Upper GI Staging

What surgical specimens may be received for esophageal cancer?

Esophagectomy

Esophagogastrectomy

What are the two major histologic types of esophageal carcinoma?

Squamous cell carcinoma (SCC)

Adenocarcinoma

Where along the esophagus is SCC most commonly found according to the lecture?

Most common in the middle to lower third

• Can occur throughout the esophagus

Where does esophageal adenocarcinoma usually originate?

Near the esophagogastric junction (EGJ)

What gross patterns can esophageal tumors demonstrate?

They can be:

• Exophytic

• Circumferential

• Obstructive

• Ulcerative

• Constricting/strictures

Viable tumors may have sharply demarcated borders

What gross appearance may be seen after treatment response in an esophageal tumor?

A white, flattened appearance with a fibrous cut surface may indicate treatment response

What should be submitted/identified in an esophagogastrectomy specimen?

Esophageal margin

Gastric margin

Adventitial margin

Lymph nodes

Uninvolved tissue

What is this showing?

Ulcerative SCC of the esophagus

Verrucoid SCC of the esophagus

What is this showing?

Adenocarcinoma of the esophagus

What determines the T category for esophageal carcinoma?

Primarily the depth of invasion through the esophageal wall and into adjacent structures

What is pTis for esophageal carcinoma?

High-grade dysplasia/carcinoma in situ with malignant cells

• Confined to the epithelium by the basement membrane

What defines pT1 esophageal carcinoma?

Tumor invades the:

• T1a — Lamina propria or muscularis mucosae

• T1b — Submucosa

What defines pT2 esophageal carcinoma?

Invasion into the muscularis propria

What defines pT3 esophageal carcinoma?

Invasion through the muscularis propria into the adventitia

What defines pT4 esophageal carcinoma?

Invasion into adjacent structures

• T4a vs T4b

NOT CONSIDERED DISTANT METS

What is pT4a for esophageal carcinoma?

A resectable tumor invading structures such as:

• Pleura

• Pericardium

• Azygos vein

• Diaphragm

• Peritoneum

What is pT4b for esophageal carcinoma?

Tumor invasion into other adjacent structures such as the:

• Aorta

• Vertebral body

• Airway

What is pN1 for esophageal carcinoma?

Metastasis in 1–2 regional lymph nodes

What is pN2 for esophageal carcinoma?

Metastasis in 3–6 regional lymph nodes

What is pN3 for esophageal carcinoma?

Metastasis in 7 or more regional lymph nodes

According to the lecture, how many lymph nodes should ideally be examined based on pT category for esophageal carcinoma?

pT1 — 10 nodes

pT2 — 20 nodes

pT3/pT4 — 30 nodes

What sites are identified as distant metastatic sites for esophageal carcinoma?

Nonregional lymph nodes

Organs

• Liver

• Lung

• Adrenal glands

What is pM1 esophageal carcinoma?

Distant metastasis

What is an important distinction regarding direct extension in esophageal cancer?

Direct extension into structures such as the:

• Pleura

• Pericardium

• Diaphragm

• Aorta, or

• Vertebral bodies

is NOT automatically considered distant metastasis

• These are considered in the T category

What major anatomic regions of the stomach should you recognize?

Cardia

Fundus

Corpus/body

Antrum

Pylorus

How is a tumor involving the EGJ classified when its epicenter is ≤2 cm below the EGJ?

It is staged according to the esophageal protocol

How is a tumor involving the EGJ classified when its epicenter is >2 cm into the proximal stomach?

It is classified/staged as a gastric cancer

What is the key measurement for determining whether an EGJ tumor is staged as esophageal or gastric?

The location of the tumor epicenter relative to the EGJ

• Particularly the 2-cm cutoff

Where is this tumor located?

The stomach

What is pTis for gastric tumors?

Carcinoma in situ

• Intraepithelial tumor WITHOUT invasion of the lamina propria

  • High-grade dysplasia

What defines gastric pT1?

Tumor invades the lamina propria, muscularis mucosae, or submucosa

• T1a — Lamina propria or muscularis mucosae

• T1b — Submucosa

What defines gastric pT2?

Tumor invades the muscularis propria

What defines gastric pT3?

Tumor penetrates the subserosal connective tissue WITHOUT invading the visceral peritoneum or adjacent structures

What defines gastric pT4?

Tumor invades:

• T4a — The serosa (visceral peritoneum), or

• T4b — Adjacent structures/organs

What are the regional lymph node categories for gastric carcinoma?

pN0 — No regional node metastasis

pN1 — 1–2 regional nodes

pN2 — 3–6 regional nodes

pN3 — ≥7 regional nodes

• pN3a — 7–15

• pN3b — ≥16

What regional lymph node groups are illustrated for gastric carcinoma?

The diagram includes:

• Perigastric nodes along lesser curvature

• Perigastric nodes along greater curvature

• Right/left paracardial nodes

• Suprapyloric nodes

• Infrapyloric nodes

• Hepatoduodenal nodes

• Common hepatic nodes

• Celiac nodes

• Splenic artery nodes

• Splenic hilum nodes

• Left gastric nodes

MAKE SURE TO LOOK FOR LYMPH NODES

What is gastric pM0 vs pM1?

pM0 — No distant metastasis

pM1 — Distant metastasis

What distant metastatic sites are emphasized for gastric cancer?

Liver

Peritoneal surfaces

Lung

Adrenal gland

Ovary

• Krukenberg tumor

Sister Mary Joseph nodules

CNS

Nonregional/distant lymph node

• Virchow node

• Irish node

What is a Krukenberg tumor?

Bilateral ovarian metastases

• Often from diffuse-type gastric carcinoma

What is a Sister Mary Joseph nodule?

A periumbilical metastatic nodule

What is a Virchow node in the context of gastric cancer?

A left supraclavicular lymph node representing nonregional/distant lymph node involvement

What is an Irish node?

A left axillary lymph node representing nonregional/distant nodal involvement.

What is this?

Gastric carcinoma

What three factors does the lecture emphasize when evaluating GIST?

Tumor site

Mitotic rate

Grade

What mitotic rate corresponds to GIST G1?

≤5 mitoses/5 mm²

What mitotic rate corresponds to GIST G2?

>5 mitoses/5 mm²

What is the GIST pT staging system based on?

Tumor size

What are the GIST pT size categories given in the lecture?

pT1 — ≤2 cm

pT2 — >2–5 cm

pT3 — >5–10 cm

pT4 — >10 cm in greatest dimension

(SIZE MATTERS)

What is T suffix (m) for GIST?

Multiple primary synchronous tumors in a single organ

How is GIST pN staged?

pN0 — No regional lymph node metastasis

pN1 — Regional lymph node metastasis

What is GIST pM1?

Distant metastasis

What is no LNs are present in GIST specimens?

An N category is not assigned/reported

What gross appearance should you recognize as a GIST?

A large, well-defined mass involving the GI tract

What type of cellular appearance is illustrated in the GIST microscopic image?

A spindle-cell morphology is illustrated