutic effect.

  • Grade 1: slightly effective
    • Apparently viable cancer cells (including cells having eosinophilic cytoplasm with vacuolation and swollen nuclei) account for 1/3 or more of tumor tissue, but there is some evidence of degeneration of cancer tissue or cells.
        • Grade 1a: Viable cancer cells accounting for 2/3 or more tumor tissue.

        • Grade 1b: Viable cancer cells accounting for 1/3 or more, but less than 2/3, of tumor tissue.

  • Grade 2: Moderately effective
    • Viable cancer cells account for less than 1/3 of tumor tissue, while other cancer cells are severely degenerated or necrotic.

  • Grade 3: Markedly effective
    • No viable cancer cells are evident.

  • Note: Definite re-proliferation of tumor cells in treated cancer lesions, after preoperative treatment, should be recorded as “re-proliferation (+)”.

4.3. Lymph node metastasis (pN)

  • Note 1: Lymph nodes should be sectioned through the hilum.

  • Note 2: The number of dissected lymph nodes and metastatic lymph nodes should be recorded.

  • Note 3: The metastatic ratio (the number of metastatic lymph nodes/the number of dissected lymph nodes) is described for each lymph node station. The total metastatic ratio is also described in parentheses.

    e.g.: No.104R (0/10), No.104 L (1/13), No.106recR (1/3), No.106recL (0/4).

  • Note 4: Metastasis to soft tissue without a lymph node structure is described as extra-lymph node metastasis, and the locations and number of metastases are recorded.

    e.g.: lymph node metastasis, 1/25; extra-lymph node metastasis, 2/2.

  • Note 5: Extranodal invasion including direct invasion and lymphatic invasion is described.

  • Note 6: A lymph node with no viable cancer cells after preoperative treatment is diagnosed as negative for metastasis (pN0).
    Fig. 1-17

    How to cut endoscopically resected specimens

[Reference]

Japanese Gastric Cancer Association: Japanese Classification of Gastric Carcinoma (in Japanese). 13th ed. Kanehara Shuppan, Tokyo, 1999; 27.

4.4. Distant organ metastasis (pM) (cf. 3.5 Distant organ metastasis (M))

4.5. Residual tumor (pR) (cf. 3.6 Residual tumor (R))

4.6. Curativity (pCur) (cf. Curativity (Cur))

5. Endoscopic treatment

5.1. Handling of specimens resected endoscopicallyNote

Extending fixation of the resected specimen: A specimen is extended and fixed immediately after resection on a cork board or polystyrene foam and is fixed in formalin solution of sufficient volume for at least half a day.
  • Note: As for the extended fixation of the resected specimen, it should be done by the doctor or co-worker who carried out endoscopic treatment. Especially in piecemeal resection, fixation of the specimen should be performed by the doctor(s) aware of the actual figure of the tumor in vivo to enable more exact restructuring.

5.2. Description of macroscopic findings and endoscopic findings

An e-mark is prefixed to macroscopic findings and endoscopic findings.

5.2.1 Number of tumors and number of resected specimens

Number of lesions

Number of specimens resected from each tumor (number of specimens):

1. en bloc resection, 2. piecemeal resection.

5.2.2 Size of resected specimen and size of tumor lesion (for each lesion)

The size is described by the greatest longitudinal dimension in millimeters multiplied by the greatest transverse dimension in millimeters: a × b (mm).

5.2.3 Tumor types

The tumor types are classified into Type 0-I, Type 0-IIa, Type 0-IIb, Type 0-IIc, Type 0-III, combined type, and others.

5.2.4 Macroscopic findings

5.2.4.1. Horizontal margin (eHM)
eHMX

Whether residual tumor is present on the horizontal margin cannot be assessed.

eHM0

Non-cancerous squamous epithelium and lamina propria mucosae have been confirmed on all horizontal resection margins.

eHM1

The tumor is exposed on one of its horizontal resection margins.

5.2.4.2. Vertical margin (eVM)
eVMX

Whether residual tumor is present on the vertical margin cannot be assessed.

eVM0

The tumor is not exposed on any of its vertical margins.

eVM1

The tumor is exposed on one of its vertical margins.

5.2.5. Clinical assessment of residual tumor Note 1, 2
eRX (non-assessable)

Whether residual tumor is present on the resection margin cannot be assessed.

eR0 (complete resection)

Non-cancerous squamous epithelium and lamina propria mucosa have been confirmed on all resection margins.

eR1 (slightly incomplete resection)

Presence of an iodine-unstained area on the margin of the resected specimen.

eR2 (incomplete resection)

Presence of residual tumor.

  • Note 1: The clinical assessment of the residual tumor, referring to the iodine staining of the resected specimen, should be performed immediately after the endoscopic resection. In cases with a piecemeal resection, iodine staining of the ulcer margin after resection should be referenced.

  • Note 2: This assessment method should be applied to squamous cell carcinoma.

5.3. Preparation for pathological examination (Fig. 1-17)
Fig. 1-18

Long segment Barrett’s esophagus (LSBE)

Before cutting, formalin-fixed specimen should be stained with iodine solution to confirm unstained area.Note Cutting lines are decided as crossing lines at right angles to the tangent line at the resection margin closest to the tumor, and a whole resected specimen is cut in slice each 2–3 mm thick.
  • Note: Rinsing the sample with tap water for at least 30 min can result in a good staining condition. To make a clearer contrast between stained and unstained areas, the sample should be treated with relatively low concentration (0.1–0.5%) of iodine solution for a little bit longer time.

5.4. Description of pathological findings

The pathological diagnosis of an endoscopically resected specimen is summarized by the histological type, depth of tumor invasion, assessment of resection margin (horizontal and vertical), and vascular invasion.

5.4.1. Pathological diagnosis

The diagnosis is based on the histological classification (4.2.1). Although most esophageal tumors are squamous cell carcinoma, the evaluation of histological differentiation is omitted for intraepithelial carcinoma.

5.4.2. Depth of tumor invasion (pT)

A mucosal cancer is categorized in three depths of pT1a-EP, pT1a-LPM and pT1a-MM. In a submucosal cancer, the distance from the lamina muscularis mucosae is described because the entire submucosal layer cannot be examined in an endoscopically resected specimen. A submucosal cancer is sub-classified as pT1b-SM1 (submucosal tumor invasion limited to within 200 μm) and pT1b-SM2 (invasion to more than 200 μm).

e.g.: pT1b-SM2, 300 μm.

5.4.3. Resection margin Note 1, 2

5.4.3.1. Horizontal margin (pHM)
pHMX

It cannot be assessed whether there is residual tumor on the horizontal margin or not.

pHM0

Non-cancerous squamous epithelium and lamina propria mucosae are confirmed on all horizontal resection margins.

pHM1

The tumor is exposed on any horizontal resection margin.

5.4.3.2. Vertical margin (pVM)
pVMX

It cannot be assessed whether there is residual tumor on the vertical margin or not.

pVM0

No tumor is exposed on any vertical margin.

pVM1

The tumor is exposed on any vertical margin.

  • Note 1: When no tumor is recognized in any resection margin, it is defined as a complete resection (pR0), and when a tumor is recognized in any resection margin, it is defined as an incomplete resection (pR1).

  • Note 2: When vascular invasion is present in the resection margin, it is defined as a positive resection margin (pHM1, pVM1).

5.4.3.3. Non-assessable resection margin (pRX)

1. Because of crushing injury or the burn effect in the specimen during endoscopic resection, non-cancerous tissue in the resection margin cannot be confirmed.

2. Reconstruction after piecemeal resection is impossible.Note

3. Suspected residual tumor in the basal layer because of non-continuous tumor extension.

4. Possible residual tumor in the vertical margin because of intra-ductal spread.

5. Indeterminable residual tumor because of other reasons.

  • Note: In piecemeal resection pR0 is confirmed only when restructuring is possible and only non-cancerous tissue is recognized at the resection margins of the restructured specimen.

5.4.4. Infiltrative growth pattern (INF)
INFa (expansive type)

Expansive growth of tumor nests with a well-demarcated border from the surrounding tissue.

INFb (intermediate type)

Intermediate growth pattern, between INFa and INFc.

INFc (infiltrative type)

Infiltrative growth of tumor nests with an ill-defined border from the surrounding tissue.

5.4.5. Vascular invasion (ly/v) Note

It is not necessary to evaluate the degree of vascular involvement: only its presence or absence should be described.

5.4.5.1. Lymphatic invasion (ly)
ly (−)

No lymphatic invasion.

ly (+)

Lymphatic invasion

5.4.5.2. Venous invasion (v)
v (−)

No venous invasion

v (+)

Venous invasion

  • Note: A special staining method for elastic fibers of the vascular wall, such as Elastica van Gieson (EVG) or Victoria blue (VB) staining, is needed to determine venous invasion. Immunostaining with an anti-D2-40 antibody is useful to confirm lymphatic invasion. When differentiating between lymphatic and venous invasion is difficult, the case should be described as ly/v. When lymphatic and/or venous invasion is prominent, this evaluation should be included in addition to ly (+) or v (+).

5.4.6. Report of pathological findings

All the above-mentioned factors should be described, and the attachment of a figure showing the general view of the resected specimen with the regional depths of tumor invasion and vascular invasion is recommended. It is better to attach a schematic figure showing pathological findings on the cut surface if necessary.

5.5 Residual tumor (pR)Note 1,2
pRX

The existence of residual tumor at the resection margin cannot be assessed pathologically.

pR0

No cancer tissue is pathologically present at any margin of the resected specimen.

pR1

Cancer tissue is pathologically present at the margin of the resected specimen.

pR2

A cancer lesion is present.

  • Note 1: For a piecemeal resection, the presence of residual tumor is evaluated after rebuilding the specimen.

  • Note 2: When multiple lesions are resected, each lesion is evaluated individually.

5.6. Curativity (pCur)

When endoscopic resection (EMR: endoscopic mucosal resection, or ESD: endoscopic submucosal dissection) is performed for superficial esophageal cancer that does not exhibit clinical metastasis, a comprehensive evaluation can be established, based on the pathological findings of depth of invasion, residual tumor, and vascular invasion (Table 1–9).
Curativity A (pCur A)

pT1a-EP or pT1a-LPM with pR0.

Curativity B (pCur B)

pT1a-EP or pT1a-LPM with pRX.

pT1a-MM or pT1b-SM1 with pR0 or pRX.

Curativity C (pCur C)

pT1b-SM2, positive micro vascular permeation despite depth of invasion, pR1 or pR2.

Table 1-9

Curativity of the endoscopic resection

Depth of tumor invasion (T)

Residual tumor (R)

Others

pR0

pRX

pR1, pR2 and/or v + , ly+

pT1a-EP

A

B

C

pT1a-LPM

A

B

C

pT1a-MM

B

B

C

pT1b-SM1

B

B

C

pT1b-SM2

C

C

C

6. Barrett esophagus and adenocarcinoma in Barrett esophagus

6.1. Definition and description methods for Barrett mucosa, Barrett esophagus and Adenocarcinoma in Barrett esophagus

6.1.1. Definition of the esophagogastric junction (EGJ)

The EGJ should be defined systematically in accordance with the criteria listed below. Among these criteria, endoscopic findings should be given priority over findings obtained using other diagnostic modalities.
  1. 1.
    Endoscopic findings
    • Lower margin of palisading small vessels

    • If the palisading small vessels are unclear, the oral margin of the longitudinal folds of the greater curvature of the stomach is defined as the EGJ.

     
  2. 2.
    Upper gastrointestinal series (UGI)
    • Narrowest locus of the lower esophagus

    • In the presence of a sliding hiatal hernia, the upper end of the longitudinal folds is defined as the EGJ.

    • In the presence of Barrett esophagus, the upper end of the longitudinal folds is defined as the EGJ.

     
  3. 3.

    Pathological study

    Macroscopic definition: The EGJ should be defined macroscopically as the point at which the luminal caliber changes in the area where the tubular esophagus is connected to the vestibule lumen of the stomach.

    Microscopic definition: For a mucosal layer with intact structures, the EGJ should be defined as follows:

    1. 1.

      Non-Barrett esophagus: The EGJ is defined as the squamocolumnar junction.

       
    2. 2.

      Barrett esophagus: Histological structures such as proper esophageal glands and their ducts, a double-layer muscularis mucosae, or palisading small vessels should be included in the microscopic definition of the EGJ.

       

    For a non-intact mucosal layer, the EGJ should be defined based on the macroscopic findings of the surgical specimen, and the EGJ should be presumed based on the presence of histological structures associated with the esophagus or stomach.

     

6.1.2. Barrett mucosa

Columnar epithelium continuous from the stomach with or without intestinal metaplasia

6.1.3. Barrett esophagus

An esophagus containing Barrett mucosa should be designated as Barrett esophagus.Note 1

At least one of the following conditions must be satisfied.
  1. 1.

    Presence of esophageal gland ducts in the mucosal layer or proper esophageal glands in the submucosal layer within the area of columnar epithelium.

     
  2. 2.

    Presence of squamous islands in the columnar epithelium.

     
  3. 3.

    Presence of a double-layer muscularis mucosaeNotes 2,3

     
  • Note 1: The presence of circular Barrett mucosa extending longitudinally for 3 cm or more is called long segment Barrett esophagus (LSBE) (Fig. 1-18). On the other hand, the presence of circular Barrett mucosa less than 3 cm in length or the presence of non-circular Barrett mucosa is designated as short segment Barrett esophagus (SSBE) (Fig. 1-19).
    Fig. 1-19

    Short segment Barrett esophagus (SSBE). Circular Barrett mucosa extending for less than 3 cm in length or non-circular Barrett mucosa is designated as short segment Barrett esophagus (SSBE). a Circular SSBE. b Non-circular SSBE

  • Note 2: New muscularis mucosae can sometimes be found immediately under the columnar epithelium. In the Japanese Classification, the primary muscularis mucosae is called deep muscularis mucosae (DMM), and the new muscularis mucosae is called superficial muscularis mucosae (SMM). The identification of SMM and DMM is occasionally difficult because of the fusion of both layers, the thickness of the layer, or the presence of irregularities.

  • Note 3: Barrett esophagus can also be defined as the presence of columnar epithelium containing small palisading vessels with diameters of greater than 100 µm within the lamina propria mucosae.

6.1.4. Adenocarcinoma in Barrett esophagus

Adenocarcinoma arising in Barrett mucosaNote 1

  • Note 1: The origin of adenocarcinoma in areas of Barrett esophagus is not the same as that of gastric adenocarcinoma, which is derived from gastric mucosa adjacent to the EGJ. Gastric cancer is described according to the Japanese Classification of Gastric Cancer, and esophageal adenocarcinoma is described according to the Japanese Classification of Esophageal Cancer. However, the histological classifications of both adenocarcinomas are described according to the Japanese Classification of Gastric Cancer.

Circular Barrett mucosa extending longitudinally for 3 cm or more is called long segment Barrett esophagus (LSBE).

6.2. Tumor location

Same as that for esophageal cancer.
  • Note: In cases with a hiatus hernia, the tumor location should be determined using barium contrast radiography.

6.3. Description of tumors

Adenocarcinoma in Barrett esophagus is described according to the Japanese Classification for Esophageal Cancer, except for the depth of tumor invasion.

6.3.1. Primary tumor

6.3.1.1. Circumferential location

6.3.1.2. Tumor size

6.3.1.3. Macroscopic tumor types

6.3.1.4. Depth of tumor invasion (T)
  1. TX

    Depth of tumor invasion cannot be assessed.

     
  2. T0

    No evidence of primary tumor.

     
  3. T1a
    Tumor has invaded the mucosa.
    1. T1a-SMM

      Tumor has invaded the superficial muscularis mucosae (SMM).

       
    2. T1a-LPM

      Tumor has invaded the lamina propria mucosae.

       
    3. T1a-DMM

      Tumor has invaded the deep muscularis mucosae (DMM).

       
     
  4. T1b
    Tumor has invaded the submucosa (SM).
    1. SM1

      Tumor has invaded the upper third of the submucosa.

       
    2. SM2

      Tumor has invaded the middle third of the submucosa.

       
    3. SM3

      Tumor has invaded the lower third of the submucosa.

       
     
  5. T2

    Tumor has invaded the muscular propria.

     
  6. T3

    Tumor has invaded the adventitia.

     
  7. T4

    Tumor has invaded adjacent structure(s).

     

6.3.2. Intramural metastasis (IM)

Same as that for esophageal cancer.

6.3.3. Lymph node metastasis (N) Note

  • Note: In cases with a hiatal hernia, the field of lymph node dissection should be designated according to the tumor location as defined using Barium contrast radiography.

6.3.4. Distant organ metastasis (M)

Same as that for esophageal cancer.

6.4. Stage

Same as that for esophageal cancer.

7. Treatment

7.1. Endoscopic treatment

7.1.1. Endoscopic resection: ER

7.1.1.1. Endoscopic mucosal resection: EMR

7.1.1.2. Endoscopic submucosal dissection: ESD

  • Note: The following items should be described.

Method of resection: (1) en bloc resection, (2) piecemeal resection.

Residual tumor: eRX, eR0, eR1, eR2.

Complications: (1) perforation, (2) bleeding requiring treatment, (3) stenosis, (4) others (including mediastinal emphysema).

Combined therapy: (1) none, (2) APC, (3) laser, (4) PDT, (5) MCT, (6) others.

7.1.2. Other Endoscopic treatments

7.1.2.1. Argon plasma coagulation: APC

7.1.2.2. Laser therapy: laser

7.1.2.3. Photodynamic therapy: PDT

7.1.2.4. Microwave coagulation therapy: MCT

7.1.2.5. Others

  • Note: Any other therapy performed should be described.

7.2. Surgical treatments

7.2.1. Resection and reconstruction procedures

7.2.1.1. Staged operations

One-stage operation

Staged operation

7.2.1.2. Surgery with multi-modality treatments

Planned surgery: planned surgery after neoadjuvant chemotherapy, radiotherapy, or both.

Salvage surgery: surgery for cases with residual tumor or cases with recurrent tumor after definitive chemoradiotherapy with more than 50 Gy radiation.

The surgical methods, such as esophagectomy, lymphadenectomy, endoscopic resection, and so on, should be described.

7.2.1.3. Approaches for tumor resection

  • Endoscopic

  • Thoracoscopic, thoracoscopy-assisted

  • Mediastinoscopic
    • Laparoscopic, laparoscopy-assisted

    • Transcervical

    • Thoracotomy
      • Right

      • Left

    • Laparotomy

    • Thoracoabdominal incision
      • Right

      • Left

    • Transhiatal

    • Sternotomy

  • Note: When several approaches are adopted, only the main approach should be described.

7.2.1.4. Extent of esophageal resection

Total esophagectomy: the cervical, thoracic and abdominal esophagus is resected, regardless of whether laryngectomy is done or not.

Subtotal esophagectomy: almost all the thoracic esophagus is resected

Middle and lower esophagectomy: the middle and lower esophagus (including abdominal esophagus) is resected Note 1

Lower esophagectomy: the lower esophagus (including abdominal esophagus) is resected

Partial esophagectomy: resection of full-thickness partial esophagusNote 2

Mucosal resection: resection of mucosal and submucosal layers

Others

  • Note 1: Lower esophagectomy includes resection of the lower esophagus and cardia.

  • Note 2: In partial esophagectomy, the location of the esophagus resected should be described.

7.2.1.5. Combined resection

The organ(s) resected together because of cancer invasion should be described.
  • Note: Total or partial resection of the organ(s) should be described.

7.2.1.6. Reconstruction

7.2.1.6.1. Reconstruction routes

Antethoracic (subcutaneous)

Retrosternal

Posterior mediastinal

7.2.1.6.2. Sites of anastomosis

Neck

Antethoracic (subcutaneous)

Thoracic cavity (proximal, distal)

Lower mediastinum
  • Note: The border between the proximal and the distal site of anastomosis is the upper level of the aortic arch.

7.2.1.6.3. Organs used for reconstruction

  • Stomach
    • Whole stomach

    • Gastric tube

  • Jejunum
    • Pedicled

    • Free

  • Colon
    • PedicledNote 1
      • Left colonNote 2

      • Right colonNote 3

      • Ileum and colon

  • Free
    • Colon

    • Ileum and colon

  • Skin and muscleNote 4
    • Skin flap
      • Local skin flap

      • Pedicled

      • Free

    • Musculocutaneous flap
      • Pedicled

      • Free

  • Note 1: Isoperistaltic or antiperistaltic should be described.

  • Note 2: For reconstruction with left colon, the transverse colon with left colic artery is used.

  • Note 3: For reconstruction with right colon, the ascending colon with the middle colic artery is used.

  • Note 4: The name of the skin flap or muscle flap that is used should be described.

    e.g.: free forearm skin flap, right pectoralis major musculocutaneous flap.

7.2.2. Conservative/palliative procedures

7.2.2.1. Stoma

Pharyngostomy

Esophagostomy

Gastrostomy

Jejunostomy

7.2.2.2. Bypass

Pharyngogastrostomy

Esophagogastrostomy

Esophagojejunostomy

Esophagocolostomy

7.2.2.3. Exploratory thoracotomy, exploratory laparotomy

7.2.2.4. Others

Lymph node dissection without esophagectomy

7.3. Stenting

7.3.1. Esophageal stents

  1. (a)
    Therapy before stenting
    • No

    • Yes (chemotherapy, radiotherapy, chemoradiotherapy, others)

     
  2. (b)
    Therapy after stenting
    • No

    • Yes (chemotherapy, radiotherapy, chemoradiotherapy, others)

     
  3. (c)
    Esophageal fistula
    • No

    • Yes

     
  4. (d)
    Type of stent
    • Covered or non-covered

    • Anti-reflux valve (yes, no)

    • Diameter

    • Length

     
  5. (e)
    Operative complications
    • No

    • Yes (bleeding requiring treatment, dyspnea, pain, others)

     
  6. (f)
    Evaluation of stent
    • Status of eating before stenting

    • Status of eating at discharge

     
  7. (g)
    Complications after stenting
    • No

    • Yes (bleeding requiring treatment, perforation, pain, regurgitation of gastric contents, dyspnea, migration, esophago-airway fistula, others)

     

7.3.2. Tracheobronchial stents

Type of stent.

7.3.3. Aortic stents

Type of stent.

7.4. Common issues for radiotherapy and chemotherapy

7.4.1. Disease status

Untreated

Macroscopic residual after surgery

Microscopically residual after surgery

No obvious residual disease after surgery

Loco-regional recurrence after surgery

Distant metastasis after surgery

Other postoperative recurrence

Residual disease after EMR/ESD

No obvious residual disease after EMR/ESD

After stenting

After intraoperative radiation therapy for macroscopic disease

After intraoperative radiation therapy for no obvious macroscopic disease

7.4.2. Aim of treatment

Definitive

Palliative

Preoperative

Preventive

Recurrent disease

Others

7.4.3. Reasons for definitive radiotherapy

Severe associated disease(s)

Advanced age

Patient’s wishes

Others

7.5. Radiotherapy (RT)

7.5.1. Clinical target volume (CTV)

Primary lesion

Entire esophagus

Resected lymph node area for prevention (supra-clavicular, mediastinal, abdominal)

Distant organ metastasis

7.5.2. Methods of radiotherapy

External beam radiation therapy

External beam radiation therapy + intra-cavitary radiation therapy

Intra-cavitary radiation therapy alone

7.5.3. External beam radiotherapy

X-ray

Proton

Carbon

Gamma-ray

Electron

7.5.3.1. Planning methods

X-ray simulator

Three dimensional

7.5.3.2. Field setting

Opposing

Anterior oblique

Three directions

More than 4 fields

Rotating

Intensity-modulated radiotherapy (IMRT)

7.5.3.3. Reference points

CTV center

Field center

Others

7.5.3.4. Dose calculation

Non-homogeneity correction

Algorithm

7.5.3.5. Dose fractionation of external beam radiotherapy

Dose/fraction

Number of fractions/week

Total dose

Overall treatment time

7.5.4. Intraluminal irradiation

Low dose rate (226Ra)

High dose rate (192Ir, 60Co, 137Cs)

7.5.4.1. Reference points

Mucosal surface

____mm below mucosa

7.5.4.2. Dose fractionation of intraluminal irradiation

Dose/fraction

Number of fractions/week

Total dose

Overall treatment time

7.5.5. Completion of treatment

Complete without break

Complete with break

Incomplete

7.5.6. Reasons for treatment cessation

Completion of the planned treatment

Disease progression

Adverse events

Patient’s refusal (related to adverse events)

Patient’s refusal (not related to adverse events)

7.6. Chemotherapy (CT)

7.6.1. Agents

Name of agent (generic name should be recorded).

7.6.2. Administration routes

Intravenous

Oral

Transarterial

Local injection (including abdominal and chest cavity)

Others

7.6.3. Administration procedures

Bolus

Continuous

Others

7.6.4. Administration doses

Dose should be recorded as per body surface area (/m2) or per body (/body).

7.6.5. Administration schedules

Course duration

Course interval

Upper limit in number of courses.

7.6.6. Duration of administration

Initial date of administration

Last date of administration

Total number of courses

7.6.7. Total administration dose

Total administration dose of each agent should be calculated as per body surface area or per body.

7.6.8. Reasons for treatment cessation

Completion of the planned treatment

Disease progression

Adverse events

Patient’s refusal (related to adverse events)

Patient’s refusal (not related to adverse events)

Others

7.6.9. Adverse events

Recorded in accordance with the “Common Terminology Criteria for Adverse Events ver. 4, (Japanese version) JCOG/JSCO edition”.

7.7. Multi-modality treatment

7.7.1 Combination of endoscopic treatment and surgery, radiotherapy, chemoradiotherapy or chemotherapy

Classification

Preoperative, intraoperative, or postoperative.

Description

Planned treatment or salvage treatment

Surgery

Evaluation of residual tumor (pR)

(If a residual tumor is present, describe the tumor location, depth of tumor invasion, tumor margin, presence of vascular invasion, presence of lymph node metastasis, etc.)

Multiple tumors: yes or no

(If multiple tumors are present, describe the tumor location and the number of lesions.)
  • Note: Evaluate residual tumors of primary and metastatic lesions.

Radiotherapy: radiation field, total dose

Chemotherapy: regimen

7.7.2 Chemoradiotherapy (CRT)

Classification according to timing: concurrent or sequential

Classification according to intent: definitive, neoadjuvant, or after surgery (adjuvant, additive)
  • Note: R0 resection should be recorded as adjuvant. R2 should be recorded as additive.

7.8. Hyperthermia (HT)

7.9. Immunotherapy (IT)

8. Results of treatment

The following matters are recorded to allow precise statistical analysis for a comprehensive registry of esophageal cancer.

8.1. Total number of patients

Total number of outpatients

Total number of admitted patients

Total number of patients admitted for various treatments

8.2. Multiple primary cancers

Primary lesion of another cancer, diagnosis (clinical and pathological), synchronous or metachronous, and treatment

8.3. Main treatment and adjuvant therapy

Endoscopic treatment

Surgical treatment

Palliative operation

Radiotherapy

Chemotherapy

Chemoradiotherapy

Other non-surgical treatment

No treatment

8.4. Total number of patients treated, and number and rate of patients treated with each procedure

8.4.1. Patients operated

The total number of patients admitted, the number of patients who underwent resection, the numbers of patients with curative and non-curative resections, and the resection rate should be recorded.

Resection rate = patients who underwent resection/patients admittedNote 1

Total number and ratio of patients with or without curative resectionNotes 2, 3

  • Note 1: Patients who have undergone an esophagectomy for the first time are evaluated.

  • Note 2: Curative operation is defined as Curativity A or B resection.

  • Note 3: Non-curative operation is defined as Curativity C resection.

8.4.2. Patients with Endoscopic treatment

Record the number of patients who underwent endoscopic treatment, and the total number and ratio of patients with or without curative resection.

Cases of treatment completed only by endoscopic treatment are recorded separately from operated cases as endoscopically treated cases.

One-piece resection rate = (number of patients who underwent one-piece resection/total number of patients who underwent endoscopic resection) × 100Note

Curativity rate = (number of patients who underwent curative endoscopic resection/total number of patients who underwent endoscopic resection) × 100

  • Note: The number of patients who underwent endoscopic resection indicates those who underwent endoscopic mucosal dissection and endoscopic submucosal dissection. It does not include the number of patients treated by laser therapy or photodynamic therapy.

8.4.3. Patients with chemotherapy and/or radiotherapy

Total numbers and rates according to response evaluation criteria after treatment.

8.5. Operative mortalityNote

Operative mortality = (operative deaths/patients operated) × 100

Mortality after esophagectomy = (deaths after esophagectomy/patients who underwent esophagectomy) × 100
  • Note: Operative death means death within 30 days after operation in or out of hospital.

8.6. Hospital mortalityNotes 1, 2

Hospital mortality = (hospital deaths/patients operated) × 100

Hospital mortality after esophagectomy = (hospital deaths after esophagectomy/patients who underwent esophagectomy) × 100
  • Note: Hospital death is defined as death during the same hospitalization, regardless of department at time of death.

8.7. Long-term outcome

The following items should be recorded for survival analysis.

8.7.1. Alive or dead

Alive: The date of the most recent follow-up

Death: The date of death

Unknown: The date of the most recent follow-up

  • Cause of death
    • Treatment-related death: death because of surgical treatment, chemotherapy, radiotherapy, or other therapies

    • Death because of esophageal cancer

    • Death because of another cancer: primary cancer-related deaths should be recorded.

    • Death because of another disease: the name(s) of the disease(s) should be recorded.

    • Death because of accident: suicide should be included.

    • Death because of unknown cause(s): this category should be basically regarded as esophageal cancer-related deaths.

8.7.2. Recurrence

  • Yes or No

  • Date of recurrence

  • Pattern and site of recurrence: Each recurrence should be recorded chronologically

  • Local recurrence
    • Primary lesion (esophagus)Note 1

    • Recurrence in the mediastinum adjacent to the primary lesion

    • Recurrence at the anastomotic site or in the esophageal stump

    • Recurrence in the regional lymph nodes

    • Others including intramural metastasis in the esophagus or stomach

  • Distant metastasisNote 2
    • Lymphogenous recurrence

    • Hematogenous recurrence (distant organ(s))

    • Disseminated recurrence (pleura, peritoneum, pericardium)

  • Unknown

  • Note 1: Recurrence at the same place as the primary lesion in the esophagus can occur after esophagus-preserving treatment including endoscopic mucosal resection, chemotherapy and radiotherapy.

  • Note 2: Recurrent organ(s) are indicated by the abbreviations of the TNM classification.

Liver: HEP, Lung: PUL, Peritoneum: PER, Lymph node: LYM, Bone: OSS.

Brain: BRA, Kidney: REN, Adrenal gland: ADR, Skin: SKI, Others: OTH.

8.8. Long-term outcomes and prognosis, especially survival rate

8.8.1. Analysis of survival rates

Target (operation, endoscopic treatment, curativity and so on)

The calculation method of survival rates

Crude survival rate: direct method, cumulative method (Life-table method, Kaplan–Meier method)

Relative survival rate

Censored cases: overall survival rate, cause-specific survival rate

Statistical analysis of survival rate

Rate of cases lost to follow-up

8.8.2. Period and rate of esophageal preservation

This is the period during which the esophagus is preserved in patients with esophageal cancer who underwent non-esophagectomy treatment such as endoscopic mucosal resection, endoscopic submucosal dissection, chemotherapy and/or radiotherapy. The rate of those patients per all patients who underwent treatment for esophageal cancer is described.

[Reference]

Murakami M, Kuroda Y, Matsumoto S, et al. Treatment results of esophageal carcinoma of clinical T3, T4 M0: histological comparison between neoadjuvant chemoradiotherapy followed by surgery or definitive radiotherapy and conventional surgery. Oncol Rep 2000; 7: 571–578.

8.9. Terminology related to survival period

8.9.1. Survival time

Time until death from the time of a certain event

8.9.2. Overall survival (OS)

Time until death regardless of cause from the initial date. In observation studies, the day starting treatment, or the day confirming diagnosis is used as the initial date. In clinical trials, the “registration date” (the allocation day in the case of a randomized controlled trial) is used.

8.9.3. Median survival time (MST)

Period from the initial date to the first date of the survival rate being less than 50% in the survival curve calculated by the Kaplan–Meier method. The initial date is the same as described in 8.9.2.

8.9.4. Survival rate

The rate of survivors at a given time

8.9.5. Progression-free survival (PFS), time to progression (TTP)

It is the shortest period among periods from the initial date to progression or recurrence, or death. Death from any cause is regarded as an event, in PFS. Death is only regarded as an event if it is caused by esophageal cancer, in TTP.

8.9.6. Relapse-free survival, recurrence-free survival (RFS)

This is the period between the initial date to recurrence or death.

The day when the disease-free state was achieved such as an operation day, is used as the initial date.

8.9.7. Disease-free survival (DFS)

It is the shortest period among the periods from the initial date to a recurrence, death, or diagnosis of a second primary cancer. The day when the disease-free state such as an operation day was achieved, is used as the initial date.

8.9.8. Time to treatment failure (TTF)

This is the shortest period among the periods from the initial date to treatment cessation, progression, and death.

8.9.9. Response duration

Period from the first day when the disease was assessed as CR or PR until progression.

8.9.10. Complete response duration

Period from the first day when the disease was assessed as CR until recurrence.

[Reference]

Japan Society for Clinical Oncology. Terminology in Clinical Oncology 2013 (in Japanese)

Copyright information

© The Author(s) 2016

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.TokyoJapan

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