Risk-based pathology reporting after endoscopic submucosal dissection for early gastrointestinal cancer: international consensus standards

Khalaf K, Li H, Iwaya M, Orr CE, Schneider M, Iwaya Y, Yuan Y, Saito Y, Shimamura Y, Messmann H, Jacques J, Hassan C, Repici A, von Renteln D, Pellisé M, Elkholy S, Anderson JT, Cai M, Pouw RE, Yang D, Chiu PWY, Lauwers GY, Kumarasinghe MP, Ushiku T, Streutker CJ, Wang T, Hurlbut D, Grin A, Bellizzi A, Kim KM, Charissoux A, Fenouil T, Terris B, de Hertogh G, Jansen M, Meijer SL, Vieth M, Nakanishi Y, Kawachi H, Xu C, Abd El-Kareem D, Ohashi K, Brown I, Kirsch R, Singh C, Knight K, Montgomery EA, Cuatrecasas M, Saez de Gordoa K, Bechara R (2026)

Publication Type: Journal article

Publication year: 2026

Journal

Article Number: gutjnl-2025-337567

DOI: 10.1136/gutjnl-2025-337567

Abstract

Background: Endoscopic submucosal dissection (ESD) enables en bloc resection of early gastrointestinal cancers and provides specimens suitable for precise pathological risk assessment. However, reporting remains variable for key parameters that determine curative resection and the need for additional treatment, including submucosal invasion depth and breadth, margin status, lymphovascular invasion, tumour budding, differentiation and use of ancillary stains. Objective: To develop practical international standards for pathology assessment and reporting of invasive carcinoma in ESD specimens. Design: An international panel of 42 experts, including 28 gastrointestinal pathologists and 14 therapeutic endoscopists from 15 countries, participated in a modified Delphi consensus process. Statements addressed measurement of invasion, margin assessment, staining, specimen handling, prognostic histological features and clinically relevant reporting. Results: 56 recommendations reached consensus across seven domains. The panel recommends using Sm1–Sm3 subclassification only when the muscularis propria is present; otherwise, submucosal invasion depth should be reported in micrometres, rounded to the nearest 100 µm. Submucosal invasion breadth should be reported in millimetres as an adjunct metric for future validation. Margin positivity should be defined as direct tumour contact with the inked surface, supported by standardised pinning, inking, complete embedding and parallel sectioning. H&E remains the baseline stain, with selective immunohistochemistry or elastic stains for equivocal lymphovascular invasion, distorted architecture or difficult margin interpretation. Tumour budding should be reported according to International Tumour Budding Consensus Conference criteria, and differentiation, histological subtype, lymphovascular invasion, perineural invasion and margin status should be integrated into composite risk assessment. Conclusions: These consensus standards provide immediately implementable, synoptic-ready pathology reporting criteria after ESD. By standardising measurement landmarks, margin terminology, ancillary stain use and reporting of adverse histological features, they aim to reduce interinstitutional variability, improve multidisciplinary decision-making and support future validation of risk models in early gastrointestinal cancer.

Authors with CRIS profile

Involved external institutions

National Cancer Center Hospital Japan (JP) Austin Health Australia (AU) Universitätsklinikum Augsburg Germany (DE) Hospital Center University De Limoges Dupuytren France (FR) Humanitas Research Hospital / IRCCS Istituto Clinico Humanitas Italy (IT) University of Iowa Hospitals and Clinics (UIHC) United States (USA) (US) Sungkyunkwan University (SKKU) Korea, Republic of (KR) Université de Limoges France (FR) Université Claude Bernard Lyon 1 (UCB) France (FR) Hôpital Cochin France (FR) University Hospital Leuven (UZ) / Universitaire ziekenhuizen Leuven Belgium (BE) St. Michael's Hospital Canada (CA) Shinshu University Hospital / 信州大学医学部附属病院 Japan (JP) Queen's University Canada (CA) Hamilton Health Sciences (HHS) Canada (CA) University College London Hospitals (UCLH) United Kingdom (GB) University of Amsterdam Netherlands (NL) H. Lee Moffitt Cancer Center & Research Institute United States (USA) (US) The Cancer Institute Hospital / がん研有明病院 Japan (JP) Fudan University / 复旦大学 China (CN) Université de Montréal Canada (CA) Universitat de Barcelona (UB) / University of Barcelona Spain (ES) Gloucestershire Hospitals United Kingdom (GB) Zhongshan Hospital / 中山医院 China (CN) University Medical Centre Utrecht (UMC Utrecht) Netherlands (NL) AdventHealth United States (USA) (US) The Chinese University of Hong Kong (CUHK) China (CN) Queen Elizabeth II Medical Centre (QEIIMC) Australia (AU) University of Tokyo Japan (JP) Cairo University / جامعة القاهرة Egypt (EG) Envoi Pathology Australia (AU) University of Glasgow United Kingdom (GB) University of Miami United States (USA) (US) Hospital Clínic de Barcelona Spain (ES)

How to cite

APA:

Khalaf, K., Li, H., Iwaya, M., Orr, C.E., Schneider, M., Iwaya, Y.,... Bechara, R. (2026). Risk-based pathology reporting after endoscopic submucosal dissection for early gastrointestinal cancer: international consensus standards. Gut. https://doi.org/10.1136/gutjnl-2025-337567

MLA:

Khalaf, Kareem, et al. "Risk-based pathology reporting after endoscopic submucosal dissection for early gastrointestinal cancer: international consensus standards." Gut (2026).

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