Measuring the Submucosal Depth of Invasion in Endoscopic Mucosal Resections for Barrett-associated Adenocarcinoma: Practical Issues and Relevance for the Decision for Esophagectomy.
Measuring the Submucosal Depth of Invasion in Endoscopic Mucosal Resections for Barrett-associated Adenocarcinoma: Practical Issues and Relevance for the Decision for Esophagectomy.
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DOI：
10.5858/arpa.2021-0072-oa
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发表时间：
2022-11-01
影响因子：
4.6
通讯作者：
Westerhoff, Maria
中科院分区：
文献类型：
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作者：
Taylor, Alexander S.;Setia, Namrata;Alpert, Lindsay;Zhao, Lili;Lamps, Laura W.;Hart, John;Waxman, Irving;Hissong, Erika;Choi, Eun-Young Karen;Shi, Jiaqi;Owens, Scott;Westerhoff, Maria
内窥镜黏膜切除术(EMR)使Barrett食道癌患者在不切除食道的情况下接受治疗成为可能。最近的指南建议测量粘膜下层癌的侵袭深度，这是基于在低风险癌症中，黏膜下侵袭500μm或更少与低淋巴结转移率相关的报道。然而，病理学家在重复性测量DOI方面面临挑战。确定DOI测量影响治疗的频率，并评估在EMR标本中测量粘膜下DOI的重复性。连续的腺癌EMR病例，包括“低组织学风险”粘膜下癌病例，如下所示：深层切缘阴性，无高级别组织学(G3)，无淋巴血管侵犯。7位病理学家根据指南测量粘膜下DOI。在213例癌EMR病例中，46例为黏膜下浸润性癌，6例为低组织学风险的粘膜下癌，测量结果可影响决策。在这些组织学风险较低的病例中，3例被归类为浅表病例，这表明在1.4%的腺癌EMR中，测量将成为临床上可操作的决策点。7位病理学家之间的深度分类观察者间的一致性为中等(κ=0.42)，55个测量样本中有40个(72.7%)的测量范围跨越了500-μm的相关阈值。虽然在我们的队列中，治疗决定很少仅依赖于DOI测量，但观察者间的变异性引发了人们对它们作为向患者提供保守治疗的唯一因素的担忧。负责任地报告和临床使用粘膜下DOI测量将需要排除常见组织学伪影的实际经验，以及对可变标本处理实践的影响的多学科意识。
Endoscopic mucosal resection (EMR) has made it possible for Barrett esophagus patients with superficial cancers to be treated without esophagectomy. Recent guidelines recommend measuring depth of invasion (DOI) in submucosal cancers based on reports that in low-risk cancers, submucosal invasion 500 μm or less is associated with low nodal metastasis rates. However, pathologists face challenges in reproducibly measuring DOI. To determine how often DOI measurements could impact treatment and to evaluate reproducibility in measuring submucosal DOI in EMR specimens. Consecutive adenocarcinoma EMR cases were identified, including cases of “low histologic risk” submucosal cancer, as follows: those with negative deep margins, no high-grade histology (G3), and no lymphovascular invasion. Submucosal DOI was measured by 7 pathologists according to guidelines. Of 213 cancer EMR cases, 46 were submucosa invasive and 6 cases were low histologic risk submucosal cancers for which measurement could impact decision-making. Of these low histologic risk cases, 3 were categorized as superficial, indicating that measurement would be a clinically actionable decision point in only 1.4% of adenocarcinoma EMRs. Interobserver agreement for in-depth categorization between 7 pathologists was moderate (κ = 0.42), and the range of measurements spanned the 500-μm relevant threshold in 40 of 55 measured samples (72.7%). While therapeutic decisions would rarely have depended on DOI measurements alone in our cohort, interobserver variability raises concerns about their use as a sole factor on which to offer patients conservative therapy. Responsibly reporting and clinically using submucosal DOI measurements will require practical experience troubleshooting common histologic artifacts, as well as multidisciplinary awareness of the impact of variable specimen handling practices.