2015-06-11 Approach to specimens from following organs Grossing of gynecologic pathology ¤ Uterus and cervix specimens ¤ Ovary and fallopian tube Harkiran Kaur ¤ Vulva Anatomical Pathologist and Assistant Clinical Professor ¤ Multiple organs (pelvic exenteration) Juravinski Hospital And Cancer Centre McMaster University Uterus and Cervix Total hysterectomy ¤ Indications: Uterus and cervix ¤ Benign conditions e.g prolapse, fibroids, adenomyosis u Supracervical hysterectomy, u Simple hysterectomy, u ¤ Malignant conditions eg uterine or cervical carcinoma, Radical hysterectomy (include vaginal cuff, sarcoma parametrium and regional lymph nodes) ¤ Knowledge of clinical history is important as will guide the u +/- bilateral salpingectomy, handling of specimen (Indication, previous biopsy results, bilateral salpingo-oophorectomy operative note and radiology, previous treatment) u Cone biopsy, LEEP Orientation of hysterectomies Orientation of hysterectomies ¤ Peritoneal reflection ¤ Round ligaments ¤ Ovaries sit behind fallopian tubes ¤ If specimen cannot be oriented, designate two sides as “A” and “B” and submit sections 1 2015-06-11 Gross findings – likely benign Handling of specimen: ¤ Uterine serosa – adhesions, hemorrhage (endometriosis, ¤ Weigh inflammed), cysts etc q Open uterine corpus along lateral sides (score with knife, open with ¤ Myometrium – white whorled nodules - characteristics, scissors, probe may help, clean cuts), make transverse incisions keeping serosa intact lacy/trabeculated appearance ¤ Fix overnight in formalin ¤ Endometrium – contour, polyp, color ¤ Measure uterus (AP X ML X SI), endometrial and myometrial thickness, exocervix and endocervical canal, ovaries and fallopian ¤ Cervix – polyp, hemorrhage, color tubes if present ¤ Describe, photograph (if unusual) Standard sections benign ¤ Document all abnormal findings including indication for surgery ¤ 1 section each from anterior cervix and posterior cervix ¤ 1 section each from anterior endomyometrium and posterior endomyometrium ¤ If ovary and fallopian tube – representative section of each ovary and fallopian tube Gross Pathology UCM 2 2015-06-11 Gross findings – likely malignant Standard sections malignant ¤ Endometrial carcinoma, sarcoma ¤ Anterior cervix and posterior cervix – 2 sections each including exocervical and paracervical resection margin ¤ Endometrial tumor – characteristics especially myometrial invasion (important cut-off 50% of myometrial invasion), ¤ Anterior and posterior lower uterine segment endometrium and myometrium thickness, distance from cervix, distance from exocervical and paracervical ¤ 3 full thickness sections each from anterior margins endomyometrium and posterior endomyometrium ¤ Uterine serosa – tumor implants or direct invasion including the area with deepest invasion ¤ Cervix – grossly involved or not ¤ If ovary and fallopian tube – representative sections or entirely depending on the institution, SEE-FIM protocol for ¤ Ovary and fallopian tube - grossly involved or not each fallopian tube Situations where will go beyond SEE-FIM protocol standard sections ¤ Patient with hyperplasia history, SIL history, uncertain about cervical status or myometrial invasion ¤ Patient had endometrial biopsy interpreted as high grade endometrial ca but cannot detect it on hysterectomy specimen ¤ Discrepancy between biopsy and final hysterectomy specimen Other points worth mentioning ¤ Avoid sampling from cornu of uterus ¤ If sarcoma diagnosis, sample border of tumor, hemorragic and necrotic areas especially transition Gross Pathology UCM 3 2015-06-11 Endometrial tumor staging Sarcoma staging Sarcoma staging Radical hysterectomy for cervical Cervix carcinoma ¤ Radical hysterectomy ¤ Handling of specimen: ¤ Cone biopsy q Weigh, ink margins ¤ LEEP/LLETZ q Amputate cervix with vaginal cuff from uterus and open cervix at 12 o’ clock, pin it q Open uterine corpus along lateral sides (score with knife, open with scissors, probe may help, clean cuts), make transverse incisions keeping serosa intact q Fix in formalin overnight 4 2015-06-11 Large loop excision of transformation zone (LLETZ) LEEP Cone biopsy Cervical ca staging Standard sections malignant ¤ Entire cervix coned including paracervical and vaginal cuff resection margin (helpful to state the section that shows maximum horizontal and vertical extent of tumor), parametrial resection margin ¤ Anterior and posterior lower uterine segment ¤ 1-2 full thickness sections each from anterior endomyometrium and posterior endomyometrium including any abnormal findings ¤ If ovary and fallopian tube – representative sections or entirely depending on the institution, SEE-FIM protocol for each fallopian tube 5 2015-06-11 Other points worth mentioning ¤ Preferably one section per cassette (e.g cone biopsy – 12 sections, 12 cassettes) ¤ If lymph node bisected, only one/cassette ¤ If sentinel lymph node – section at 5 mm intervals Salpingo-oophorectomy specimen Salpingo-oophorectomy specimen ¤ Indications: Handling of specimen: ¤ Ovarian cyst/mass ¤ Weigh, review frozen consultation if done ¤ Prophylactic reasons or part of a larger resection q Slice it further and fix overnight in formalin ¤ Usually frozen section performed as management defined by it ¤ Knowledge of clinical history is important Salpingo-oophorectomy specimen Salpingo-oophorectomy specimen ¤ Ovarian mass: unilateral/bilateral/fragmented ¤ Measurements for each ovary and corresponding ¤ Residual ovarian tissue - identified/not identified fallopian tube (start with the main mass/finding first) ¤ Fallopian tube - Identified/not identified/probably ¤ External surface/capsule: Intact/not intact/ solid identified , measurements/ fimbria seen or not, if tube deposits/papillary excrescences interrupted or complete ¤ Cut surface: cystic (unilocular/multilocular), solid ¤ If uterus and cervix unremarkable, handle like benign (uniform/variegated), hair and cheesy material , hard areas such as bone and cartilage, color, fleshy ¤ Contents: serous/mucoid/cheesy/chocolate or dark brown 6 2015-06-11 Standard sections malignant/big Standard sections benign mass ¤ One section per cm focussing on grossly different and viable looking areas ¤ Simple small cyst or grossly unremarkable or part of a large specimen for benign reasons – a couple of cross- ¤ If nodule or papillary excrescences on surface – selective inking sections of ovary sufficient, fallopian tube representative ¤ Clear designation of the section on gross description extremely helpful sections as surface epithelium very delicate and can be abraded ¤ Fallopian tube embedded entirely or at least as per SEE-FIM protocol ¤ Such as prophylactic procedure – All tissue submitted (ovary and fallopian tube) ¤ Usually accompanied with omentum – if grossly positive (couple of sections good), if unremarkable generous sampling, primary peritoneal also a possibility ¤ Usually accompanied with peitoneal biopsies, lymph node dissection Salpingo-oophorectomy specimen Ovarian ca staging for mass Wide local excision and partial vulvectomy Vulva ¤ Partial or complete vulvectomy ¤ Superficial (skinning) or deep vulvectomy ¤ Indications – VIN2-3, invasive squamous cell carcinoma, Paget’s disease, melanoma 7 2015-06-11 Vulvectomy Vulvectomy ¤ Handling of specimen: q Usually pin it like skin q Fix in formalin overnight Vulvectomy specimen Standard sections ¤ Measure, orient, pay attention to structures like vagina, ¤ If specimen of reasonable size and for VIN3, Paget’s etc, urethra, closest margin etc ca usually in toto ¤ Area of abnormality – dicolored pale or erythematous ¤ If specimen big – thoughtful sampling (at least 1 section/ areas, mass, measure it and its distance from different cm of the tumor paying attention to accurate margins including vaginal and urethral margin measurement of size, maximum depth of invasion, close margins (perpendicular sections) ¤ If in doubt, ask for help and clarification ¤ If specimen has a sentinel lymph node, section them at 5 mm interval ¤ Picture of specimen with mapping of sections taken very helpful ¤ If specimen has a node dissection – note no. of suspicious LNs, size, extranodal extension etc ¤ Surgeon’s diagram also very helpful 8 2015-06-11 Vulvar ca staging Pelvic exenteration ² Identify organs present ² Identify margins present especially ureters ² Inflate bladder, ² Insert gauze in vagina and rectum ² Fix in formalin overnight Take home points ¤ Check identification of case, cassettes ¤ Check OR note, clinic note and previous pathology ¤ If in doubt or case is complex, take photographs (map sections) and clarify with clinical colleagues if required ¤ Pay attention to key points that upstage the patient ¤ Uterus – avoid cornu ¤ Cervix cone biopsy preferably one section per cassette ¤ If lymph node bisected, only one/cassette ¤ If sentinel lymph node – section at 5 mm interval ¤ Ovary - If nodule or papillary excrescences on surface – selective inking ¤ Clear designation of the section on gross description extremely helpful as surface epithelium very delicate and can be abraded 9 .