Pathologists are able to differentiate reliably the lamina propria associated with Barrett's musculofibrous anomaly from submucosa in oesophageal endoscopic resections.

AIMS: Endoscopic resection (ER) is the standard therapy for early oesophageal neoplasia and is used for diagnosis and treatment. Accurate staging is especially important, as further treatment depends on this. Because Barrett's mucosa often develops fibromuscular hyperplasia with a fibrotic lamina propria and reduplicated muscularis mucosae, pathologists have expressed concern that it may not be possible to differentiate lamina propria reliably from submucosa in such resections. This study aimed to develop criteria for distinguishing submucosa from abnormal lamina propria and test reproducibility. METHODS AND RESULTS: Virtual slides of oesophagectomy cases with early cancer were reviewed by participants, all gastrointestinal (GI) pathologists. Criteria were agreed for recognition of submucosa - the presence of any of submucosal glands, fat and large muscular vessels. A set of 20 endoscopic resections were then uploaded and 45 areas annotated and participants asked to categorize as submucosa or lamina propria. Agreement was excellent, with 35 areas showing agreement by all pathologists and a further seven areas with four of five agreeing. Paired interobserver kappa values varied between 0.69 and 0.955. CONCLUSION: With the application of usually easily recognizable criteria, pathologists are able to differentiate submucosa from lamina propria with musculofibrous anomaly in oesophageal ER specimens with a high degree of reproducibility.

A pathologist's survey on the reporting of sessile serrated adenomas/polyps.

AIM: The purpose of this survey was to ascertain reporting habits of pathologists towards sessile serrated adenomas/polyps (SSA/P). METHODS: A questionnaire designed to highlight diagnostic criteria, approach and clinical implications of SSA/P was circulated electronically to 45 pathologists in the UK and North America. RESULTS: Forty-three of 45 pathologists agreed to participate. The vast majority (88%) had a special interest in gastrointestinal (GI) pathology, had great exposure to GI polyps in general with 40% diagnosing SSA/P at least once a week if not more, abnormal architecture was thought by all participants to be histologically diagnostic, and 11% would make the diagnosis if a single diagnostic histological feature was present in one crypt only, while a further 19% would diagnose SSA/P in one crypt if more than one diagnostic feature was present. The vast majority agreed that deeper sections were useful and 88% did not feel proliferation markers were useful. More than one-third did not know whether, or did not feel that, their clinicians were aware of the implications of SSA/P. CONCLUSIONS: 98% of pathologists surveyed are aware that SSA/P is a precursor lesion to colorectal cancer, the majority agree on diagnostic criteria, and a significant number feel that there needs to be greater communication and awareness among pathologists and gastroenterologists about SSA/P.

Staging rectal cancer: MRI compared to MDCT.

PURPOSE: To audit the accuracy with which pre-operative MRI and multi-detector row CT determine the relationship between rectal tumour and the circumferential resection margin (CRM). MATERIALS AND METHODS: The MR and CT scans of 72 patients with rectal adenocarcinoma were retrieved. The relationship between tumour and the mesorectal fascia was determined by two observers, who classified appearances into three categories: no tumour within 5 mm of the mesorectal fascia; tumour within 5 mm of the mesorectal fascia ('threatened' margin); tumour at the mesorectal fascia ('involved' margin). Agreement with post-operative histopathology was assessed by Kappa statistics. RESULTS: There was poor agreement between both MRI and CT, and post-operative histology, both in all 72 patients and in the 42 who had received no pre-operative therapy or short-course radiotherapy only. Both imaging modalities had a tendency to overstage patients whose CRM was uninvolved subsequently. However, the negative predictive value for an uninvolved margin was 81.8% by MRI and 84.6% by CT. There was no patient with an involved margin by histopathology whose imaging had suggested the margin was uninvolved. CONCLUSION: Both pre-operative MRI and multi-detector row CT have high negative predictive values for a subsequently uninvolved resection margin.

Emerging aspects of oesophageal and gastro-oesophageal junction cancer histopathology - an update for the surgical oncologist.

Adenocarcinoma of the oesophagus and gastro-oesophageal junction are rapidly increasing in incidence and have a well described sequence of carcinogenesis: the Barrett's metaplasia-dysplasia-adenocarcinoma sequence. During recent years there have been changes in the knowledge surrounding disease progression, cancer management and histopathology specimen reporting. Tumours around the gastro-oesophageal junction (GOJ) pose several specific challenges. Numerous difficulties arise when the existing TNM staging systems for gastric and oesophageal cancers are applied to GOJ tumours. The issues facing the current TNM staging and GOJ tumour classification systems are reviewed in this article. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as circumferential resection margin status and lymph node metastases, have implications for specimen reporting. With the rising use of multimodal treatments for oesophageal cancer it is important that the response of the tumour to this therapy is carefully documented pathologically. In addition, several controversial and novel areas such as endoscopic mucosal resection, lymph node micrometastases and the sentinel node concept are being studied. We aim to review these aspects, with special relevance to oesophageal and gastro-oesophageal cancer specimen reporting, to update the surgical oncologist with an interest in upper gastrointestinal cancer.

The modern abdominoperineal excision: the next challenge after total mesorectal excision.

OBJECTIVES: Examine the cause of local recurrence (LR) and patient survival (S) following abdominoperineal resection (APR) and anterior resection (AR) for rectal carcinoma and the effect of introduction of total mesorectal excision (TME) on APR. METHODS: A total of 608 patients underwent surgery for rectal cancer in Leeds from 1986 to 1997. CRM status and follow-up data of local recurrence and patient survival were available for 561 patients, of whom 190 underwent APR (32.4%) and 371 AR (63.3%). Also, a retrospective study of pathologic images of 93 specimens of rectal carcinoma. RESULTS: Patients undergoing APR had a higher LR and lower survival (LR, 22.3% versus 13.5%, P = 0.002; S, 52.3% versus 65.8%, P = 0.003) than AR. LR free rates were lower in the APR group and cancer specific survival was lowered (LR, 66% versus 77%, log rank P = 0.03; S, 48% versus 59%, log rank P = 0.02). Morphometry: total area of surgically removed tissue outside the muscularis propria was smaller in APR specimens (n = 27) than AR specimens (n = 66) (P < 0.0001). Linear dimensions of transverse slices of tissue containing tumor, median posterior, and lateral measurements were smaller (P < 0.05) in the APR than the AR group. APR specimens with histologically positive CRM (n = 11) had a smaller area of tissue outside the muscularis propria (P = 0.04) compared with the CRM-negative APR specimens (n = 16). Incidence of CRM involvement in the APR group (41%) was higher than in the AR group (12%) (P = 0.006) in the 1997 to 2000 cohort. Similar results (36% and 22%) were found in the 1986 to 1997 cohort (P = 0.002). CONCLUSIONS: Patients treated by APR have a higher rate of CRM involvement, a higher LR, and poorer prognosis than AR. The frequency of CRM involvement for APR has not diminished with TME. CRM involvement in the APR specimens is related to the removal of less tissue at the level of the tumor in an APR. Where possible, a more radical operation should be considered for all low rectal cancer tumors.

Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery.

OBJECTIVE: To analyze the potential variability in rates of circumferential resection margin (CRM) involvement between different surgeons and time periods and to determine the suitability of using CRM status as an immediate predictor of outcome after rectal cancer surgery. SUMMARY BACKGROUND DATA: After disease stage has been taken into account, survival in rectal cancer has been shown to be very variable between surgeons and institutions. One of the major factors influencing survival is local recurrence, and this in turn is strongly related to inadequate tumor excision, particularly at the CRM. METHODS: In a study involving 608 patients who underwent surgery for rectal cancer in Leeds during the 12-year period 1986 to 1997, the authors examined the role of CRM status as an immediate predictor of likely outcome, paying particular attention to its relationships with different surgeons and time periods. RESULTS: Of 586 patients on whom full clinical follow-up was obtained, 165 (28.2%) had CRM involvement by carcinoma on pathologic examination. Up to the end of 1998, 105 (17.9%) patients had developed local recurrence. A significantly higher proportion (38.2%) of CRM-positive patients developed local recurrence than CRM-negative ones (10.0%). Kaplan-Meier survival analysis showed significant improvements in survival for CRM-negative patients over CRM-positive patients. Survival analysis in relation to two gastrointestinal surgeons and a group of other surgeons showed survival improvements that paralleled a reduction in the rates of CRM involvement for the two gastrointestinal surgeons during the period of the study. No improvement in survival or reduction in rates of CRM involvement was seen in the group of other surgeons. CONCLUSIONS: These results show that CRM status may be used as an immediate predictor of survival after rectal cancer surgery and serves as a useful indicator of the quality of surgery. The frequency of CRM involvement can be used both for overall surgical audit and for monitoring the value of training programs in improving rectal surgery by individual surgeons. Its use in the current MRC CR07 study is valid and the best indicator of a requirement for further local therapy.