Surgical Pathology Dissection: An Illustrated Guide, Second Edition William H. Westra, M.D., et al. Springer Surgical Pathology Dissection Second Edition Surgical Pathology Dissection An Illustrated Guide Second Edition William H. Westra, M.D. Ralph H. Hruban, M.D. Department of Pathology Department of Pathology The Johns Hopkins University The Johns Hopkins University School of Medicine School of Medicine Baltimore, Maryland Baltimore, Maryland Timothy H. Phelps, M.S. Christina Isacson, M.D. Department of Art as Applied to Medicine Department of Pathology The Johns Hopkins University Virginia Mason Medical Center School of Medicine Seattle, Washington Baltimore, Maryland With Forewords by Frederic B. Askin, M.D. With 58 Illustrations William H. Westra, M.D. Ralph H. Hruban, M.D. Department of Pathology Department of Pathology The Johns Hopkins Hospital The Johns Hopkins Hospital The Weinberg Cancer Building, Room 2242 The Weinberg Cancer Building, 401 North Broadway Room 2242 Baltimore, MD 21231-2410, USA 401 North Broadway Baltimore, MD 21231-2410, USA Timothy H. Phelps, M.S. Christina Isacson, M.D. Department of Art as Applied Department of Pathology to Medicine Virginia Mason Medical Center The Johns Hopkins University 1100 Ninth Avenue, C6-Path School of Medicine Seattle, WA 98101, USA 1830 East Monument Street, Suite 7000 Baltimore, MD 21205-2100, USA Cover illustration: Extrahepatic biliary tract resection for carcinoma of the common bile duct. Illustration by Timothy H. Phelps. Library of Congress Cataloging-in-Publication Data Surgical pathology dissection: an illustrated guide/[edited by] William H. Westra . [et al.].—2nd ed. p.; cm. Includes bibliographical references and index. ISBN 0-387-95559-3 (s/c: alk. paper) 1. Pathology, Surgical—Laboratory manuals. 2. Human dissection— Laboratory manuals. I. Westra, William H. [DNLM: 1. Pathology, Surgical—Laboratory Manuals. 2. Dissection—Laboratory Manuals. WO 142 S9615 2002] RD57. S87. 2002 617′.07—dc21 2002029448 ISBN 0-387-95559-3 Printed on acid-free paper. ą 2003, 1996 Springer-Verlag New York, Inc. All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed in the United States of America. 98765432 SPIN 10888565 www.springer-ny.com Springer-Verlag New York Berlin Heidelberg A member of BertelsmannSpringer Science+Business Media GmbH To the Breakfast Club. Fond memories of hooping it up. To the team: Sharon, Caryn, Janine, and Willem. William H. Westra To my wonderful wife, Claire, and our three terrific children, Zoe, Emily, and Carolyn. Ralph H. Hruban To my wife, Lyn, for her ever-present love and support; my two children, Katie and Kevin, who bring me great and constant joy; my art instructors of the past for all they have shared with me; and, particularly and most importantly, my Father; and in loving memory of my Mother. Timothy H. Phelps To my sisters, Charlotte and Patty. Christina Isacson This page intentionally left blank Foreword to the Second Edition It is a pleasure, an honor, and a distinct privilege to write the foreword for the second edition of Surgical Pathology Dissection: An Illustrated Guide. Iam delighted to see that my predictions were accurate in regard to this effective and useful book. It has become an extremely popular dissection manual with regard to both its text and illustrative material. In fact, the manual and its medical illustrator, Timothy H. Phelps, received the Illustrated Book Award from the Association of Medical Illustrators in 1996. Pathologist reviewers have uniformly characterized the text as valuable and inclusive while still leaving room for individual variation in specimen handling. Just as our other clinical colleagues continually endeavor to improve pa- tient care by adding new diagnostic tests and techniques, it is incumbent on anatomic pathologists to do the same. The authors’ goal in the development of the second edition of this manual was not to replace the first edition but, rather, to build on its strength. In this second edition, one finds the addition of new coauthors with recognized expertise in their respective fields of interest. These coauthors have provided chapters on contemporary topics not covered in the first edition and new illustrations (the specifics are listed in the Preface). In addition, a number of the original illustrations, such as the breast specimen dissection, have been significantly revised and improved. In an attempt to provide more uniform description and tumor staging, the existing chapters have been updated to conform with the recently published College of American Pathologists (CAP) and Association of Direc- tors of Anatomic and Surgical Pathology (ADASP) guidelines. The basic goals for the first edition have been retained: to provide an accurate, concept-oriented, easy-to-use manual that provides a logical, concise approach to the most commonly encountered specimens. Although new authors and new material have been added, the basic solid framework of the manual persists. I am confident that the second edition provides significant improvements and that this manual will continue to be a mainstay in the anatomic pathology armamentarium. Frederic B. Askin, M.D. Professor of Pathology The Johns Hopkins University School of Medicine and Director of Surgical Pathology The Johns Hopkins Hospital Baltimore, MD 21231-2410, USA vii This page intentionally left blank Foreword to the First Edition The modern surgical pathology cutting room is replete with tools of the electronic age. Computers, automatic cassette labelers, bar coding, and even electronic voice-recognition systems are available to help the surgical pathol- ogist be an effective, efficient, and highly productive cog in the machinery of healthcare delivery. In spite of this automated armamentarium, much of our ability to render diagnoses rests with the surgical pathology ‘‘cutters.’’ These personnel need to be trained to handle surgical specimens consistently and appropriately, with the goal of providing optimal diagnostic information and adequate pathologic correlation with clinical and radiologic findings. This dissection manual is an outgrowth of what Waldemar Schmidt has called the ‘‘oral tradition’’ of surgical pathology. Traditionally, the senior pathologist passed down to the trainee an individual accumulation of ex- pertise on the handling of specimens. This transfer of information was often random and based solely on the specific case at hand. Now, despite the importance of training personnel, the exigencies of modern practice limit the amount of time available for individual training, and so most laboratories have developed their own local manual. Unfortunately, many of these manu- als are incomplete or not user-friendly. Drs. Hruban, Westra, and Isacson have prepared this manual with the help of a distinguished and talented medical artist. Timothy H. Phelps’s pen and ink drawings bring a unique vitality and multidimensional effect to the reader throughout the manual as dissection techniques are explained and illustrated. The editors and contributors have effectively shared their talents and experience by providing general principles that can be employed to resolve even the most complex problems in dissection and effective tissue sampling. The methods are broadly applicable and unusually easy to follow. This text should be at hand in all surgical pathology laboratories, where it will be useful to a wide variety of personnel including staff pathologists, residents, pathologist’s assistants, histotechnologists, and other laboratory personnel. It is highly likely that many surgeons would also benefit from use of this manual, through which they can gain an understanding of how specimens are dissected and can become familiar with the way in which margin and tumor sampling are carried out. This is a very practical manual. The authors discuss the clinically im- portant features of various types of specimens and lesions in each organ system. They instruct the prosector in every instance as to what information is needed to provide the clearest clinical picture. I suspect that this work will ix x Foreword to the First Edition be most valuable to the surgical pathology cutter late in the evening or on weekends, when the redoubtable oral historian of surgical pathology is not available. This manual should serve as a cornerstone on which to build a stable but malleable standard of excellence in the surgical pathology cut- ting room. Frederic B. Askin, M.D. Professor of Pathology The Johns Hopkins University School of Medicine and Director of