From the Department of Pathology, University of Michigan Medical School, Ann Arbor, (Taylor, Lamps, Hissong, Choi, Shi, Owens, Westerhoff).
Department of Pathology (Setia, Alpert, Hart), University of Chicago, Chicago, Illinois.
Arch Pathol Lab Med. 2022 Nov 1;146(11):1338-1344. doi: 10.5858/arpa.2021-0072-OA.
CONTEXT.—: 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.
OBJECTIVE.—: To determine how often DOI measurements could impact treatment and to evaluate reproducibility in measuring submucosal DOI in EMR specimens.
DESIGN.—: 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.
RESULTS.—: 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%).
CONCLUSIONS.—: 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.
内镜黏膜切除术（EMR）使得能够对浅层癌症的 Barrett 食管患者进行治疗而无需进行食管切除术。最近的指南建议根据报告，在低风险癌症中，黏膜下浸润<500μm 与淋巴结转移率低相关，对黏膜下癌症进行深度浸润（DOI）的测量。然而，病理学家在重复性测量 DOI 方面面临挑战。
确定 DOI 测量值有多少次可能影响治疗，并评估 EMR 标本中黏膜下 DOI 测量的可重复性。
连续确定腺癌 EMR 病例，包括“低组织学风险”黏膜下癌症病例，如下：深层边缘阴性、无高级别组织学（G3）和无血管淋巴管侵犯。根据指南，由 7 名病理学家测量黏膜下 DOI。
在 213 例癌症 EMR 病例中，46 例为黏膜下浸润，6 例为低组织学风险黏膜下癌症，测量结果可能影响决策。在这些低组织学风险病例中，有 3 例被归类为浅层，这表明在仅 1.4%的腺癌 EMR 中，测量将成为一个临床可行的决策点。7 名病理学家之间对深入分类的观察者间一致性为中度（κ=0.42），在 55 个测量样本中有 40 个（72.7%）的测量范围跨越了 500μm 的相关阈值。
在我们的队列中，治疗决策很少仅依赖于 DOI 测量，但观察者间的变异性引起了对将其作为唯一因素来为患者提供保守治疗的担忧。负责任地报告和临床使用黏膜下 DOI 测量值将需要解决常见组织学伪影的实际经验，以及多学科对可变标本处理实践的影响的认识。
