The safe proximal resection margin in esophagectomy for esophageal squamous cell carcinoma was determined on the basis of the extent of epithelial and subepithelial accessory lesions from the main lesions of esophageal cancer. One hundred and twenty-two specimens of whole resected esophagus were examined histopathologically and the proximal spreading patterns were classified into six types, these are (1) direct margin, (2) intraepithelial spread, (3) multiple cancer, (4) subepithelial direct spread, (5) vascular invasion and (6) intramural metastasis. Among the 122 cases, the direct margin type was seen in 44 (36%), intraepithelial spread in 50 (40%), multiple cancer in 7 (6%), subepithelial direct spread in 13 (11%), vascular invasion in 5 (4%) and of intramural metastasis in 3 (2%). There were no differences in the incidence of the proximal spreading types according to the histologic types of squamous cell carcinoma of the main lesions. On the other hand, there were tendencies that the intraepithelial spread type occurred in 18 (64%) from 28 sites of main lesions restricted to the mucosa, and that subepithelial spreading types, such as subepithelial direct spread, vascular invasion and intramural metastasis occurred from 12 (33%) of 39 sites of main lesions invading the adventitia. For the detection of epithelial accessory lesions, careful endoscopie examination throughout the entire esophagus is necessary. On the other hand, especially for advanced cancer, the resection margin should be determined done in consideration of subepithelial spread of the lesions.
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