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Ucla gross manual - By The University of Chicago Department of Pathology
Cutting Manual - Genitourinary
The anatomic orientation of the specimen in the axial plane allows the parametrial tissue to be oriented as right or left. Radical trachelectomy specimen viewed from anterior surface A and from en face of the cervix B. Bilateral parametrial tissues white arrows should be inked. The vaginal cuff black arrows may retract around the cervix and should be stretched out before measuring its length and before pinning for formalin fixation.
The endocervical margin red arrows should be inked as well as the connective tissue at the outer surface of the anterior wall white star of the cervix and the posterior wall. The nonperitonealized connective tissue at the outer surface of the anterior and posterior cervical walls is not a true surgical margin though this is often referred to as a radial or paracervical margin Nevertheless, as the status of this surface involved by tumor vs. The margins to ink are the endocervical, vaginal, and parametrial margins, as well as the nonperitonealized connective tissue at the outer surface of the anterior and posterior cervical walls.
It is recommended to document the measurements of the cervix, vaginal cuff, and parametria. As the vaginal cuff may retract around the cervix, it should be stretched out before taking measurements. Documenting the anatomic location of grossly visible tumor assists in the pathologic correlation with radiologic and intraoperative findings, particularly if there is clinical concern for margin involvement by tumor.
We recommend using positions on a clock face and then correlate with the anatomic terminology used by the surgeon to designate the tumor location. If grossly visible tumor invades the cervical wall, the greatest depth of invasion should be documented as well as the total thickness of the cervical wall at that point. A unified approach to determine tumor size measurements in cervical cancer is critical for several reasons: There is significant variation in the method used by gynecologic oncologists, radiologists, and pathologists to estimate tumor size, and currently there is no single recommendation for standard practice.
Importantly, the current FIGO staging system for cervical cancer recognizes pathologic variables to influence stage. Moreover, tumor size measurements taken by the pathologist supercede those obtained clinically or radiologically Size measurements should be obtained in the fresh specimen.
The distance to the margins should also be measured at this time. Measuring the lesion and its distance to margins after fixation and handling opening, pinning is discouraged for 2 reasons.
First, it will likely lead to overestimation of tumor size, as the specimen will be stretched out. Second, there is conflicting evidence on the effect of fixation on specimen and tumor size, with several studies reporting shrinkage after fixation 18 , 19 while others report no significant differences 20 , The 3 macroscopic dimensions of a cervical tumor are its length parallel to the endocervical canal , width in the plane perpendicular to the endocervical canal , and thickness from tumor surface to the tumor deepest invasion point Fig.
Tumor length L is defined as the dimension parallel to the endocervical canal while tumor width W is the plane perpendicular to the endocervical canal.
The tumor depth cannot be appreciated in the specimen in image A A until the specimen is sectioned further. The tumor in B , a different specimen, diffusely replaces the wall of the cervix circumferentially without exhibiting an exophytic component. Tumor depth D is defined as the dimension from the endocervical mucosa through the cervical wall towards the outer connective tissue surface.
Image A is a trachelectomy red arrow is endocervical margin. B A radical hysterectomy red arrow is site of amputation from uterine corpus. If possible, the cut should be perfomed in an area free of gross tumor, though this may not always be possible. This will convert the intact cylindrical shape of the specimen into a rectangle that can be pinned out flat for formalin fixation and will permit the tissue to be sliced in a way that maximizes the preservation of the orientation of all margins for microscopic examination.
This will also permit the vaginal cuff, which normally retracts around the ectocervix, to be stretched out before fixation so that the true distance between this margin and the tumor can be evaluated; otherwise, tissue retraction may lead to a significant underestimate of the length of the vaginal cuff that the surgeon resected.
Removing the parametrial tissues before opening and pinning the trachelectomy is advised. Pins should be placed in a way that does not disrupt the mucosal margins or the tumor itself.
Adequate formalin-fixation will facilitate optimal tissue sectioning. Overnight fixation may be needed. Each slice should have mucosa along one edge from the vaginal cuff margin to the endocervical mucosal margin and the radial paracervical connective margin along the other edge. If the slices are too large to fit in a cassette, they can be divided into 2 or 3 sections and placed in consecutive cassettes. Large format macro blocks, if available, may be of value in such cases. If tumor is grossly visible, sampling should be focused to document the deepest point of invasion as well as the closest distance to all margins.
Aside from these key anatomic landmarks, there is no evidence to guide whether the entire tumor or representative sections should be submitted for microscopic examination. If tumor is not grossly visible then the entire specimen should be submitted for microscopic examination. The vaginal margin should be examined by a perpendicular section at the site of the closest approach of the tumor. In such a case, there is variability across practices as to whether the remainder of the vaginal margin should be examined entirely en face or whether an additional representative perpendicular section away from the tumor is sufficient.
If there is no macroscopic tumor, there is also variability among practices as to whether the entire vaginal margin should be examined en face or whether representative perpendicular sections are sufficient. The parametria should be thinly sliced and entirely submitted, preserving the right and left side orientation.
If lymph nodes are present within parametria, their number, size, and appearance should be documented For this reason, intraoperative evaluation of the proximal endocervical margin is routinely performed in this setting. Margin status is critical in the management of these patients: 1 recurrence rates are influenced by margin status, and 2 while the pregnancy success rate is high in these patients, the pregnancy is at risk of complications such as prematurity and first-trimester miscarriage For these reasons, preservation of as much of the proximal canal as possible is imperative.
The status of the endocervical proximal resection margin determines the need for additional excision 24 , If the proximal margin is positive for invasive carcinoma, radical hysterectomy would be considered.
Alternatively, if feasible, an additional portion of the upper endocervix will be removed. The status of the deep paracervical and vaginal mucosa margins is usually not required intraoperatively. In the absence of any evidence directly comparing these strategies, it is recommended that the protocol of choice be defined at the local practice level, in conjunction with the surgeon to understand their specific intraoperative needs from the pathologic evaluation of the trachelectomy intraoperatively.
The margin status should be reported as either positive or negative for invasive carcinoma and for in-situ carcinoma. If the margin is negative, the distance of the closest approach of tumor should be reported. In sections taken perpendicularly, a positive margin is defined as invasive carcinoma in direct contact with the inked surface of the margin; all other instances are defined as a negative margin. In en face margin sections, a positive margin is defined as invasive carcinoma present in the section, and a negative margin as absence of invasive carcinoma in the section.
Intraoperative frozen section examination of the endocervical margin requires good visualization of the entire wall thickness and the inked margin edge if section is perpendicular. If the initial section is significantly folded or fragmented, obtaining a new level is highly advisable.
Identification of tissue gaps or incision marks before inking is very important, as they may distort the endocervical margin. Ink must be applied carefully, avoiding surfaces that do not represent resection margins. Examination of the specimen with the surgical team may be required.
Benign Mimickers. Mimickers of endocervical adenocarcinoma include tubo-endometrioid metaplasia and endometriosis. In addition, the proximal margin of the trachelectomy specimen may sometimes be at the lower uterine segment or even endometrium functionalis. These scenarios feature mucin-depleted glands and variable degrees of nuclear pseudostratification as well as proliferation, thus highly resembling human papillomavirus HPV -related adenocarcinoma.
In addition, tubo-endometrioid metaplasia can feature reactive stroma, further raising concern for malignancy. Attention to the nuclear characteristics is important. There are 3 types of hysterectomy performed for cervical cancer: radical, modified radical, and simple extrafascial 9.
Parametrectomy is a key surgical goal of radical hysterectomy given the overall risk for microscopic parametrial involvement by cervical cancer, which carries adverse prognostic significance 33 — Modified radical hysterectomy may be considered in some women with stage IA1 with lymphovascular space invasion or stage IA2 cervical cancer. The modified procedure is less extensive. As the risk for parametrial involvement is significantly lower for early stage cervical cancer, less radical surgery has been offered to selected patients stage IA1 without lymphovascular invasion using simple hysterectomy without parametrectomy or upper vaginectomy 36 , In such specimens, there may be some connective tissue attached to the cervix, which should be examined microscopically, but not reported as formal parametrial tissue Two anatomic landmarks permit orientation of a hysterectomy specimen: 1 the peritoneal reflection is shorter on the anterior surface of the uterus because of the normal position of the urinary bladder anterior to the uterus, whereas the peritoneal reflection extends further down the posterior aspect of the uterus.
The parametrial tissue white arrows, A—D at the lateral sides of a radical hysterectomy may vary in size and shape. It may retract B and should be stretched out to ink, measure and dissect. The nonperitonealized connective tissue white stars, A—D at the anterior and posterior surfaces of the cervical wall should be inked to assess for tumor involvement. In some cases C, D a small rim of connective tissue that is not part of the parametrial tissue may also be present at the lateral surfaces of the cervical wall green arrowheads, C, D and should be inked.
The vaginal cuff in all 4 images A—D has retracted around the cervix and should be stretched out before measuring and pinned out for formalin fixation refer to Fig.
The nonperitonealized connective tissue at the outer surface of the anterior and posterior cervical walls is not a true surgical margin though this is often referred to as a radial or paracervical margin Fig.
The margins to ink are the vaginal and parametrial margins, as well as the nonperitonealized connective tissue at the outer surface of the anterior and posterior cervical walls. It is recommended to document the measurements of the cervix, vaginal cuff, parametria, uterine corpus, and, if present, the ovaries and tubes.
As the vaginal cuff may retract around the cervix, it should be stretched out before taking measurements Fig. The vaginal cuff arrows, A—F on a radical hysterectomy may retract around the cervix A, B , which may cause under-reporting of the true measurement of the cuff length and of the distance from tumor to the cuff margin.
Therefore, the vaginal cuff should be stretched out to its full length and pinned before formalin fixation C. This preserves the true dimensions of the vaginal cuff D and permits slicing the formalin fixed cervix E while preserving the relationship of the vaginal cuff margin to tumor and allowing for accurate assessment of the margin status F.
Furthermore, the certification requirements of the American Board of Obstetrics and Gynecology mandate candidates to document specimen weights during their training experience in performing hysterectomies.
For these reasons, pathology practices in the United States typically document the weight of hysterectomies, regardless of the clinical setting. As such conditions may not necessarily apply in other countries, documentation of specimen weight is regarded as an optional recommendation defined by the local practice conditions. If there is no suspicion that the tumor is extending into the parametria, then they can be removed at the interface with the uterine wall before opening the uterus.
If there is suspicion of tumor extension into the parametria then it is recommended to leave the parametria attached in order to permit slicing of the cervix and parametria in continuity to demonstrate direct tumor extention. Even if the hysterectomy is received by the laboratory already in formalin, the endocervical and endometrial lining, as well as any tumor, are the least likely parts of the specimen to be exposed to the formalin if the uterus was not opened.
Thus, such specimens should also be opened immediately upon receipt in the pathology laboratory. If the specimen is received fresh, 2 options exist to open the uterus. The first consists of amputation of the uterine cervix from the corpus and process the cervix using the same strategy as for an intact cone or trachelectomy Fig. The uterine body is then opened along the lateral walls using the conventional bivalve approach, resulting in an anterior and a posterior half.
The advantage of this strategy is that it permits well-oriented, uniformly thin slices of the cervix to be cut, which facilitates optimal microscopic evaluation for invasion and margin assessment. The disadvantage is that this requires laboratory staffing to be available to perform this processing immediately upon receipt of the fresh specimen.
The second option is to use the conventional bivalve approach for opening a uterus along the lateral wall resulting in an anterior half and a posterior half 42 , and can also be used if the hysterectomy is received in formalin. The disadvantage is that the cervix will have to be dissected using a radial slice strategy, similar to that for a formalin-fixed intact cone, which produces slices of uneven thickness that have to be trimmed down to fit in the cassette properly.
The decision is left to each local practice as to which of these 2 strategies to use. Dissection of a fresh radical hysterectomy using the strategy of cervical amputation begins with inking of the parametrium, paracervical connective tissue and vaginal cuff margins A. If there is no suspicion for tumor extension into the parametrium, then the parametrium from each side is removed with scissors B, C and the cervix is amputated D from the uterine corpus E.
The resulting opened cervix G is pinned out flat for formalin fixation H. The uterine corpus is opened either by using scissors along the lateral borders not shown or by placing forceps into the endometrial cavity and guiding a knife between the forceps arms I to bivalve the specimen into anterior and posterior halves J.
Once the uterus is opened using either strategy above, immediate formalin-fixation is advised before conducting any further tissue sampling. In addition to preventing the consequences of tissue autolysis, formalin-fixation facilitates cutting thin, well-oriented tissue slices of the cervix and tumor, which in turn facilitates accurate microscopic assessment of tumor dimensions and distances to margins.
Fixation times vary depending on the size of the specimen but a practical approach is to permit the specimen to fix overnight and complete the dissection and tissue sampling the next day. The vaginal cuff, which may retract around the cervix, should be stretched out before pinning.
We recommend using positions on a clock face and then correlating with the anatomic terminology used by the surgeon. This 3-tier system of assessing cervical wall involvement is part of the Sedlis criteria, along with tumor size and lymphovascular space invasion status, used to determine eligibility for external pelvic radiation in cervical cancer patients whose radical hysterectomy shows node-negative, margin-negative, and parametria-negative disease 47 — If parametrectomy is performed, it should be documented whether tumor is confined to the cervix or involves the parametrium.
Tumor involvement of the uterine corpus is important to document as it is associated with increased risk of ovarian and para-aortic lymph node metastasis 39 — The distance of tumor to the vaginal cuff margin, parametrial margin, and nonperitonealized connective tissue at the outer surface of the anterior and posterior cervix walls should be recorded.
As stated in the trachelectomy section, a standardized approach to document tumor size is critical. Tumor dimensions and distance to the margins should be obtained in the fresh specimen, before pinning, stretching and fixation. The 3 macroscopic dimensions of a tumor are its length parallel to the endocervical canal , width in the plane perpendicular to the endocervical canal , and thickness from tumor surface to the tumor deepest invasion point.
However, for practical purposes it is recommended to record macroscopic length, width, thickness, and depth of invasion in the gross description since these data are eventually needed to determine the final dimensions after review of the microscopic findings.
For the purposes of reporting and assigning pathologic tumor stage, only a single final value for each dimension should be given. Details on determining the final tumor dimension are discussed in the separate review in this issue on tumor staging recommendations.
Each slice should have mucosa along one edge from the vaginal cuff margin to the endocervical mucosal margin and the paracervical connective tissue surface along the other edge.
Because of the half-cylindrical shape of the fixed cervix, this will create wedge shaped slices that are thicker at the outer cervical wall. These wedge shaped slices will have to be trimmed so they lay flat in the tissue cassette.
Sampling of any grossly visible tumor follows recommendations stated in the trachelectomy section. If tumor is not grossly visible then the entire cervix should be submitted for microscopic examination. The uterine corpus and lower uterine segment should be examined for tumor involvement. In addition to sampling any gross abnormalities, representative sections of the full thickness ie from endometrium to serosa of the lower uterine segment in respect to any visible lesion and the anterior and posterior walls of the corpus is recommended.
There is no clear evidence to guide whether grossly normal appearing ovaries and fallopian tubes should be microscopically examined in their entirety in this setting. At a minimum it is recommended that the entire fimbriae of each fallopian tube be examined microscopically along with representative sections of the ampullary portion of the fallopian tubes, representative sections of the ovaries, and sampling of any abnormalities.
Pelvic exenteration consists of en bloc resection of pelvic organs with the uterus and vagina. Posterior pelvic exenteration includes the rectum.
Total pelvic exenteration includes both the anterior and posterior organs The procedure is indicated in patients with cervical or vaginal carcinoma recurrent in the central pelvis in which conventional radiation therapy fails to control disease, and in those with advanced stage cancer that are amenable for extensive surgical resection 52 , The examination starts by identifying all anatomic structures Fig.
Taking photographs of the specimen is recommended to document orientation and to permit correlation with the microscopic sections.
Total exenteration for recurrent cervical adenocarcinoma in the vagina A, B, higher magnification of A. Vagina with recurrent tumor black arrow , rectum and sigmoid white arrow and urinary bladder white arrowheads. The margins to ink are the vagina, parametria, urethra, ureters, proximal and distal rectal margins, and soft tissue margins beyond the parametria eg, pararectal and paravesical soft tissues. Measurements of all organs should be taken in the fresh state before fixation.
For the uterus and bladder, 3 dimensions should be obtained. For the rectum, vagina, and ureters, the dimensions to report include the length and the range of their diameter. Inflation of the urinary bladder and rectum with formalin and fixation of the specimen for at least several hours, or overnight, is advised to optimize the quality of the sections Once fixed, the entire specimen can be hemisected to demonstrate the relationship of the tumor to the bladder, rectum and soft tissues.
The tumor should be measured in three dimensions superior to inferior, anterior to posterior, and lateral dimensions and its location with respect to all organs present should be reported, including whether each organ is involved or the gross distance between the lesion and the organ.
Similarly, the distance of the tumor to all margins should be recorded. Recommendations for tumor sampling are the same as those made for hysterectomy specimens. Sections should show the interface between the tumor and other structures vagina, bladder, rectum, soft tissue. Perpendicular sections are advised to show the relationship between the tumor and mucosal surfaces of the bladder, vagina, and rectum. Representative sections of all uninvolved organs should be submitted as should any incidental lesions eg, rectal polyps.
The margins of the vagina and parametrium should be processed according to the recommendations made for hysterectomy specimens. The urethral and ureteral margins, as well as proximal and distal rectal margins, should be obtained en face. Soft tissue margins beyond the parametria eg, pararectal and paravesical soft tissues should be sampled perpendicular to the nearest approach of tumor.
Representative en face margins can be taken if the tumor is far away. Intraoperative consultation in the setting of a pelvic exenteration procedure is rare. It is performed to assess the closest soft tissue margins to the tumor to determine the need for additional margins.
Such margins can be obtained from the main specimen or be submitted separately by the surgeon. En face sampling of the margin is more practical if the tumor is far away, but perpendicular sections are preferred if the tumor or any tissue abnormality is detected at the margin or close to it. A positive or close margin will prompt excision of additional soft tissue. The distance between tumor and margin at which re-excision is recommended has not been standardized. If positive for malignancy, the exenteration is aborted.
Potential pitfalls in the interpretation of these specimens include crushed artifact and radiotherapy induced changes, which can be misinterpreted as tumor. Pelvic lymphadenectomy is part of primary surgical treatment of all stages of cervical carcinoma except stage IA1 without lymphovascular invasion 9.
Sentinel lymph node SLN mapping and biopsy of pelvic lymph nodes for early stage cervical cancer has emerged as a strategy to mitigate the risk for lower extremity lymphadenoma that accompanies systematic pelvic lymphadenectomy SLN mapping also helps identify unusual lymph drainage patterns In both Europe and the United States, current guidelines recommend consideration of SLN biopsy as an option for early stage cervical cancer 9 , The use of intraoperative evaluation of SLN biopsy as a method to triage patients to proceed with radical surgery or to abort and pursue chemoradiotherapy has also been proposed, though diagnostic sensitivity has been shown to be a limitation Prospective clinical trials evaluating the role of SLN biopsy in early stage cervical cancer management are ongoing 56 , Para-aortic lymph node dissection is considered for stage IB1 and higher cancers 9.
Most HPV-independent endocervical adenocarcinoma are pattern C. The stage assignment based on lymph node involvement depends on the size of the nodal metastasis in both the FIGO staging system and the 8th edition AJCC staging system 17 , 60 , Consequently, the strategy for gross management of lymph nodes should be designed to reliably detect nodal metastasis of at least 0. The clinical significance of isolated tumor cells is still being studied.
Specimen measurements, dissection, and tissue sampling strategies are the same for non-SLN and SLN; however, the processing of blocks is different. Therefore, at the time of gross evaluation, the pathologist should clearly determine whether the specimen is a non-SLN or SLN. This distinction may not always be clear based on macroscopic examination of the specimen since a variety of markers are available for the surgeon to choose from to map SLN 9.
Whereas direct visual mapping with blue dye may impart a blue color to the lymph node specimen, fluorescence mapping by the fluorescent marker indocyanine green or gamma probe mapping by radiocolloid technetium do not affect the appearance of the lymph nodes. Thus, the pathologist should use the specimen requisition form and specimen container label to determine if a lymph node specimen is a SLN in order to determine the proper specimen management strategy.
The 3 dimensions of the overall lymph node specimen, including associated adipose tissue, should be documented in the gross description. If the specimen consists of multiple fragments, the dimensions of the fragments aggregated together can be reported. The number of macroscopically visible lymph nodes should be recorded as well as the dimension long axis of the largest node.
If metastatic tumor is macroscopically visible after dissection, the largest dimension should be recorded for each involved lymph node.
Excess adipose tissue can be carefully trimmed from the lymph node but it should not be stripped entirely away as this may disrupt the capsule of the lymph node and may also preclude evaluation for extranodal extension of tumor if metastasis is present.
This approach has a higher chance of detecting metastasis than slicing parallel to the long axis of the node as more tissue can be evaulated All slices B are submitted for microscopic examination. Details of tissue block processing for ultrastaging are discussed in the text.
If there is macroscopic metastatic tumor, a representative section can be submitted for microscopic examination. However, if there is no macroscopic evidence of metastasis, all of the sliced lymph node should be submitted. Excess adipose lacking any visible abnormality does not need to be submitted.
The number of lymph nodes in each cassette should be documented in a way that permits an accurate total count of all lymph nodes examined and of the total with metastasis. If the specimen contains no definitive lymph nodes, the tissue should be submitted entirely for microscopic examination. For SLN, the optimal strategy for tissue block processing remains controversial. The aim to detect low-volume metastases micrometastases and isolated tumor cells needs to be balanced with the still unresolved questions about their clinical significance and the utilization of laboratory resources.
The concept of SNL ultrastaging refers to using multiple deeper level sections of the tissue block with or without keratin immunohistochemistry aiming at the detection of low-volume nodal disease. One of the largest studies to date on SLN in cervical cancer demonstrated that up to 6.
Depending on the parameters of the protocol, ultrastaging can be labor and resource intensive, as well as expensive. Whether this conceptual approach is feasible outside of a clinical trial may depend on local practice conditions. Thus, the evidence is clear that some form of ultrastaging is needed for SLN but there is no clear mandate on the exact details of the ideal ultrastaging protocol. Currently, the best practice should be decided at the local practice level and applied uniformly for all patients within that practice.
From a practical perspective, if SNL ultrastaging is to be performed, we recommend taking several sections at multiple intervals though the tissue block. The total number of intervals should be decided at the local practice level. Likewise, the use of routine keratin immunohistochemistry should be decided at the local practice level.
European guidelines recommend that intraoperative evaluation of SLN can be used to triage whether early stage cervical cancer patients should proceed to radical surgery if there is no nodal metastasis or whether radical surgery should be abandoned and definitive chemoradiation pursued instead This strategy is tempered by the imperfect sensitivity of intraoperative evaluation.
Therefore it is recommended that intraoperative SLN evaluation be performed only if the surgeon is prepared to alter the intraoperative plan based on the results and is aware of the limitations to diagnostic sensitivity.
Remove excess adipose but avoid stripping too close to the outer surface of the node. Evaluate each slice by frozen section but take caution not to cut too deeply into the tissue and do not perform deeper level sections except to pursue suspicious findings as that would potentially exhaust the residual tissue and impair ultrastaging of the residual tissue For the permanent section processing, the standard ultrastaging protocol should be used on the remainder of the frozen section tissue block.
The remaining authors declare no conflict of interest. International Journal of Gynecological Pathology. Int J Gynecol Pathol. Published online Feb 9. Carlos Parra-Herran , M. Ramirez , M. Rabban , M. Author information Copyright and License information Disclaimer.
Corresponding author. Address correspondence to Joseph T. E-mail: ude. Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution License 4. Abstract The International Society of Gynecological Pathologists ISGyP Endocervical Adenocarcinoma Project aims to provide evidence-based guidance for the pathologic evaluation, classification, and reporting of endocervical adenocarcinoma. Open in a separate window.
Specimen Orientation Fragmented LEEP specimens have a mucosal surface on one side and cervical wall connective tissue on the opposite side so-called deep margin. Recommendations The presence of thermal artifact on microscopic examination of the tissue edges of a fragmented LEEP specimen in the best marker of a true surgical margin.
Specimen and Tumor Measurements The number of fragments and the range of the dimensions minimum size and maximum size should be recorded. Recommendations Document the number of tissue fragments and size range minimum to maximum. Limit the number of slices per cassette in order to avoid incomplete representation due to sectioning artifacts. Alternatively it may be more efficient to routinely examine 2 or more sections per block, depending on the local practice.
Specimen Orientation and Inking The 3 margins are the mucosal endocervical margin, the mucosal ectocervical margin, and the deep connective tissue margin. Recommendations Ink the ectocervical and endocervical mucosal margins as well as the deep connective tissue margin. If anatomic orientation of the specimen is designated, preserve this orientation in the tissue block designations. Specimen Measurements The length parallel to the endocervical canal , diameter and wall thickness of the specimen should be recorded.
Recommendations Document length, diameter and wall thickness of the specimen. Tumor Location If the surgeon provided orientation of the specimen, then the anatomic location of grossly visible tumor should be recorded as this may assist to correlate with radiologic and intraoperative findings, particularly if there is clinical concern for margin involvement by tumor.
Recommendations Document the anatomic location of tumor in the cervix using positions on a clock or designating anterior versus posterior lip of the cervix. Document the distance of tumor to the endocervical margin, ectocervical margin and deep connective tissue margin. Macroscopic Tumor Dimensions The 3 macroscopic dimensions of a cervical tumor are its length parallel to the endocervical canal , width in the plane perpendicular to the endocervical canal , and thickness from tumor surface to the tumor deepest invasion point.
Recommendations Document the tumor length parallel to the endocervical canal , tumor width perpendicular to the endocervical canal , tumor thickness, and depth of tumor invasion. Specimens opened and pinned before fixation should be thinly sliced parallel to the endocervical canal.
Specimens should be entirely submitted for microscopic examination, including any excess trimmed pieces. If an additional so-called top hat specimen is submitted, it should be inked, sliced using the same strategy for the main LEEP specimen, and entirely submitted. Specimen Orientation and Inking Identification of the endocervical and vaginal margins of the specimen is usually straightforward based on the appearance of the vaginal cuff Fig.
Ink the endocervical, vaginal, and parametrial margins, as well as the nonperitonealized connective tissue at the outer surface of the anterior and posterior cervical walls.
Specimen Measurements It is recommended to document the measurements of the cervix, vaginal cuff, and parametria. Recommendations Measure the cervix length parallel to the endocervical canal , diameter and wall thickness.
Measure the parametrial tissue length from superior to inferior and lateral dimension from uterine wall to outer edge. Measure the vaginal cuff minimal and maximal length after stretching it out if it is retracted.
Tumor Location Documenting the anatomic location of grossly visible tumor assists in the pathologic correlation with radiologic and intraoperative findings, particularly if there is clinical concern for margin involvement by tumor.
Recommendations Document the anatomic location of tumor in the cervix using positions on a clock face and then correlate with the anatomic terminology used by the surgeon. Document the distance of tumor to the endocervical margin, vaginal margin, parametrial margin, and nonperitonealized connective tissue at the outer surface of the anterior and posterior cervix walls.
Macroscopic Tumor Dimensions A unified approach to determine tumor size measurements in cervical cancer is critical for several reasons: There is significant variation in the method used by gynecologic oncologists, radiologists, and pathologists to estimate tumor size, and currently there is no single recommendation for standard practice. Recommendations Document the tumor length parallel to the endocervical canal , tumor width in the plane perpendicular to the endocervical canal , tumor thickness and depth of tumor invasion.
Recommendations Remove parametria and place in cassettes before opening specimen. Open the specimen and obtain measurements anatomic structures and any lesion immediately upon receipt.
After intraoperative consultation if performed , pin the specimen for overnight formalin fixation, taking care to stretch out the vaginal cuff to its full length and pin. Tissue sections should demonstrate the deepest tumor invasion and the closest approach of the tumor to the vaginal, radial, and parametrial margins.
Perpendicular sections of the vaginal margin closest to the tumor should be examined. Whether the remainder of the vaginal margin should be examined entirely en face or by representative perpendicular sections is left to local practice standards.
Surgical procedures. Step by step procedure. Sections to obtain. Thyroid without nodules diffuse inflammatory lesions, i. Gross appearance of main thyroid lesions. Gross description template.
Anterior surface has a fragment of attached skeletal muscle. The right upper pole is oriented with a white surgical suture. The central portion is densely white, firm and focally calcified. The lesion is poorly circumscribed and grossly invades the thyroid capsule at the posterior plane but is 0.
The remainder of the parenchyma is red-brown and homogeneous with a single colloid filled nodule 0. Parathyroid glands are not recognized grossly. Encapsulated solitary nodule follicular adenoma, noninvasive follicular thyroid neoplasm with papillary-like nuclear features [NIFTP], follicular carcinoma Received in the fresh state is a specimen identified as left hemithyroidectomy left lobe with isthmus. A black suture is present at the isthmusectomy margin.
The outer surface is smooth and the consistency is homogeneously firm. An ill defined bulging is noted in the lower pole of the left lobe. No parathyroid glands or lymph nodes are identified. Parallel longitudinal sections of the specimen reveal a round nodule in the lower lobe measuring 25 mm in greatest diameter. It is entirely surrounded by a very thin fibrous capsule that shows no gross evidence of invasion. The cut surface of the nodule is solid, slightly bulging and tan, with punctate areas of fresh hemorrhage.
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