Tadrous P.J. Diagnostic criteria handbook in histopathology: a surgical pathology vade mecum

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Cut-Up and Reporting Guidelines 39

The term ‘glottis’ refers to the true vocal cords and space between them (called the rima glottidis).

The laryngeal spaces are based on the natural ﬁbroelastic membrane and lymphatic territories that are

relevant to the local spread of tumour. The ﬁbroelastic membranes (akin to the muscularis mucosae in

other sites) mark the boundary between mucosa and submucosa and penetration of this membrane by

tumours limited to the true cord contraindicates local ablation Rx.

The laryngeal regions are for description of tumour subsite and distribution. The lower limit of the

glottic region is not universally agreed but one should state if a glottic tumour extends >1cm below

the true cord (= ‘glottic tumour with subglottic extension’) and distinguish these from tumours that

are entirely subglottic (i.e. no true cord involvement).

Axilla (Lymph node levels)

I (low axilla and intramammary): low axillary LN lie below and lateral to the pectoralis minor

II (mid axilla) lie superﬁcial and deep to the pectoralis minor

III (apical axilla region) lie above and medial to the pectoralis minor. The actual apical nodes lie just

lateral to the 1

rib below the axillary vein

Other named regions are: internal mammary, infraclavicular (= subclavicular) and supraclavicular

All the above count as locoregional LN for breast carcinoma by TNM6 if they are ipsilateral

Inguinal Lymphadenectomy

pubic

symphysis

anterior superior

iliac spine

inguinal

ligament

iliac vessels:

common

internal

external

limits of dissection for

inguinal lymphadenectomy:

modified

standard

fossa ovalis (filled with

the loose cribriform fascia)

great saphenous vein

superficial fascia

(= subcutaneous fat

of Camper plus deeper

membranous layer

of Colles)

deep fascia

(fascia lata)

CR node

region of superficial

inguinal nodes

Points to Note:

•

The femoral artery begins as

the continuation of the external iliac

at the midpoint between the anterior

superior iliac spine & pubic symphysis.

•

The fossa ovalis here refers to the

saphenous opening in the fascia lata.

•

The external iliac nodes are shown

in grey.

•

The deep inguinal nodes (in the

fossa ovalis) are shown in yellow and

one is constant, labelled as 'CR Node',

at the medial high point of the femoral

vein (= Cloquet's node of Rosenm

ller).

•

The superficial inguinal nodes lie near

Colles' fascia, are arranged in vertical

& horizontal groups and total upto 25.

The lateral part of the horizontal group

receive lymph from the lower back.

The region marked 'SN' is where the

sentinel nodes of penile

are found.

•

The modified lymphadenectomy field

is that of Catalona and is a saphenous

vein-sparing method with fewer complic-

ations used prophylactically in clinically

node negative patients - but may be

converted to the standard radical

dissection if positive nodes are found

(incl. by the use of frozen section).

FIGURE 4.5 Inguinal lymphadenectomy

Heart: Conducting system

Key (View of heart from the right)

SVC

IVC

aorta

position of

crista terminalis

strip to be taken

for SA node

block to be taken

for AV node & His bundle

block to be taken

for left & right

bundle branches

1. Rt. atrial appendage

2. fossa ovalis

3. coronary sinus

4. eustachian valve (of IVC), the continuation of which

(shown as a dotted grey line) overlies the tendon

of Todaro

5. annulus (attachment) of the septal cusp of the tricuspid

6. triangle of Koch (base = 3, sides = 4 & 5)

7. septal cusp of tricuspid

8. membranous septum

9. septal papillary muscle(s)

10. moderator band

FIGURE 4.6 Heart: Conducting system

For the dissection method, block-taking and relevant bibliography, see pp. 389–390.

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Cut-Up and Reporting Guidelines 40

Upper GI Anatomy

Pancreatic Components

1. Head (to the Rt. of the Lt. border of the SMV)

2. Uncinate process of the head

3. Body (between the head & the Lt. border of the aorta )

4. Tail (to the Lt. of the Lt. border of the aorta)

Left gastric

Oeso

phag

eal

bran

hes

Short gastric arteries

Right & Left gastroe

iploics

Inferior mesenteric vein

(joining the splenic vein)

IVC

Superior mesenteric vein (SMV)

and artery

Hepatic arteries

Portal Vein

Common bile duct

Gastroduodenal artery

(goes behind D1)

Superior and Inferior

pancreaticoduodenal

arteries

Porta Hepatis Contents

1. Portal veins (Lt. & Rt.)

2. Hepatic ducts (Lt. & Rt.)

3. Hepatic arteries (Lt. & Rt.)

4. LNs (draining liver & gallbladder)

Operative Specimens (Pancreas)

Whipple's:

1. head of pancreas

2. distal bile ducts & gallbladder

3. duedenum

4. stomach (distal 2/3)

Pylorus-preserving pancreaticoduodenectomy:

1.- 3. above

Total pancreaticoduodenectomy:

as for subtotal ± spleen

Sub-total pancreaticoduodenectomy:

+ body of pacreas

± stomach

1.- 3. above

Distal pancreatectomy:

body & tail of pancreas ± spleen

Branches of the Coeliac Axis

1. Lt. gastric artery

2. Splenic

3. Hepatic

Lt. gastroepiploic

pancreatic branches

short gastrics

Rt. & Lt. hepatic

gastroduodenal

Rt. gastric

Rt. gastroepiploic

superior

pancreaticoduodenal

Main Vessels Labelled

FIGURE 4.7 Upper GI anatomy

The minor duodenal papilla, when present, is 2cm proximal to the ampulla of Vater ± a little anterior

The Lt gastric artery is most commonly involved with gastric ulcers; the gastroduodenal with DU

Surgical alterations

Normal

Proximal gastrectomy with gastric tube reconstruction

Proximal gastrectomy with direct oesophageal anastomosis

Total gastrectomy

CUT HERE

Billroth 1 (Hofmeister anastomosis) Billroth 2

Colon

Gastric bypass

Total gastrectomy

Distal gastrectomy

Choledochojejunostomy

Billroth 2 Anterior gastrojejunostomy

FIGURE 4.8 Surgical alterations

The Billroth distal gastrectomies have many modiﬁcations e.g. Hofmeister anastomoses only allow a

patent lumen near the greater curve part of the cut stomach while Polya anastomoses allow lumenal

continuity over the whole length (a Polya Billroth 2 also tends to have a retrocolic anastomosis).

The middle row shows some procedures for which a Roux-en-Y jejunal anastomosis is used.

A pyloroplasty is often performed with proximal gastrectomies.

A jejunal pouch (e.g. ‘U’-shaped) may be used to restore continuity after proximal or total gastrectomy.

A segment of colon or jejunum may be used to reconstruct after a high oesophagogastrectomy.

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Cut-Up and Reporting Guidelines 41

Liver (Segmental anatomy)

falciform ligament

gallbladder

caudate lobe

hepatic artery &

portal vein branches

IVC

hepatic veins

ANTERIOR VIEW

POSTERIOR VIEW SUPERIOR VIEW

hepatic veins (projected)

left

middle

right

IVC

FIGURE 4.9 Liver (Segmental anatomy)

Although Rt and Lt lobes are deﬁned by the falciform ligament; segments are vascular compartments

useful for planning surgery and are precisely deﬁned for any individual by pre-op radiology.

The bold broken line in the ﬁgure joins the left side of the groove for the IVC to the mid-part of the

gallbladder fossa and divides the liver into left and right hemilivers.

The falciform ligament divides the left hemiliver into segments 4 and 2+3.

The caudate lobe is segment 1.

Lower GI Anatomy (blood supply)

SMA

IMA

ILEO

RIGHT

MIDDLE

LEFT

SIGMOID

SUPERIOR

RECTAL

Key to Arteries:

1. ileocolic

2. right colic

3. middle colic

4. left colic

5. sigmoid

6. superior rectal

NB: The IMA arises

≈

4 cm

above the aortic bifurcation

& may be small.

Operation Vascular Ties

Rt. hemicolectomy ileocolic, Rt. colic ± mid colic

Transverse colectomy midcolic ± Lt. colic

Lt. hemicolectomy

Lt. colic, sigmoid, ± superior rectal

Anterior resection/APR superior rectal

FIGURE 4.10 Lower GI anatomy (blood supply)

Some lesions (e.g. carcinoids) may be categorised according to the part of the gut they arise in using

embryonic terminology as: foregut, midgut, hindgut, tailgut. The ﬁrst 3 correspond to those parts of

the adult GIT supplied by the coeliac axis, SMA and IMA.

The tailgut (a diverticulum of the hindgut under the tail-root of some animals) may persist to form a

tailgut cyst (multilocular retrocaecal hamartoma with smooth muscle in the wall and a variable lining

from columnar to transitional/squamous) or adenocarcinoma.

Kidney (Hilar structures)

The renal vein is (usu.) the most anterior structure (anterior to the renal arteries and pelvis/ureter).

The renal artery usu. has three branches at the pelvis – two go anterior to the pelvis/ureter and 1

posterior.

The renal sinus is that part of the pelvis lateral to the hilar plane, its fat envelops the collecting system

and abuts the renal cortex without an intervening ﬁbrous capsule.

Invasion (incl. microscopic invasion) of the sinus fat by carcinoma constitutes stage pT3a.

The sinus contains muscular tributaries of the renal vein, gross invasion of which by carcinoma consti-

tutes stage pT3b (renal vein involvement).

Urinary Bladder

The superior posterior aspect is covered by serosa.

The urethral aspect is tapered.

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Cut-Up and Reporting Guidelines 42

Prostate

Bladder

PZ PZ

A S E

A P E X

Internal

urethral

meatus

External

urethral

sphincter

Urethral crest and

Verumontanum

(with openings for

ejaculatory ducts

& prostatic utricle)

Ampulla of vas deferens

Seminal vesicle

Fascia of Denonvilliers with its

median (longitudinal smooth) muscular

thickening - ! not rectal muscularis propria

Adipose

Neurovascular

bundle (capsular invasion

is most common in the

regions of nerve penetration

at the superior and inferior

pedicles)

Glands

Main

Submucosal

Periurethral

(= mucosal)

P O S T E R I O R

Apex

Base

Posterior View

Attachment of

bladder base

Internal

urethral

meatus

Anterior View

Attachment of

rectum

Oblique

transverse

slice of the

superior half

Cowper's

bulbourethral

gland

FIGURE 4.11 Prostrate

For TNM staging the prostate may be divided into Lt. and Rt. halves (=‘lobes’) ignoring the anatomical

middle lobe as a distinct entity; involvement of the external sphincter urethrae (striated muscle) or

bladder neck (smooth muscle) = pT4.

pT2b (tumour restricted to >1/2 of 1 lobe) is interpreted as >50% volume by some (in which case it

is vanishingly rare) or tumour linear dimension >1/2 of the lobe’s linear dimension by others.

Penis

Ventral

Dorsal

FIGURE 4.12 Penis

Specimens may be distorted by disease and ﬁxation artefact.

The most dorsal aspect contains the dorsal vein overlying the paired corpora

cavernosa, the latter enclosed in a thick ﬁbrous coat – the tunica albuginea

corporum cavernosum.

The urethral is most ventral and surrounded by the corpus spongiosum

invested in a thinner tunica albuginea corporis spongiosi.

The spongiosum overshoots the cavernosa and expands to cover the distal

cavernosa in the form the conical glans penis. Its oblique basal rim, the

corona glandis, overhangs the shaft and the groove be-

tween the shaft and corona is the coronal sulcus. The

obliquity is such as to allow the dorsal corona to be more

proximal than the ventral part.

The overlying skin contains a sub-dermal dartos smooth

muscle layer with Buck’s vascular ﬁbroelastic fascia sep-

arating this muscle from the tunica albuginea of the 3

corpora.

(anterior

peritoneal

reflection)

(posterior ovarian pedicle)

3. (anterior round ligaments

with forcep marks)

UTERUS ANTEROLATERAL VIEW

FIGURE 4.13 Uterus

Uterus (Orientation)

There are three main landmarks, some of which may not

be present in every specimen):

1. the peritoneal reﬂection is higher anteriorly

(bladder) than posteriorly (pouch of Douglas)

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Cut-Up and Reporting Guidelines 43

2. the ovarian pedicles (or ovaries if present) are on the posterior surface of the broad ligament

3. the round ligaments are anterior (these usu. have forceps marks imprinted on them as the

surgeon grasps the uterus and pulls it forward by the round ligaments during an abdominal

hysterectomy).

Specimen Handling and Reporting Guidelines

Interpretation of LN Metastases w.r.t. the TNM6 Classiﬁcation

Tumour in a LN is considered LN +ve whether it got there by metastasis or direct extension

Tumour deposit without residual LN structure is LN +ve if it has a smooth outline consistent with the

form of a LN (else = vascular +/ discontinuous tumour spread). In the UK this is controversial (2007)

and some (e.g. GI pathologists) advocate continued use of the TNM5 rule based on size not contour

(viz. a deposit >3mm

 in a lymph draining region is a LN metastasis, if ≤3mm = discontinuous 1

◦

tumour spread and is included in the pT category). See also Neck Dissection below

Tumour nodules in a LN that are >2mm in max. dimension are LN +ve with no further qualiﬁcation

If ≤2mm but >0.2mm =‘micrometastasis’: use the ‘mi’ qualiﬁer, e.g. pN1(mi), only if there are none

bigger

If ≤0.2mm then = ‘isolated tumour cells’ (ITC) and staged as pN0(i+)

The ITC concept is also valid for the pM classiﬁcation in bone marrow (pM0(i+))

That ITC results in a pN0 stage is controversial in the UK (2007) so some advocate adding a comment

like ‘this would previously have been called pN +ve’

In some pN stages, size of the LN metastasis is important (not the size of the whole LN)

LN mets distant to the regional lymph drainage ﬁelds are included in the pM category (not pN)

Use of pTNM implies a resection sufﬁcient to assess the most extreme scores

Central Nervous System (CNS)

Record volume of sample and nature of procedure (incl. whether CUSA was used)

Decalcify bony fragments and consider samples for glutaraldehyde (EM) or freezing (molecular genet-

ics) if CPC suggests an unusual tumour.

Lobectomy: give anatomical description, bread-slice coronally (5mm intervals), record presence/extent

of necrosis and comment if there is margin / meningeal involvement

Blocks: embed all if small/stereotactic biopsies else take sufﬁcient blocks to document tumour hetero-

geneity, invasion across anatomical boundaries and margins

Margin status should not be described as ‘clear’ for most 1

◦

CNS tumours except for intact meningioma

resections

Reporting: give tumour type and WHO grade (there is no TNM staging because CNS tumours inﬁltrate

diffusely and rarely metastasise; however, describe if anatomical boundaries are breached: into bone,

through pia into subarachnoid space, meningioma invading brain or dura/bone, etc.)

Brain smears: place a tiny piece of fresh sample (≤1mm

) onto a slide, squash gently with a second

slide on top until it forms a thin layer then sweep the top slide over the ﬁrst to produce the smear. Fix

in alcohol and stain with H&E (cytoplasmic detail) or 1% toluidine blue (good nuclear detail)

Muscle Biopsy (Non-neoplastic)

1–2 pieces received fresh (sutured to a stick while in situ +/ laid out on card to avoid contraction and

to preserve orientation). Site is usu. deltoid or quadriceps.

≈1mm

taken to glutaraldehyde for EM (longitudinal sections)

≈0.5 × 0.5 × 2cm snap frozen (unﬁxed) for transverse sections for LM (! avoid ice crystal artefacts)

Routine stains: H&E, PAS, myosin ATPase (various pH), NADH, Sudan Black, Gomori trichrome

Others as indicated: dystrophins, spectrin, myosins, phosphorylase, cytochrome oxidase, etc.

See table 13.3 on p. 188 for interpretation of these stains.

Peripheral Nerve Biopsy (Non-neoplastic)

(See p. 389, under ‘Nerves for ? Neuropathy’.)

or pN0(mol+) if tumour cells were detected by non-morphological methods e.g. ﬂow cytometry

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Cut-Up and Reporting Guidelines 44

Eye

The terms ‘inner’ [or ‘internal’] and ‘outer’ [or ‘external’] refer to ‘towards the centrepoint of the globe’

(the centre of the vitreous) and ‘towards the surface of the globe’ respectively.

Measure globe (length and ), pupil  and optic nerve length.

The vortex veins are harvested and embedded (longitudinally) with the cut end (margin) of the optic

nerve in a standard cassette.

After transillumination via the cornea (to mark the base of any tumour) or via the optic nerve (to

examine the cornea/iris), the globe is cut into three slices (‘calottes’) where the cuts pass 1mm into the

corneal limbus – either horizontal (for macular lesions), vertical (for glaucoma / cataract assessment)

or oblique – with the middle calotte containing the pupil, iris, lens, optic nerve and main bulk of any

tumour. Each calotte is embedded in a separate deep cassette. However, this is not always optimum

with some tumours so the specimen should be cut so as to yield the following information:

 for iris melanoma radial extent (in terms of clock hours) and extension (ciliary body, sclera

and extraocular) is important for staging

 for ciliary body and choroidal melanoma the largest basal diameter (in mm or optic disc di-

ameters) and maximum height of the tumour (in mm or diopters) are important for T stage.

Penetration of the sclera with extraocular extension and vascular invasion (including vortex

vein) are important but penetration of Bruch’s membrane is irrelevant (unlike with retinoblas-

toma)

 for retinoblastoma tumour height, distance from tumour base to fovea and optic nerve, retinal

detachment, subretinal deposits (penetration of Bruch’s membrane) ± choroidal / scleral in-

vasion or orbital (extra-ocular) spread, optic nerve invasion (Magramm gade 1 = prelaminar,

2 =upto and including the lamina cribrosa, 3 = beyond it, 4 =optic nerve margin involved),

deposits in the vitreous (seeding) should be distinguished from true multifocality (>1 deposit

within the retina), vitreous extension to contact the lens, deposits in ciliary body / iris / anterior

chamber

 for exenterations, measure skin margins, ink superior/inferior halves and nasolacrimal duct

margin (sample this margin and the optic nerve margin), remove and decal any bone, then

bread slice in vertical sections 1cm thick (ﬁrst and last cuts should just avoid the eyeball).

Temporal Artery Biopsy for ? Arteritis

Cut the biopsy into 2mm long transverse slices.

Embed all the slices en face and request levels and EVG.

Head and Neck (SCC and Other Types of Carcinoma)

Clinical data

The surgeon should:

 orientate the specimen (and pin-out a neck dissection, marking the major LN levels)

 give the clinical TNM stage and state whether prior therapy was given

 specify the side and op-type e.g. neck dissection – selective / radical / modiﬁed radical.

Biopsies

State if dysplasia or vascular invasion is present in addition to tumour characteristics.

Main resection (general)

Some advocate decalciﬁcation of specimens with soft tissue in situ before dissection.

Measure (mm) max. depth and  of tumour. Tumour depth is measured from the lumenal surface

(extrapolated to the level of the surrounding, uninvolved, surface if there is ulceration).

Take 1 block per cm  of tumour (plus margins, uninvolved mucosa, thyroid, etc.)

Tumour type, extent, and subsite (e.g. supraglottic, glottic, transglottic or infraglottic – see Figure 4.4)

Grade (by worst area) – well / moderately / poorly diff

Pattern of invasive front: cohesive/non-cohesive (non-cohesive = strands <15 cells wide/single cells)

Distance to margins (mucosal and soft tissue) <1mm = ‘involved’, >5mm = ‘clear’, else = ‘close’

Invasion of:

 vessels

 nerves (esp. if beyond the invasive front of the main tumour)

 bone (distinguish erosion of cortex from invasion of intertrabecular spaces)

Dysplasia (presence, degree, distance to margins)

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Cut-Up and Reporting Guidelines 45

Laryngectomy

If it will not disrupt the tumour, a longitudinal posterior midline incision may be made to assess tumour

extent – otherwise, leave the specimen intact.

Some advocate sharp dissection to remove the hyoid (to avoid decalcifying the whole specimen) with

examination of the soft tissue thus exposed and histology of the hyoid only if that tissue is involved.

The UK National Dataset advises whole decalciﬁcation followed by serial 5mm transverse slicing.

Assess the caudal and anterior (tongue base) submucosal margins (as well as mucosal) by sagittal

sections.

State if (and where) tumour has perforated the cartilages with extralaryngeal soft tissue spread.

State if tumour has crossed the midline.

State what other structures are present (e.g. parathyroids) and examine as appropriate.

Maxilla, mandible, sinuses and other specimens

See Slootweg, 2005

Neck dissection

For each level state: n˜o. of LN present and n˜o. of LN involved and whether extracapsular spread (if

extracapsular spread approaches a surface of the specimen, ink that surface and block such as to estimate

distance of / involvement by tumour).

Measure size of largest metastasis (for TNM).

For matted LN state the max. dimension of the mass and its level.

Ignore TNM6 rule and call a LN metastasis if there is a deposit in a lymph drainage ﬁeld (call it

‘discontinuous spread’ only if it is <10mm from the 1

◦

and there is no residual LN structure).

State if vascular invasion is seen (= poor prognostic).

Take blocks of other structures involved by tumour (salivary gland, sternomastoid, jugular vein).

Oesophageal Tumours (incl. Siewert & Stein Type 1 Adeno

CA)

Biopsies

Type of cancer and depth of invasion (state if submucosal tissue is present and whether it is invaded)

Presence of dysplasia or the metaplasia of Barrett’s oesophagus

Resections macro

Length of oesophagus (state if pinned prior to ﬁxation) and any stomach

Tumour site relative to GOJ / highest peritoneal reﬂection: if >50% above = oesophageal (if exactly

at the junction then = oesophageal if SCC/SmCC/undiff

CA but = gastric if adenocarcinoma)

Tumour max. , length, distance to margins and whether polypoidal or not

Always take both proximal and distal margins (circumferential en face method preferred)

Location of any LN found (e.g. coeliac vs. other perigastric)

Resections micro

Tumour type and grade (well, moderately or poorly diff – by worst area)

Depth (incl. level) of invasion (TNM) and if CRM is involved (i.e. <1mm clearance) [NB: CRM

clearance can’t be assessed if the surgeon has dissected LN from it separately]

Serosal surface involvement (NB: only the gastric part will have a serosa)

Vascular invasion

Total n˜o. of any LNs found as well as n˜o involved by tumour

Presence of dysplasia or the metaplasia of Barrett’s oesophagus

Gastric Carcinoma (incl. Siewert and Stein Types2&3Adeno

CA)

Specify gastrectomy type: total, partial (proximal/distal), oesophago; measure length of components

Normally open along anterior greater curve (but avoid tumour and any gastrojejunostomy line)

Tumour: size (max. ), distance to margins, Borrmann type (polypoid / fungating / ulcerated vs. diffuse)

Tumour site incl. Siewert and Stein type for peri-cardiac adenocarcinoma (Type:

◦

midpoint of tumour

is 1–5cm above the anatomical cardia;

◦

from 1cm above to 2cm below the cardia;

◦

2–5cm below

the cardia). ‘Anatomical cardia’ = the most proximal limit of the gastric rugae

(or highest peritoneal

reﬂection).

≥3 blocks from tumour + all LN; take margin blocks parallel to the margin (esp. at oesophageal end)

+ take adventitial CRM if tumour goes near the lower oesophagus

NB: Siewert & Stein deﬁned these types of adenocarcinomas using endoscopic and radiological localisation

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Cut-Up and Reporting Guidelines 46

Type (adeno/other), class (by Laur´en), grade (poor/other – by worst area), vasc. invasion (lymph and

blood)

Depth:

into subserosa = pT2b, penetration of serosa = pT3 (not invading other organs, else = pT4)

Liver (for 1

◦

HCC or Metastatic Carcinoma)

Macro

Measure, incise and drain gallbladder, weigh; capsule intact? any adherent structures?

Serial 1cm slicing in ‘CT-plane’ if practicable; distance of tumour(s) to all margins

Note number, size and site of all tumours ± satellites (= nodules <10mm  surrounding a larger

tumour) ± vascular invasion

Tumour blocks: HCC →≥3; mets → 1 from each met (more if neoadjuvant Rx given)

Micro

Tumour type (and grade if HCC), margin and LN status, background liver

PT vascular invasion requires the identiﬁcation of a residual lumen and endothelium

Exocrine Pancreas, Bile Ducts and Ampulla of Vater

Macro

Ink, open duodenum; some recommend slicing the pancreas prior to ﬁxation

Note named structures e.g. vessels

Record specimen dimensions and lengths (incl. ducts)

Tumour size and site (head / body / tail / whole / Ampulla / bile ducts) incl. multicentricity

Spread to other structures: LN, portal vein

Distance to margins: duodenal +/ gastric, ducts, pancreatic (transection, retroperitoneal, medial

)

LN groups: bile duct, infrapyloric (regional to head tumours only), pancreaticoduodenal (ante-

rior/posterior), pancreatic (superior/inferior), pancreatic tail and splenic hilum (not regional to head

tumours), coeliac (not regional to body/tail tumours); [Note: tumours <2cm

 are unlikely to be node

+ve]

Micro

Tumour type and grade (according to worst area – see p. 176)

Margins (as above) or anterior pancreatic capsule invasion / extension

Local spread (pT stage is that of TNM5):

 perineural

 (pT3): duodenum, Ampulla, bile ducts, peripancreatic fat

 (pT4): stomach, colon, spleen, large named vessels (portal, superior mesenteric or common

hepatic)

Appendix (for Carcinoid)

Tumour subtype, size (</>2cm), clearance at base, LN involvement, invasion of mesoappendix or onto

serosal surface, vascular invasion and perineural invasion may all inﬂuence further Mx

Colorectal Carcinoma

Macro (rectal only):

 relation to anterior peritoneal reﬂection (and distance to dentate line if APR)

 grade the CRM plane as:

◦

mesorectal (bulky, no coning, no defect deeper than 5mm);

◦

intramesorectal (coning to levators, moderate bulk but irregular, no muscularis propria

visible);

◦

muscularis propria (not bulky / deep defects with muscularis visible)

A margin is considered ‘involved’ if tumour (main, separate deposit or in a LN or any vessel) extends

to 1mm from it

If the tumour is a poorly diff / inﬁltrative subtype then proximal and distal margins / doughnuts should

be sampled for histology (even if the tumour is >3cm clear macroscopically)

Extratumoural deposit ≥3mm = ‘LN +ve’ (in TNM6, only if form and smooth outline are consistent

with a LN else = ‘vascular invasive deposit’ V1 if micro only / V2 if visible macroscopically)

‘early gastric cancer’ = pT1 (limited to mucosa/submucosa) i.e. not muscle invasive (pT2a) or beyond

The medial pancreatic margin (= ‘SMV margin’) is the fatty tissue deep to the head – it is the plane dissected off the superior

mesenteric vein / portal vein and superior mesenteric artery

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Cut-Up and Reporting Guidelines 47

Serosal involvement does NOT imply incomplete excision (because it is not a surgical margin)

pT3 or greater: measure the greatest extent of extramural extension

pT4 = serosal breach (pT4b) or adjacent organ spread (pT4a) including colon to colon (by way of the

serosa – so may be pT4 a and b) or direct spread into the levator striated muscles

pM1 includes non-regional LN mets (e.g. para-aortic)

Extramural vasc. invasion = tumour cells in endothelial-lined space with blood or muscle

Use ypTNM if previous chemo/radioRx and decide if response to neoadjuvant Rx is ‘complete’,

‘marked’ (tumour epithelium identiﬁed with difﬁculty) or ‘not-marked’

High risk subgroup of Dukes B CA has any of the following:  CRM involvement

 perforation

 serosal surface involvement

 extramural venous invasion

Lymphoma

Cases where referral to a haematopathologist is advisable:

All paediatric lymphomas, any TCL, ? Burkitt’s or lymphomas assoc

with immunosuppression

Where the distinction between reactive and neoplastic is blurred (e.g. in AITCL or some FCL)

Any which have atypical morphology or immuno or where distinction between types is difﬁcult (e.g.

lymphocyte depletion HL vs. ALCL or CLL vs. MCL)

Specimen handling and reporting

Specify site and use a standard ﬁxation regimen (helps standardise immuno results).

Remember to look for hilar LN and splenuncula in splenic resections.

Cut thin sections and use WHO classiﬁcation (use immuno, even if H&E seems obvious).

An H&E, PAS, retic, Giemsa on one block may help (± Perls’ for trephines).

For trephine involvement specify type of lymphoma present.

Lung (for Cancer)

Biopsies

Conﬁrm if it is cancer and, if so, whether it is small cell / non-small cell type.

Only attempt to sub-classify further if deﬁnite features are present (‘report only within your limits’).

Resections

Inﬂate lung with formalin (if bronchus is blocked you can inject the parenchyma with a needle).

Sample bronchial and vasc. margins then slice longitudinally down bronchi or multiple transverse cuts

or sagittally.

Describe site according to bronchopulmonary segmental anatomy

Blocks: ≥3 of tumour (block all if ≤2cm ) and ≥3 of uninvolved lung and others

LN:  describe separately sent LN according to their station

 N1 nodes are in the lung

 N2 nodes are outside the hilar pleural envelope e.g. peribronchial or mediastinal.

Use the WHO classiﬁcation for tumours (see Chapter 8: Respiratory and Mediastinum)

Visceral pleural invasion is deﬁned as tumour breaching the superﬁcial elastic layer (the pleura has a

characteristic double elastic layer which differentiates it from ﬁbrosis .

. use EVG)

Features to note re staging

Largest tumour  (= pT3 if >3cm)

Distance of invasive tumour to the bronchial resection margin

Whether the tumour is in the main bronchus or a lobar / more distal bronchus (if in main bronchus,

distance from carina determines stage: pT2 if >2cm, pT3 ≤2cm and pT4 if invading the carina itself

– may need CPC to stage)

Is there >1 tumour in the same lobe as the 1

◦

(= pT4) or a deposit in a different lobe (= pM1)?

Is there invasion of pleura (= pT2), mediastinal pleura (= pT3) or mediastinal soft tissues (= pT4) ?

Does any assoc

‘atelectasis’ or obstructive pneumonia extends to the hilar region (= pT2) or involve

the entire lung (= pT3) ?

Is there a cytology positive pleural effusion (= pT4) ?

Peritoneal deposits away from the 1

◦

site are classiﬁed as ‘pM1 PER’ but make sure your oncologist knows that this does not imply

distant haemoatogenous/lymphatic mets

JWBK208-04 December 8, 2007 15:59 Char Count= 0

Cut-Up and Reporting Guidelines 48

Lung (for Non-neoplastic Occupational Disorders / Pneumoconioses)

Examine externally for pleural plaques, hilar LN, etc. and note size and n˜o of lesions.

Inﬂate the lung with formalin via the main bronchus to ﬁx.

Slice sagittally at 1–2cm intervals and prepare one wholemount (Gough-Wentworth) section [protocol

for this can be found in Gibbs and Attanoos (2000) – see Bibliography]

Asbestos body concentration can vary 10-fold depending on site so, for each lung, sample at least 4

(non-tumour) blocks: apex of upper and lower lobe + base of lower lobe + main bronchus with LN.

Include pleura in some of the blocks and sample any focal lesions.

Describe and quantitate 1

◦

and 2

◦

dust foci, interstitial ﬁbrosis and emphysema (for grading systems

see p. 85, and Gibbs and Attanoos, 2000)

Skin Cancers

Specify type, site and 3-dimensions and ink the margins

Fusiform / ellipse excision: bread slice,

embed max. 1 slice per cassette for malignant melanoma or 2

slices for SCC / BCC; embed polar ends with your cut face down (to be sectioned ﬁrst)

Re-excision Bx: treat such as to be able to comment on completeness of excision of the scar

Measure peripheral and deep margins to nearest whole mm if >1mm clearance, else state ‘<1mm’ (if

involved record as ‘0 mm’); state measures for invasive and in situ components in SCC/melanoma

Comment on neural / vascular invasion

BCC

Type (nodular (NST), superﬁcial multicentric, inﬂammatory / morphoeic, micronodular, etc.)

Moderately / severely atypical squamous component present

pT stage ∝ diameter and whether invades muscle / cartilage / bone (= pT4)

SCC

Type (NST, spindle, acantholytic, verrucous, desmoplastic, pseudoangiosarcomatous, etc.)

Grade: well / mod. / poorly / undifferentiated (see p. 284)

Clark level (but some clinicians may ﬁnd this confusing so local protocols may not require it)

Tumour thickness (from beneath keratin layer)

pT stage as for BCC

Malignant melanoma

Type (lentigo maligna, superﬁcial spreading, nodular, acral lentiginous, desmoplastic, neurotropic,

naevoid [i.e. symmetrical, cytologically homogeneous and minimal stromal reaction], etc.)

Macro: nodule present, pigment, border

Growth phase (VGP / HGP) – deﬁned in Chapter 20, p. 291

If VGP → mitotic count per 10hpf and tumour lymphocytic response (brisk, non-brisk, absent)

Ulceration (incl.  of ulceration)

Presence of:

A microsatellite, deﬁned by T.J. Harrist et al. (1984), is a

nest (>0.05mm

) in the reticular dermis, subcutis or vessels

beneath the main tumour and separate from it [by ≥0.5mm

according to the RCPath Dataset].

a) regression

b) microsatellites

c) a benign naevus component

Clark level and Breslow thickness to 2 d.p. of a mm (from beneath the keratin layer or ulcer base

ignoring appendigeal sheath extension of melanoma); NB: Clark level only adds signiﬁcant prognostic

information for thin melanomas (i.e.Breslowthickness ≤0.75 mm) that usu. havean excellentprognosis.

pT stage ∝ depth and ulceration

Frozen Sections and Mohs’ Micrographic Surgery

FS is not usu. done on skin cancer (and should normally be avoided in melanoma)

Mohs’ surgery (the pathology is usu. done by the surgeon – a dermatologist trained in pathology):

 usu. done for BCC / SCC which is recurrent, ill-deﬁned or in an anatomically sensitive site

 is an iterative surgical procedure involving mapped excision of a lesion with FS of all margins

and re-excision of involved areas at the same sitting.

Renal Biopsies (Medical/Transplant)

Put Bx in saline immediately after taking it and look for glomeruli with a dissecting microscope.

Under the dissecting microscope, divide into three pieces: 1mm of glomerulus-containing cortex for

EM (glutaraldehyde), 2mm of glomerulus-containing cortex for IF (place in special transport medium

For a very large circular Bx, cruciate-type sampling is acceptable; for a very small Bx (<5mm) with no clear lesion, embedding

whole is acceptable.