* A protocol for the pathologic examination and reporting of specimens from patients with gastric carcinoma has been developed by the Cancer Committee of the College of American Pathologists and a multidisciplinary task force of specialists dealing with patients with gastric carcinoma. The protocol incorporates all basic pathology data of diagnostic and prognostic significance appropriate for the treatment of patients with gastric carcinoma. The purpose of the protocol is to serve as a basis for the development of checklists, as on outline for full narrative reporting, as a basis for research protocols, or as a guide for other types of synoptic or reporting formats. The protocol is stratified to accommodate the surgical procedures usually employed for gastric carcinomas, including acquisition of cytologic specimens, incisional endoscopic biopsy, excisional biopsy, and gastric resection (partial or complete). Explanatory notes detailing specific procedures and rationales for documentation of specific pathologic data are included in the protocol. The protocol uses the staging system for gastric carcinoma defined by the American Joint Committee on Cancer and the International Union Against Cancer. (Arch Pathol Lab Med. 1998;122:9-14)
The Cancer Committee of the College of American Pathologists has developed a protocol for data to be included in surgical pathology reports for patients with carcinoma of the stomach. The Committee, as part of its program in quality assurance for anatomic pathology,l continues to develop protocols for the examination of surgical specimens with cancer. Previously, the Committee published protocols for cancers of the breast, the urinary bladder, Hodgkin's disease (Pathologist, 1986;40:18-23), the colon and rectum,2 and the lung.3 This protocol is not a mandate, but a guide for pathologists who would like assistance. It is not intended for pathologists who have already satisfied their quality assurance commitments with their own protocols.
PURPOSE
The purpose of this protocol is to serve as a basis for the development of checklists, as an outline for full narrative reporting, as a basis for research protocols, or as a guide for other types of synoptic or reporting formats. The protocol specifies information that documents appropriate examination of the specimen, as well as the anatomic extent of tissue removed, the anatomic extent of carcinoma in the specimen, histologic type, and other information that may be used by the referring physician to select primary or adjuvant treatment, evaluate new types of therapy, estimate prognosis, and analyze outcome. Pathologists may report additional information not specified by the protocol or modify this protocol to suit individual institutional needs. This protocol applies only to carcinomas arising in the stomach. The protocol is stratified to accommodate the surgical procedures usually employed for carcinomas of the stomach, including acquisition of cytologic specimens, incisional (endoscopic) biopsy, excisional biopsy, and gastrectomy (total or subtotal, with or without other organs, including distal esophagus, duodenum, pancreas, liver, and/or spleen).
PROTOCOL DEVELOPMENT
A provisional protocol was developed by a multidisciplinary task force established by the Cancer Committee. Pathologists, surgeons, medical oncologists, radiologists, and radiation oncologists constituted the Task Force, which initially met in 1995. The charge of the Task Force was to document the basic pathology data appropriate for the treatment of patients with gastric carcinoma. Documentation was obtained from the medical literature, personal experience, and consultation with colleagues. The provisional protocol was further reviewed by pathologists, surgeons, and other specialists involved in the care of patients with gastric carcinoma. The protocol was approved by the Board of Governors of the College of American Pathologists.
SYNOPTIC REPORTING
Recently, significant interest in the synoptic form of reporting has emerged as a replacement for the traditional narrative descriptive format.45 Checklists or other descriptive reporting formats based on this protocol would ensure a uniform system of reporting consonant with quality care. All appropriate information that is needed clinically would be provided. The Cancer Committee is developing checklists based on this protocol that will be available from the College of American Pathologists.
EXPLANATORY NOTES
A: Histologic Type.-This protocol applies to all carcinomas of the stomach. The protocol excludes carcinoid tumors, but applies to carcinomas with focal neuroendocrine differentiation. For consistency in reporting, the histologic classification proposed by the World Health Organization is recommended.6 However, this protocol does not preclude the use of other systems of classification or histologic types which may be used in addition to the World Health Organization system.7
With the exception of the rare small cell carcinoma of the stomach, which has an unfavorable prognosis, most multivariate analyses show no effect of tumor type, independent of stage, on prognosis.8
World Health Organization Classification
Adenocarcinoma in situ/severe dysplasia Adenocarcinoma
Papillary adenocarcinoma Tubular adenocarcinoma Mucinous adenocarcinoma (>50% mucinous) Signet-ring cell carcinoma (>50% signet-ring cells) Adenosquamous carcinoma Squamous cell carcinoma Small cell carcinoma Undifferentiated carcinoma Other (specify)
The Lauren classification (namely intestinal or diffuse type) and/or the Ming classification (namely, expanding or infiltrating type) may also be included. Some pathologists classify in situ carcinoma under the diagnostic term severe or high-grade dysplasia. The term carcinoma, NOS (not otherwise specified) is not part of the World Health Organization classification.
C: Configuration.-Tumor configurations include the following types: exophytic (polypoid), infiltrative, diffusely infiltrative (linitis plastica), expansile (noninfiltrative), ulcerating, or annular. Exophytic is divided into pedunculated and sessile. Tumor configuration has been shown to have prognostic significance in several large studies.8 However, the prognostic value of tumor configuration is controversial, in as much as numerous smaller studies have failed to demonstrate independent prognostic significance for this pathologic feature.
D: Tumor Size.-Although not a factor in the T classification of gastric carcinoma (see note E below), tumor size has been shown to be an independent adverse prognostic factor in many studies." However, the prognostic value of tumor size is controversial, in as much as a large number of other studies have failed to demonstrate independent prognostic significance for this pathologic feature.
E: TNM Staging System.-The following classification is the American Joint Committee on Cancer/ International Union Against Cancer TNM staging system for gastric carcinoma.13 The symbol "p" preceding a T, N, or M category is used to refer to pathologic classification as opposed to clinical classification, which is denoted by the symbol "c." Pathologic classification of the TNM system is based on gross and microscopic examination. Therefore, pT entails a resection of the primary tumor or biopsy adequate to evaluate the highest pT category, pN entails removal of nodes adequate to validate lymph node metastasis, and pM implies microscopic examination of distant lesions. Clinical classification (cTNM) is usually carried out by the referring physician before treatment during initial evaluation of the patient or when pathologic classification is not possible.
F: Blood/Lymphatic Vessel Invasion.-Both venous and lymphatic vessel invasion have been shown to be adverse prognostic factors.8 However, the microscopic presence of tumor in lymphatic vessels or veins does not qualify as local extension of tumor as defined by the T classification (see note E).14
G: Perineural Invasion.-Perineural invasion has been shown to be an adverse prognostic factor."
H: Specimen Dimensions.--Open specimen along greater curvature, avoiding tumor if located in this position. Measure length of stomach along lesser curvature and circumference of distal margin. Measure length and width of tubular esophagus.
I: Tumor Location.-Tumor location should be described in relation to the following landmarks: (1) gastric region: cardia (including gastroesophageal junction), fundus, corpus, antrum, pylorus; (2) greater curvature, lesser curvature; (3) anterior wall, posterior wall.
For tumors involving the gastroesophageal junction, specific observations should be recorded in an attempt to establish the exact site of origin of the tumor. The gastroesophageal junction is defined as the junction of the tubular esophagus and the stomach irrespective of the type of epithelial lining of the esophagus. The pathologist should record (1) the proportion of tumor mass located in the esophagus and stomach, (2) the greatest dimensions of esophageal and gastric portions of the tumor, and (3) the anatomic location of the center of the tumor.
If more than 50% of the tumor involves the esophagus, the tumor is classified as esophageal. If more than 50% of the tumor involves the stomach, the tumor is classified as gastric.l4 If the tumor is equally located above and below the gastroesophageal junction or is designated as being at the junction (anatomic center of the tumor), carcinomas of the squamous, small cell, and undifferentiated types are classified as esophageal, whereas adenocarcinomas and signet-ring cell carcinomas are classified as gastric.14
Tumor site has been shown to be an independent prognostic factor in gastric carcinoma. The long-term prognosis for patients with proximal carcinomas (ie, tumors of the upper third of the stomach, including the gastric cardia and gastroesophageal junction) is poorer than for those with distal cancers.8
J: Margins.-Margins include the proximal, distal, and radial margins. The radial margin represents the nonperitoneal soft tissue margin closest to the deepest penetration of tumor. In the stomach, the mesenteric resection margin is the only radial margin. It may be helpful to mark the margin(s) closest to the tumor with ink. Margins marked by ink should be designated in the macroscopic description.
K: Regional Lymph Nodes.-Regional lymph nodes include12 (1) perigastric nodes along the lesser and greater curvatures and (2) nodes located along the left gastric, common hepatic, hepatoduodenal, splenic, and celiac arteries. Involvement of other intra-abdominal lymph nodes, such as hepatoduodenal, retropancreatic, mesenteric, and para-aortic, is classified as distant metastasis.
Members of the Task Force for the Protocol on the Examination of Specimens From Patients With Gastric Carcinoma included Carolyn Compton, MD, PhD and Leslie H. Sobin, MD (co-chairs); Donald Antonioli, MD; Harvey Goldman, MD; Rodger C. Haggitt, MD; Robert V P. Hutter, MD; J. Milburn Jessup, MD; Randall Lee, MD; Klaus Lewin, MD; Pablo Ross, MD; Heidrun Rotterdam, MD; Stuart Spechler, MD; Miriam E. Vincent, MD; Christopher Willett, MD; and Donald E. Henson, MD.
Members of the College of American Pathologists Cancer Committee included Karen R. Cleary, MD; Carolyn C. Compton, MD, PhD; George M. Farrow, MD; Elizabeth Hammond, MD; Gerald Nash, MD; Mary L Nielsen, MD; Kyung-Whan Min, MD; David L. Page, MD; Stephen G. Ruby, MD; Robert E. Scully, MD; Ira Schwartz, MD; Diane L. Sneed, MD; Michael P. Thompson, MD; Mark R. Wick, MD; Robert V P. Hutter, MD (advisor); and Donald E. Henson, MD (chair).
Accepted for publication March 17, 1997.
References
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Carolyn Compton, MD, PhD; Leslie H. Sobin, MD; for Members of the Cancer Committee, College of American Pathologists, and the Task Force for Protocols on the Examination of Specimens From Patients With Gastric Cancer
From the Department of Pathology, Massachusetts General Hospital, Boston, and the Armed Forces Institute of Pathology, Division of Gastrointestinal Pathology, Washington, DC.
Reprint requests to the Department of Pathology, Warren-2, Massachusetts General Hospital, 35 Fruit Street, Boston, MA 02114 (Dr Compton).
Copyright College of American Pathologists Jan 1998
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