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Pathology

Added 06 March 2013

per College of American Pathologists (CAP) 2012 guidelines

Specimen: specify 

  • Type
  • Procedure 

Tumour: specify 

  • Primary tumour site- cervical esophagus, mid-esophagus, distal esophagus, esophago-gastric junction (EGJ). [Adenocarcinoma arising at the EGJ or within the proximal 5cm of the stomach and involving the EGJ are staged as an esophageal tumour ]
  • Histologic type
  • Histologic grade (well, moderately, poorly differentiated or undifferentiated)
  • Size (Longitudinal tumour dimension, semi-circumferential/ circumferential lesion)
  • Microscopic tumour extension/invasion
  • Lymph-Vascular invasion (present/absent)
  • Surgical margins: proximal, distal, omental (radial), deep (for endoscopic resections); state if involved by dysplasia or invasive carcinoma; state closest approach of invasive carcinoma to ​margin in mm.) 
  • Treatment effect(post neo-adjuvant therapy, if applicable) (present/absent)
  • Status of background mucosa (i.e. Barrett’s esophagus, dysplasia, etc.)
  • Lymph node status (x of y lymph nodes positive)
  • HER2-neu testing in gastroesophageal adenocarcinoma:
    • by immunohistochemistry (IHC)
    • fluorescen​ce in-situ hybridization if IHC is 2+
  • pTNM tumor stage (AJCC 7th edition)

Primary Tumor (pT) (Note: this is optional)

pTX: Cannot be assessed

pT0: No evidence of primary tumor

pTis: High-grade dysplasia

pT1: Tumor invades lamina propria, muscularis mucosae, or submucosa

pT1a: Tumor invades lamina propria or muscularis mucosae

pT1b: Tumor invades submucosa

pT2: Tumor invades muscularis propria

pT3: Tumor invades adventitia

pT4: Tumor invades adjacent structures (specify): ______________________

pT4a: Resectable tumor invading pleura, pericardium, or diaphragm

pT4b: Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc

Regional Lymph Nodes (pN) 

pNX: Cannot be assessed

pN0: No regional lymph node metastasis

pN1: Regional lymph node metastasis involving 1 to 2 nodes

pN2: 3 to 6 nodes involved

pN3: 7 or more nodes involved

Distant Metastasis (pM)

Not applicable

pM1: Distant metastasis (specify site(s)) 

SOURCE: Pathology ( )
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