Importance of Pathology in Esophageal Cancer

by Charles M. LeVea, MD, PhD
Director of Surgical Pathology

Esophageal cancer is best treated by a multidisciplinary team. The surgical pathologist contributes by making the pathological diagnosis and presenting the pathological findings at the multidisciplinary esophageal tumor board. This face-to-face communication is essential for ensuring clear communication among team members and identifying individualized treatment options for our patients.

Biopsy specimens enable the surgical pathologist to determine the tumor type. The most common tumor types in the esophagus are adenocarcinomas and squamous cell carcinomas, but adenoid cystic carcinomas, mucoepidermoid carcinomas, neuroendocrine carcinomas, granular cell tumors, lymphomas, and others can occur. A pathological diagnosis is essential to making localized treatment decisions and deciding on proper neoadjuvant therapy. Ancillary Her2/neu studies, both immunohistochemistry and fluorescent in-situ hybridization, can be performed on the biopsied tumor to determine if the tumor overexpresses Her2/neu proteins or contains an amplified Her2 gene. This information gives the medical oncologist the option of adding Herceptin to the therapy regimen.

The surgical pathologist is consulted during the esophagectomy procedure to guide complete removal of the tumor. Both the proximal and distal margins are sampled, and a frozen section diagnosis is rendered. Once all margins are clear of tumor, the surgery can be completed. When patients consent to donate remnant tumor for research, remnant tumor is banked by Surgical Pathology. Further histological diagnosis will confirm the tumor type, determine the extent of involvement of the esophagus, and analyze the effects of neoadjuvant treatment on the tumor.

In addition, the margins of the esophagectomy specimen will be reexamined to ensure that the entire tumor has been removed, and 15 or more lymph nodes will be examined for metastatic tumor and/or effects of neoadjuvant therapy within them. This thorough examination of the esophagectomy specimen ensures that the tumor is correctly typed and adequately staged.

All of this pathological data is presented again at the multidisciplinary esophageal tumor board to develop an individualized adjuvant treatment plan for the patient.