Atlas of Surgical Pathology Grossing [1st ed.] 978-3-030-20838-7;978-3-030-20839-4

Table of contents :
Front Matter ....Pages i-xv
Skin (Monica B. Lemos, Patricia Chevez-Barrios)....Pages 1-4
Breast (Monica B. Lemos, Nour Sneige)....Pages 5-12
Head and Neck (Monica B. Lemos, Alberto Ayala)....Pages 13-25
Gastrointestinal Tract (Monica B. Lemos, Mary Schwartz)....Pages 27-41
Hepatobiliary and Pancreas (Monica B. Lemos, Mary Schwartz)....Pages 43-53
Genitourinary (Monica B. Lemos, Steven Shen)....Pages 55-65
Female Reproductive Tract (Monica B. Lemos, Donna Coffey, Michael Deavers)....Pages 67-81
Lung (Monica B. Lemos, Roberto Barrios)....Pages 83-87
Bone and Soft Tissue (Monica B. Lemos, Michael Deavers)....Pages 89-94
Back Matter ....Pages 95-97

Citation preview

Monica B. Lemos Ekene Okoye Editors

Atlas of Surgical Pathology Grossing

123

Atlas of Anatomic Pathology Series Editor Liang Cheng Indianapolis, Indiana, USA

This Atlas series is intended as a “first knowledge base” in the quest for diagnosis of usual and unusual diseases. Each atlas will offer the reader a quick reference guide for diagnosis and classification of a wide spectrum of benign, congenital, inflammatory, nonneoplastic, and neoplastic lesions in various organ systems. Normal and variations of “normal” histology will also be illustrated. Each atlas will focus on visual diagnostic criteria and differential diagnosis. It will be organized to provide quick access to images of lesions in specific organs or sites. Each atlas will adapt the well-known and widely accepted terminology, nomenclature, classification schemes, and staging algorithms. Each volume in this series will be authored by nationally and internationally recognized pathologists. Each volume will follow the same organizational structure. The first Section will include normal histology and normal variations. The second Section will cover congenital defects and malformations. The third Section will cover benign and inflammatory lesions. The fourth Section will cover benign tumors and benign mimickers of cancer. The last Section will cover malignant neoplasms. Special emphasis will be placed on normal histology, gross anatomy, and gross lesion appearances since these are generally lacking or inadequately illustrated in current textbooks. The detailed figure legends will concisely summarize the critical information and visual diagnostic criteria that the pathologist must recognize, understand, and accurately interpret to arrive at a correct diagnosis. This book series is intended chiefly for use by pathologists in training and practicing surgical pathologists in their daily practice. The atlas series will also be a useful resource for medical students, cytotechnologists, pathologist assistants, and other medical professionals with special interest in anatomic pathology. Trainees, students, and readers at all levels of expertise will learn, understand, and gain insights into the complexities of disease processes through this comprehensive resource. Macroscopic and histological images are aesthetically pleasing in many ways. This new series will serve as a virtual pathology museum for the edification of our readers. More information about this series at http://www.springer.com/series/10144

Monica B. Lemos  •  Ekene Okoye Editors

Atlas of Surgical Pathology Grossing

Editors Monica B. Lemos Houston Methodist Hospital Houston, TX USA

Ekene Okoye Houston Methodist Hospital Houston, TX USA

ISSN 2625-3372     ISSN 2625-3380 (electronic) Atlas of Anatomic Pathology ISBN 978-3-030-20838-7    ISBN 978-3-030-20839-4 (eBook) https://doi.org/10.1007/978-3-030-20839-4 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

My special thank you to my son, Jaymesson Bezerra, for being with me in my moments of fear and frustration, for always showing me the light at the end of the tunnel.  Monica B. Lemos To my beloved family – Chike, Chiamaka, Nkechi, and Oluchi – for their love and support. To my amazing mentors and colleagues in pathology, and to all the wonderful residents and fellows I have had the fortune of working with.  Ekene Okoye

Series Preface

One Picture Is Worth Ten Thousand Words — Frederick Barnard, 1927

Remarkable progress has been made in anatomic and surgical pathology during the last 10 years. The ability of surgical pathologists to reach a definite diagnosis is now enhanced by immunohistochemical and molecular techniques. Many new clinically important histopathologic entities and variants have been described using these techniques. Established diagnostic entities are more fully defined for virtually every organ system. The emergence of personalized medicine has also created a paradigm shift in surgical pathology. Both promptness and precision are required of modern pathologists. Newer diagnostic tests in anatomic pathology, however, cannot benefit the patient unless the pathologist recognizes the lesion and requests the necessary special studies. An up-to-date Atlas encompassing the full spectrum of benign and malignant lesions, their variants, and evidence-based diagnostic criteria for each organ system is needed. This Atlas is not intended as a comprehensive source of detailed clinical information concerning the entities shown. Clinical and therapeutic guidelines are served admirably by a large number of excellent textbooks. This Atlas, however, is intended as a “first knowledge base” in the quest for definitive and efficient diagnosis of both usual and unusual diseases. The Atlas of Anatomic Pathology is presented to the reader as a quick reference guide for diagnosis and classification of benign, congenital, inflammatory, nonneoplastic, and neoplastic lesions organized by organ systems. Normal and variations of “normal” histology are illustrated for each organ. The Atlas focuses on visual diagnostic criteria and differential diagnosis. The organization is intended to provide quick access to images and confirmatory tests for each specific organ or site. The Atlas adopts the well-known and widely accepted terminology, nomenclature, classification schemes, and staging algorithms. This book series is intended chiefly for use by pathologists in training and practicing surgical pathologists in their daily practice. It is also a useful resource for medical students, cytotechnologists, pathologist assistants, and other medical professionals with special interest in anatomic pathology. We hope that our trainees, students, and readers at all levels of expertise will learn, understand, and gain insight into the pathophysiology of disease processes through this comprehensive resource. Macroscopic and histological images are aesthetically pleasing in many ways. We hope that the new series will serve as a virtual pathology museum for the edification of our readers. Indianapolis, IN, USA

Liang Cheng, MD

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Preface

The idea for this book came from Dr. Alberto Ayala, my mentor. He called me into his office and said “Monica, you should write a grossing manual.” Immediately my answer was “I don’t know how to do that!” He said very calmly, “Just put on paper everything that you have been teaching the residents.” At first, I freaked out; I did not want to disappoint him. But then I started to think about it, and the first idea that came to my mind was the image of a specimen with a white background, giving the resident, PA, or fellow that would open this book the impression that the specimen was right there in front of them. The second idea was that it should be predominantly pictures, following a step-by-step approach, trying to lessen the fear of a person who is just beginning to gross specimens, and also lessen doubts they might have about more complex specimens. The idea is to gross in a simple and efficient way. Knowing how to gross thoroughly and efficiently is incredibly important. The focus of this Atlas is intentionally on the images of actual gross specimens, as opposed to solely illustrations of gross specimens. The images highlight key features of various types of gross specimens. The use of actual gross images will allow the reader to more readily apply the grossing tips to actual specimens that they encounter at the grossing bench. This book contains many grossing tips, as well as sample dictations, that complement and complete the visual grossing lessons this book provides. The goal of this book is to help pathology trainees (residents, fellows, pathology assistant students) learn how to gross a variety of specimens, and to give more experienced practitioner’s additional ideas for how to gross in the most efficient manner. Thus in addition to pathology trainees, we hope that attending pathologists and practicing pathologist assistants may also benefit from this book. Finally, always think about how you would like a case to be grossed as if the patient were a member of your own family. With that thought in mind, you will always perform a gross examination with care and efficiency. Houston, TX, USA

Monica B. Lemos Ekene Okoye

ix

Acknowledgments

Teaching residents has become my heart. Working as a PA in Houston Methodist Hospital and also continuing part time at MD Anderson is for me the basis of my accomplishments. Along the path I met people who gave me so much knowledge and support for everything that I have achieved as a PA. Thank you to all the residents and fellows along these 4 years (2012–2016): Drs. Sergio Pina, Miguelina De La Garza, Daniel Wimmer, Jana Wimmer, Nicole Nelles, Suzanne Crumley, Natasha Golardi, Andreia Barbieri, Ziad El-Zaatari, and Ahmed Shehabeldin. To the Department of Pathology and Genomic Medicine at Houston Methodist Hospital for all the amazing support from the attendings: Drs. Alberto Ayala, Dina Mody, Steven Shen, Patricia Chevez Barrios, April Ewton, Ekene Okoye, Blythe Gorman, Mary Schwartz, Donna Coffey (for her unconditional friendship and support), Michael Deavers, Roberto Barrios, and Mukul Divatia (for his vast knowledge and for always going completely out of his way to help me). Also, thank you to the attendings from MD Anderson who became part of my life: Drs. Aysegul Sahin, Nour Sneige, Patricia Troncoso, Elvio Silva, Victor Prieto, Fraser Symmans, and Stanley Hamilton. I also thank Dr. Michelle Williams for her guidance. And especially to the person who started my history in this country, Dr. Janet Brunner. Many thanks to Dr. Ziad El-Zaatari for his great assistance and work on the digital image editing for this book. We greatly thank Dr. Sasha Pejerrey for her assistance. I especially want to thank Dr. Alberto Ayala. This book is your idea, the seed that you planted with love and care. The only thing I want is for you to be proud. Thank you for believing in me, for pushing me through my fears, and for holding my hand through my career. You are a real teacher, a teacher and mentor of us all, the example of character, knowledge, patient care, love, and dedication. As a daughter to a father, I want to say with all my heart: Thank you, Dr. Ayala. Monica B. Lemos

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Contents

1 Skin���������������������������������������������������������������������������������������������������������������������������������   1 Monica B. Lemos and Patricia Chevez-Barrios 2 Breast�����������������������������������������������������������������������������������������������������������������������������   5 Monica B. Lemos and Nour Sneige 3 Head and Neck �������������������������������������������������������������������������������������������������������������  13 Monica B. Lemos and Alberto Ayala 4 Gastrointestinal Tract���������������������������������������������������������������������������������������������������  27 Monica B. Lemos and Mary Schwartz 5 Hepatobiliary and Pancreas�����������������������������������������������������������������������������������������  43 Monica B. Lemos and Mary Schwartz 6 Genitourinary���������������������������������������������������������������������������������������������������������������  55 Monica B. Lemos and Steven Shen 7 Female Reproductive Tract �����������������������������������������������������������������������������������������  67 Monica B. Lemos, Donna Coffey, and Michael Deavers 8 Lung�������������������������������������������������������������������������������������������������������������������������������  83 Monica B. Lemos and Roberto Barrios 9 Bone and Soft Tissue�����������������������������������������������������������������������������������������������������  89 Monica B. Lemos and Michael Deavers Index�������������������������������������������������������������������������������������������������������������������������������������  95

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Contributors

Alberto Ayala, MD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA Roberto Barrios, MD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA Patricia  Chevez-Barrios, MD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA Donna  Coffey, MD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA Michael Deavers, MD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Ziad El-Zaatari, MD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Monica B. Lemos, MD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Mary Schwartz, MD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Steven Shen, MD, PhD  Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA Nour  Sneige, MD Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA

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Skin Monica B. Lemos and Patricia Chevez-Barrios

Dermatologic specimens, including skin biopsies and skin excisions, are commonly encountered in the surgical pathology grossing suite. This chapter focuses on skin excisions and provides instruction on how to properly handle such specimens.

to aid in a more localized and precise re-excision, if necessary (Figs. 1.4, 1.5 and 1.6). In addition to proper orientation, accurate measurement of the size of the lesion and the distance from the lesion to the peripheral and deep margins is essential.

Skin Excision

Sample Dictation: Skin Excision

Skin excisions are performed primarily for complete removal of a lesion and to ensure accurate diagnosis of the lesion in question. Skin excisions are often in the shape of a circle or ellipse, but they can have irregular or non-symmetrical shapes. (For specimens with complex shapes, a picture or diagram made before sectioning can be a useful tool). Margins include all of the soft tissue that was cut by the surgeon deep to the skin surface. Orientation is often indicated by the surgeon with sutures. It is frequently designated in terms of clock positions (1 o’clock to 12 o’clock all around). Typically, 12 o’clock is at the superior-most portion, 3 o’clock and 9 o’clock are at the medial and lateral positions, and 6 o’clock is at the inferior-­most portion (Figs.  1.1, 1.2 and 1.3). Inking is performed in such a way that this orientation can be reconstructed while examining the specimen microscopically, so that if microscopic lesions are detected close to or involving a specific margin, the location of the positive margin can be accurately conveyed to the surgeon, in order

Received fresh/in formalin and labeled as “_____” is a tan-­ white/brown, oriented/unoriented, irregular/oval/circular/ elliptical skin excision (____ × ____ × ____ cm). The surface of the skin shows a ____  cm ulcer/healed scar/macule/papule/nodule or multiple pigmented lesion(s) (____ to ____ cm), that is/are centrally/peripherally located, abutting the peripheral edges/deep margin in the superior/ inferior aspect of the specimen. The specimen is serially sectioned from lateral to medial and the cut surface is yellow-tan/tan-white and unremarkable (or) includes a tan-white/black lesion (____  cm) present ____ cm from the superior margin, ____ cm from the inferior margin, and ____ cm from the deep margin. The specimen is submitted sequentially from lateral to medial into cassettes A1–A12 in its entirety. Ink code: • Superior – Blue • Inferior – Orange

M. B. Lemos (*) Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected] P. Chevez-Barrios Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA © Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_1

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2 Fig. 1.1  Skin excision: orientation. The excision specimen is oriented with a long stitch placed by the surgeon at 12 o’clock and a short stitch at 9 o’clock. An ulcerated lesion can be clearly seen at the center, with a surrounding area of normal skin extending to the margins circumferentially

Fig. 1.2  Skin ellipse. A skin excision in the shape of an ellipse. This specimen is oriented and grossed in the same manner as a circular skin excision (see Fig. 1.1), with the additional step of submitting the tips of the ellipse separately

M. B. Lemos and P. Chevez-Barrios

1 Skin Fig. 1.3  Skin excision with scarred and pigmented lesions. Lesions on the surface of skin excisions can have varied appearances. In addition to pigmented lesions, this specimen includes a depressed area representing the possible site of a scar

Fig. 1.4  Skin excision: inking. The right and left halves of the skin excision specimen are inked with separate colors. In this picture, the specimen is oriented with the skin surface facing down. The margins on any skin excision specimen include all the surfaces of the soft tissue deep to the superficial skin surface

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M. B. Lemos and P. Chevez-Barrios

Fig. 1.5  Skin excision: Sectioning. Sections are taken here sequentially from 9 o’clock to 3 o’clock, perpendicular to the inked superior and inferior halves. Sections are submitted sequentially from lateral to

medial. Sections can be bisected to fit into individual cassettes. Sutures should be removed before submitting sections in cassettes. The tips or peripheral-most sections should be placed ink side up in the cassette

Fig. 1.6  Irregular skin excision. This irregularly shaped skin excision was oriented by the surgeon’s sutures with a short suture on the superior aspect and a long suture on the medial aspect. The superior and inferior

margins were inked differentially, and the specimen was serially sectioned from lateral to medial, perpendicular to the superior/inferior halves

Suggested Reading

Smith-Zagone MJ, Schwartz MR.  Frozen section of skin specimens. Arch Pathol Lab Med. 2005;129:1536–43. Weinstein MC, Brodell RT, Bordeaux J, Honda K. The art and science of surgical margins for the dermatopathologist. Am J Dermatopathol. 2012;34:737–45.

Bell WC, Young ES, Billings PE, Grizzle WE. The efficient operation of the surgical pathology gross room. Biotech Histochem. 2008;83:71–82. Ghauri RR, Gunter AA, Weber RA. Frozen section analysis in the management of skin cancers. Ann Plast Surg. 1999;43:156–60.

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Breast Monica B. Lemos and Nour Sneige

Breast cancer, one of the most commonly diagnosed cancers, accounts for 30% of all new cancer diagnoses in women. Therefore, breast specimens, including breast biopsies, lumpectomies, and mastectomies, are commonly encountered in the surgical pathology grossing suite. This chapter examines the proper handling of mastectomy and lumpectomy specimens, as well as sentinel lymph nodes. There are multiple types of mastectomy procedures. A total simple mastectomy removes the whole breast and most of the overlying skin, including the nipple. A modified radical mastectomy is similar to a simple mastectomy, but includes an axillary dissection. A radical mastectomy includes removal of the whole breast, overlying skin and nipple, pectoralis muscles, and axillary lymph nodes. (Though previously widespread, radical mastectomies now are rarely performed.) More modern mastectomy methods include skin-sparing mastectomies, which removes the breast tissue, nipple, and areola only, as well as nipple-­ sparing mastectomies, which removes the breast tissue without removing the overlying skin or nipple. Lumpectomy procedures remove a portion of the breast and are performed for removal of both palpable and non-­ palpable breast lesions. Breast-conserving therapy is becoming more common, as many women with breast cancer are candidates for this therapy, which includes a partial breast excision (i.e., lumpectomy), usually with subsequent radiation therapy. Survival outcomes are similar between patients undergoing breast-conserving therapy with radiation therapy versus patients who have a mastectomy. Axillary lymph node sampling, most commonly in the form of sentinel lymph node biopsy, is a standard staging modality. Instruction on how to handle these specimens is also included in this chapter.

M. B. Lemos (*) · N. Sneige Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected]

Mastectomy Mastectomy is performed for malignant lesions of the breast that are not amenable to localized excisions (see Lumpectomy), or on an elective basis for other indications. At our institution, margins of mastectomy specimens with tumors, are grossly assessed during intraoperative consultation, making careful attention and quick mastery of orientation and grossing techniques essential.

Grossing Tips: Mastectomy • When the specimen is received, first note the laterality (right or left) and orientation of the mastectomy specimen (e.g., short stitch, superior; long stitch, lateral). • Imagine the patient in front of the prosector in order to see the correct orientation. For example, lateral will be on the left-hand side for a right breast and on the right-hand side for a left breast (with superior being up in both examples) (Fig. 2.1). • Once the correct orientation is certain, ink the superior and inferior halves of the specimen, each a different color (Fig. 2.2). • Next, flip the breast so that the deep surface now faces the prosector and superior is still upwards. • The deep surface of the specimen can now be inked. This surface is usually flatter than its surroundings. • With the breast still flipped, section the breast from lateral to medial (right breast) or medial to lateral (left breast) (Fig. 2.3). • Lay out the slices as they are cut from lateral to medial (right breast), or medial to lateral (left breast), keeping track of the orientation of the slices. • Number the slices (Fig. 2.4). • Grossly locate any tumor(s) and measure the closest distance to each of the margins.

© Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_2

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Fig. 2.1  Right mastectomy: Orientation. The mastectomy specimen consists of four quadrants in addition to superior, inferior, medial, and lateral sides. The specimen pictured also includes an axillary tail. The orientation can be described by clock positions, with 12 o’clock superiorly, 3 o’clock medially, 6 o’clock inferiorly, and 9 o’clock laterally. Note that the 3 o’clock and 9 o’clock positions would be switched with

respect to the medial and lateral sides in a left mastectomy specimen. The nipple (or the base of nipple excision in nipple-sparing mastectomies) is considered the center point around which the four quadrants are arranged. This orientation scheme is used to describe the position of masses or other breast lesions

Fig. 2.2  Mastectomy: Inking of margins. Three margins should be inked on a mastectomy specimen: superior, inferior, and deep. The superior and inferior halves are inked different colors. The specimen

should then be flipped and the deep surface inked. (Black, shown here, is a common choice.) In a nipple-sparing mastectomy, the nipple area should also be inked

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Fig. 2.3  Sectioning a mastectomy. The mastectomy specimen should be sliced along the long axis (medial to lateral, or lateral to medial), with the deep aspect always facing the prosector. The slices should be made as thin as possible so that lesions on the cut surface can be effectively detected. To cut effectively and keep track of orientation, always slice the breast with the skin (superficial aspect) facing down on the cutting board and the superior aspect directed upwards

Fig. 2.4  Mastectomy slices. Thinly sliced sections are laid out from lateral to medial and numbered sequentially. Now, the cut surface can be examined for the presence of lesions and their proximity with respect to the inked margins

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• Take sections sequentially according to the slice numbers and document the slice number from which each section was taken in the dictation (Note: Sequential sectioning can help determine tumor size when tumors are detected microscopically.) • In some cases, it can be very helpful to make a diagram of where sections were taken, so when viewing slides microscopically it can be precisely known where in the breast the section is from. This is also known as “mapping” of breast sections (Fig. 2.5). • The nipple, if included, should be submitted. Transect the nipple and base of the nipple from the breast. Then transect the base of the nipple from the everted portion of the nipple (after transecting, the base will have a circular, disc like shape). Then serially section the remainder of the nipple (everted part of the nipple). Submit the base of the nipple and the serial sections of everted portion nipple in two separate cassettes. • For axillary dissections, a minimum of ten lymph nodes should be found.

M. B. Lemos and N. Sneige

_____  ×  _____  ×  _____  cm). Attached to the specimen there is a _____  ×  _____  cm tan white/brown ellipse of skin. The nipple and areola complex are grossly unremarkable (or the nipple is inverted). The nipple is _____ cm in diameter. The breast is serially sectioned sequentially from medial to lateral (left breast)/lateral to medial (right breast) into _____ slices. The nipple is located in slice number _____. The cut surface reveals on slice numbers _____, _____, and _____ in the (UOQ/LOQ/UIQ/LIQ/UC/LC)∗∗ a tan/white irregular firm mass with areas of fat necrosis. There is a surgical clip (shape, location/slice number) that has been removed. The lesion is _____ cm from the superior margin, _____ cm from the inferior margin, _____ cm from the deep margin, and _____ cm from the skin. The remainder of the parenchyma is fibrous-fatty tissue (_____% fibrous, _____% fatty) with multiple cysts ranging from 0.2 to 0.4  cm and filled with tan brown dense fluid. Ink code:

Sample Dictation: Mastectomy Received fresh labeled as “right/left mastectomy” is an oriented right/left mastectomy specimen (_____ grams,

Fig. 2.5  Mapping a mastectomy. Breast slices can be mapped to show the locations of submitted sections. A photocopy of the breast slices is taken by placing the slices between two clear plastic sheets; then the

• Superior – Blue • Inferior – Orange • Deep – Black

photocopy is annotated with the location of each section submitted, as well as inked resection margins. (In this image, blue = superior, black = deep, and orange = inferior.)

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Section code:

Grossing Tips: Lumpectomy

Slice 8 • A1 – Junction of lower and upper aspect- central breast • A2–A4 – Upper central Slice 9 • A5–A7 – Upper outer quadrant (UOQ) • A8 – Lower outer quadrant (LOQ) Slice 10 • A9 – Upper outer quadrant (UOQ) • A10 – Upper outer quadrant (UOQ); area with clip • A11 – Lower outer quadrant (LOQ) Slice 11 • A12–15 – Upper outer quadrant (UOQ) • A16 – Junction of lower and upper aspect- outer breast Slice12 • A17–20 – Upper outer quadrant (UOQ) Etc.

• When the specimen is received, first note the laterality (right or left) and orientation of the lumpectomy specimen (e.g., short stitch, superior; long stitch, lateral) (Fig. 2.6). • Once the correct orientation is certain, ink the superior, inferior, superficial, medial, lateral and deep aspects each a different color (Fig. 2.7). • Section the breast lateral to medial (right breast) or medial to lateral (left breast) (Fig. 2.8). • Lay out the slices as they are cut from lateral to medial (right breast) or medial to lateral (left breast), keeping track of the orientation of the slices. • Number the slices. • Grossly locate any tumor(s) and measure the closest distance to each of the margins. • At our institution, in most cases, lumpectomy specimens are submitted entirely. The specimen can be submitted sequentially according to the slice number. Document the slice the sections are taken from. • Just as in mastectomy specimens, mapping out where sections are taken from in a lumpectomy specimen can be extremely helpful (Fig. 2.9). See Sect. 2.1.1 above.

∗∗UOQ – upper outer quadrant; UIQ – upper inner quadrant; LOQ – lower outer quadrant; LIQ – lower inner quadrant; UC – upper central; LC – lower central

Lumpectomy

Sample Dictation: Lumpectomy

A lumpectomy consists of removal of only a portion of the breast. In many cases, the margins of resection in these specimens are assessed during intraoperative consultation, similarly to mastectomy specimens. The gross examination of lumpectomy specimens is similar to that of mastectomy specimens, however there are important differences as noted below.

Received fresh labeled as “____” is an oriented (_____ grams, _____ × _____ × _____ cm), right/left lumpectomy specimen. A needle localization wire is present within the specimen, and the specimen is submitted for Faxitron imaging.

Fig. 2.6  Lumpectomy with localization wire. A needle localization wire is protruding from the surface of this oriented lumpectomy specimen. At our institution, lumpectomies are first placed in a Faxitron

machine (Hologic; Marlborough, MA) before sectioning to confirm radiographically the presence of a tumor localization clip. The actual tumor, as well as calcifications, can also be seen on the x-ray images

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Fig. 2.7 Lumpectomy: Inking. There are six margins, corresponding to the six faces of a cube: superior, inferior, medial, lateral, superficial, and deep. Each margin is inked in a different color

Fig. 2.8  Lumpectomy: Sections, clip localization, and margin assessment. Thin slices are made from lateral to medial and are numbered (top). The localization clip placed in a lumpectomy (bottom left) should

be found and removed before submitting sections. (This also applies to clips in mastectomies.) The closest distance of the tumor to each of the lumpectomy margins (bottom right) should be measured and recorded

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Fig. 2.9  Mapping lumpectomy sections. One can use the scheme in this image to submit the sections for a lumpectomy

The specimen is serially sectioned from lateral to medial (right lumpectomy), or medial to lateral (left lumpectomy) into ____ slices. The cut surface reveals in slice numbers ____, ____, and ____, a ____  ×  ____  ×  ____  cm mass [describe the mass here]. The mass is associated with a surgical clip in slice ____. The mass is ____ cm from the superior margin, ____ cm from the superficial margin, ____ cm from the inferior margin, ____ cm from the deep margin, ____ cm from the most lateral margin, and ____  cm from the most medial margin. The remainder of the breast parenchyma is fibro-fatty tissue (____% fibrous, ____% fatty). Ink code: • • • • • •

Superior – Blue Superficial – Yellow Inferior – Green Lateral – Red Medial – Orange Deep – Black

Section code: Slice 1 (Most lateral or most medial) • A1–A3 – In perpendicular sections Slice 2 • A4 – Superior superficial • A5 – Superior deep

• A6 – Superficial • A7 – Deep • A8 – Inferior superficial • A9 – Inferior deep Slice 3 • A10 – … Etc.

Sentinel Lymph Nodes Sentinel lymph nodes are often removed and sent for intraoperative consultation for both mastectomy and lumpectomy specimens (Fig.  2.10). The objective is to assess for metastatic tumor deposits in the sentinel lymph nodes, to help determine whether to perform an axillary dissection in patients with breast malignancies.

Grossing Tips: Sentinel Lymph Nodes • For sentinel lymph nodes (or generally for lymph nodes from any body site), never put more than one bisected or serially sectioned lymph node piece from a different lymph node in a single cassette. This can lead to confusion when lymph nodes are positive. For example, if two lymph nodes are bisected and placed in the same cassette,

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Fig. 2.10  Grossing sentinel lymph nodes for intraoperative consultation. The lymph node is separated from surrounding fat, then serially sectioned along its long axis into thin slices. Next, touch preparations are performed by touching the lymph node cut surface

to a slide. The lymph node slices are then flipped, and the opposite surfaces of each lymph node piece are touched to another slide. Slides are immediately placed into alcohol (to avoid air-drying artifact) and then stained

and two of four fragments are microscopically positive, it would not be possible to determine whether this represents one or two positive lymph nodes. Serially section the lymph node along the long axis. Touch slices to a glass slide, and also touch the opposite surface of the slices to another glass slide. Place slides in alcohol immediately, followed by routine H&E staining. Placing the slides in alcohol immediately after a touch imprint is made will help avoid air-drying artifact, which can hinder microscopic interpretation.

Goodman S, O’Connor A, Kandil D, Khan A. The ever-changing role of sentinel lymph node biopsy in the management of breast cancer. Arch Pathol Lab Med. 2014;138:57–64. https://doi.org/10.5858/ arpa.2012-0441-RA. Lemos M, Sahin A.  Surgical margin evaluation. In: Babiera GV, Skoracki RJ, Esteva FJ, editors. Advanced therapy of breast disease. 3rd ed. Shelton: People’s Medical Publishing House; 2012. p. 569–80. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019;69:7–34. https://doi.org/10.3322/caac.21551. Stolnicu S. Prognostic and predictive factors in breast carcinoma. In: Stolnicu S, Alvarado-Cabrero I, editors. Practical atlas of breast pathology. Springer International Publishing; 2018. p.  327–56. https://doi.org/10.1007/978-3-319-93257-6. Valencia-Cedillo R.  Sampling and evaluation of the breast surgical specimens. In: Stolnicu S, Alvarado-Cabrero I, editors. Practical atlas of breast pathology. Springer International Publishing; 2018. p. 475–89. https://doi.org/10.1007/978-3-319-93257-6. Zahoor S, Haji A, Battoo A, Qurieshi M, Mir W, Shah M.  Sentinel lymph node biopsy in breast cancer: a clinical review and update. J Breast Cancer. 2017;20:217–27. https://doi.org/10.4048/ jbc.2017.20.3.217.

• • • •

Suggested Reading Agarwal S, Pappas L, Neumayer L, Kokeny K, Agarwal J.  Effect of breast conservation therapy vs. mastectomy on disease-specific survival for early-stage breast cancer. JAMA Surg. 2014;149:267–74. https://doi.org/10.1001/jamasurg.2013.3049.

3

Head and Neck Monica B. Lemos and Alberto Ayala

The head and neck region, with its many organs and structures, is divided into different areas, which include the oral cavity, pharynx, larynx, paranasal sinuses and nasal cavity. Head and neck pathology specimens encountered in the surgical pathology suite range from routine tonsil specimens to complex specimens such as a laryngectomy. When handling head and neck specimens, an appreciation of the anatomic landmarks is essential, and understanding the anatomic orientation before specimen sectioning begins is particularly critical. A systematic approach to complex specimens will aid in providing a thorough and complete gross examination, and will help to ease any anxiety that may arise in the face of potentially intimidating specimens. This chapter discusses the gross examination of a variety of head and neck specimens, as well as thyroid specimens, and includes a stepwise and straightforward approach to grossing laryngectomy specimens.

imen is serially sectioned showing a tan-pink rubbery cut surface. Tan-yellow granules are identified in crypts. No gross lesions are identified. Sections Code: • A1 – Tonsil, representative section

Glossectomy Before sectioning a glossectomy specimen, the orientation of the specimen, as designated by the surgeon, should be properly understood (ie, anterior/posterior aspects). After inking the resection margins, the specimen is serially sectioned (Fig. 3.4).

Uvulectomy Tonsillectomy Tonsillectomy specimens commonly have a cerebriform appearance. After examination of the outer surface, the specimen is serially sectioned (Figs. 3.1, 3.2 and 3.3).

Sample Dictation: Tonsillectomy Received fresh/in formalin labeled as “_____” is a tan-pink ovoid lobulated tonsil (____ × _____ × _____ cm). The specM. B. Lemos (*) Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected] A. Ayala Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA

Grossing of a uvula specimen (Fig.  3.5) is usually straightforward.

Sample Dictation: Uvula Received is a tan-pink smooth and glistening conical portion of tissue (____ × ____ × ____ cm). The base of the specimen is inked blue. The uvula is bisected, and the cut surface is tan-pink and rubbery. [Describe any lesions]. The specimen is entirely submitted in cassette A1.

Floor of the Mouth Resected specimens from the floor of the mouth should be properly oriented and inked (Figs. 3.6 and 3.7) before being sequentially sectioned (Fig. 3.8).

Weill Cornell Medicine, New York, NY, USA © Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_3

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Fig. 3.1  Tonsillectomy specimens. Right and left tonsils are shown. Note the “cerebriform” appearance and the tan-yellow “sulfur” granules, representing Actinomyces bacterial colonies, which are commonly seen in tonsils

Fig. 3.2  Sectioned tonsils. Note the tan-pink cut surface and tan-yellow “sulfur” granules present within tonsillar crypts

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Fig. 3.3  Tonsil with papilloma. This tonsil has a papilloma in addition to the frequently identified “sulfur” granules

Fig. 3.4  Glossectomy. An ulcerated, mucosal-based lesion makes up the majority of the surface of this glossectomy specimen. Resection margins are present circumferentially, in addition to the deep margin

(not shown is the resected surface deep to the mucosa). The medial and lateral halves of the specimen are inked two different colors. The specimen is serially sectioned from anterior to posterior

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Salivary Gland Parotid glands and submandibular glands may be received as part of a neck dissection, or received individually. All salivary glands should be weighed, if received individually, and not as part of a neck dissection. This section will focus on how to handle salivary glands when received separately, and not as part of a neck dissection. If there is a history of tumor, or if after palpation of the gland, a mass is felt, the outer surface of the gland should be inked one color, before serially sectioning (Figs.  3.9, 3.10 and 3.11).

Thyroidectomy Grossing Tips: Thyroidectomy Fig. 3.5  Uvula. To gross this specimen, simply ink the base (resection margin), bisect, describe the cut surface and any lesions, and submit entirely

• Always weigh thyroid specimens (total or partial) in addition to measuring their dimensions.

Fig. 3.6  Floor of the mouth. This resection of a floor of the mouth lesion is oriented by the surgeon with a long stitch at 12 o’clock and a short stitch at 3 o’clock. Resection margins are present circumferen-

tially along all the clock positions in addition to the deep margin (which is not shown and is on the resected surface deep to the mucosa)

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Fig. 3.7  Floor of the mouth: Margins. The left and right halves of the specimen are inked with two different colors. Dots are placed along the various o’clock positions to give a more precise location for each marFig. 3.8  Floor of the mouth: Sectioning. After submitting the margins, the specimen is sectioned sequentially along the 12 to 6 o’clock direction. Serial sections should be examined for depth of invasion of the lesion. If a frozen section is requested and the lesion comes close to the deep margin, an additional section of the deepest invasion may be required. The specimen should be submitted entirely and sequentially from 12 to 6 o’clock

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gin section. The margins are shaved circumferentially with care to include a portion of mucosa in each section

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Fig. 3.9  Submandibular gland. This submandibular gland resection specimen included attached fibroadipose tissue. The specimen should be first weighed. Note the ovoid, lobulated, and smooth surface of the submandibular gland, which is different from the more rough and irregular surface of a parotid gland. The fat should be sectioned to look for

lymph nodes. In this case, there was no history of tumor, and no mass was palpated, thus the outer surface of the specimen was not inked. The gland tissue is subsequently serially sectioned to look for lesions. In this case, serial sections of the submandibular gland showed an unremarkable cut surface

Fig. 3.10  Parotid gland. Shown here is a parotid gland and following serial sections. Before sectioning, the specimen should be weighed and palpated for any masses. Note the rough and irregular surface. In this

case, there was no history of tumor, and no mass was palpated, so the outer surface was not inked before the specimen was serially sectioned. The cut surface of this serially sectioned parotid is grossly unremarkable

• The convex side is anterior; the concave side is posterior (Fig. 3.12). • Ink the anterior surface, posterior surface, and isthmus each a different color (Fig. 3.13). • It is useful to use the same colors consistently to ink thyroid specimens. That way, if the ink code is lost, one will still know which colors were used for each part of the specimen. • Section the specimen from superior to inferior (Fig. 3.14). • Keep the sections laid out as corresponds to the normal thyroid (i.e., superior up and inferior down, with the left lobe sections on the left and the right lobe sections on the right) (Fig. 3.15). • Examine the cut surface for any nodules and describe the appearance of any noted nodules.

• Nodules may have areas of hemorrhage due to degenerative change or due to prior fine needle aspiration • Note if the nodule is encapsulated or not. For encapsulated nodules, it is important that sections include the entire capsule (capsular-parenchymal interface). • Papillary thyroid carcinomas often have a gray-white or tan-brown cut surface. Associated calcifications may also be noted, as well as cystic change. • Follicular carcinomas are encapsulated and have a thicker capsule than adenomas. • Submit sections in sequential order from most superior to inferior, even if the sections are only representative sections.

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Fig. 3.11  Parotid gland with tumor. The cut surface of this parotid gland shows a tumor, which is distinct from the grossly normal surrounding cut surface. Note that the outer surface of the parotid has been inked (black)

Fig. 3.12  Total thyroidectomy. Note the positions of right and left lobes and the isthmus. Also, note that the posterior surface is more roughened and concave than the anterior thyroid surface

Sample Dictation: Thyroid Received fresh/in formalin labeled as “______” is a total thyroidectomy specimen (or right/left thyroid lobe) (_____ grams, ____ × ____ × ____ cm right lobe, ____ × ____ × ____ left lobe, and ____ × ____ × ____ cm isthmus). The capsular surface is intact/disrupted.

The specimen is serially sectioned and in the superior/mid portion/inferior aspect of the left/right thyroid lobe, there is a ______ cm tan-gray/yellow, firm/gelatinous/calcified nodule, well-circumscribed nodule (or multiple nodules ranging from ____ cm to ____ cm in greatest dimension). The remainder of the thyroid parenchyma is dark-red and homogeneous.

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Fig. 3.13  Total thyroidectomy: Inking. The anterior surface of both right and left lobes is inked blue, except for the isthmus, which is inked red. The posterior surface of both right and left lobes is inked black, except for the isthmus, which is again inked red Fig. 3.14 Total thyroidectomy: Sectioning. Sectioning of the thyroid is done from superior to inferior while keeping track of sections from each lobe (right, left, or isthmus). Depending on the type of case, the specimen may be submitted entirely or representative sections may be taken. In this particular case, there was a diagnosis of papillary thyroid carcinoma, thus the entire thyroid was submitted

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Fig. 3.15  Thyroid nodules. Thyroid nodules with various gross appearances

Fig. 3.16  Laryngectomy: Anterior aspect (post-formalin fixation) and inking. The anterior right surface of the laryngectomy is inked one color, and the anterior left side is inked another color. The epiglottis

should also be inked a third color. This specimen includes a tracheostomy site, which is inked in yellow around the skin

Ink Code:

Laryngectomy

• Blue – Anterior thyroid surface • Black – Posterior thyroid surface • Red – Anterior and posterior isthmus

Grossing Tips: Laryngectomy

Section Code: Serial sections from superior to inferior, as follows: • A1–A11 – Left lobe, from superior to inferior sequentially • A12–18 – Isthmus from left to right • A19–29 – Right lobe, from superior to inferior sequentially

• Ink the left and right anterior surfaces (Fig. 3.16) and the left and right posterior surfaces (Figs. 3.17 and 3.18) with four separate colors. • If a tracheostomy is present, ink the resection margin there with an additional color. • If the thyroid is present, keep it attached, and ink its left and right anterior surfaces (as one would ink a specimen without a thyroid).

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Fig. 3.17  Laryngectomy: Posterior aspect (fresh, pre-formalin fixation). The posterior aspect of the laryngectomy specimen includes the structures and margins shown

Fig. 3.18 Laryngectomy: Posterior aspect inking. The laryngectomy is opened with a longitudinal cut along the middle of the posterior surface. Similar to the anterior side, the left posterior surface in inked one color and the right posterior surface is inked another color. The tracheal margin is inked in a third color

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• If a thyroid is present, include it in the sections to evaluate invasion into the thyroid. • Open the specimen along its posterior surface. Cut along the midline (Fig. 3.19). • Look for abnormalities or tumor, and if present, measure the size and comment on the location. • Take the tracheal margin for frozen section. • Also, take sections of the right and left mucosal margins. • Place a wooden stick to keep the specimen open as it fixes (Fig. 3.20). • After fixing, take serial perpendicular sections of the epiglottis and serial perpendicular transglottic sections. Mark slices with tumor or any other abnormalities with a broken wooden stick. This will make it easy to keep track of which areas are abnormal and should be submitted. • Separate the sections to those that are supraglottic/glottic and subglottic, and submit sequentially as follows: –– Posterior left: submit from mid to lateral –– Anterior left: submit from lateral to mid –– Anterior right: submit from mid to lateral –– Posterior right: submit from lateral to mid • If a tumor is located posteriorly, near the pyriform sinus, take sections horizontally and submit from superior to inferior in that area (Fig. 3.21). • In sections of the supraglottis/glottis, place a dot of ink on each section to indicate the supraglottic aspect (Fig. 3.22).

Fig. 3.19  Laryngectomy: Opened view. Note the normal anatomic structures seen on the inside of this opened laryngectomy. The subglottis is located approximately 1  cm below the commissure. A tumor is

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This makes it easier to identify true and false vocal cords microscopically.

Sample Dictation: Laryngectomy Received fresh labeled as “____” is a total laryngectomy specimen (___  ×  ___  ×  ___  cm) including a hyoid bone (___ × ___ × ___). A right/left/right and left thyroid lobe is attached to the specimen (___ × ___ × ___). On the anterior aspect is a tracheostomy site with tan white/brown skin (___ cm length and ___ cm width). The specimen is opened posteriorly and shows a ___ × ___ × ___ cm gray-white friable/ulcerated/nodule/lesion located at the supraglottis/glottis/subglottis and ___ cm above/below the commissure, ___ cm from the distal tracheal margin, and ___ cm from the mucosal margin. The tumor grossly appears/does not appear to infiltrate into the lamina propria and appears/does not appear to infiltrate the thyroid. The lesion does/does not grossly involve the true/false vocal cord(s). The remainder of the mucosa is tan/pink and unremarkable/with edema etc. Ink code: • • • •

Blue – Right anterior surface of larynx Black – Left anterior surface of larynx Red – Epiglottis Yellow – Tracheostomy site

located beneath the epiglottis. Note the formalin-fixed and sectioned specimen to the right, which separates epiglottis, supraglottis/glottis, and subglottis

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Fig. 3.20  Laryngectomy: Opened view after fixation. The opened laryngectomy specimen is held open with a small wooden stick and fixed in formalin overnight. Note again the anatomic structures

Fig. 3.21  Laryngectomy: Sectioning. Serial sections are made across the tumor in the pyriform sinus

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Fig. 3.22  Laryngectomy: Sections. Sections are divided into those from the epiglottis, supraglottis/glottis, and subglottis. Supraglottis/ glottis sections are made to include both true and false vocal cords. Note the wooden stick pieces placed to keep track of the sections with

tumor. Also, the sections of supraglottis/glottis are inked with a dot on their superior aspect (supraglottic surface) to help keep track of their orientation

• Orange – Left posterior surface • Red – Right posterior surface • Purple – Tracheal margin

Suggested Reading

Section Code: • A1 – Epiglottis, representative sections • A2–A4 – Supraglottis and glottis, posterior left, submitted from mid to lateral • A5–A8 – Supraglottis and glottis, anterior left, submitted from lateral to mid • A9–A15 – Supraglottis and glottis, anterior right, submitted from mid to lateral • A16–A20 – Supraglottis and glottis, posterior right, submitted from lateral to mid • A21–A24 – Subglottis, representative sections, posterior left, submitted from mid to lateral • A25–A29  – Subglottis, representative sections, anterior left, submitted from lateral to mid • A30–A33  – Subglottis, representative sections, anterior right, submitted from mid to lateral • A34–A39 – Subglottis, representative sections, posterior right, submitted from lateral to mid

Faquin W.  The thyroid gland: recurring problems in histologic and cytologic evaluation. Arch Pathol Lab Med. 2008;132(4):622–32. Gnepp DR, Barnes L, Crissman J, Zarbo R. Recommendations for the reporting of larynx specimens containing laryngeal neoplasms. Am J Clin Pathol. 1998;110:137–9. Helliwell TR, Giles TE. Pathological aspects of the assessment of head and neck cancers: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016;130(Suppl S2):S59–65. https:// doi.org/10.1017/S0022215116000451. Hiatt JL, Gartner LP. Palate, pharynx, and larynx. In: Textbook of head and neck anatomy. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 243–62. Lydiatt WM, Patel SG, Ridge JA, O’Sullivan B, Shah JP. Staging head and neck cancers. In: Amin MB, editor-in-chief. AJCC cancer staging manual. 8th ed. Chicago: American College of Surgeons; 2018.p. 55–65. https://doi.org/10.1007/978-3-319-40618-3.

4

Gastrointestinal Tract Monica B. Lemos and Mary Schwartz

Gastrointestinal tract specimens are among those most commonly received in the surgical pathology grossing suite. Besides the numerous gastrointestinal tract biopsy specimens, many of the more common larger routine specimens come from the gastrointestinal tract, including appendectomy, cholecystectomy, and colectomy specimens. Standard gross evaluation and sectioning is recommended, regardless of the apparent presence or absence of a neoplastic lesion. This procedure ensures that if an unexpected neoplasm is discovered microscopically, the important information needed, such as margin status, will be documented. This chapter provides instruction on grossing many of the various types of gastrointestinal tract specimens that may be encountered in the surgical pathology grossing suite.

Esophagogastrectomy Specimens include portions of the esophagus and stomach (Figs. 4.1 and 4.2).

Sample Dictation: Gastrectomy Received fresh/in formalin labeled as “_____” is a total/subtotal gastrectomy specimen. The specimen measures ___ cm along the greater curvature and ___ cm along the lesser curvature. The circumference ranges from ___ cm at the proximal margin to ___ cm at the distal margin. A portion of the duodenum is present (___ cm in length and ___ cm in circumference). The serosal surface is tan-pink smooth and glistening/includes an area of adhesions or perforation (areas of adhesions or perforation are inked ___). The wall thickness is ___ cm. M. B. Lemos (*) · M. Schwartz Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected]

The specimen is opened through the greater curvature and reveals a ___  ×  ___  cm friable/fungating/polypoid firm tumor located on the greater/lesser curvature or in the cardia/ fundus/antrum/pre-pyloric region. The tumor is ___ cm from the proximal margin and ___ cm from the distal margin. The tumor grossly invades/does not invade through the muscularis propria and invades/does not invade into the perigastric soft tissue. The remainder of the mucosa is unremarkable, with normal folds. In the attached perigastric adipose tissue are __# lymph nodes ranging in size from ___ to ___ cm. Ink code: • Blue – Proximal margin • Black – Distal margin Section code: • • • • •

A1 – Proximal margin A2 – Distal margin A3–A10 – Tumor A11 – Normal stomach A12 – Lymph nodes

Sample Dictation: Esophagectomy Received fresh/in formalin labeled as “____” is an esophagectomy specimen (___ cm in length and ___ cm in circumference) with a small attached portion of stomach (___ cm in length and ___ cm in circumference). The serosal surface is tan-pink and smooth with attached adipose tissue. The mucosal surface reveals a ___ × ___ cm tan/tan-gray firm friable/fungating mass located at the gastroesophageal junction, which invades/does not invade the muscularis propria and soft tissue. The tumor is ___ cm from the proximal margin and ___ cm from the distal margin. The remainder of the mucosa is unremarkable. The stomach mucosa is tan/pale tan/erythematous with normal folds. In the paraesophageal

© Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_4

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Fig. 4.1  Esophagogastrectomy. Note the presence of esophagus and a portion of the proximal stomach with staples along the surgical resection margin. Cut directly under the staples and ink this resection margin

Fig. 4.2 Esophagogastrectomy: Opened. The stomach should be opened along the greater curvature. Note the esophageal mucosa and a rugated portion of gastric mucosa. There is a tumor at the gastroesopha-

geal junction. Take longitudinal sections of the area with a tumor. Also submit the proximal and distal margins

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tissue, __# of lymph nodes are identified ranging from ___ to ___ cm. In the paragastric tissue, __# lymph nodes are identified ranging from ___ to ___ cm. Ink code: • Blue – Proximal (esophageal) margin • Black – Distal (stapled gastric) margin Section code: • • • • •

A1 – Proximal margin A2 – Distal margin A3–A10 – Tumor A11–A12 – Normal esophagus A15 – Stomach mucosa

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intestinal neoplasms, and bowel injuries, among others. After reversal of an ileostomy, an ileostomy specimen may be received in the surgical pathology grossing suite (Figs. 4.3 and 4.4).

Sample Dictation: Ileostomy Received fresh/in formalin and labeled as “_____” is an ileostomy specimen (____ cm length, ____ cm circumference). An ostomy site is present (____  cm diameter). A tan-gray rim of skin surrounding the ostomy site is present (____ cm width). The serosa is tan-white. The mucosa is tan with normal folds, and no gross lesions are identified. The wall of the bowel is ____ cm thick. Section code:

Ileostomy Various bowel conditions may require a temporary ileostomy. Such conditions include inflammatory bowel disease,

• A1, A2 – Margins • A3–A4 – Representative sections

Fig. 4.3  Ileostomy. This specimen consists of a portion of bowel with a rim of skin. Measure the ostomy site diameter and the rim of skin surrounding the ostomy site

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Fig. 4.4  Ileostomy: Sectioning. Open the stapled end by cutting beneath the staples. Cut through the ostomy site. Take sections so that both the skin and mucosa are included

Small Bowel A portion of the small bowel may be resected because of a tumor (Figs. 4.5 and 4.6) or diverticulum (Fig. 4.7), among other indications.

Large Bowel Segments of the large bowel may be resected because of tumors (Figs. 4.8, 4.9, 4.10, 4.11, 4.12 and 4.13), diverticulitis (Figs. 4.14, 4.15, 4.16 and 4.17), inflammatory bowel disease (Figs. 4.18, 4.19 and 4.20), or ischemia (Figs. 4.21 and 4.22), among other indications.

Grossing Tips: Large Bowel Colon with a neoplasm: • Ink the serosal surface and fat overlying the tumor to aid in the determination of the extent of invasion of the tumor into the colonic wall upon microscopic examination.

• Ink the proximal and distal margins different colors. • After opening the colon, determine the location of the tumor and its size and distance from margins (Figs. 4.8 and 4.9). • Take the fat off the serosa, except for the fat in the area of tumor. Keep separate the fat proximal to the tumor and the fat distal to the tumor (Fig. 4.10). • Take longitudinal sections (i.e., parallel to the length of the colon) of tumor to help show the relationship of the tumor to the adjacent normal bowel and other adjacent structures (Fig. 4.11). • Be sure to include sections of the deepest gross invasion of the tumor (e.g., into the muscle wall or pericolonic fat). • If the tumor is very close to the proximal or distal margin of resection, take perpendicular sections to include the margin as well as the tumor. Otherwise (if the tumor is further away from the margins), submit the margins en face (Figs. 4.12 and 4.13). • Look for lymph nodes in the fat and submit separately those from the proximal fat, the distal fat, and the peritumoral fat.

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Fig. 4.5  Small bowel: Resection of subserosal tumor. Note the peritonealized surface and both the bowel and tumor resection margins

Fig. 4.6  Small bowel: Inking and sectioning of subserosal tumor. The soft tissue resection margin adjacent to the tumor is inked one color, and the peritoneal surface adjacent to the tumor is inked another color.

The tumor is then serially sectioned. Note the change in the appearance of the bowel mucosal surface in the area involved by the tumor

Fig. 4.7  Meckel’s diverticulum. Intact (left) and bisected (right) Meckel’s diverticulum specimen. There is an area of gastric-type mucosa that can be appreciated grossly and microscopically. (H&E image courtesy of Andreia Barbieri, MD, Houston Methodist Hospital)

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Fig. 4.8  Right hemicolectomy. This specimen includes a portion of the ileum, cecum, and right colon. An exophytic mass is located adjacent to the ileocecal valve in the cecum. The position of the tumor, its size, and

Fig. 4.9 Right hemicolectomy: Inking. Inking the serosa and pericolonic fat overlying the tumor helps when assessing the depth of tumor invasion

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its distance to proximal and distal margins should be recorded. It is also helpful to ink the proximal and distal margins before taking sections

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Fig. 4.10  Rectum: Radial margin. The radial margin is the non-peritonealized bare area of the rectum, located anteriorly and posteriorly. This represents tissue through which the surgeon has cut

Fig. 4.11  Colon tumor: Longitudinal sectioning. Longitudinal sections help show the relationship of the tumor to adjacent structures. This can be especially important when the tumor is very close to one of the margins

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Fig. 4.12  Rectum with anal mucosa and dentate line. The anatomy of the dentate line is demonstrated in this gross image and corresponding sketch. The dentate line divides the upper two thirds and lower one third of the anal canal; it is located at the inferior limit of the anal valves. It

M. B. Lemos and M. Schwartz

should be noted whether any tumor in this area crosses or involves the dentate line, as does the tumor in this specimen. (Sketch courtesy of Ahmed Shehabeldin, MD, Houston Methodist Hospital.)

Fig. 4.13  Colon tumor: Depth of invasion. It is important to assess the depth of invasion of colon tumors grossly and to submit sections of the deepest areas seen. Sectioning this tumor shows grossly apparent invasion into the fat and a lymph node grossly positive for metastasis

Colon with diverticula: • Before cutting into the specimen, look carefully at the outside surface for areas of serosal exudate or adhesions (Figs. 4.14 and 4.15). These areas could represent sites of perforation. • If an area of adhesion is identified, ink this area, but remove the non-inflamed adipose tissue. • Take longitudinal sections, as this helps to identify the diverticula (Figs. 4.16 and 4.17).

tion (patchy vs. continuous) of mucosal changes (mucosal eryhthema, ulceration, pseudopolyps, etc); as well as the presence or absence of strictures (Fig.  4.18, 4.19 and 4.20). • Make sure to evaluate for any nodules or massess. • Numerous lymph nodes are often present in the peri-­ intestinal adipose tissue. It is not uncommon to identify dozens of lymph nodes, in cases of inflammatory bowel disease. Colon with ischemia:

Colon with inflammatory bowel disease: • In cases of inflammatory bowel disease (ulcerative colitis and Crohn’s disease), make sure to document the distribu-

• Evaluate the serosal surface and note for changes in color. The serosal surface is often dark, and has a dusky apperance (Fig. 4.21)

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Fig. 4.14  Diverticulitis. When grossing a colon with diverticular disease, identify areas of adhesions or exudate on the surface first. These areas may represent sites of diverticular rupture or colon perforation Fig. 4.15 Diverticulitis: Adhesions. Seen here are adhesions on the surface of a colon with diverticulitis

Fig. 4.16 Diverticular disease: Mucosal surface. Several diverticular openings are apparent on the mucosal surface of this segment of bowel

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Fig. 4.17  Diverticula: Sections. Longitudinal sections need to be taken to identify and submit diverticula. Once identified, submit diverticula for microscopic examination. These sections should include the entire depth of the diverticulum into the colonic wall Fig. 4.18  Colon with ulcerative colitis. Note the multiple pseudopolyps and diffuse mucosal involvement of the large bowel

Fig. 4.19  Colon with Crohn’s disease. Note the patchy distribution of affected colon and mucosal erythema. Also seen is the “cobblestone” mucosa characteristic of Crohn’s disease

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Fig. 4.20  Colon with Crohn’s disease: Stricture. Strictures such as this are common findings in Crohn’s disease

Fig. 4.21  Bowel with adhesed ovary. This bowel shows features of ischemia and has a dusky serosal surface, as well as serosal exudates. Extensive adhesions are present, including adhesion of an ovary. Due to the dense adhesions, the ovary was surgically resected along with the colon

• Evaluate for any adhesions, serosal exudate, or perforations. • Examine the appearance of the mucosa, noting if the mucosal folds appear depressed, flattened, or discolored. • Examine the blood vessels to evaluate for any grossly obvious sites of thrombosis or other vascular lesion. • In some cases of ischemia with associated rupture and adhesions, there may be adhesions to other structures.

Note the adhesed ovary in Figs. 4.21 and 4.22. The area of adhesion between the ovary and colon is inked green. In addition to submiting bowel margins and represenative sections of bowel wall, sections at the site of adhesions are taken to microscopicaly examine the relationship between the colon and ovary.

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Fig. 4.22  Bowel with adhesed ovary: Opened. The area of adhesions is inked in green, after which the ovary is bisected and examined. In this case, the ovary happened to be cystic

 ample Dictation: Right Hemicolectomy/ S Ileocolectomy Received fresh/in formalin and labeled as “_____” is a segment of terminal ileum (____ cm length, _____ cm circumference), cecum (____ × ____ cm) and right colon (____ cm length, ____  cm circumference). An appendix is present (____ cm length, ____ cm circumference) (or the appendix is not identified). The serosal surface is tan-pink and smooth/ with an area of adhesion measuring ___ × ___ cm and located ___ cm from the proximal margin and ___ cm from the distal margin. There is attached adipose tissue along the entire length of the specimen. A fungating/ulcerated and firm tan-brown mass (____ × ____ × ____ cm) is located in the cecum/ileocecal valve/ascending colon. The tumor grossly invades/does not invade the muscularis propria/pericolic fat. The tumor is located ____  cm from the proximal margin and ____  cm from the distal margin. There are ____ # polyps (____ cm to ____ cm in greatest dimension) located in _____, and are present ____ cm from the tumor and _____ cm from the closest margin. __# ­possible lymph nodes are identified in the pericolic adipose tissue. Ink code: • • • •

Black – Radial or mesenteric margin Blue – Serosa underlying tumor Orange – Proximal margin Green – Distal margin

Section code: • • • • • • • • •

A1 – Proximal margin∗ A2 – Distal margin∗ A3 – Radial/mesenteric margin A4 – Tip of the appendix, bisected A5 – Representative cross-sections of appendix A6–A10 – Mass A11 – Polyp #1 A12 – Polyp #2 A13  – Non-neoplastic right colon, representative section • A14–A16 – Lymph nodes from adipose tissue proximal to tumor • A17–A19  – Lymph nodes from peritumoral adipose tissue • A20–A22  – Lymph nodes from adipose tissue distal to tumor ∗Note: Submit margin(s) perpendicularly, if close to the tumor.

Sample Dictation: Low Anterior Resection Received fresh/in formalin labeled as “____” is a segment of sigmoid colon (____  cm length, ____  cm circumference), a segment of rectum (____ cm length, ____ cm circumference) with perirectal and mesenteric adipose tissue. The serosal surface is tan-pink, and an area of adhesion is

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identified measuring ____  ×  ____  cm and ____  cm from the proximal margin and ____ cm from the distal margin. Perirectal and mesenteric adipose tissue is present. A ____ × ____ × ____ cm firm tan-brown and ulcerated/ fungating mass is located in the sigmoid colon/rectum, and is ____ cm from the proximal margin, ____ cm from the distal margin, and ____  cm from the radial margin. The tumor grossly invades/does not invade the muscularis propria/pericolic adipose tissue. There are ____ # polyps (____ cm to ____ cm in greatest dimension) located in _____ and present ____ cm from the tumor, and _____  cm to the closest margin. __# possible lymph nodes are identified in the pericolic adipose tissue.

39

• A12 – Polyp #2 • A13  – Non-neoplastic sigmoid colon, representative section • A14 – Non-neoplastic rectum, representative section • A15–A16 – Lymph nodes from adipose tissue proximal to tumor • A17–A19  – Lymph nodes from peritumoral adipose tissue • A20–A22  – Lymph nodes from adipose tissue distal to tumor ∗Note: If the tumor is very close to the margins, take perpendicular sections.

Ink code: • Black – Radial margin • Blue – Proximal margin • Orange – Distal margin

Appendectomy Figure 4.23 illustrates the grossing of an appendix. Serosal exudate (Fig. 4.24) is not always seen.

Section code: • • • • •

A1 – Proximal margin A2 – Distal margin A3 – Radial margin (if rectal tumor) A4–A10 – Mass A11 – Polyp #1

Fig. 4.23  Appendectomy. When received, measure the appendix and always ink the proximal margin. Then examine the serosal surface for abnormalities, including exudate and perforation. The distal tip should be bisected and submitted entirely. Also submit the inked proximal margin. (This can be submitted in the same cassette as the tip.). Finally,

Sample Dictation: Appendix Received fresh/in formalin and labeled as “______” is an appendectomy specimen with a small amount of peri-­ appendiceal fat. The appendix is ____  cm in length and

serially section the appendix and submit representative cross-sections. If the appendix appears grossly normal but appendicitis is suspected clinically, the entire appendix should be submitted for microscopic examination. In these images, note the blue ink on the proximal margin, the presence of a fecalith within the lumen, and the bisected appendix tip

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Fig. 4.24 Appendix: Purulent serosal exudate. Note the presence of tan-white exudate material at the tip of this appendectomy specimen

Fig. 4.25  Polypectomy. Seen here is a polyp with its stalk. The base of the polyp (tip of the stalk) should be inked. When no stalk is present, ink the base of the polyp. The polyp is serially sectioned parallel to the stalk and submitted sequentially from one end to the opposite end.

Alternatively, both ends of the polyp can be submitted in a single cassette, as long as it is indicated in which cassettes the ends are submitted

____ cm in diameter. The proximal margin is inked blue. The outer appendiceal surface is tan-pink and smooth/with areas of serosal exudate. The specimen is serially sectioned, and the lumen ranges from ____ cm to _____ cm in diameter. No fecaliths or perforations are present (or the lumen is partially filled with fecaliths or purulent material).

Polypectomy

Ink code: • Blue – Proximal margin Section code: • A1 – Tip of the appendix bisected and entirely submitted; proximal margin ink side down • A2 – Representative cross-sections of appendix

Figure 4.25 illustrates the grossing of a polyp, including serial sectioning.

Sample Dictation: Polypectomy Received fresh/in formalin and labeled “polyp” is a tan-pink/ red-brown polyp measuring __ × ___ × ___ cm with a stalk present measuring ____  cm in diameter and ____  cm in length. The base of the polyp is inked blue. The specimen is serially sectioned. The cut surface is tan-pink and rubbery/ slightly friable. It is entirely submitted sequentially from one end to the opposite end in cassettes A1–A__.

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Suggested Reading Burroughs SH, Williams GT. Examination of large intestine resection specimens. J Clin Pathol. 2000;53:344–9. https://doi.org/10.1136/ jcp.53.5.344. Glickman JN, Odze RD.  Epithelial neoplasms of the esophagus. In: Odze RD, Goldblum JR, editors. Surgical pathology of the GI tract, liver biliary tract and pancreas. Philadelphia: Elsevier; 2015. p. 674–709. Plesec TP, Owens SR.  Inflammatory and neoplastic disorders of the anal canal. In: Odze RD, Goldblum JR, editors. Surgical pathology of the GI tract, liver biliary tract and pancreas. Philadelphia: Elsevier; 2015. p. 887–918.

41 Poulin EJ, Shen J, Gierut JJ, Haigis KM.  Pathology and molecular pathology of colorectal cancer. In: Loda M, Mucci L, Mittelstadt M, Van Hemelrijck M, Cotter M, editors. Pathology and ­epidemiology of cancer. Cham: Springer; 2017. p. 409–46. https:// doi.org/10.1007/978-3-319-35153-7_22. Royston D, Warren B.  Pathology of anorectal and colonic specimens. In: Givel JC, Mortensen N, Roche B, editors. Anorectal and colonic diseases. Berlin: Springer; 2010. p.  81–115. https://doi. org/10.1007/978-3-540-69419-9_7. Shen S, Haupt B, Ro J, Baily HR, Schwartz M.  Number of lymph nodes examined and associated clinicopathologic factors in colorectal carcinoma. Arch Pathol Lab Med. 2009;133:781–6. https://doi. org/10.1043/1543-2165-133.5.781.

5

Hepatobiliary and Pancreas Monica B. Lemos and Mary Schwartz

The volume of hepatobiliary and pancreatic specimens received in the surgical pathology grossing suite is highly dependent on the individual hospital practice setting. Some of these specimens, such as pancreaticoduodenectomy specimens, can be very complex. A pancreaticoduodenectomy procedure, also known as a Whipple procedure, includes resection of the head of the pancreas, a portion of the bile duct, a portion of the distal stomach, and a portion of the duodenum. Whipple procedures are typically performed for resection of tumors in the head of the pancreas, distal common bile duct, or ampulla of Vater. Whipple procedure specimens are one of the most anxiety-inducing specimens encountered by pathology trainees and practitioners unfamiliar with such specimens. In practice settings where these surgeries are performed infrequently, acquiring confidence in handling such specimens may be challenging. This chapter outlines step-by-step procedures on how to handle hepatobiliary and pancreatic specimens, including pancreaticoduodenectomy specimens, and gives helpful tips on how to properly orient these specimens upon their receipt in the grossing suite.

Hepatectomy Grossing Tips: Hepatectomy • Draw the outlines of the liver segment surfaces with a light-colored ink (yellow works best). Then, with a different color, blot each segment’s surface inside the lines drawn (Figs. 5.1, 5.2, 5.3, 5.4 and 5.5). This method will reduce the time required to ink the entire liver. • Do not forget to take vascular and hepatic duct margins before serially sectioning the liver (Figs. 5.6 and 5.7). M. B. Lemos (*) · M. Schwartz Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected]

Sample Dictation: Hepatectomy Received fresh/in formalin is a hepatectomy specimen (____  grams, ____  ×  ____  ×  ____  cm) with an attached intact gallbladder (____  cm length, ____  cm maximum circumference). The liver capsule is red-brown and smooth (or, for a cirrhotic liver, diffusely nodular with nodules ranging from ____ cm to ____ cm). There is a ____ cm retracted area on the surface. The specimen is serially sectioned, and there is a ____ × ____ × ____ cm tan-gray mass located in segment # ____ (describe any additional characteristics of the mass such as areas of necrosis, hemorrhage, calcification, etc.). The mass is ____ cm from the capsular surface. The gallbladder surface is tan-pink with a ____ cm cystic duct. There is dark green bile within the gallbladder lumen. The mucosa is green with yellow-speckled areas, consistent with cholesterolosis (or velvety green and trabeculated). The wall of the gallbladder is ____ cm thick. Ink code: • • • • • • • •

Black – Segment VIII surface Purple – Segment II surface Orange – Segment III surface Red – Segment IV surface Yellow – Segment V surface Blue – Segment VI surface Green – Segment VII surface No color – Caudate surface

Section code: • A1 – Hepatic duct and vascular margins • A2–A6 – Lesion in segment # ____ • A7  – Representative section of liver parenchyma from segment # ____ • A8 – Representative section of gallbladder

© Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_5

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Fig. 5.1  Hepatectomy. Note the right and left lobes, falciform ligament, and caudate lobe, as seen in this anterior view of a total hepatectomy specimen

Fig. 5.2  Hepatectomy: Segments in anterior view. The liver is divided into eight anatomical segments

Fig. 5.3  Hepatectomy: Segments in posterior view. Note also the position of the attached gallbladder

Fig. 5.4  Hepatectomy: Inking (anterior). The liver surface is inked with different colors for each of the anatomic segments. The inking will aid in describing the location of lesions with respect to the segments after the liver is serially sectioned (see Figs. 5.6 and 5.7)

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Fig. 5.5  Hepatectomy: Inking (posterior). Inking of the liver segments posteriorly, using the same colors as for anterior inking

Fig. 5.6  Hepatectomy: Sectioning. Thin serial sections should be made to look closely for any abnormality or mass. It is helpful to review any available preoperative radiographic imaging of the liver to see if any lesions were identified radiographically, and if so, which segment

the lesion(s) is located in. This will allow the prosector to pay additional attention to this segment(s), in order to identify the radiographically detected lesion(s)

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Fig. 5.7  Hepatectomy: Serial sections with tumor. After inking the surface of the different liver segments and thinly sectioning the liver, the location of any tumor in serial sections can be identified. Note the tan-white mass seen here

Fig. 5.8 Cholecystectomy. This cholecystectomy specimen has a smooth serosal surface, roughened hepatic aspect (where the surgeon dissected the gallbladder off the liver surface), and a pericystic lymph

node. Do not forget to assess whether a pericystic lymph node is present before grossing the rest of the gallbladder

Cholecystectomy

Sample Dictation: Cholecystectomy

After examining the surface of the gallbladder (Fig. 5.8) and submitting the cystic duct margin (Fig. 5.9), open the gallbladder, examine the mucosal surface, and take representative sections (Fig. 5.10).

Received in formalin labeled “gallbladder” is an intact/previously opened gallbladder (____  cm length and ____  cm maximum circumference) with a cystic duct. The serosal surface is tan-green/green, etc. The bile is dark green. The

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Fig. 5.9  Cholecystectomy: Cystic duct margin. The cystic duct margin is usually stapled or clipped and should be submitted (en face)

Fig. 5.10  Cholecystectomy: Sectioning. The gallbladder is opened and its contents, which consist of bile and possibly stones, are removed. Then the mucosal surface can be examined. This picture shows gallbladder mucosa with a characteristic yellow-spotted appearance indi-

cating cholesterolosis. Representative sections of the gallbladder are submitted; these sections are made longitudinally to include the greatest surface area possible for examination

mucosa is velvety and green/pink-green and trabeculated/ with cholesterolosis/with multiple yellow granular polyps (____ cm to ____ cm in greatest dimension). The wall of the gallbladder measures ____ cm in thickness. Multiple green/ black/yellow-green and smooth/granular/irregularly shaped gallstones are present (____ to ____ cm in greatest dimension). A ____ cm tan-pink single lymph node is identified.

Whipple Resection (Pancreaticoduodenectomy)

Section code: • A1  – Representative section of the gallbladder (include cystic duct margin and three sections of gallbladder) • A2 – Lymph node (if present)

Grossing Tips: Whipple Resection • When a Whipple resection specimen is received, orient it so that the stomach is on the left-hand side of the prosector and the duodenum is on the right-hand side (Fig. 5.11). When positioned this way, the pancreatic resection margin will face the prosector. • Probe the pancreatic duct from the visible pancreatic surface. Ink this surface and submit it for frozen section evaluation (en face section) in one or two blocks.

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Fig. 5.11  Pancreaticoduodenectomy (Whipple procedure) specimen. The specimen consists of the pancreas, a portion of the stomach, and the duodenum. The probes seen here are in the pancreatic duct and the common bile duct. For frozen sections, the common bile duct and pan-

creatic resection margins are submitted. For the latter, shave the entire visible pancreatic surface and submit in one or two cassettes (en face section)

Fig. 5.12  Pancreaticoduodenectomy (Whipple procedure) specimen: Vascular groove and retroperitoneal margin. The vascular groove is a linear indentation that represents the area from which the superior mes-

enteric artery was dissected off by the surgeon. The retroperitoneal margin is adjacent to the vascular groove; it can be found using the technique shown in Fig. 5.13

• It can be helpful for the histotechnologist to know the correct orientation of the section, so leave the probe in the shaved pancreatic duct as it is placed on the frozen chuck. • Locate and ink the common bile duct margin. Shave and submit this margin en face. • To find the retroperitoneal resection margin (Fig.  5.12), the prosector should take their left hand and place their middle finger over the pancreatic resection margin, place their index finger in the vascular groove, and place their thumb on the other end of the pancreas. The area between

the prosector’s index finger and thumb is the retroperitoneal margin (as shown in Fig. 5.13). • Keep the specimen oriented as above (with the stomach on the left and the duodenum on the right). • Use a different color to ink the vascular groove, which is near the retroperitoneal margin but appears slightly depressed or concave. • Sometimes the surgeon may request a frozen section of the retroperitoneal margin. In this case, palpate the surface and submit the area that is most firm (where the tumor is closest to the margin).

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Fig. 5.13  Pancreaticoduodenectomy (Whipple procedure) specimen: Finding the retroperitoneal margin. The vascular groove is a slightly depressed linear indentation along the pancreas. To find the retroperitoneal margin, place the left middle finger over the pancreatic resection margin (see Fig.  5.11) and the left index finger along the vascular

groove. The left thumb should be at the end of the pancreas opposite the pancreatic resection margin. The retroperitoneal margin is between the groove (index finger) and the end of the pancreas (thumb). The retroperitoneal margin, vascular groove, and pancreatic resection margin should all be inked different colors

Fig. 5.14  Pancreaticoduodenectomy (Whipple procedure) specimen: Ampulla. After opening the duodenum and stomach, the ampulla is probed. The ampulla is visible on the mucosal surface, and the probe

extends from the common bile duct throughthe ampulla. The ampulla should be the first submitted section following frozen sections and before further sectioning

• Probe the ampulla and submit it as the first section (after submission of margins) before grossing further (Fig. 5.14). This helps to avoid the possibility of not being able to locate the ampulla later after fixation and sectioning.

• Open the pancreatic and common bile ducts, and ink their opened edges each with a different color (Fig. 5.15). Ink only the edges and avoid inking over the remainder of the mucosa. Use the same colors used for the frozen sections

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Fig. 5.15 Pancreati­ coduodenectomy (Whipple procedure) specimen: Opened ducts. The pancreatic and common bile ducts are opened and inked at the opened edges, marking each with a different color. The specimen can then be fixed in formalin before further sectioning

Fig. 5.16  Pancreaticoduodenectomy (Whipple procedure) specimen: Sections. The pancreas is horizontally/transversely sectioned, and sections are submitted sequentially. Note the presence of tumor on the cut

• •

• • •

of the pancreatic resection and bile duct margins. After inking, fix the specimen in formalin before taking further sections. Transversely section the pancreas, including the attached duodenal mucosa (Fig. 5.16). Next, examine the sections for tumor (Fig. 5.17). Submit sections sequentially and in an order that will help keep track of the size, location, and extent of the tumor (Fig. 5.18). Take sections of the gastric margin and duodenal margin. Take representative sections of the stomach and duodenum that are uninvolved by the tumor. Look for lymph nodes present in the peripancreatic fat.

surface and its relationship to adjacent ducts and the duodenum. If a tumor is not grossly identified, the entire pancreas should be submitted

Sample Dictation: Whipple Resection Received fresh labeled as “Whipple” is a Whipple resection specimen consisting of stomach (____ cm in length × ____ cm in circumference), duodenum (____ cm in length × ____ cm in circumference), and pancreatic head (____ × ____ × ____ cm). The pancreas is serially sectioned and shows a ____ cm mass obstructing the pancreatic duct (or the pancreatic duct is patent). The common bile duct is patent (or there is a ____ cm tan-white area of induration). The mass is ____ cm from the pancreatic resection margin and involves/does not involve the ampulla. The bile duct is dilated/not dilated with an adjacent ____ cm tan-pink lymph node.

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Fig. 5.17  Pancreaticoduodenectomy (Whipple procedure) specimen: Slice. This slice from a Whipple resection shows a close-up view of both the tumor and the normal pancreas. Also note the common bile duct and pancreatic duct

Fig. 5.18  Pancreaticoduodenectomy (Whipple procedure) specimen: Submitting sections. The slice on the left is partially submitted (representative sections). The slice on the right is completely submitted. In

both cases, care is taken to submit sections in such a way that the size, location, and extent of a tumor or any lesion can be reconstructed later. It should be similar to putting together pieces of a puzzle

The mucosa of the duodenum is tan-pink with normal folds. The gastric mucosa is tan-pink and unremarkable. Identified are ___ # periduodenal lymph nodes ranging from ____ to ____ cm. Also identified are ___ # lymph nodes in the adipose tissue adjacent to the pancreas measuring ____ cm. Gross photographs are obtained.

Ink code: • • • •

Violet – Retroperitoneal margin Blue – Common bile duct margin Black – Pancreatic resection margin Green – Vascular groove

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Section code: • • • • • • • • • •

AFS 1∗ – Pancreatic resection margin AFS 2∗ – Common bile duct margin A3 – Ampulla A4–A10 – Mass, sequential sections A11–A14  – Peripancreatic lymph nodes (specify # in each cassette) A15–A19 – Periduodenal lymph nodes (specify # in each cassette) A20 – Duodenum margin A21 – Duodenum, representative section A22 – Gastric margin A23 – Stomach, representative section

∗The pancreatic resection margin and common bile duct margin are typically submitted at the time of frozen section. Thus in this sample dictation, “FS” is added to the section code to indicate that these sections were submitted for frozen section.

Distal Pancreatectomy A distal pancreatectomy specimen may also include the spleen (Figs. 5.19 and 5.20).

Fig. 5.19 Distal pancreatectomy. The specimen includes the distal pancreas and spleen. The pancreatic resection margin should be inked and submitted separately

Fig. 5.20  Distal pancreatectomy: Sections. The pancreas and spleen are transversely sectioned and laid out sequentially. In this picture, a tumor is visible in the sections of the pancreas

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Fig. 5.21  Splenectomy. The intact spleen is weighed and measured, and the capsule is examined for any lesions or surface disruptions. Here, a scarred area is identified on an intact splenic capsule. The vas-

cular margins at the splenic hilum are then submitted. Finally, serial sections of the spleen are made and the cut surface is examined

Sample Dictation: Distal Pancreatectomy

Splenectomy

Received fresh/in formalin is a distal pancreatectomy and splenectomy specimen, which consists of the tail of the pancreas (____  ×  ____  ×  ____  cm) and the spleen (____ × ____ × ____ cm). Sections through the soft/firm/cystic pancreas show an area of fibrosis (or tumor) (____ × ____ cm) located ____ cm from the resection margin. The lesion does/does not involve the spleen. The remainder of the pancreatic parenchyma is lobulated/ fibrotic. Sections of the spleen are unremarkable, without gross lesions or masses. Several lymph nodes are identified in the fat around the pancreas and the hilar area.

Weigh the spleen, and examine the splenic capsule; submit the hilar vascular margins and serially section the spleen (Fig. 5.21).

Ink code: • Blue – Pancreatic resection margin Section code: • • • • • •

A1 – Pancreatic resection margin A2–A10 – Mass, submitted sequentially A11 – Uninvolved spleen, representative section A12 – Uninvolved pancreas, representative section A13–A15 – Peripancreatic lymph nodes A16–A20 – Hilar lymph nodes

Suggested Reading Saka B, Balci S, Basturk O, Bagci P, Postlewait LM, Maithel S, et al. Pancreatic ductal adenocarcinoma is spread to the peripancreatic soft tissue in the majority of resected cases, rendering the AJCC T-stage protocol (7th edition) inapplicable and insignificant: a size-­ based staging system (pT1: ≤2, pT2: >2-≤4, pT3: >4 cm) is more valid and clinically relevant. Ann Surg Oncol. 2016;23:2010–8. https://doi.org/10.1245/s10434-016-5093-7. Soer E, Lodewijk B, Van de Vijver M, Dijk F, Van Velthuysen ML, Farina-Sarasqueta AF, et  al. Dilemmas for the pathologist in the oncologic assessment of pancreatoduodenectomy specimens. Virchows Arch. 2018;472:533–43. https://doi.org/10.1007/ s00428-018-2321-5. Verbeke CS, Gladhaug IP. Resection margin involvement and tumour origin in pancreatic head cancer. Br J Surg. 2012;99:1036–49. https://doi.org/10.1002/bjs.8734. Verbeke CS.  Operative specimen handling and evaluation of resection margins. In: Kim SW, Yamaue H, editors. Pancreatic cancer: with special focus on topical issues and surgical techniques. Berlin, Heidelberg: Springer; 2017. p.  67–88. https://doi. org/10.1007/978-3-662-47181-4_5.

6

Genitourinary Monica B. Lemos and Steven Shen

Of the various types of genitourinary specimens, nephrectomy specimens are some of the most common. Nephrectomy specimens may include the entire kidney (radical nephrectomy) or only a portion of the kidney (partial nephrectomy). Total nephrectomy specimens may be received for removal of a neoplasm or a non-neoplastic condition. A partial nephrectomy is typically performed to remove a mass lesion and includes the mass and a small amount of non-neoplastic kidney tissue. Depending on the size and location of the tumor, a partial nephrectomy may be preferred, as this technique allows for the preservation of kidney function and lowers the risk of subsequent chronic kidney disease. Other types of genitourinary specimens include bladder resections (cystectomy) and removal of the testis and spermatic cord (orchiectomy). In male patients, the bladder may be received with the prostate (cystoprostatectomy). This chapter discusses the proper handling of all of these specimens.

Radical Nephrectomy Grossing Tips: Nephrectomy • First, find the ureter margin. Ink and submit this margin, and then open the ureter. • The lower pole is identified as the pole toward which the ureter points as it leaves the hilum (Fig. 6.1). • Find and submit the vascular margins. These are usually stapled or clipped (Fig. 6.2). M. B. Lemos (*) Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected]

• If the vascular margins are not easily visible, pull up the area with staples and make a deep en face section. It should be possible to cut through and remove all the margins with this technique. • Check the renal vein for tumor involvement. • Ink the outside surface of the kidney closest to where the mass is palpated. • Bivalve the kidney (Fig. 6.3). • Describe the location of the tumor with respect to the kidney poles (upper, mid, or lower). • Take a parallel section to look for involvement of the renal sinus by the tumor (Fig.  6.4). Make this section very thin, so representative sections can be placed in a cassette. • Include a section of the tumor with the renal sinus, if the tumor is close enough to the renal sinus area (Fig. 6.5). • Include sections of any areas where perirenal fat or capsular invasion is suspected. • Include a section of the tumor with adjacent normal kidney parenchyma. • After taking a parallel section, take perpendicular sections to complete the gross evaluation and assess for tumor invasion of the capsule or perirenal fat (Fig. 6.6). • Nephrectomy specimens may be received in cases of polycystic kidney disease. In such cases numerous variable sized cysts are typically present. It is important to also look for any possible tumors that may also be present (Fig. 6.7). • Make sure to assess whether an adrenal gland is present in the fat adjacent to the upper pole. Sometimes, only a rim of adrenal is present, so look carefully to ensure it is not missed. Measure and submit any adrenal tissue that is present.

S. Shen Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA © Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_6

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Fig. 6.1 Radical nephroureterectomy: Orientation. Use the ureter as a guide in identifying the upper and lower poles of the kidney. The ureter travels downward, away from the upper pole and toward the direction of the lower pole. The vascular margins are found in the area where the ureter inserts into the kidney and the renal pelvis. These margins are often stapled or sutured. (See Fig. 6.2.)

Fig. 6.2  Radical nephroureterectomy: Margins. The ureter and vascular margins should be located and submitted before dissection of the kidney. There is usually a staple line or clip, which helps to identify the

vascular margins. If only a short segment of the ureter is excised, the ureter margin should still be located in the hilar area where the vessels are also clipped or stapled

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Fig. 6.3  Radical nephrectomy: Bivalved surface. After bivalving the kidney along the longitudinal axis, the relationship of the tumor with respect to the kidney poles, perirenal fat, renal pelvis, and hilum is vis-

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ible. Because invasion into the perirenal fat, hilum, or renal sinus upstages the tumor, an accurate gross examination is critical

Fig. 6.4 Radical nephrectomy: Parallel sectioning. After bivalving the kidney, a parallel section will help in further examining the critical relationship of the tumor to the hilar fat, renal sinus, renal pelvis, and perirenal tissue

Sample Dictation: Radical Nephrectomy Received fresh/in formalin is a right/left nephrectomy specimen with perirenal fat and adrenal gland. The kidney is ___ × ____ × ____ cm and weighs ____ grams, and the adrenal gland is ____  ×  ____  ×  ____  cm. Extending from the renal pelvis is a ureter measuring ____  cm in length and ____ cm in diameter. The specimen is bivalved, and the cut surface reveals a ____  ×  ____  ×  ____  cm mass located in the upper/mid/

lower pole with a heterogeneous golden yellow and focally hemorrhagic cut surface. The tumor is ____  cm from the renal pelvis. The tumor pushes against the renal capsule and appears to invade/not invade the capsule/perirenal fat. The tumor protrudes into the renal vein and is ____ cm from the renal vein margin. The remainder of the renal cortex is red-brown with a well-defined cortical ­medullary junction. The pelvis and calyces are covered by smooth, glistening mucosa. The adrenal gland/rim of the adrenal gland is yellow-brown and grossly unremarkable.

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Fig. 6.5  Hilar invasion. Pictured is a tumor with obvious gross hilar invasion

Fig. 6.6 Radical nephrectomy: Perpendicular sectioning. After taking a parallel section and examining the relationship of the tumor to the renal sinus and hilum, take perpendicular sections to completely examine the relationship of the tumor to the kidney capsule and perirenal fat

The perirenal adipose tissue is serially sectioned, and __# of lymph nodes are identified/no lymph nodes are identified.∗ Section code: • • • •

A1 – Ureter margin A2 – Vascular margins A3–A4 – Renal sinus/hilar region, in parallel sections A5 – Tumor with renal capsule and/or perirenal fat, parallel section • A6–A15 – Tumor, representative sections, perpendicular • A16–A18  – Normal kidney parenchyma, representative sections • A19 – Renal fat, representative sections (or lymph nodes)

Fig. 6.7  Polycystic kidney. A radical nephrectomy has been performed to remove a polycystic kidney, which also happens to have a tumor

∗Note that most times, no lymph nodes are found. When lymph nodes are present in the fat, they are most often found in the hilar area.

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Sample Dictation: Polycystic Kidney Received fresh and labeled as “____” is a kidney (____ × ____ × ____ cm, weight _____ g) with attached perirenalfat. The specimen has a multinodular surface. The renal capsule is intact, and a ureter is present, measuring ____ cm in length and ___ cm in diameter. The renal artery and renal vein are identified in the hilum. The renal parenchyma is completely replaced by multiple cortical and medullary cysts measuring from ____  cm to ____ cm in greatest dimension. The majority of the cysts are filled with clear to brown fluid. The inner lining of the cysts is tan-red and smooth. The cysts are separated by tan fibrous tissue with no/a small amount of normal renal parenchyma grossly noted. No papillary or mass lesions are noted (or) a tumor is present within the upper/lower pole and measures ____  ×  ____  ×  ____  cm and is located ____  cm from the hilum and invades/does not invade the hilar fat, renal sinus, renal pelvis, and/or perirenal fat. The renal vein is patent and shows no evidence of thrombosis/is invaded/is not invaded by the tumor located ____ cm from the ureter mar-

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gin. The attached perirenal fat contains/does not contain __# of lymph nodes. Gross photographs are taken. Ink code: • Blue – Surgical margin Section code: • • • • •

A1 – Ureter margin A2 – Vascular margins A3–A4 – Renal sinus; hilum A5–A9 – Tumor, representative sections A10–A18 – Cysts, representative sections with adjacent normal parenchyma

Partial Nephrectomy Attention to orientation and inking of the entire resection margin should precede sequential sectioning of a partial nephrectomy specimen (Figs. 6.8 and 6.9).

Fig. 6.8  Partial nephrectomy: Orientation. On the left is the smooth kidney capsular surface; on the right is the rough-appearing kidney parenchymal resection margin. The resection margin should be inked entirely before sectioning the specimen

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Fig. 6.9  Partial nephrectomy: Sectioning. Sequential perpendicular sections of the specimen are made to demonstrate the relationship of the tumor to the inked parenchymal margin. Be sure to identify and submit the tumor closest to the inked resection margin

Cystectomy Grossing Tips: Cystectomy • To orient properly, think of the anterior surface of the bladder as a rough, large abdomen, whereas the posterior surface is like a smooth, flat back (Fig. 6.10). • Ink the bladder using four colors for anterior, posterior, left, and right (Fig. 6.11). • For bladders received from female patients, extend the ink to cover the urethra, then shave the urethral margin before proceeding to open the bladder. • Cut the bladder open with a “Y”-shaped incision from the base to the dome (Fig. 6.12). • Find the “bladder mouth,” and the dimples will be where the ureteral orifices are. When probing, direct the probe horizontally and almost parallel to the bladder mucosa surface. • Keep the probes in the ureters, then fix the opened bladder overnight. • While serially sectioning the bladder, mark slices with a tumor or other abnormalities with a broken wooden stick.

This will make it easy to keep track of which areas are abnormal and should be submitted (Fig. 6.13). • Submit full-thickness sections in areas with a tumor so that microscopic tumor extension can be properly assessed. • If a prostate is present (cystoprostatectomy), the prostate is typically removed with the seminal vesicles and grossed separately. (In our institution, this is done by a specifically designated Pathologist Assistant who only grosses prostates.) Figure 6.14 however shows an image of a cystoprostatectomy specimen with both bladder and prostate

Sample Dictation: Cystectomy Received is a cystectomy specimen that consists of urinary bladder (____ × ____ × ____ cm), and attached adipose tissue (____ × ____ × ____ cm). There is an ulcerated/fungating/papillary mass (____ × ____ × ____ cm) present in the right/left bladder wall/trigone/dome. Grossly, the mass appears to invade

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Fig. 6.10 Cystectomy: Orientation. The anterior surface of the cystectomy specimen is rough, and bulges like a large abdomen. The posterior surface is smooth and flat like a back

Fig. 6.11  Cystectomy: Inking. The anterior and posterior surfaces are inked different colors. In addition, the right and left sides of the specimen are inked with two different colors

into the bladder muscularis propria without extension into the fat. [The prosector should also mention if the tumor involves any of the inked outer margins.] There is a ____  ×  ____  cm erythematous/fibrotic mucosal area located in the right/left bladder wall/trigone/dome. The

left and right ureteral orifices do not show involvement of the tumor. There is a ____ × ____ × ____ cm diverticulum located in the left lateral bladder wall. No involvement of the tumor or other mucosal abnormality is seen in the diverticulum.

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Fig. 6.12  Cystectomy: Opening. Cut the bladder open from inferior to superior using a “Y”-shaped incision. After opening, it should resemble this picture. The ureter orifices may be difficult to identify on the mucosal surface; to aid in finding them, locate the ridge between the two

ureters, which resembles lips. If these “lips” are found, the openings should be the two “dimples” at either end (see “Bladder Face” in the inset). Probe the ureters and allow the bladder to fix before sectioning further

Fig. 6.13 Cystectomy: Sectioning. Serially section the bladder sequentially from superior to inferior. Submit sections to show the depth of invasion of the tumor and to include any abnormal areas (scarring or erythema) that were seen on the mucosal surface. While sectioning, keep the probes in the right and left ureteral orifices in the serial

sections, in order to keep track of them so that it is easy to submit sections of the ureteral orifices. The ink placed on anterior, posterior, right, and left portions of the bladder (see Fig. 6.11) will also help to keep track of the location of any lesion seen on serial sections

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Fig. 6.14 Cystopro­ statectomy with verumontanum. In this cystoprostatectomy specimen, a tumor involves most of the mucosal surface of the bladder. The verumontanum of the prostate is also visible

Ink code: • • • •

Blue – Anterior Black – Posterior Yellow – Left Red – Right

Section code: • • • • • •

A1 – Urethral margin∗ A2 – Right ureter, full-thickness A3 – Left ureter, full-thickness A4–A__ – Sequential full-thickness sections of tumor A__–A__ – Erythematous mucosal area A__–A__  – Grossly uninvolved bladder, representative sections • A__–A__ – Dome, representative sections ∗Note: If the cystectomy is from a female, shave the urethral margin

Orchiectomy Grossing Tips: Orchiectomy • Ink the testis and spermatic cord margin different colors (Fig. 6.15).

• Take the spermatic cord margin first, before cutting into the tumor (to avoid false positive margins due to tumor contamination). • Bivalve the testis (Fig. 6.16). • Note the size and appearance of the tumor on the cut surface (Fig. 6.17). • Take parallel sections to see the relationship of the tumor to the capsule, normal testis parenchyma, and epididymis. • After parallel sections, take perpendicular sections.

Sample Dictation: Orchiectomy Received fresh/in formalin labeled as “_____” is a right/left orchiectomy specimen consisting of testis (____ × ____ × ____ cm), epididymis (____ × _____ × ____ cm), and spermatic cord (____ cm length, ____ cm diameter). The testis is bivalved, and there is a ____ × ____ × ____ cm tan-white firm, fleshy, well-circumscribed mass. Focal areas of necrosis and hemorrhage are present. The tumor does not grossly extend into the epididymis. The tumor extends ____ cm and closely abuts the tunica albuginea. The remainder of the testicular parenchyma is tan and unremarkable. The tunica albuginea is tan-white, smooth, and glistening. The epididymis is unremarkable. The spermatic cord consists of vas deferens, arteries, and veins, and is grossly unremarkable.

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Fig. 6.15  Orchiectomy. This orchiectomy specimen includes the testis and spermatic cord, the surfaces of which are inked different colors. Also note the position of the epididymis. The spermatic cord margin is

Fig. 6.16  Bivalved testis. The testis is bivalved to reveal a tumor

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also inked a separate color; this margin is cut and submitted before sectioning the testis further

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Fig. 6.17  Testis cut surface with tumor. Note the tumor, which looks different than the adjacent normal testis parenchyma. Sections of the tumor close to the normal parenchyma, tunica albuginea, epididymis, and spermatic cord should be submitted

Ink code:

Suggested Reading

• Blue – Spermatic cord resection margin

Compérat E, Varinot J, Moroch J, Eymerit-Morin C, Brimo F. A practical guide to bladder cancer pathology. Nat Rev Urol. 2018;15:143– 54. https://doi.org/10.1038/nrurol.2018.2. Grignon DJ, Al-Ahmadie H, Algaba F, Amin MB, Compérat E, Dyrskjøt L, et  al. Tumors of the urinary tract. In: Moch H, Humphrey P, Ulbright T, Reuter V, editors. WHO classification of tumors of the urinary system and male genital organs. Zurich: International Agency for Research on Cancer (IARC); 2016. p. 77–133. Kunath F, Schmidt S, Krabbe LM, Miernik A, Dahm P, Cleves A, et al. Partial nephrectomy versus radical nephrectomy for clinical localised renal masses. Cochrane Database Syst Rev. 2017;(5):CD012045. https://doi.org/10.1002/14651858.CD012045.pub2. Lopez-Beltran A, Bassi P, Pavone-Macaluso M, Monitroni R. Handing and pathology reporting of specimens with carcinoma of the urinary bladder, ureter and renal pelvis. Eur Urol. 2004;45:257–66. https:// doi.org/10.1016/j.eururo.2003.09.018. Moch H, Amin MB, Argani P, Cheville J, Delahunt B, Martignoni G, et  al. Tumors of the kidney. In: Moch H, Humphrey P, Ulbright T, Reuter V, editors. WHO classification of tumors of the urinary system and male genital organs. Zurich: International Agency for Research on Cancer (IARC); 2016. p. 11–76.

Section code: • • • • •

A1 – Spermatic cord margin A2 – Mid portion of spermatic cord A3–A8 – Tumor, representative sections A9–A15 – Tumor with adjacent normal parenchyma A16–A21 – Testis normal parenchyma and tunica, representative sections • A22–A24 – Epididymis

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Female Reproductive Tract Monica B. Lemos, Donna Coffey, and Michael Deavers

Gynecologic pathology specimens constitute a sizable percentage of the specimens received in the surgical pathology grossing suite, as many non-neoplastic and neoplastic conditions of the uterus, ovary, and fallopian tube may require surgical management. Hysterectomy specimens are among the most common gynecologic specimens received. The adnexa (ovary, fallopian tubes and ligaments) may also be removed at the same time, depending on the clinical scenario. There are various types of hysterectomies. A total simple hysterectomy, the most common type, includes the uterine corpus and cervix. Total simple hysterectomy specimens are performed for most endometrial cancers, as well as most non-­ cancerous lesions of the uterus. A supracervical hysterectomy is less common and includes the uterine corpus only, without the cervix. A radical hysterectomy includes the uterine corpus, cervix, parametrium, and the upper portion of the vagina (vaginal cuff). This procedure is typically performed for primary cervical carcinoma or endometrial carcinomas that extensively involve the cervix or that are centered in the lower uterine segment. Other common gynecologic specimens include cervical excisions for cervical dysplasia or carcinoma, using a loop electrosurgical excision procedure (LEEP) or cold knife cone biopsy. Handling of oophorectomy and vulvectomy specimens will also be discussed. This chapter discusses the proper handling of commonly received gynecologic specimens, and addresses clinical situations that require additional specimen sampling.

M. B. Lemos (*) · M. Deavers Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected] D. Coffey Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA

Hysterectomy Grossing Tips: Hysterectomy • Check the patient history found on the provided requisition or in the patient’s chart. • Ink the anterior and posterior surfaces different colors (Figs. 7.1 and 7.2). • Weigh the specimen and adnexa (if included). Detach the adnexa but keep track of which is anterior and which is posterior. • Before bivalving the uterus along the lateral uterine walls (3 and 9 o’clock), shave the posterior cul-de-sac serosa (which corresponds to the serosal “tail”), serially section it, and submit it on-edge in the cassette (Fig. 7.3). • Take measurements of the opened endometrial cavity and any gross lesions (Figs. 7.4, 7.5 and 7.6). • Take a vertical/longitudinal section of the lower uterine segment and cervix first. • Horizontally (transversely) section each half of the bivalved uterus into thin slices from the fundus to the lower uterine segment (Fig. 7.7). • For uteri with endometrial carcinoma, measure the deepest point of myometrial invasion (Fig. 7.8). • Measure the myometrial thickness. A trabeculated myometrial cut surface may indicate adenomyosis. • For endometrial tumors, submit representative sections (at least one section per centimeter of tumor), to include full thickness sections at the deepest point of invasion (Figs. 7.9, 7.10 and 7.11). • If the cervix is grossly involved with carcinoma, submit at least two representative sections of tumor involving the cervix. It is important that the sections of the cervix include the full thickness of the cervical wall and the ectocervical or vaginal cuff margin. • In cases where the endometrial carcinoma extensively involves the cervix, a radical hysterectomy may be performed. In such cases, parametrial tissue can be found at

© Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_7

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Fig. 7.1  Hysterectomy: Anterior. The smooth serosal surface extends lower posteriorly than it does anteriorly. This allows distinction between the anterior and posterior uterine surfaces. Once anterior and posterior

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aspects are identified, one can infer the laterality of attached adnexa. (Imagine the specimen in the patient either lying towards the prosector or facing away from the prosector.)

Fig. 7.2  Hysterectomy: Posterior. The serosal surface extends lower posteriorly, forming a “tail” towards the cervix

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Fig. 7.3  Hysterectomy: Anterior and posterior. This side-by-side picture of both anterior and posterior aspects of a uterus shows the greater inferior extent of the smooth serosal surface on the posterior side

Fig. 7.4  Hysterectomy: Bivalved. The uterus is sectioned along the lateral uterine walls (3 and 9 o’clock). Sectioning this way will provide the best visualization of the endometrial cavity, lower uterine segment, and endocervix. The endometrial cavity here is lined by a smooth, glis-

tening, unremarkable endometrial lining. (Compare with the endometrium involved by a tumor in Figs. 7.9 and 7.10.) There is a leiomyoma in the superior myometrium

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Fig. 7.5 Supracervical hysterectomy. This uterus has been resected above the cervix; only a stump is present in the cervical area. The uterus is markedly distorted by multiple large leiomyomas

Fig. 7.6  Submucosal leiomyoma. Many nodules can be seen in this bisected uterus, including submucosal leiomyomas located immediately beneath the endometrial lining

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Fig. 7.7  Hysterectomy: Serial sectioning and intramural leiomyomas. Serial sections of the uterus are taken horizontally (transversely) from the superior aspect to the inferior. The myometrium in these sections is remarkable for several intramural leiomyomas. Leiomyomas can also

be subserosal (located immediately beneath the serosal surface towards the outer aspect of the uterus). It is important to document any possible areas of necrosis or hemorrhage in a suspected smooth muscle neoplasm

Fig. 7.8  Hysterectomy with polyp. Two polyps can be seen in this hysterectomy specimen. A cervical polyp is present within the endocervical canal and can be seen protruding from the cervix before the uterus

is bivalved (left image). An endometrial polyp is also present within the endometrial cavity superiorly (right image). Also, note a submucosal leiomyoma (right image)

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Fig. 7.9  Endometrial carcinoma. A mass can be seen filling the entire endometrial cavity. The lower uterine segment and cervix appear grossly uninvolved, but representative sections should always be taken to rule out microscopic involvement by the tumor Fig. 7.10 Endometrial carcinoma: Lower uterine segment section. This figure demonstrates a longitudinal section of the lower uterine segment. Similar longitudinal sections of the cervix should also always be taken. Take these sections first before serially sectioning (Fig. 7.11), so as not to forget or inadvertently section through the lower uterine segment and cervix before such sections can be taken

the lateral aspects of the cervix (3 o’clock and 9 o’clock), along with the vaginal cuff. Radical hysterectomy ­specimens are typically performed in cases of primary cervical carcinoma. • If parametrium is present, measure the size of the parametrial tissue on each lateral aspect of the cervix. The parametrial margins should be inked. If a tumor is near the parametrium, take sections to include the cervix, parametrium, and parametrial margin.

• If the tumor does not appear to involve the parametria, the sections may include cervix, parametrium, and parametrial margins contiguously (as described above), or the parametrial margins may be taken en face (depending on the amount of parametrial tissue present), and the remainder of the parametrium may be submitted entirely in a sequential manner, from lateral to medial. • If a vaginal cuff is present, ink the cut surface of each quadrant a different color (1 to 3 o’clock, 3 to 6 o’clock,

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Fig. 7.11  Hysterectomy with carcinoma: Sectioning. Each anterior and posterior half of the uterus is serially sectioned from the fundus to the cervix in order to examine the depth of invasion of the tumor or any other lesions within the myometrium

6 to 9 o’clock, and 9 to 12 o’clock) (Fig. 7.12). Shave off each quadrant and submit each in a cassette ink-side down, or place on a chuck ink-side up if a frozen section is requested. • In benign uteri, or those with carcinoma of a non-serous histotype, representative sections of the fallopian tube, to include the entire fimbriated end (longitudinally sectioned), and representative cross-sections of the remainder of the tube should be submitted. In cases of uterine serous carcinoma, the SEE-FIM protocol should be performed (see Fig. 7.19). • The ovaries, if present, should be serially sectioned along the long axis. Submit sections of any abnormal nodules or lesions. In benign uteri and endometrial carcinoma of a non-serous histotype, representative sections will suffice. In cases of uterine serous carcinoma, the entire ovary should be submitted.

Sample Dictation: Hysterectomy Received fresh labeled as “_____” is a total hysterectomy specimen/supracervical hysterectomy specimen/hysterectomy specimen with an amputated cervix (_____  grams, ____ × ____ × ____ cm) with attached bilateral adnexa (right ovary ____ × ____ × ____ cm, right fallopian tube ____ cm

in length and ____  cm in diameter, left ovary ____ × ____ × ____ cm, left fallopian tube ____ cm in length and ____ cm in diameter). The uterine serosal surface is tan-pink and smooth (or) has tan-white areas of granularity (____ cm). The ectocervix is white-gray smooth and glistening with a ____ cm cervical os/slit-like os. The endometrial cavity is ____ × ____ cm and lined by a ____ cm tan-pink smooth and glistening endometrium (or) the endometrial cavity is replaced/partially replaced by a ____ × ____ × ____ cm tan-pink friable mass, infiltrating __ cm into a ___ cm thick myometrium. Attached to the fundus in the posterior/anterior aspect is a ____  cm tan-pink polyp. The myometrium is tan-pink and rubbery/trabeculated and is ____  cm in thickness. Multiple tan-white whorled intramural/submucosal/subserosal nodules are present. The cut surfaces of the nodules are grossly unremarkable without hemorrhage or necrotic areas. The surface of the right ovary is yellow-tan and convoluted/tan-pink and smooth. The cut surface shows corpora albicantia ranging from ____  cm to ____  cm. There are also multiple cysts filled with clear fluid/seromucinous fluid and ranging from ____  cm to ____  cm. The surface of the right fallopian tube is tan-pink and smooth with paratubal cysts present ranging from ____  cm to ____  cm and filled with clear fluid.

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Fig. 7.12  Vaginal cuff. Some hysterectomy specimens may be received with a vaginal cuff (typically received as part of a radical hysterectomy specimen, indicated for some cervical carcinomas). The vaginal cuff margins may also need to be assessed intraoperatively in the frozen section suite. In this case, the left and right edges of the margin are inked

different colors (in this figure, blue and black, respectively). Single dots of different colored ink are placed at intervals indicating clock position around the margin for greater accuracy. The margin is shaved and submitted from each dot to the next. A diagram (shown to the right) can be drawn as a legend of the ink colors used for each section submitted

Ink code:

• A___–A___ – Left ovary • A___–A___ – Left fallopian tube

• Blue – Anterior • Black – Posterior

Oophorectomy and Salpingectomy

Section code: • • • •

•

• • •

A1 – Anterior cervix A2 – Posterior cervix A3 – Posterior cul-de-sac serosa A4–A7 – Endometrium and myometrium, anterior aspect, representative sections from fundus to lower uterine segment A8–A11  – Endometrium and myometrium, posterior aspect, representative sections from fundus to lower uterine segment A12–A14 – Representative sections of intramural nodules (for nodules 5 cm or larger, take one section per cm) A15–A___ – Right ovary A___–A___ – Right fallopian tube

Ovary and fallopian tube specimens require the use of some specific procedures. For ovarian specimens with mass lesions, the outer surface of the ovary should be inked before sectioning. (Figs. 7.13, 7.14, 7.15, 7.16, 7.17, 7.18 and 7.19).

Sample Dictation: Cystic Ovary Received fresh and labeled as “_____” is an intact/previously opened cystic ovary (____  grams, ____ × ____ × ____ cm). The surface of the specimen is tan-­ white to pink and smooth (or with nodules or papillary excrescences present).

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Fig. 7.13  Cystic ovary. This ovary is almost completely replaced by a cystic lesion. Notice the fallopian tube attached to the cystic ovary. The presence of the fallopian tube should be noted; detach it before opening the cyst

Fig. 7.14  Cystic ovary: Inner lining and papillary excrescences. Seen here is the inner lining of an opened ovarian cyst. This inner surface should be carefully evaluated for papillary excrescences (right image)

and sections of such areas submitted. Any solid areas should also be noted and sections submitted

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Fig. 7.15  Cyst roll. The advantage of submitting an ovarian cyst as a roll is that it maximizes visualization of the greatest surface area of the cyst per section submitted. This technique can be used to submit ovarian cysts for frozen (left) as well as permanent (right) sections. The disadvantage is that in some cases, this technique may distort the epi-

Fig. 7.16  Cystic teratoma. This ovarian cyst includes a solid tumor component and a cystic component with hair, representing a mature teratoma. Various elements, including teeth and bone, can also be present in teratomas. Solid portions or any areas that look different should be sampled in such cystic ovary specimens

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thelial lining of the cyst, and thus may hinder microscopic interpretation. Therefore, submitting in this manner will depend on the preference of the pathologist. An alternative method of sectioning a cystic ovary includes submitting longitudinal strips of cyst wall placed in the cassette on edge

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Fig. 7.17  Ovary: Sectioning. Shown are the intact ovary (left) and serial sections (right). Note the tan-white corpora albicantia seen on the cut surface

Fig. 7.18  Ovary: Corpora lutea and albicantia. The cut surface of this ovary shows the corpus luteum (golden-yellow and cystic) as well as the corpora albicantia (white-colored)

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Fig. 7.19  Ovary and fallopian tube: SEE-FIM protocol (Sectioning and Extensively Examining the FIMbriated End protocol). In patients with BRCA mutations who have undergone prophylactic salpingo-­ oophorectomy, the fimbriated end of the fallopian tube is amputated at the infundibulum (distal 2 cm of fallopian tube). The distal 2 cm of the fallopian tube is sectioned parallel to the long axis of the tube and submitted entirely. Alternatively, the distal fimbriated end of the fallopian

tube may first be opened with scissors, and then additional parallel sections may be made. The remainder of the fallopian tube is sectioned horizontally (“bread loafed”) at intervals of 2–3  mm and submitted entirely. In this image, the fallopian tube shows small paratubal cysts, a very common finding. In these cases, the ovaries should be serially sectioned at intervals of 2–3 mm along the long axis and submitted entirely

Sectioning of the ovary reveals a ____  cm unilocular/ biloculated/multiloculated cyst(s) ranging from ____ to ____ cm in diameter and filled with yellow, clear, gelatinous material (or gray-white paste-like material and hair, in a mature cystic teratoma). The inner lining of the cyst is tan-­ pink and smooth (or tan-pink with papillary excrescences measuring up to ____ cm). The thickness of the wall ranges from ____ to ____ cm.

Sample Dictation: Cervical Cone Received fresh labeled as “_____” is an oriented conical portion of tissue. The endocervical margin is inked black, and the ectocervical margin is inked blue. The specimen is radially sectioned, and the cut surface is pale-tan and rubbery/ slightly firm. The specimen is entirely submitted sequentially from 1 to 12 o’clock in cassettes A1–A12.

Ink code: • Blue – Entire outer surface of ovary

Vulvectomy

• A1–A10 – Representative sections of cyst wall • A11–A13 – Papillary excrescences∗

When examining vulvectomy specimens, understanding the proper orientation is the first crucial step. The specimen should then be inked and subsequently sectioned (Figs. 7.22, 7.23 and 7.24).

∗Note: Always make sure to submit any areas of papillary excrescences or solid areas.

Sample Dictation: Vulvectomy

Section code:

Cervical Cone Cone-shaped portions of cervix from cervical cone biopsies are inked and radially sectioned (Figs. 7.20 and 7.21).

Received labeled as “____” is an oriented/unoriented irregular piece of vulvar skin with underlying fibroadipose tissue (____  ×  ____  ×  ____  cm). The surface of the specimen reveals an ulcerated/nodular/discolored friable lesion (___ × ___ cm), which is ____ cm from the closest margin

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Fig. 7.20  Cervical cone: Oriented specimen. The ectocervical margin and endocervical margins should be identified and inked different colors. The base of the specimen opposite the cervical opening is the endocervical margin. The endocervical margin should be inked. The periphery of tissue all around the specimen, excluding the surface ecto-

cervical mucosa, includes the ectocervical and deep margins; these margins should also be inked a different color. After the margins have been inked, the specimen is bivalved horizontally along the lateral aspect (3 and 9 o’clock), and sections are taken for each clock position (see Fig. 7.21)

Fig. 7.21  Cervical cone: Radial sectioning. Each half of the bivalved cone specimen should be sectioned radially. This should result in at least 12 cassettes, one for each position (i.e., A1 = 1 o’clock, A2 = 2

o’clock, A3  =  3 o’clock, and so on until A12). The cuts are made towards the center of the cone (similar to sections of a pie)

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Fig. 7.22  Vulvectomy. A vulvectomy specimen is shown, which is oriented by the surgeon with sutures. Note the lesion in the center, which appears as a tan-white discolored area

Fig. 7.23  Vulvectomy: Inking of margins. The margins are inked two colors on both sides (including the peripheral edges and deep surface) to indicate 12-3-6 o’clock and 6-9-12 o’clock positions. Then dots are

placed at various o’clock positions, and the margins are shaved. A diagram is drawn to keep track of the colors used for each position

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Ink code: • Blue – Superior • Orange – Inferior or • Blue – Medial • Orange – Lateral or • Black – 12-3-6 o’clock • Purple – 6-9-12 o’clock Fig. 7.24  Larger vulvectomy specimen. Some vulvectomy specimens include more extensive tissue resection. In such larger vulvectomy specimens, a more selective strategy of sampling the margin can be used. Ink the right and left parts different colors (including the peripheral edges and deep surface), but submit only the portion of the margin(s) closest to the lesion for frozen section (if the specimen is received in the frozen section suite). Then make perpendicular sections to evaluate the deepest invasion of the lesion and submit the closest deep margin. For permanent sections, the complete specimen may be submitted, or only the remainder of the lesion with adjacent normal tissue

(e.g., 3 o’clock margin, 6 o’clock margin, deep margin, etc.). The remainder of the surface reveals multiple satellite ­nodules/pigmented lesions ranging from ____ to ____  cm and located ____ cm from the closest margin(s). The specimen is inked and serially sectioned sequentially from medial to lateral (or) from 12 o’clock to 6 o’clock and submitted entirely/representatively, sequentially from 12 o’clock to 6 o’clock or from medial to lateral in cassettes A1–A12.

Suggested Reading Ismill N, Ghorab Z, Covens A, Nofech-Mozes S, Saad R, Khalifa MA.  Intraoperative margin assessment of the radical trachelectomy specimen. Gynecol Oncol. 2009;113:42–6. https://doi. org/10.1016/j.ygyno.2008.12.025. Koc N, Ayas S, Arinkan SA. Comparison of the classical method and SEE-FIM protocol in detecting microscopic lesions in fallopian tubes with gynecological lesions. J Pathol Transl Med. 2018;52:21– 7. https://doi.org/10.4132/jptm.2016.06.17. Malpica A, Euscher ED, Hecht JL, Ali-Fehmi R, Quick CM, Singh N, et  al. Endometrial carcinoma, grossing and processing issues: recommendations of the International Society of Gynecologic Pathologists. Int J Gynecol Pathol. 2019;38(Suppl 1):S9–24. https:// doi.org/10.1097/PGP.0000000000000552. Medeiros F, Muto MG, Lee Y, Elvin JA, Callahan MJ, Feltmate C, et al. The tubal fimbria is a preferred site for early adenocarcinoma in women with familial ovarian cancer syndrome. Am J Surg Pathol. 2006;30:230–6.

8

Lung Monica B. Lemos and Roberto Barrios

Pulmonary specimens may be received in the surgical pathology grossing suite as part of the clinical workup and management of both neoplastic and non-neoplastic conditions, including infectious processes. Types of lung specimens commonly encountered include lung biopsies, wedge resections, lobectomy specimens, and pneumonectomy specimens. A lung wedge resection consists of removal of a smaller portion of lung tissue; the parenchymal surgical margin of resection is typically stapled. A lobectomy specimen consists of an entire lung lobe; in such specimens, the key margin is the bronchial resection margin. A pneumonectomy specimen consists of the entire lung, which may be received for a variety of conditions, including neoplastic and non-­ neoplastic processes. In the case of malignancy, a pneumonectomy, rather than a smaller resection, may be indicated because of the location of a tumor. Pneumonectomy specimens may also be encountered in practice settings with a lung transplantation service. This chapter discusses the handling of pneumonectomy specimens, lobectomy specimens, and wedge resections.

Pneumonectomy After identifying and submitting the bronchial and vascular margins, the pneumonectomy specimen is serially sectioned (Figs. 8.1, 8.2 and 8.3).

M. B. Lemos (*) Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected]

Lung Lobectomy and Wedge Resections  rossing Tips: Lung Lobectomy and Wedge G Resections • When the specimen is received, wear a mask, especially in cases where tuberculosis infection is possible. • Weigh the specimen and take bronchial and vascular margins first. • Check for staple lines. Remove the staples and ink the lung parenchyma beneath them (Figs. 8.4, 8.5 and 8.6). • If received fresh in the frozen section pathology suite, prepare touch preparation slides on lesions identified (particularly in wedge resections). • If granulomas are found on touch preparation, be sure to wear a mask, because of the risk of tuberculosis. Frozen sections will not likely be performed in this case, but if they are, the cryostat should be promptly decontaminated following any possible exposure.

Sample Dictation: Lung Lobectomy Received fresh labeled as “____” is a right/left upper/middle/lower lobe (____ grams, ___ × ___ × ___ cm). The pleural surface is dark red and shows a ____ cm area of retraction or a ____ cm firm area. The remainder of the pleural surface is smooth and unremarkable. The specimen is serially sectioned along the long axis and shows a white-gray, firm, well-circumscribed mass ____ cm from the bronchial margin and ___ cm from the stapled margin. The remainder of the parenchyma is red-pink with scattered black spots ranging from 0.1 to 0.3 cm, suggestive of anthracosis.

R. Barrios Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA Weill Cornell Medicine, New York, NY, USA © Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_8

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Fig. 8.1  Left pneumonectomy. Two lobes (left upper and left lower) are identified in a left pneumonectomy specimen. The resected portions of bronchus and vessels are seen in the hilar area; these represent margins and should be submitted first before sectioning the rest of the lung

Fig. 8.2  Right pneumonectomy. Three lobes (right upper, right middle, and right lower) are identified in a right pneumonectomy specimen. Again, the hilar bronchial and vascular margins are identified and should be submitted first

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Fig. 8.3  Pneumonectomy: Sections. The pneumonectomy is serially sectioned along the long axis, and the cut surface is examined for areas of fibrosis, tumor, or other abnormalities. Note the areas of fibrosis seen in these sections

Fig. 8.4  Lung lobectomy. A lung lobe resection with a palpable subpleural tumor is pictured. The pleural surface overlying the tumor is inked. Note that pleural invasion will affect the stage of malignant lung tumors

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Fig. 8.5  Lung lobectomy: Bronchial and vascular margins. The bronchial and vascular margins in this lobectomy specimen are stapled (left image). The staples are removed, and the lumen of the bronchus and vessel can be seen (right image)

Fig. 8.6  Lung wedge resection. A wedge resection typically includes a parenchymal margin, which should be inked and submitted. This resection margin is identified by the surgeon’s staples. In this wedge, a tumor

is visible and is protruding through the pleural surface. Serial sections of the wedge are made. The tumor can be seen clearly in these sections, which are laid out sequentially

Ink code:

• A6–A__ – Tumor • A__–A__ – Normal parenchyma

• Blue – Retraction (or firm area) of pleural surface • Orange – Stapled margin Section code:

Suggested Reading

• A1 – Vascular margin • A2 – Bronchial margin • A3–A5 – Hilar lymph nodes

Harrison S, Stiles B, Altorki N.  What is the role of wedge resection for T1a lung cancer? J Thorac Dis. 2018;10(Suppl 10):S1157–62. https://doi.org/10.21037/jtd.2018.03.188.

8 Lung Lackey A, Donington JS.  Surgical management of lung cancer. Semin Intervent Radiol. 2013;30:133–40. https://doi.org/10.105 5/s-0033-1342954. Ritterhouse L, Sholl LM.  The molecular pathology of lung cancer: pre-analytic considerations. In: Cagle PT, Allen TC, Beasley MB, et al., editors. Precision molecular pathology of lung cancer. 2nd ed.

87 Cham: Springer International Publishing; 2018. p.  79–92. https:// doi.org/10.1007/978-3-319-62941-4. Sienko A, Allen TC, Zander DS, Cagle PT.  Frozen section of lung specimens. Arch Pathol Lab Med. 2005;129:1602–9. https://doi. org/10.1043/1543-2165(2005)129[1602:FSOLS]2.0.CO;2.

9

Bone and Soft Tissue Monica B. Lemos and Michael Deavers

Acquiring competence in the gross examination of bone and soft tissue specimens can be challenging, particularly as these specimens are not common. Of the bone specimens that are received in the surgical pathology grossing suite, femoral head and knee arthroplasty specimens are among the most frequent. Such specimens are typically received during surgical procedures indicated for osteoarthritis. Other types of bone and soft tissue specimens seen include amputations, such as below-the-knee and above-the-knee amputations, often due to gangrene. Bone resections for neoplastic conditions are rare. In such cases, review of the pre-operative radiographic imaging is essential. Furthermore, in certain cases, tumor mapping may be required. When performing gross examinations of bone specimens, having appropriate cutting instruments and ensuring proper fixation and adequate decalcification are very important. Inadequate fixation and decalcification can both be problematic and lead to suboptimal sections. This chapter illustrates examples of various bone specimens and describes the appropriate handling of such specimens.

with a hemorrhagic and jagged margin of resection (for history of fracture). The articular surface varies from smooth to focally scratched and pitted. The underlying bone is tan-­ yellow with hemorrhage at the margin. There is a ____ cm tan, pale, wedge-shaped area with detached cartilage (for cases of avascular necrosis). The cartilage thickness ranges from ____ to ____ cm. • A1–A3  – Representative decalcification

sections

following

Knee Arthroplasty Specimens obtained during knee arthroplasty are likely to include both bone and soft tissue (Fig. 9.3).

Sample Dictation: Knee Arthroplasty

Sample Dictation: Femoral Head

Received in formalin and labeled “right/left bone and tissue” is a ____ × ____ × ____ cm aggregate of irregular to ovoid portions of tan-yellow bone and gray-white cartilage, in addition to soft tissue. Tibial plateau and femoral condyle configurations are present. The bone is partially covered by concave and convex articular surfaces. The articular surface varies from smooth to pitted, nodular, and partially eroded. There are focal areas of eburnation measuring up to ____ cm. Osteophyte formation in the peripheral aspect is identified.

Received in formalin labeled as “right/left femoral head” is a femoral head resection specimen (____ × ____ × ____ cm)

• A1–A2 – Representative sections of bone • A3 – Soft tissue

Femoral Head Thin sections made with a bone saw will include the overlying cartilage and the cortex (Figs. 9.1 and 9.2).

M. B. Lemos (*) · M. Deavers Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA e-mail: [email protected] © Springer Nature Switzerland AG 2019 M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology, https://doi.org/10.1007/978-3-030-20839-4_9

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Fig. 9.1  Femoral head. This femoral head resection specimen was removed during hip replacement surgery. A thin section is made with a bone saw through the center of the femoral head, and sections are submitted as shown to include the overlying articular cartilage and cortex

Fig. 9.2  Avascular necrosis. An area of avascular necrosis is seen in this femoral head resection specimen. The lesion is tan, pale, and wedge-shaped. Submitted sections (right) include the area of avascular necrosis and detached cartilage

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Fig. 9.3  Knee: Bone and tissue. These fragments of tissue from a knee arthroplasty show areas of eburnation and erosion, characteristic of osteoarthritis. Note the femoral condyle and tibial plateau portions of the specimen

Amputations Grossing Tips: Leg Amputation

Fig. 9.4  Bone tumor resection. The specimen should be oriented by the surgeon, usually with sutures. The specimen is inked and oriented with different colors. The bone margins should be taken, and then the specimen should be bivalved (see Fig. 9.5)

Bone Tumor Resection Bone tumor resection specimens should be oriented, inked, bivalved, and subsequently mapped (Figs. 9.4, 9.5 and 9.6).

• Measure the specimen. • Check for lesions including ulcers and areas of gangrene. Measure these lesions and their location with respect to the resection margin (Figs. 9.7, 9.8 and 9.9). • Ink the skin and soft tissue resection margins in the area closest to any noted lesions (Fig. 9.10). Submit representative sections of skin and soft tissue at the resection margin. • To assess the bone resection margin, a section of bone at the margin may be taken, or the bone marrow at the margin may be scraped, and submitted in a biopsy bag. Submitting a cut section of the bone resection margin is preferable in cases of osteomyelitis. • Locate the anterior tibial artery. This can either be found at the resection margin, or it can be found by making a transverse section on the anterior leg between the tibia and fibula (Fig. 9.11). • The artery can likely be found by probing with the finger. • The posterior tibial artery can be found easily by palpating the soft tissue at the resection margin in a below-the-­ knee amputation. It is often calcified and can thus be easily felt.

92 Fig. 9.5  Bone tumor resection: Bivalved. The cut halves of the bone tumor resection show a tumor that has eroded and replaced much of the bone. There are two bone resection margins, one at each end of the portion of the resected bone. These resection margins should be inked and submitted in two different cassettes, which are subsequently placed into decalcification solution. Then the main specimen should be placed in formalin overnight before further sectioning

Fig. 9.6  Bone tumor resection: Mapping. A thin slice is cut from each side of the bivalved specimen (see Fig. 9.5). The slices are then mapped to show the location of each submitted section. After submitting each of the sections, the cassettes are placed into decalcification solution before processing

Fig. 9.7 Above-the-knee amputation. This above-knee amputation specimen includes the foot, lower leg, and knee

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Fig. 9.8  Above-the-knee amputation: Lesions. Notice the difference between normal skin, dry scaly skin, and a gangrenous area

Fig. 9.9  Gangrenous toe lesion. Note the black, hard, gangrenous area on the great toe. There is also skin slippage on portions of the toes

Fig. 9.10  Above-knee amputation: Resection margins. The resection margins include the soft tissue margin (skin, fat, and muscle) and the bone resection margin

Fig. 9.11  Anterior tibial artery dissection. The anterior tibial artery has been dissected out and should be opened and assessed for calcification and/or atherosclerotic stenosis

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Fig. 9.12  Popliteal artery dissection. The popliteal artery is also dissected out and opened to assess for calcification or atherosclerosis

Sample Dictation: Transmetatarsal Amputation Received in formalin, labeled “right/left transmetatarsal amputation” is a ____  ×  ____  ×  ____  cm transmetatarsal amputation specimen with five toes/previously amputated ____ toes. Tan-yellow unremarkable toenails are present. There is a black ulcerated and gangrenous black lesion on the dorsal/plantar surface/toe. The lesion is ____  cm from the soft tissue resection margin. Ink code: • Blue – Soft tissue resection margin • Black – Bone resection margin Section code:

Fig. 9.13  Transmetatarsal amputation. Shown is a transmetatarsal amputation of a gangrenous foot. The skin and soft tissue resection margins closest to any noted lesion should be inked, and sections should then be taken. The bone resection margin should also be inked and submitted, particularly in cases of osteomyelitis. Note the absence of the fifth toe, which in this patient was previously amputated

• Similarly, the popliteal artery can be easily found by palpation of the resection margin in an above-the-knee amputation (Fig. 9.12). • Mention the maximum percent stenosis by any calcification or plaque in the vessels. • When there is a history of osteomyelitis, submit a section of bone underlying the lesion. • In some cases, there has been a previous amputation, so be sure to check for the presence of missing (previously amputated) toes (Fig. 9.13).

• • • • • • •

A1 – Soft tissue resection margin A2 - A3 – Lesions (areas of gangrene, etc.) A3 – Anterior vessels A4 – Posterior vessels A5 – Normal skin A6 – Bone resection margin, following decalcification A7 – Representative sections of bone underlying lesions (osteomyelitis), perpendicular, following decalcification

Suggested Reading Dimenstein IB.  Bone grossing techniques: helpful hints and procedures. Ann Diagn Pathol. 2008;12:191–8. https://doi.org/10.1016/j. anndiagpath.2007.06.004. Khurana JS, Arguello-Guerra V.  Grossing of bone and soft tissue (common specimens and procedures). In: Khurana J, editor. Bone pathology. New  York: Humana Press; 2009. https://doi. org/10.1007/978-1-59745-347-9_7. Klein MJ, Memoli VA. Orthopaedic specimen preparation: what pathologists should know and do. Semin Diagn Pathol. 2011;28:4–12.

Index

A Amputations anterior tibial artery dissection, 91, 93 gangrenous toe lesion, 91, 93 lesions, 91, 93 popliteal artery dissection, 94 resection margins, 93 specimen, 91, 92 transmetatarsal amputation, 94 Appendectomy, 39, 40 Appendix, 38–40 Axillary lymph node sampling, 5 B Bone and soft tissue amputations lesions, 91, 93 anterior tibial artery dissection, 91, 93 gangrenous toe lesion, 91, 93 popliteal artery dissection, 94 resection margins, 93 specimen, 91, 92 transmetatarsal amputation, 94 femoral head avascular necrosis, 89, 90 resection, 89, 90 sample dictation, 89 knee arthroplasty, 89, 91 Bone tumor resection bivalved, 92 mapping, 92 specimen, 91 Breast axillary lymph node sampling, 5 cancer diagnosis, 5 lumpectomy (see Lumpectomy) mastectomy (see Mastectomy) sentinel lymph nodes, 11, 12 Breast-conserving therapy, 5 C Cervical cone oriented specimen, 78, 79 radial sectioning, 78, 79 sample dictation, 78

Cholecystectomy cystic duct margin, 46, 47 gallbladder, 46 sample dictation, 46, 47 sectioning, 47 sections, 46 specimen, 46 Cystectomy inking, 60, 61 opening, 60, 62 orientation, 60, 61 sample dictation, 60, 61, 63 sectioning, 60 Cystoprostatectomy, 60, 63 D Distal pancreatectomy distal pancreas and spleen, 52 pancreas and spleen, 52 sample dictation, 53 sections, 52 spleen, 52 E Esophagogastrectomy esophagectomy, 27, 29 esophagus, 28 gastrectomy, 27 stomach, 28 F Female reproductive tract cervical cone oriented specimen, 78, 79 radial sectioning, 78, 79 sample dictation, 78 hysterectomy (see Hysterectomy) oophorectomy (see Oophorectomy) salpingectomy, 74, 78 vulvectomy inking of margins, 78, 80 larger vulvectomy specimen, 78, 81 sample dictation, 78, 81 specimen, 78, 80 Follicular carcinomas, 18

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96 G Gastrointestinal tract appendectomy, 39, 40 esophagogastrectomy esophagectomy, 27, 29 esophagus, 27, 28 gastrectomy, 27 stomach, 27, 28 ileostomy, 29 ostomy site, 29 sample dictation, 29 sectioning, 30 large bowel (see Large bowel) polypectomy, 40 routine specimens, 27 small bowel inking, 31 Meckel’s diverticulum, 30, 31 subserosal tumor resection, 31 subserosal tumor sectioning, 31 Genitourinary cystectomy inking, 60, 61 opening, 60, 62 orientation, 60, 61 sample dictation, 60, 61, 63 sectioning, 60, 62 cystoprostatectomy, 60 nephrectomy (see Nephrectomy) orchiectomy bivalved testis, 63, 64 sample dictation, 63, 65 testis and spermatic cord margin, 63, 64 testis cut surface with tumor, 63, 65 Glossectomy, 13, 15 H Head and neck floor of the mouth, 13, 16, 17 glossectomy, 13, 15 laryngectomy (see Laryngectomy) salivary gland, 16 thyroidectomy, 16, 18 tonsillectomy, 13–15 uvula, 13, 16 Hepatectomy anterior view inking, 44 segments in, 44 total hepatectomy specimen, 44 grossing tips, 43 posterior view inking, 45 segments in, 44 sample dictation, 43 sectioning, 45 serial sections with tumor, 46 Hilar invasion, 55, 58 Hysterectomy adnexa, 67 anterior, 67, 68 anterior and posterior, 67, 69 bivalved, 67, 69 endometrial carcinoma, 67, 72 with polyp, 67, 71 posterior, 67, 68 radical hysterectomy, 67 sample dictation, 73, 74

Index sectioning, 67, 73 serial sectioning and intramural leiomyomas, 67, 71 submucosal leiomyoma, 67, 70 supracervical, 67, 70 total simple hysterectomy, 67 vaginal cuff, 72, 74 I Ileocolectomy, 38 Ileostomy, 29 ostomy site, 29 sample dictation, 29 sectioning, 30 L Large bowel with adhesed ovary, 37, 38 colon tumor depth of invasion, 30, 34 longitudinal sectioning, 30, 33 colon with Crohn’s disease, 34, 36, 37 colon with ulcerative colitis, 34, 36 diverticulitis, 35 adhesions, 34, 35 mucosal surface, 34, 35 sections, 34, 36 low anterior resection, 38, 39 rectum with anal mucosa and dentate line, 30, 34 radial margin, 30, 33 right hemicolectomy ileum, cecum, and right colon, 30, 32 inking, 30, 32 sample dictation, 38 serosal surface, 34 Laryngectomy anterior aspect, 21 inking, 21, 22 opened view, 23 opened view after fixation, 23, 24 posterior aspect, 21, 22 sample dictation, 23, 25 sections, 23–25 Lobectomy bronchial and vascular margins, 86 grossing tips, 83 lobe resection with palpable subpleural tumor, 85 sample dictation, 83 Lumpectomy grossing, 9 inking, 9, 10 with localization wire, 9 mapping, 9, 11 margins of resection, 9 sample dictation, 9, 11 sections, 9, 10 survival outcomes, 5 Lung lobectomy, 83, 85, 86 pneumonectomy, 83–85 wedge resection, 83, 86 M Mastectomy grossing, 5, 8 inking of margins, 5, 6

 Index mapping, 8 margins, 5 modified radical mastectomy, 5 nipple-sparing mastectomy, 5 orientation, 5, 6 radical mastectomy, 5 sample dictation, 8, 9 sectioning, 5, 7 skin-sparing mastectomy, 5 slices, 5, 7 total simple mastectomy, 5 Meckel’s diverticulum, 31 Myometrium, 71, 73, 74 N Nephrectomy partial nephrectomy orientation, 59 sectioning, 59, 60 radical nephrectomy bivalved surface, 55, 57 Hilar invasion, 55, 58 margins, 55, 56 orientation, 55, 56 parallel sectioning, 55, 57 perpendicular sectioning, 55, 58 polycystic kidney, 55, 58, 59 sample dictation, 57, 58 O Oophorectomy, 67 corpora lutea and albicantia, 77 cystic ovary, 75 cyst roll, 76 cystic teratoma, 76 inner lining and papillary excrescences, 75 sample dictation, 74, 78 sectioning, 77 Orchiectomy bivalved testis, 63, 64 testis and spermatic cord margin, 63, 64 testis cut surface with tumor, 63, 65 P Pancreaticoduodenectomy, see Whipple resection Parotid glands, 16 Pneumonectomy left pneumonectomy, 84 right pneumonectomy, 84 sections, 85 specimen, 83 Polycystic kidney, 55, 58, 59 Polyp, 38–4071 Polypectomy, 40 Purulent serosal exudate, 40 S Salivary glands parotid glands, 16, 18, 19 submandibular glands, 16, 18 Salpingectomy, 74, 78, 79 SEE-FIM protocol, 73, 78 Sentinel lymph nodes

97 biopsy, 5 grossing, 11, 12 Skin ellipse, 1, 2 Skin excision clock positions, 1 ellipse shape, 1, 2 inking, 1, 3 irregular, 1, 4 margins, 1 orientation, 1, 2 pigmented lesion, 1 sample dictation, 1 with scarred and pigmented lesions, 3 sectioning, 1, 4 Small bowel inking, 31 Meckel’s diverticulum, 30 subserosal tumor resection, 31 subserosal tumor sectioning, 31 Splenectomy, 53 Splenic capsule, 53 Submandibular glands, 16, 18 Supracervical hysterectomy, 67, 70, 73 T Thyroid nodules, 18, 21 Thyroidectomy inking, 18, 20 lobes and isthmus positions, 18, 19 sample dictation, 19, 21 sectioning, 18, 20 thyroid nodules, 18, 21 Tonsillectomy cerebriform appearance, 13, 14 with papilloma, 13, 15 sectioned tonsils, 13, 14 Tracheostomy, 21, 23 Transmetatarsal amputation, 94 U Uvulectomy, 13, 16 V Vulvectomy, 67 inking of margins, 78, 80 larger vulvectomy specimen, 78 sample dictation, 78, 81 specimen, 78, 80, 81 W Wedge resection, 83, 86 Whipple resection ampulla, 49 duodenum, 48 opened ducts, 49, 50 pancreas, 47, 48 portion of the stomach, 47, 48 retroperitoneal margin, 48, 49 sample dictation, 50, 52 sections, 50 slice, 50, 51 submitting sections, 50, 51 vascular groove, 48, 49