Rodger C. Haggitt Slide Seminar: Lesions of Esophagus, Stomach, and Duodenum
Moderators: Dr. Cecilia Fenoglio-Preiser and Dr. Wendy Frankel
Case 9 -
Early esophageal squamous cell carcinoma, endoscopic mucosal resection
Professor Kaiyo Takubo
Department of Human Tissue Research,
Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
Miwako ARIMA, MD
Saitama Cancer Center Hospital
Saitama-ken , Japan
A 72-year-old man underwent endoscopic examination during mass screening for upper GI tract
cancer. He had been asymptomatic up to the time of the examination. He had drunk an equivalent of 30 mg
of ethanol per day for 50 years, and his Smoking Index was 800. His medical history included
arteriosclerosis obliterans of both lower extremities. At endoscopy, a slightly depressed lesion was
observed in the esophageal mucosa, and a biopsy specimen from the lesion was diagnosed as a carcinoma.
One month after detection of the lesion, the patient underwent endoscopic mucosal resection (EMR) of the
esophageal carcinoma. Since the EMR, the patient has been well for the last 2 years. The histologic
slides used for this presentation were prepared from the EMR specimen.
Case 9 - Slide 1
Case 9 - Slide 2
Squamous cell carcinoma of the esophagus associated with squamous cell carcinoma in situ
Depth of invasion: m3 = the lamina muscularis mucosae (explained later)
Lymphatic invasion: mildly positive. Venous invasion: negative
The resection margin is negative for carcinoma.
Subclassification of Depth of Invasion by Superficial Carcinoma
Mucosal carcinoma (intramucosal carcinoma)
Submucosal carcinoma (carcinoma invading the tunica submucosa)
- m1 = intraepithelial non-invasive carcinoma, namely carcinoma in
- m2 = carcinoma invading the lamina propria mucosae
- m3 = carcinoma attached to, or invading the lamina muscularis mucosae
(Japanese Society of Esophageal Diseases, 1995.6; Takubo et al. Superficial carcinoma of the
esophagus in Japan : curable lesion, Imamura ed. in Superficial Esophageal Neoplasm, Springer-Verlag
- sm1 = carcinoma invading the upper one third of the tunica submucosa in the surgically resected
specimen or carcinoma invading within 200 μm in the submucosa in the EMR specimen
- sm2 = carcinoma invading the middle one third of the tunica submucosa
- sm3 = carcinoma invading the lower one third of the tunica submucosa
Indication for Endoscopic Mucosal Resection
Mucosal carcinomas that do not reach the muscularis mucosae (m1 and m2 carcinomas, n = 96) have no
lymph node metastasis, and are therefore curable by endoscopic mucosal resection alone.
Early, Superficial and Advanced Carcinoma of the Esophagus
Superficial carcinoma, defined as carcinoma in situ or carcinoma
involving the mucosa or submucosa, regardless of the presence of lymph node metastasis, can occasionally
be distinguished from advanced carcinoma (invading the muscularis propria) by macroscopic observation of
cut surfaces of the tumor or by determining whether or not a superficial tumor is fixed to the muscularis
propria; if the tumor is not fixed, it will slide over the muscularis propria when slight force is
applied parallel to the mucosa.
Early carcinoma (stage 0 carcinoma) of the esophagus was previously defined as a superficial
carcinoma with no nodal or distant metastases, but this definition has now been changed. There is a high
likelihood of cure. The term "early carcinoma" is widely used in Japan but is not strictly correct
because the time from tumor onset is unknown. The term is mentioned in the "Guidelines for Clinical and
Pathologic Studies on Carcinoma of the Esophagus" (8th edition, 1992) and, in recent years, has also
apparently become accepted in the medical literature in USA and Europe . Advanced carcinoma (stage I, II,
III, and IV carcinoma) of the esophagus was previously defined as a superficial carcinoma with
metastasis, or a carcinoma that had invaded the muscularis propria or adventitia. This definition has
now also been changed slightly, in accordance with the changes made to the definition of early carcinoma.
Although the term advanced carcinoma is widely used, it is not really the true opposite of the term
In the most recent edition of the "Guidelines for Clinical and Pathologic Studies on Carcinoma of
the Esophagus" (9th edition, 2001) early carcinoma is now defined as an intramucosal carcinoma without
nodal or distant metastases.
- Endo M et al. Endoscopic treatment for early carcinoma of the esophagus. Shokaki-Shinyo Practice. Bunkodo, Tokyo,1998
- Japan Esophageal Society. The Comprehensive Registry of Esophageal Cancer in Japan (1988-1997, 2000), First Edition, 2000, http://www.esophagus/
- Japanese Society for Esophageal Diseases. Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus" (9th edition, 2001, English version) Kanehara & Co. Ltd, Tokyo .
- Makuuchi H. et al. Prognosis of early esophageal cancer: prognosis according to macroscopic and microscopic types Rinsho-Shokakinaika 12:1749-1756, 1997
- Makuuchi H, et al. Treatment of mucosal and submucosal cancer in esophagus. The turning point to decide whether surgical operation or endoscopic surgery. Jpn J Gastroenterol Surg 26:2517-2521, 1993.
- Takubo K. Pathology of the Esophagus. Educa, Tokyo 2000. p131-161.
- Takubo et al. Superficial carcinoma of the esophagus in Japan: curable lesion, Imamura ed. in Superficial Esophageal Neoplasm, Springer-Verlag Tokyo, Tokyo , 2002. p21-27.