EMR-ESD specimens – public comments

[Rodger C. Haggitt Gastrointestinal Pathology Society]

We invite comments from GIPS members regarding the Endoscopic Mucosal Resection-Endoscopic Submucosal Dissection document developed jointly by GIPS and AGPS. The file can be downloaded here:
https://usgips.com/wp-content/uploads/2019/04/GIPS-AGPS-EMR-ESD-2nd-revision.pdf

Public comments can be posted as a reply to this post. They will be accepted for one month, and this topic will then be closed on May 18, 2019.

Thank you for your input.

• This topic was modified 5 years ago by Rodger C. Haggitt Gastrointestinal Pathology Society.

[Yantiss]

This is a nice paper that provides a good overview for handling these specimens. I have several comments.
1. There are a lot of typographical errors throughout the manuscript (e.g. radiall on page 5, verb/noun agreement on page 5, others).
2. The authors advocate pinning out EMR/ESD specimens. While I don’t disagree, maybe they should suggest the person to do the pinning. We often receive shriveled specimens in formalin hours after the procedure.
3. Where are the data to suggest that 2-3 up front levels of every block of an EMR/ESD are necessary? Do they have data suggesting that only one initial level fails to document the lesion and its relationship to margins? If not, I suggest they omit this recommendation. We can always obtain deeper sections based on judgement.
4. The authors seem to use “radial” margin to denote the lateral margin. Maybe they shouldn’t? Some folks may confuse the “radial” margin of an EMR/ESD with the “deep” margin. By convention, we often consider the deep soft tissue margin to be the radial margin elsewhere in the GI tract.
5. The authors should cite references for using ancillary stains to detect vascular invasion.
6. The section on tumor budding could be expanded. We have an opportunity to stop the madness here. I see no compelling evidence to suggest that tumor budding and tumor grade are substantially different concepts, especially if you go back to the days of Haggitt who first evaluated predictive markers in limited excisions. I have never seen a low-grade tumor with high-grade budding. I don’t think it exists if you define grade based on extent of gland differentiation. We could simply say that high-grade tumor (including tumor budding) should warrant high-grade terminology, or something along those lines.
7. Lesion, really? Can’t we call these dysplasias, cancers, or neoplasms? Most of the lesions we are talking about are epithelial neoplasms, aren’t they?

[Michael Vieth]

Very sound, indeed!
Just some minor remarks :
Page 9ff. Radial margins, deep margins :
In Japan and Europe the terms horizontal (HM) and Vertical (VM) margin is Used. HM and VM Can be ‚0‘ For not Beeing involved, ‚1‘ For beeing involved ; followed by the grade of involvement 1c means cancer at the margin , 1dl means LGD at the margin and 1hl means HGD at the margin (European Guidelines on ESD).
Page 10: instead of stating ‚over-stretching‘ May result in tears ok the margin, I would explicitly state that the specimen should be pinned ‚loosely‘ to the cardboard or cork !
Page 12 (gross exam) : I would recommend to use the updated PARIS classification to describe a lesion as recommended by Japanese and European guidelines also for pathology!
Page 13 : radial margin : See comment above on HM and VM
Bottom of page 13 : photograph : in brackets I would recommend a microscope with reverse light since this enables you to identify the closest margin to the lesion and appropriate later slicing of the specimen.
Page 15 : deep and radial margin : see comment above on HM and VM!
Page 17 : same
Page 20 : other associated histological risk factors: I would like to recommend to name these in detail : eg G3, diffuse type, L1, (V1), budding , perineural Invasion , lymphocytes …. etc …
Page 22: May listing the meaning of m1-m3. Because m1 is HGD , m2 is cancer not reaching the deep muscularis mucosae and m3 is the Invasion Into the Deep Layer of muscularis mucosae. ??
The first description I think was not by Arnulf Hölscher from Cologne but Westerterp et al from the AMC in Amsterdam in December 2004 as far as I remember.

On general : I would recommend to describe budding a little more in detail esp after the consensus in Bern by Alessandro Lugli et al. (Ref 41)
Ref : 38. I would cite the updated PARIS classification consensus in Kyoto. First author Kudo or René Lambert. I think it was two papers, one in GI endoscopy some five years ago or so.
Ref : 41 : the format seems to be a bit corrupted ?
Ref 49 : format
Ref 51-65 volume in bold letters ?
Ref 81 Fujishiro : partly underlined ?
Ref 84 format
Ref 83-88 volume in bold letters ?
Ref 93-94 MB after the pages ?
Ref 102 ‚_‘ in front of Beaton
Ref 100- 114 : Empty spaces in front of first authors ?
Ref 107 : names underlined ?
Ref 112 : brackets erroneously used

On general : sometimes the issue and month and volume is given and sometimes not

All a bit very much in detail but it is nicely written and sound since it covers the whole GI tract and needs to be published !!!!

[Michael Vieth]

One further remark on terminology and the figures : it is not the outer true muscularis mucosae. Both layers are ‚true‘ layers of the muscularis mucosa, they are just divided and intermingle at some point on some slices. You can also observe it in early esophageal squamous cell carcinomas and in ulcerative colitis on general. It seems to be more something reactive rather than something new or true or old or original. I would recommend the Japanese terminology by Kaiyo Takubo : superficial versus deep !?
He is not the one who described it first in the esophagus but the first who published it properly and realized the importance possibly resulting in overdiagnosing a mucosal lesion as submucosal invasion.

[Darly Knoedler]

Overall, a very nice paper as others have stated.
A couple of comments/suggestions:
1. Table 1-There is nothing given for small bowel lesions. As is stated in the text, the literature is smaller and conflicted for small bowel, but given that small bowel is included on Table 2, it is somewhat confusing to the reader. I suggest making both tables similar with the same organs listed in each.
2. Formal fixation time (page 11) should be cited or modified. This is different that is applied in other cancers (ASCO/CAP for breast prognostics), for example.
3. Routine levels for EMR specimens (page 14) should be cited or modified. One routine level on ESD specimens seems reasonable.
4. Many typos throughout will need proof reading to correct.

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