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Esophagus (2009) 6:1–25

DOI 10.1007/s10388-009-0169-0

© Japan Esophageal Society and Springer 2009

SPECIAL ARTICLE

Japan Esophageal Society

Japanese Classification of Esophageal Cancer, tenth edition: part I

President
Kaiyo Takubo

Tokyo Metropolitan Institute of Gerontology

Former President
Hiroyasu Makuuchi

Tokai University

English Edition Committee, Chairman
Hiromasa Fujita
Kurume University
English Edition Committee Members
Takashi Aikou
Kagoshima University
Yoshiaki Kajiyama
Juntendo University
Tatsuyuki Kawano
Tokyo Medical and Dental University
Hisahiro Matsubara
Chiba University
Kenji Nemoto
Yamagata University
Atsushi Ohtsu
National Cancer Center Hospital East
Soji Ozawa
Fujita Health University
Yutaka Shimada
Toyama University
Tadakazu Shimoda
National Cancer Center Hospital
Yuji Tachimori
National Cancer Center Hospital
Harushi Udagawa
Toranomon Hospital
English Editing
J. Patrick Barron

Tokyo Medical University

Editorial Assistants
Toshiaki Tanaka
Yukihiro Nakanishi
Kazu Kaihara

Kurume University
National Cancer Center Research Institute
Tokyo Medical University

Japanese Edition Committee, Chairman
Hiromasa Fujita
Kurume University
Japanese Edition Committee Members
Takashi Aikou
Kagoshima University
Tatsuyuki Kawano
Tokyo Medical and Dental University
These guidelines were published by Kanehara & CO., Ltd., Tokyo, copyright 2008 by Kanehara & CO., Ltd., and Japan Esophageal Society.
They are reprinted here by permission of the copyright holders.
Japan Esophageal Society
Sun-city Inohana B, 3-2-4 Inohana, Chuo-ku, Chiba 260-0856, Japan

2

Hisahiro Matsubara
Kenji Nemoto
Atsushi Ohtsu
Soji Ozawa
Yutaka Shimada
Tadakazu Shimoda
Yuji Tachimori
Masahiko Tsurumaru
Harushi Udagawa
Misao Yoshida

Chiba University
Yamagata University
National Cancer Center Hospital East
Fujita Health University
Toyama University
National Cancer Center Hospital
National Cancer Center Hospital
Juntendo University
Toranomon Hospital
Foundation for Detection of Early Gastric Carcinoma

Pathological Research Committee, Chairman
Tadakazu Shimoda
National Cancer Center Hospital
Pathological Research Committee Members
Shingo Ishiguro
Osaka Medical Center for Cancer and Cardiovascular Diseases
Masayuki Itabashi
Ibaraki Prefectural Central Hospital
Akinori Iwashita
Fukuoka University Chikushi Hospital
Hiroshi Kato
Ishikiriseiki Hospital
Touichirou Takizawa
Tokyo Medical and Dental University
Kaiyo Takubo
Tokyo Metropolitan Institute of Gerontology
Takashi Yao
Juntendo University
Akio Yanagisawa
Kyoto Prefectural University of Medicine
Suguru Yonezawa
Kagoshima University
Endoscopy Research Committee, Chairman
Misao Yoshida
Foundation for Detection of Early Gastric Carcinoma
Endoscopy Research Committee
Miwako Arima
Masayuki Itabashi
Haruhiro Inoue
Harushi Udagawa
Masamitsu Unakami
Tai Ohmori
Tsuneo Oyama
Hiroshi Kawachi
Tatsuyuki Kawano
Morio Koike
Hideo Shimada
Kaiyo Takubo
Setsuo Tamai
Yukihiro Nakanishi
Hiroyasu Makuuchi
Youko Murata
Kumiko Monma

Members
Saitama Cancer Center
Ibaraki Prefectural Central Hospital
Showa University Northern Hospital
Toranomon Hospital
Watari Hospital
Kawasaki Municipal Hospital
Saku Central Hospital
Tokyo Metropolitan Cancer and Infectious Diseases Komagome Hospital
Tokyo Medical and Dental University
Bunkyo Gakuin University
Tokai University
Tokyo Metropolitan Institute of Gerontology
Kanagawa Cancer Center
National Cancer Center Research Institute
Tokai University
Murata Clinic
Tokyo Metropolitan Cancer and Infectious Diseases Komagome Hospital

Radiotherapy and Chemotherapy Research Committee, Chairman
Yasumasa Nishimura
Kinki University
Radiotherapy and Chemotherapy Research Committee Members
Satoshi Ishikura
National Cancer Center Hospital East
Atsushi Ohtsu
National Cancer Center Hospital East
Hiroyuki Kato
Gunma University
Michio Sato
Tokyo Dental College Ichikawa General Hospital
Kenji Nemoto
Yamagata University
Kazuma Fujimoto
Saga University
Miyako Myojin
National Hospital Organization Hokkaido Cancer Center
Takashi Yoshioka
Institute of Development, Aging and Cancer, Tohoku University

The Japanese 10th edition was published in 2007 under the guidance of Professor Hiroyasu Makuuchi. the presentations and discussions on esophageal diseases at the meetings of the JSED and JED have always been based on the common rules stipulated in the Guidelines. the Comprehensive Registry was started in 1988. Esophagus. the acting president at the 61st Annual Meeting of the JES. tumor type and histological classification. Japanese Society for Esophageal Diseases . It is my wish that these Guidelines will become familiar to all esophageal specialists around the world. of whom about 1000 usually participate in each annual meeting. 2) Improved compatibility with the TNM classification by changing the abbreviation of the depth of tumor invasion from “A” to “T” and the term “respectability” to “residual tumor” or “R” 3) Partial revision of the pathological classification according to the revision of the clinical classification The English version of the Guidelines is intended mainly for international use. In 2003. For about 40 years. including stage. This edition of the English Version of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus corresponds to the Japanese Version of the 9th edition published in February 1999. In 2001. definitions of early and superficial carcinomas. July. especially as to the classification of lymph nodes and related subjects. The new Revision may be somewhat too complicated for ready familiarization.3 Preface Preface of the Ninth Edition The Japanese Society for Esophageal Diseases (JSED) was founded by Professor Komei Nakayama (1910–2005) of Tokyo Women’s Medical College (now Tokyo Women’s Medical University) and his colleagues in 1965 to gain a deeper understanding of esophageal diseases and improve the prognosis of esophageal malignancies. All descriptions in the Comprehensive Registry were recorded on the basis of the Guidelines. and these are now the standard criteria used among Japanese hospitals.jp/). 2007 Kaiyo Takubo. treatment and care of patients with esophageal diseases. The activities of the JES contribute to the wellbeing of patients with esophageal diseases. M. The present second English version -Japanese Classification of Esophageal Cancer. Finally. however. the dedicated efforts of committee members which have made the publication of this Revision possible are deeply appreciated. We hope that the Japanese Classification will be used worldwide to bring about improvements in all aspects of diagnosis. and other criteria of esophageal carcinoma.esophagus.D. The major points of emphasis in this edition are: Nov. The JES has 2500 members. the esophagogastric junction. President. On the basis of the Guidelines. Based on discussions at the JES scientific meetings. Scientific meetings of the JES are held annually for 2 days. MD President The 61st Annual Meeting of the Japan Esophageal Society Hiromasa Fujita. the Japan Esophageal Society 1) Renewal of the descriptions of lymph node metastases consequently accompanied by modification of stages. Selection of the method of treatment based on the Guidelines should improve treatment results. and subclassification of the depth of superficial carcinoma have been decided. and in 2004 this was made available on the website of the Japan Esophageal Society (http://www. The Guidelines describe these changes as accurately as possible. The Society publishes an official quarterly English-language journal. MD President The 62nd Annual Meeting of the Japan Esophageal Society Hiroyasu Makuuchi. 30. the 9th Japanese edition was translated into English and published for the first time.(Japanese Classification) is a translation of the Japanese 10th edition. the anatomical structure and pathophysiological picture of carcinoma of the esophagus has become clearer in detail. MD Chairperson Committee of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus. the JSED changed its name and organization to the Japan Esophageal Society (JES). The first edition of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus (Guidelines) was published in 1969. Along with progress of the treatment for carcinoma of the esophagus. The scientific meeting of the JSED has been held usually twice a year for the last 38 years. 2001 Kaichi Isono.

6.2.2.1. Handling of Specimens Resected Endoscopically 5.4 Contents Preface General Principles of this Edition Abbreviations Part I General Rules 1. Tumor Location 6.6. Description of Pathological Findings 4. Distant Organ Metastasis (pM) 4. Macroscopic Findings 5.2. Pathological Findings 4.3. and Methods of Descriptions 1.2. Distant Organ Metastasis (M) 3. Endoscopic Treatment 5. Purpose 1. Methods of Descriptions 2. Stage 2.2. Object. Lymph Nodes 3.1. Handling of the Surgically Resected Specimens 4. Definition and Methods of Description for Barrett Mucosa.4.4.3.1.5. Object 1. Residual Tumor (R) 3. Barrett Esophagus and Adenocarcinoma in Barrett Esophagus 6. Intramural Metastasis and Multiple Cancers of the Esophagus 3.3. Purpose. Comprehensive Evaluation of Curativity 6. Curativity (pCur) 5.2.5. Handling of the Resected Specimen 3. Description of Surgical Findings and Macroscopic Findings of Primary Tumor 3. Description of Primary Tumor 2.3. Stage . Barrett Esophagus and Adenocarcinoma in Barrett Esophagus 6.5.4. Lymph Node Metastasis (pN) 4. Curativity (Cur) 5. Residual Tumor (pR) 4. Description of Tumors 6. Metastatic Lesions from Esophageal Cancer 2.3. Curativity (Cur) 4.4. Multiple Primary Cancers 3.1.1. Preparation for Pathological Examination 5.7.3. Description of Pathological Findings 5. Surgical Aspects 3. Clinical Aspects 2.4.1.6.

4. The lymph node grading for cancer at the esophagogastric junction of the esophagus-dominant tumor (EG) is the same as that for cancer in the abdominal esophagus. 3. The clinical. basaloid (-squamous) carcinoma. the General Rules and the Explanations 1. 2. gastrointestinal stromal tumor (GIST). Non-epithelial tumors are classified into smooth muscle tumor. The classification of lymph nodes in the abdominal esophagus was revised.2.1. pathological. neurogenic tumor. Surgical Aspects Macroscopic findings of the resected specimens are included in surgical findings. carcinosarcoma. the lesion is described in the order of the size. The major revisions in this 10th Edition are as follows. and the extent is also denoted by largefont Arabic numbers. and final findings are expressed by c. 2. The submucosal layer is classified into two layers: the shallower layer up to 200 μm from the lower margin of the muscularis mucosa and the layer deeper than 200 μm. adenocarcinoma. The submucosal layer (T1b) is sub-classified into three layers. Radial Margin The abbreviation for the radial margin of the resected specimens is RM. Malignant epithelial tumors are classified into squamous cell carcinoma.2. It is defined as a lesion localized within the mucosal layer of the esophagus. The abbreviations for the horizontal margin (HM) and the vertical margin (VM) are established. 3. 2. 3.5 General Principles of this Edition Since 1969. 101) is not included in three-field dissection. The unclassified type (type 5) is divided into the unclassifiable type without treatment (5a).1.3. Histological Classification All esophageal tumors and tumor-like lesions.6. endocrine cell carcinoma. it has been constantly revised giving consideration to consistency with the TNM classification and Japanese Classification concerning other gastrointestinal cancers along with progress in the diagnosis and treatment of esophageal cancer. Most small cell carcinomas are included in this category. either malignant or benign are described. and its histological risk criteria presented. R1 is not defined as histopathologically confirmed residual tumor. and divided into that for cervical esophageal cancer with (CePh) or without (Ce) involvement of the hypopharynx. Methods of Descriptions All symbols are described using upper case letters. when the first edition of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus was published by the Japanese Society for Esophageal Diseases.1. Macroscopic Tumor Type The macroscopic tumor types are expressed by the macroscopic tumor type classification and the sub-classification for the superficial types. Intraepithelial neoplasia is defined.3.4.3. and others.4. surgical. Lymph Node Metastasis The locations of the cervical and thoracic lymph nodes are the same as those in the English version of the 9th edition. Residual Tumor Definition of microscopic residual tumor R1 is revised. This version is divided into two parts. The definition of high grade intraepithelial neoplasia is almost identical to that of carcinoma in situ. Tumor Location The zone of the esophagogastric junction is defined. 3. Multiple Primary Cancers Multiple primary cancers of the esophagus and multi-organ primary cancers including the esophagus are defined. and that after treatment (5b).2. The definition of early esophageal cancer is changed. Intraepithelial neoplasia is classified into low grade intraepithelial neoplasia and high grade intraepithelial neoplasia. 2. The superficial and protruding type (0-I) is sub-classified into the pedunculated type (0-Ip) and the sessile type (0-Is). but as suspected or minute residual tumor. The lymph node grading in the cervical esophagus was changed. Curativity The assessment of curativity in transhiatal esophagectomy is revised. mucoepidermoid carcinoma. Endocrine cell carcinoma is defined.1. The computed tomography images of the lymph nodes were added. and the deepest lesion is enclosed by double quotation marks. Reactive changes accompanying inflammation and regeneration are excluded. The assessment of clinical (endoscopically recognizable) residual tumor is defined. and others.7. Endoscopic Treatment The methods for handling and excising endoscopicallyresected specimens are described. 2. 4.1. adenosquamous carcinoma. The Japan Esophageal Society (formerly the Japanese Society for Esophageal Diseases) continues to publish the Japanese Classification of Esophageal Cancer in English.5. and f. p. The lymph node grading for cancers at the esophagogastric junction which has two gradings for the esophagusdominant tumor (EG) and for stomach-dominant tumor (GE) is established. respectively. The presence of metastatic lymph nodes is not referred to. adenoid cystic carcinoma. 5. s. and diagnostic methods at the esophagogastric junction are described. Lymph Node Dissection Cervical lymph node dissection only of the cervical paraesophageal nodes (No. The definition of GIST is established.2. Depth of Tumor Invasion The mucosal layer (T1a) is sub-classified into three layers. 3. The criteria of impossible assessment of the . undifferentiated carcinoma. In the mixed type.

Surgical Treatments Planned surgery and salvage surgery are defined. and adenocarcinoma in Barrett esophagus are defined. 8. 8. Common Issues for Radiotherapy and Chemotherapy Condition of the target lesion. Response Evaluation Criteria in Radiotherapy and Chemotherapy for Esophageal Cancer Based on the Response Evaluation Criteria in Solid Tumors (RECIST). 7. and the assessment of curative or non-curative resection in cases of endoscopic treatment are defined. Curativity. Multi-modality Treatment Multi-modality treatments are defined. 7. Stenting Various types of stenting are described. . Endoscopic Treatments Various kinds of endoscopic treatments are described.6 residual tumor in the resected margin (pRX) are defined.7.1.8. 7. Terminology Related to Survival Period The terminology related to survival period is defined. Period and Rate of Esophageal Preservation Periods and rates of esophageal preservation are defined. Barrett esophagus. Others Important references. tables of abbreviations and an index are added.2. Barrett Esophagus and Adenocarcinoma in Barrett Esophagus The assessment methods of the esophagogastric junction are established. The macroscopic tumor types are classified in a manner similar to those of esophageal carcinoma.3.9. 7. 7. the guidelines to evaluate the response to radiotherapy. purpose of treatment. chemotherapy and chemoradiotherapy for esophageal cancers are established. and reasons for selection of method(s) for curative treatment are defined. PartIII.2.4. Barrett mucosa. The method of deciding the depth of tumor invasion for adenocarcinoma in Barrett esophagus is defined. 6.

7 Abbreviations AD Ae AI APC B c Ce CR CRT CT CTV Cur D DFS DM DMM E EG EGJ EMR EP ER ESD f G GE GIST H HM IM INF IR/SD IT LN LPM LSBE Laser Lt ly ly/v M MCT MFH MM MP MST Mt N adventitia abdominal esophagus Invasion to the adjacent structures argon plasma coagulation tracheal bifurcation clinical findings cervical esophagus complete response chemoradiotherapy chemotherapy clinical target volume curativity lymph node dissection disease-free survival distal margin deep muscularis mucosa esophagus tumor located in the esophageal side esophagogastric junction endoscopic mucosal resection epithelium endoscopic resection endoscopic submucosal dissection final findings stomach tumor located in the gastric side gastrointestinal stromal tumor esophageal hiatus horizontal margin intramural metastasis infiltrative growth pattern incomplete response/stable disease immunotherapy lymph node lamina propria mucosa long segment Barrett esophagus laser therapy lower thoracic esophagus lymphatic invasion vascular invasion distant organ metastasis microwave coagulation therapy malignant fibrous histiocytoma muscularis mucosa muscularis propria median survival time middle thoracic esophagus lymph node metastasis O OS p PD PDT PFS Ph PM PR R RECIST RFS RM RT s S SCE SCJ SD SM SMM SSBE T Te Tis TT TTF TTP Ut v VM X esophageal orifice overall survival pathological findings progressive disease photodynamic therapy progression free survival pharynx proximal margin partial response residual tumor Response Evaluation Criteria in Solid Tumors relapse/recurrence-free survival radial margin radiotherapy surgical findings superior margin of the sternum specialized columnar epithelium squamocolumnar junction stable disease submucosa superficial muscularis mucosa short segment Barrett esophagus depth of tumor invasion thoracic esophagus carcinoma in situ thermotherapy time to treatment failure time to progression upper thoracic esophagus venous invasion vertical margin cannot be assessed 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. c: ⭌ 8 . b: 4–7.

5 cm. are identified using the lower case “c”. INFa.: Mt.g. sM0. “p”. Four categories of findings. (f) T4. including cancer. sM0. and cancer metastatic to the esophagus is excluded.3. histological type. (f) N3. The order of clinicopathological description is: Tumor location. lymph node metastasis. intramural metastasis. CRT-sT3. cStage IVa As the tumor responded to chemoradiotherapy. lymph node metastasis. e. multiple primary cancers.g. and stage. fStage III The order of pathological description is: Tumor location. moderately differentiated squamous cell carcinoma. namely Clinical. tumor length. involvement of the resection margins (proximal margin. fStage III e. venous invasion. cT4. pPM0. IM0. effects of radiation and/or anticancer chemotherapy. the Society is publishing this handbook in English entitled “The Japanese Classification of Esophageal Cancer”.8 Part 1 General Rules 1. distal margin. pT3. one lesion). Methods of Descriptions 1. All primary malignant tumors in the esophagus. CRT-pT0 (T3). macroscopic tumor type. pattern of infiltration. pDM0. pN2. depth of tumor invasion. sN2. The extent of each finding is expressed by Arabic numerals following each upper-case letter.3.2. and radial margin). and Methods of Descriptions 1.1. Table 1-2). 1. pN3. Object The term esophageal cancer in the Japanese Classification refers to cancer originating in the esophagus. Purpose “The Guidelines for the Clinical and Pathologic Studies on Carcinoma of the Esophagus” was originally published in 1969 by the then Japanese Society for Esophageal Diseases. histological type (when identified). “s”. To promote the international use of the Guidelines and the Classification. depth of tumor invasion. should be described according to the Japanese Classification. pStage III Final findings. Object. lymphatic invasion. 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. Principles of Descriptions and Abbreviations Findings are recorded using upper-case letters T (depth of tumor invasion). v1. . pT3. The “f” of Final findings can be omitted (Table 1-1.g. sStage III Although the tumor completely responded to chemoradiotherapy on pathological findings. Surgical. cN2. before each upper case letter. sM0.: Tracheal invasion was observed from clinical findings. CRT-grade 2. 5 cm. “X” is used in unknown cases. distant organ metastasis. tumor length. Type 2. distant organ metastasis and stage. metastasis to Group 3 lymph nodes was observed. ly1. macroscopic tumor type. N (lymph node metastasis) and M (distant organ metastasis). pN1 (2/30). Purpose. findings should be recorded as the estimated most advanced condition throughout the treatment. sM0. moderately differentiated squamous cell carcinoma.1. 1. Pathological. and “f”. Type 2. (f) Stage IVa Note: In cases in which any findings are modified by combined treatment. the Society has changed its name in 2003 to become the Japan Esophageal Cancer Society. respectively. e.: Mt. and Final findings. (f) M0. cM0. Since then. surgery was performed. multiple primary carcinomas (present. pRM0.

Anatomical Regions (Subsites) of the Esophagus The esophagus lies between the hypopharynx and stomach. the methods of diagnosis such as barium swallow. thoracic esophagus (Te) and abdominal esophagus (Ae). the portion at the central point of the tumor can be recorded as the main tumor location.Note 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 Fig.2. transverse dimension (mm) and circumferential ratio of the tumor to the entire esophagus should be described. The zone of the esophagogastric junction is divided into the esophageal side (E) and gastric side (G) (Figure 1-1). the locations of the lesions are described in the order of depth of tumor inva- . 2.1. Endoscopic submucosal dissection: ESD-.2. 2. cervical esophagus (Ce). Number of Primary Tumors. Chemotherapy: CT-.1.1. and can be anatomically divided into the following portions.2. The identification of the esophagogastric junction (EGJ) will be described later. In addition. Laser therapy: Laser-.1.1.9 Note: Findings modified by treatment methods other than surgery are abbreviated as follows. The abdominal esophagus is included in this zone. In the case of multiple primary lesions.1. Chemoradiotherapy: CRT-. The esophageal orifice is at the lower margin of the cricoid cartilage. Description of Primary Tumor 2. Size and Circumferential Location Maximal longitudinal dimension (mm).2. Clinical Aspects 2. If it is difficult to determine the site of deepest tumor invasion. Endoscopic mucosal resection: EMR-. Anatomical Definition of the Esophagus The esophagus is defined anatomically from the esophageal orifice to the esophagogastric junction. Principles of Description of Tumor Location When the tumor extends continuously in more than one portion of the esophagus. 1-1 Tumor location and anatomical esophageal nomenclature O: esophageal orifice S: superior margin of the sternum B: tracheal bifurcation D: diaphragm EGJ: esophagogastric junction H: 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.1. endoscopy and endoscopic ultrasonography are to be recorded. 2. Radiotherapy: RT-.3.1. Tumor Location 2. Photodynamic therapy: PDT- 2.2. the main tumor location is that with the deepest tumor invasion.

It may be noted additionally in the macroscopic tumor type.3. 2 Note 1: The macroscopic tumor type before chemotherapy and/or radiotherapy is described. If it is difficult to determine the order of the depth. Tumors in which invasion is macroscopically diagnosed to be limited to within the submucosa are classified as superficial type. Depth of Tumor Invasion (T) TX Depth of tumor invasion cannot be assessed T0 No evidence of primary tumor T1a Tumor invades mucosa Note 1 T1a-EP Carcinoma in situ (Tis) T1a-LPM Tumor invades lamina propria mucosa (LPM) T1a-MM Tumor invades muscularis mucosa (MM) T1b Tumor invades submucosa (SM) Notes 2.g. Radiological and endoscopic classifications are based on the macroscopic classification. 8th ed.3. The largest lesion is described first. it is classified as 5. Subclassification of Superficial Type (type 0) Type 0-I Superficial and protruding type Type 0-Ip Pedunculated type Type 0-Is Sessile (broad based) type Type 0-II Superficial and flat type Type 0-IIa Slightly elevated type Type 0-IIb Flat type Type 0-IIc Slightly depressed type Type 0-III Superficial and excavated type Other notations Note 1: Combined type: When multiple macroscopic tumor types are mixed in one lesion. 3.10 sion. the most advanced type is described first and double quotation marks are unnecessary. Macroscopic Classification (Figure 1-2) Note Type 0 Type 1 Type 2 Type 3 Type 4 Type 5 Type Type 1 Superficial type Protruding type Ulcerative and localized type Ulcerative and infiltrative type Diffusely infiltrative type Unclassifiable type 5a Unclassifiable type without treatment 5b Unclassifiable type after treatment Notes 1. 3+0-IIc Note 2: Superficial spreading type: superficial type 0-IIc which extends 5 cm or more longitudinally. The wider type is described first and types are connected with+. In this case. the description order depends on the size of the area occupied by the lesion. 0-II or 0-III. 1-2 Macroscopic classification (Type 0–4) 2. Kanehara Shuppan.1.1.: 0-IIc+ “0-Is”. it is called a combined type. while tumors in which invasion is diagnosed to extend to the muscularis propria or beyond are classified as advanced type. the main macroscopic tumor type is the deepest one.g.3. when an advanced type is mixed.1.3. Guidelines for the Clinical and Pathologic Studies on Carcinoma of the Esophagus (in Japanese).g. e. Previous treatment is indicated. The deepest lesion is described first. However. 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. Principles of Tumor Type Classification The tumor type classification is based on the macroscopic findings.1.1. 34. When a tumor cannot be classified into any of the 5 (0–4) categories or their combinations.3.: CT-3. The advanced type is divided into 4 categories: 1.: MtLt. 1992. 2. 2.3. Note 2: Any former treatment(s) is mentioned before the macroscopic tumor type. [Reference] Japanese Society for Esophageal Diseases. Double quotation marks (“ “) are placed around the macroscopic tumor type that has the deepest tumor invasion. CRT-5b.2. The superficial type has the prefix ‘0’ and is classified into 0-I. e. Macroscopic Tumor Type 2. Tokyo. or 4. EMR-0-IIc Fig.4. LtAeG 2.4 SM1 Tumor invades the upper third of the submucosal layer SM2 Tumor invades the middle third of the submucosal layer SM Tumor invades the lower third of the submucosal layer .1. 2. e.

e.11 Fig. m2: T1a-LPM. a tumor invading the submucosa to a depth of 200μm or less from the lamina muscularis mucosa is classified as SM1. 2. 1-4 Station numbers of regional lymph nodes 2.2. e.g. recurrent laryngeal nerve. m3: T1a-MM.g. 2007. sm2: SM2. Note 6: Invaded organs such as the pericardium.1. Guideline\s for Diagnosis and Treatment of Esophageal Cancer (in Japanese).6. Metastatic Lesions from Esophageal Cancer 2.: early esophageal cancer: T1aNxMx Note 2: Superficial esophageal cancer: T1a and T1b are designated as a superficial cancer regardless of lymph node or distant organ metastasis. Lymph Node Metastasis Fig.1. lung.7 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. m1: T1a-EP. e. Note 5: Lesions invading the mediastinal pleura beyond the extent of the primary tumor are classified as T4.1. trachea.: superficial esophageal cancer: T1NxMx Note 3: Formerly-used subclassification of superficial type generally corresponds to the following.: T4 (lung) Note 7: If a metastatic lymph node invades an organ other than the esophagus. while a tumor extending more than 200μm is classified as SM2. 2nd ed. diaphragm.2. vena cava. sm1: SM1. thoracic duct.g. Kanehara Shuppan. sm3: SM3 Note 4: In endoscopically resected specimens. azygos vein should be recorded. Tokyo. e. . that should also be classified as T4. 1-3 Subclassification for superficial cancer (modified from the Guidelines for Esophageal Cancer Treatment) T2 T3 T4 Tumor invades muscularis propria (MP) Tumor invades adventitia (AD) Tumor invades adjacent structures (AI) Notes-5.: T4 (No.g. and it should be recorded as “T4 (metastatic node number-invaded organ”. 108-lung) [Reference] Japan Esophageal Society. aorta. Naming and Numbers of Lymph Node Stations The names and numbers of lymph nodes are defined as shown in Table 1-3 and Figure 1-4.2.

2. N4 Lymph node metastasis cannot be assessed No lymph node metastasis Metastasis involving only Group 1 lymph nodes Metastasis to Group 2 lymph nodes. The names and numbers of abdominal lymph node stations are defined in the Japanese Classification of Gastric Carcinoma. 106recR [Reference] Japanese Gastric Cancer Association. 13th ed. Kanehara Shuppan. Note: The number of lymph node stations should be recorded using “No.12 Table 1-3 Numbers and Naming of Regional Lymph Nodes Note: The left or right side of lymph nodes location should be recorded using a number plus “L” or “R”. the location of the deepest tumor invasion takes precedence in documentation.g.” plus a number.3.2. 2.2.1. Lymph Node Groups Lymph node groups are defined according to the location of the tumor as shown in Table 1-4 and Figures 1-8 to 1-14.1. The stations of cervical and thoracic lymph nodes are shown in Figures 1-5 to 1-7. Japanese Classification of Gastric Carcinoma.: No. Tokyo. regardless of involvement of Group 1 or 2 lymph nodes Metastasis to distant (Group 4) lymph nodes. Grading of Lymph Node Metastasis (N) NX N0 N1 N2 N3 2. Note: In deciding the lymph node group of multiple esophageal cancers and widely extending esophageal cancer. 1999. regardless of involvement of Group 1 lymph nodes Metastasis to Group 3 lymph nodes. regardless of whether any other group(s) of regional lymph nodes are involved or not . e.

stomach) Fig.2. M1 (liver. 1-7 Tracheobronchial lymph nodes Note 2: Pleural.13 2.: T2N2M0. Stage III Fig. and pericardial dissemination should be recorded as M1.2.g. 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. Stage (Table 1-5) The stage should be recorded based on the following TNM stage classification.3.: M1 (lung). peritoneal. e. 1-5 Superficial cervical lymph nodes Fig. 1-6 Deep cervical lymph nodes (Right view of the trachea) (Posterior view of the trachea) . 2.g.

and if it is adenocarcinoma it is defined as GE. If the center of a tumor is located exactly at the esophagogastric junction.14 Note 1: Cancer at the esophagogastric junction should be classified as EG or GE. Note 2: Lymph node grading in EG tumors is the same as in Ae tumors. it is defined as EG. . Note 3: The D Category is not affected by excision or non-excision of lymph nodes in parentheses. and if it is squamous cell carcinoma.

1-8 Lymph node groups for tumors located in CePh Fig. 1-11 Lymph node groups for tumors located in Mt . 1-10 Lymph node groups for tumors located in Ut Fig.15 Fig. 1-9 Lymph node groups for tumors located in Ce Fig.

.Fig. 1-14 Lymph node groups for tumors located in GE The D category is not affected by excision or non-excision of these lymph nodes designated by*. 1-13 Lymph node groups for tumors located in Ae (EG) The D category is not affected by excision or non-excision of lymph nodes designated by*. Fig. 1-12 Lymph node groups for tumors located in Lt Fig.

4. Note: The description of location of multiple primary cancers of the esophagus should be made in the order of the depth of tumor invasion (deeper to shallower) inserting “/” between the abbreviations of the location of each lesion. 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”. pharyngeal.. and the pathological tumor type should be described based on the post-fixation findings. Tumor Size (Figure 1-15) The greatest longitudinal dimension in millimeters and the greatest transverse (at 90°to the longitudinal tumor axis) dimension in millimeters: a (mm) ×b (mm) Metastatic lesions in the esophageal.4. Description of Surgical Findings and Macroscopic Findings of Primary Tumor Operative findings should be identified in the record putting <sc in front of each factor.2.4. 3. The opened esophagus should be gently stretched longitudinally and fixed so that the length of the specimen becomes similar to its size in vivo.g. the macroscopic tumor type should be described according to pre-fixation observations.: 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. . 3.1.e. Intramural Metastasis and Multiple Cancers in the Esophagus 3.2. Surgical Margin 3.3. 3. Pathological tumor types can be classified referring to the cross-sectional observation. and the number of such lesions should be described. This is particularly important in superficial carcinoma.5. Photographic recording is recommended for both fresh and fixed specimens. sStageII 3.4.2. PM: Proximal (Oral) Margin PMX Proximal margin cannot be assessed. and the total number of lesions should be recorded in parentheses. Surgical Aspects 3. Note: The presence of preoperative chemotherapy and radiotherapy should be recorded with the macroscopic tumor type. e. IM: Intramural Metastasis 3.2. Distance from Surgical Margin to the Tumor (Figure 1-15) Proximal (oral) margin (PM) (mm) Distal (anal) margin (DM) (mm) 3.2. RM: Radial Margin RMX Radial margin cannot be assessed. Under such circumstances. DM: Distal (Anal) Margin DMX Distal Margin cannot be assessed.g. i.3. e.3.g. 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. the organ other than the esophagus should be specified in parentheses.2.: Multi-organ primary cancers: stomach (synchronous) 3.1.1.2. Macroscopic tumor types should be determined regardless of microscopic depth of tumor invasion.: sT2. PM0 No evidence of tumor i nvasion PM1 Tumor invasion 3. e. 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 specimen should be treated with iodine solution after fixation in order to accurately describe the macroscopic findings. 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. Macroscopic Tumor Type The macroscopic appearance of tumors before and after fixation can be different. Note 2: Whether the multiplicity is synchronous or metachronous should be recorded. the outer surface of the surgical dissection plane.2.2.17 2. RM0 No evidence of tumor invasion RM1 Tumor invasion Note: The radial margin is the surgical margin in the radial direction. Note 1: In cases of multi-organ primary cancers including the esophagus.1. 3.2. or gastric wall macroscopically (clearly) separate from the primary tumor should be recorded as IM.

1-16 How to cut specimens surgically resected Fig. Field of Lymph Node Dissection Three-field dissection Dissection through cervical incision.4. cervical incision. Kanehara Shuppan. It is classified as organ metastasis (M1).1. 101 L) are dissected in the neck. 1-15 Tumor size and the distance from resection margin to tumor a. The lymph nodes dissected en bloc with the esophagus should be isolated from the specimen before fixation. 1-17 Histological efficacy of chemotherapy and/or radiotherapy Japanese Gastric Cancer Association: Japanese Classification of Gastric Carcinoma (in Japanese). thoracotomy or laparotomy Note: The term “three-field dissection” should not be applied when only the cervical paraesophageal nodes (101R. Lymph Nodes 3. Lymph Node Dissection (D) 3. 27.4.3. immediate pathological diagnosis with frozen 3..3. Extent of Lymph Node Dissection (D) DX Extent of lymph node dissection cannot be assessed. Fig. IMX Intramural metastasis cannot be assessed. 3. but no or incomplete dissection of Group-3 lymph nodes D3 Complete dissection of Group-1. 3.2. e.4.3.1. Tokyo. IM0 No intramural metastasis IM1 Intramural metastasis Note: IM in the gastric wall should be recorded as “IM1St”. i. and macroscopic findings obtained during postoperative preparation.3. 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. greatest longitudinal dimension (mm) b. Group-2 and Group3 lymph nodes .4. 3. 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.2.18 Fig.2. given individual names or numbers and sent to pathologists. 3. greatest transverse dimension (mm) Fig.4. Preparation of Resected Lymph Nodes for Pathological Examination Surgically dissected lymph nodes are classified according to the definition of regional lymph nodes. 1-18 How to cut specimens endoscopically resected section. Multiple cancers and IM should be clearly differentiated in the description. imaging examinations. 13th ed. and laparotomy Note Two-field dissection Dissection through thoracotomy and laparotomy Dissection through cervical incision and laparotomy Dissection through cervical incision and thoracotomy One-field dissection Dissection through a single operative field. thoracotomy.4. Multiple Cancers of the Esophagus Multiple cancers are two or more primary cancer lesions separate from each other. 1999.

Neurofibroma. Others 4. Schemas or photographs of the sites of cut sections should be preserved.2. Adenoid cystic carcinoma 8. Pathological Findings perpendicular to the esophagus should be blocked and used for microscopic examination. DM1. Malignant Epithelial Neoplasms 1. Neurogenic tumor Schwannoma.1. and sR0. Adenocarcinoma a. Adenoma 3. Whole step sections are made in superficial type cancer. One representative section of an advanced tumor at the site of deepest invasion. 3. moderately-differentiated type c. M1 evident residual tumor in distant organ(s) (M1).2. i.1. Histological Classification 4. Others 4. e. Columnar intraepithelial neoplasia 4. Adenosquamous carcinoma 6. Mucoepidermoid carcinoma 7. Intraepithelial Neoplasias 1. Handling of the Surgically Resected Specimens The resected specimen should be cut parallel along the long axis of the esophagus. Low grade intraepithelial neoplasia b. or surgical margin(s) (PM1. lymph nodes.2. Residual Tumor (R) RX R0 R1 R2 Note 1 Residual tumor cannot be assessed.4.2. and sD > sN Neither Cur A nor Cur C R1 sStage IV (T4. e. intraoperative imaging examinations such as intraoperative ultrasound examination.2.1. pStageII 4. Carcinosarcoma 4.: p0-Is.2.7.3. sStage 0∼III. Endocrine cell tumor a. Endocrine cell carcinoma 9. Curativity (Cur) (Table 1-6) Cur A Cur B Cur C Complete removal of the tumor is strongly believed. poorly-differentiated type 2. Smooth muscle tumor 2.19 3. Benign Epithelial Neoplasms 1. 3. and intraoperative immediate pathological diagnosis with frozen section.g.1. but R0 was achieved with resection of a T4 tumor or complete removal of metastatic tumor (M1) or lymph nodes. Distant Organ Metastasis (M) Surgical findings of distant organ metastasis (sM) should be determined through comprehensive consideration of operative macroscopic findings.. pT2. 4. Basaloid (-squamous) carcinoma 3. 4. Undifferentiated carcinoma 10. Granular cell tumor .5. Squamous cell papilloma 2. RM1). M1) or sD⬉sN. poorly-differentiated type 5.1.1. R2. Note 3: This means that the amount of residual tumor is macroscopically obvious. well-differentiated type b.6.2. pType 2. parallel or 4. Squamous cell carcinoma a. Squamous intraepithelial neoplasia a. Description of Pathological Findings The p (pathology) mark is prefixed to the pathological findings except for vascular invasion as follows. Non-epithelial Tumors 1. High grade intraepithelial neoplasia (Carcinoma in situ) 2. Note 2: This means that the presence of residual tumor is strongly suspected but very small in amount. well-differentiated type b. Carcinoid tumor b. Whether the distant organ metastasis was resected or not should be recorded. No residual tumor Microscopic residual tumor Note 2 Macroscopic residual tumor Note 3 Note 1: The postoperative state of both primary tumor and metastatic lesions should be evaluated. moderately-differentiated type c.1. Gastrointestinal stromal tumor (GIST) 3. macroscopic observation of resected specimen.

5. However if vascular invasion is found outside the confines of the primary tumor. Infiltrative Growth Pattern (INF) The growth and infiltrative pattern of a tumor can be classified into one of the following three types. et al. e. Lymphatic Invasion (ly) Note ly0 None ly1 Slight ly2 Moderate ly3 SevereNotes 2–4 1 Note 1: Examination by immunohistochemical staining using antibody D2–40 should be described. Lyon. Venous Invasion (v) Note v0 None v1 Slight v2 Moderate Note 2 v3 Severe 1 Note 1: Examination by elastic fiber staining methods should be described. Other Malignant Tumors 1. Others 4.1. Malignant melanoma 2.4. Tumor-like Lesions Ectopic gastric mucosa Heterotopic sebaceous gland Cowden disease Glycogenic acanthosis 4.2. the last in parentheses. Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues.2.2.g.2. 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.2.6. depth of invasion by residual tumor. WHO Classification of Tumours.g.g.1.1. Depth of Tumor Invasion (pT) Note 1–7 Note 1: Intraductal spreading of cancer is categorized as pT1a.4.g. Note 3: Lymphangitis carcinomatosa in distant organ(s) is categorized as T4.4. between INF-a and c INF-c (infiltrative type) Infiltrative growth of tumor nests with an ill-defined border from surrounding tissue 4. Note 5: Direct invasion of tumor from lymph node metastasis to the adjacent organ(s) is categorized as pT4. Lymphangioma. and the depth is recorded in parentheses. Note 7: If no residual tumor is found in an entire specimen after preoperative treatment. v2 (Elastica van Gieson) Note 2: Indefinite for determination of lymphatic or venous invasion is described as ly/v. Stein H.1.: v1 (Victoria blue).: RT-pT1b (T4). both the depth of invasion by residual tumor and the estimated depth of tumor invasion prior to treatment should be considered. CRT-. e.: pSM2 (400μm) Note 3: The depth of tumor invasion is defined histologically as the point of deepest direct invasion by the primary tumor. . e. N0. and histologically. EMR-). Note 2: The vertical depth of sm invasion is measured from the muscularis mucosa. malignant tissue recognized on the surgical radial margin (pRM1) is pT4.7.: Direct invasion from No. Note 4: When the tumor mass is found in the thoracic duct. this is designated as pT1b (ly-T2).3. and estimated depth of tumor invasion prior to treatment should be specified in that order. et al. and if the tumor invades beyond the duct of the esophageal gland. INF-a (expansive type) Expansive growth of tumor nests with a well-demarcated border from surrounding tissue INF-b (intermediate type) Intermediate growth pattern. 2001. Harris NL. Lymphoid Tumors The definition is according to the WHO classification. The type of adjuvant therapy (RT-.2. 4. IARC Press. the designation should be pT0.2. the depth of tumor invasion is defined as the layer presenting extraductal invasion of cancer. 4. M0. and its stage is recognized as the same as T1a. e.: CRT-pT0 (T3). 108 lymph node metastasis to the lung: pN1 (108-lung) T4 Note 6: In determining the depth of invasion of an advanced cancer after preoperative treatment. Vascular Invasion (ly/v) 4.g.20 4.2.g. Vascular invasion within the confines of the primary tumor should be regarded as the depth of direct tumor invasion. e. Others Hemangioma. CT-. CRT-pStage 0 4. [Reference] Jaffe ES. e.2. with regard to the predominant pattern observed at tumor margins.: ly1 (D2–40) Note 2: The description of wide spreading of tumor through lymphatic vessels should be described as lymphangitis carcinomatosa. Lipoma.2. Note 4: Cancer macroscopically invading the adjacent organ(s) (sT4). the depth of such invasion should be specified in parentheses after the depth of direct invasion. 4. it is described as lymphatic invasion in the thoracic duct.

Grade 1a: Viable cancer cells accounting for 2/3 or more tumor tissue Grade 1b: Viable cancer cells accounting for 1/3 or more. 4.6.2. Radial Margin (pRM) 4. Curativity (pCur) Table 1-7 Curativity is comprehensively assessed based on both the surgical and pathological findings.9.7.21 4. The total metastatic ratio is also described in parentheses.2.5. but less than 2/3. Note 6: A lymph node with no viable cancer cells after preoperative treatment is diagnosed as negative for metastasis. while other cancer cells are severely degenerated or necrotic. e. after pre-operative treatment. pDM) Note Note: The distance from surgical margin to tumor edge in pPM0 or pDM0 is measured in histological specimens (mm). Curativity A: Cur A pStage 0∼III. 106recL (0/4) Note 4: Metastasis to soft tissue without lymph node structure is described as extra-lymph node metastasis. Others 1) Metastatic or invasive cancer from other organs 2) Co-existing tumor Leiomyoma etc.2. Note 7: When the N category (pN) is modified based on the number of the metastatic lymph nodes. Residual Tumor (pR) 4. Distant Organ Metastasis (pM) 4. 104R (0/10). all the specimens in which the primary tumor is macroscopically possibly present should be examined histologically. Note: Definite re-proliferation of tumor cells in treated cancer lesions. Intramural Metastasis (pIM) 4.6. Note 3: The metastatic ratio (the number of metastatic lymph nodes/the number of dissected lymph nodes) is described for each lymph node station. In cases of preoperative treatment. Proximal and Distal Margin (pPM. No. pR0 and pD > pN Curativity B: Cur B . 4. Distance from Surgical Margin 4. should be recorded as “re-proliferation (+)”. No.8. type and dose of chemotherapy.3. 104 L (1/13).4.5. 4. Achalasia etc.2.2.g. 3) Other non-neoplastic lesions Barrett esophagus. No. 4. of tumor tissue Grade 2: Moderately effective Viable cancer cells account for less than 1/3 of tumor tissue. Multiple Primary Cancers Present (lesions) Absent Note: Lesions with a histological type different from that of the main tumor.: No. 106recR (1/3).2.2. then describe as “modified pN”. 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. and isolated lesions with an intraepithelial component. are defined as multiple primary cancers. refer to the explanation on page 96.1. 4. the radiation dose and method of administration.6. Pathological Criteria for the Effects of Radiation and/or Chemotherapy (Figure 1-17) In cases of preoperative radiation and/or chemotherapy. and time interval between pre-operative therapy and surgical resection of the tumor are described. Lymph Node Metastasis (pN) Note 1: Lymph nodes should be sectioned through the hilum.6. Note 2: The number of dissected lymph nodes and metastatic lymph nodes should be recorded. Note 5: Extranodal invasion including direct invasion and lymphatic invasion is described.2. but there is some evidence of degeneration of cancer tissue or cells. Grade 3: Markedly effective No viable cancer cells are evident.

1. Handling of Specimens Resected Endoscopically Note Extending fixation of the resected specimens: 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 2: When vascular invasion is present in the resection margin. 5.: pSM2. 2) Reconstruction after piecemeal resection is impossible. A submucosal cancer is sub-classified to SM1 (submucosal tumor invasion is limited up to 200μm) and SM2 (more than 200μm). Note: As for the extended fixation of the resected specimen. Resection Margin Note1. pHM0: Non-cancerous squamous epithelium and lamina propria mucosa are confirmed on all horizontal resection margins. Clinical Assessment of the Residual Tumor (R) Note1. The diagnosis is based on the histological classification (4.4.3.1.2.2. Preparation for Pathological Examination (Figure 1-18) Cutting lines are decided as crossing lines at right angles to the tangent line at the resection margin closest to the tumor. pVM1). it is defined as an incomplete resection (pR1).22 pStage IV (T4. Especially in piecemeal resection. 300μm 5. pRM1). pHM1: The tumor is exposed on any horizontal resection margin.3. Pathological Diagnosis 5. 5. pVM0: No tumor is exposed on any vertical margin. pDM1. .1. and a whole resected specimen is cut in slice each 2–3 mm thick. M1) or pD⬉pN. it is defined as a positive resection margin (pHM1.2 RX (non-assessable): it cannot be assessed whether there is an iodine unstained area in the margin of the resected specimen or not R0 (complete resection): there is no iodine unstained area in any margin of the resected specimen R1 (incomplete resection): there is an iodine unstained area in the margin of the resected specimen Note 1: A clinical assessment of the residual tumor referring to the iodine staining is done immediately after endoscopic resection Note 2: This method for assessment is applied to squamous cell carcinoma 5. and when a tumor is recognized in any resection margin. and vascular invasion. and the iodineunstained area is confirmed as a lesion.6% iodine solution more than shorter staining using more concentrated iodine solution. pVM1: The tumor is exposed on any vertical margin.2. lymph node metastasis or distant organ metastasis. non-cancerous tissue in the resection margin cannot be confirmed. Non-assessable Resection Margin (pRX) 1) Because of crushing injury or the burn effect in the specimen during endoscopic resection. better findings are obtained in the specimen stained using about 0.4.4. Vertical Margin (VM) pVMX: It cannot be assessed whether there is residual tumor on the vertical margin or not. LPM and MM. 5.g. it should be done by the doctor or co-worker who carried out endoscopic treatment. it is defined as a complete resection (pR0). e.4. 5. Although most esophageal tumors are squamous cell carcinoma. 5. Note 1: When no tumor is recognized in any resection margin.1.Note Note: Although it takes longer.3.4. 5. Macroscopic Findings Findings of iodine staining: The specimen is stained by iodine solution after fixation with formalin. Description of Pathological Findings The pathological diagnosis of an endoscopically resected specimen is summarized by the histological type. Note 3) Suspected residual tumor in the basal layer because of non-continuous tumor extension. assessment of resection margin (horizontal and vertical).2 5. 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.2. and R0 Surgical curativity B or C.4.1). Horizontal Margin (HM) pHMX: It cannot be assessed whether there is residual tumor on the horizontal margin or not.4. the evaluation of histological differentiation is omitted for intraepithelial carcinoma. Depth of Tumor Invasion (T) A mucosal cancer is categorized in three depths of EP. 5.2. depth of tumor invasion. In a submucosal cancer. but pathologically R0 Curativity C: Cur C pR1.3.3. the distance from the lamina muscularis mucosa is described because the entire submucosal layer cannot be examined in an endoscopically resected specimen. Endoscopic Treatment 5.3. pR2: pathologically residual tumor including the primary tumor (pPM1.

each lesion is evaluated.4. Note 1: If there are multiple lesions. INFb (intermediate type): Intermediate pattern. Barrett Esophagus and Adenocarcinoma in Barrett Esophagus 5. 5. Barrett Esophagus and Adenocarcinoma in Barrett Esophagus 6. giving a clinical (cR) and pathological assessment (pHM and pVM) of the resection margin. Curativity (Cur) Notes 1.1.4. 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 in the resection margins of the restructured specimen.5. it is finally evaluated as a complete resection. 5.5. Infiltrative Growth Pattern (INF) INFa (expansive type): Tumor extends downward continuously and expansively from the epithelium. if results similar to complete resection can be expected by an additional endoscopic treatment. and the lesion with the lowest possibility of curative resection is used for comprehensive evaluation. Comprehensive Evaluation of Curativity Curative resection: the complete resection for a cancer invading within the lamina propria mucosa and having no vascular invasion The situation of EP or LPM at the depth of tumor invasion.4. the evaluation is made by histological examination after accurate restructuring of the resected specimen. between INFa and INFc INFc (infiltrative type): Tumor infiltrates in the pattern of single cells. Cur A and ly0/v0 Non-curative resection: situations other than curative resection 6.1. When differentiation between lymphatic and venous invasion is difficult.1. In piecemeal resection. it is described as ly/v.5.5.2. Note 2: In cases of clinical and/or histological incomplete resection. 5. a comprehensive evaluation is established. Report of Pathological Findings 6.6. Definition of the Esophagogastric Junction (EGJ) All above mentioned factors should be described. Definition and Methods of Description for Barrett Mucosa.23 4) Possible residual tumor in the vertical margin because of intra-ductal spread. and a figure showing a general view of the resected specimen Border of esophageal muscle and gastric muscle. Lymphatic Invasion (ly) ly (−) No lymphatic invasion ly (+) Lymphatic invasion 5. Immunostaining with D2–40 is useful for confirmation of lymphatic invasion. Vascular Invasion (ly/v) Note It is not necessary to evaluate the degree of vascular involvement: only its presence or absence should be described.4. 5. 2 (Table 1-8) When endoscopic resection (EMR: endoscopic mucosal resection or ESD: endoscopic submucosal dissection) is performed.4.1.4.6. small and large tumor nests or trabecular arrangement of tumor cells in the lamina propria mucosa or submucosa. It is better to attach a schematic figure showing pathological findings on the cut surface if necessary. Venous Invasion (v) v (−) No venous invasion v (+) Venous invasion Note: Special staining methods for the elastic fibers of the vascular wall such as EVG and Victoria blue dyeing are necessary in determining the venous invasion. with depth of tumor invasion and vascular invasion by the part is needed. 5.

T1a-LPM Tumor invades lamina propria mucosa. 6.1. the primary muscularis mucosa is called deep muscularis mucosa (DMM). .3.1. Adenocarcinoma in Barrett Esophagus is described according to the Japanese Classification for esophageal cancer except for the depth of the tumor invasion. Description of Tumors 1) Lower margin of the palisading small vessels in the lower esophagus by endoscopic findings (Figure 1-19).3. T4 Tumor invades adjacent structure(s) (AI). Barrett Mucosa The columnar epithelium continuous from the stomach with or without intestinal metaplasia.1.3.1. Intramural Metastasis (IM) Same as esophageal cancer.1.3. Distant Organ Metastasis (M) 6. Barrett Esophagus < cf. SM1 Tumor invades the upper third of submucosa. T0 No evidence of primary tumor T1a Tumor invades mucosa. T1a-SMM Tumor invades superficial muscularis mucosa (SMM). Same as esophageal cancer. Note: In the presence of hiatus hernia.Note 1 At least one of the following conditions must be satisfied. Tumor Locat ion Same as esophageal cancer.24 6.1.3.5.2. and the new muscularis mucosa is called superficial muscularis mucosa (SMM).3. T1b Tumor invades submucosa (SM).3.3. Note: Squamocolumnar junction (SCJ) is not always consistent with EGJ. Circumferential Location 6.3.2.4. T3 Tumor invades adventitia (AD).4. 6. the tumor location is diagnosed using barium contrast radiography. On the other hand.2. T2 Tumor invades muscular propria (MP).1.3. thickness and irregularity. Tumor Size 6. SM2 Tumor invades the middle third of submucosa.2. (1) Esophageal glands in the area of columnar epithelium (2) Squamous islands in the columnar epithelium (3) Double layer structure of muscularis mucosa Note 2 Note 1: Circular Barrett mucosa extending longitudinally 3 cm or more is called long segment Barrett esophagus (LSBE) (Figure 1-21). 2) Horizontal level at the same level as the angle of His in an upper gastrointestinal series (UGI). Macroscopic Tumor Types 6. In the Japanese Classification.4.4. Primary Tumor 6. p97 > The esophagus having Barrett mucosa is designated Barrett esophagus.1. less than 3 cm Barrett mucosa or non-circular Barrett mucosa is designated as short segment Barrett esophagus (SSBE) Note 2: Sometimes there is new muscularis mucosa just under the columnar epithelium. 6.1. T1a-DMM Tumor invades deep muscularis mucosa (DMM).1. Depth of Tumor Invasion (T) TX Depth of tumor invasion cannot be assessed. Stage Same as esophageal cancer. 6.3.3. Adenocarcinoma in Barrett Esophagus 6. 3) Oral margin of longitudinal folds of the greater curvature of the stomach by endoscopic findings and UGI (Figure 1-20). Diagnosis of the Esophagogastric Junction (EGJ) 6. 6. Lymph Node Metastasis (N) Adenocarcinoma arising in Barrett mucosa 6. SM3 Tumor invades the lower third of submucosa. 4) Obvious macroscopic caliber change of resected esophagus and stomach. 6. The identification of SMM and DMM is occasionally difficult due to fusion of both of the layers.

. Circular SSBE. 1-21 Long segment Barrett esophagus (LSBE). Fig. Non-circular SSBE Fig. 1-22 Short segment Barrett esophagus (SSBE) a. 1-20 Esophagogastric junction The site of the oral edges (arrows) of longitudinal gastric folds is defined as the EGJ.25 Fig. 1-19 Esophagogastric junction The site of the lower edges of the palisading small vessels is defined as EGJ. Fig. b.