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 Department Gastroenterology Saitama Cancer Center Hospital Saitama-ken , Japan

Clinical history: 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 Click to view with ImageScope Click to view with a Web-Based Viewer Case 9 - Slide 2 Click to view with ImageScope Click to view with a Web-Based Viewer Pathologic Diagnosis: Squamous cell carcinoma of the esophagus associated with squamous cell carcinoma in situ Pathologic findings: 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) m1 = intraepithelial non-invasive carcinoma, namely carcinoma in situ m2 = carcinoma invading the lamina propria mucosae m3 = carcinoma attached to, or invading the lamina muscularis mucosae Submucosal carcinoma (carcinoma invading the tunica submucosa) 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 (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 Tokyo, 2002) 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 superficial carcinoma. 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. References 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.