Lymph node – biopsy
Table App E-3
BROCK’S NOMENCLATURE
Right bronchial tree (I, main bronchus; A, upper lobe bronchus; B, middle lobe bronchus; C, lower lobe bronchus)
a Apical bronchus, upper lobe
b Subapical bronchus, upper lobe
c Pectoral bronchus, upper lobe
d Medial division, middle lobe
e Lateral division, middle lobe
f Anterior basal bronchus, lower lobe
g Middle basal bronchus, lower lobe
h Posterior bronchus, lower lobe
i Cardiac bronchus, lower lobe
j Apical bronchus, lower lobe
Left bronchial tree (I, main bronchus; A, upper lobe bronchus; B, lower lobe bronchus; (1), lingular bronchus)
a Apical bronchus, upper lobe
b Subapical bronchus, upper lobe
c Pectoral bronchus, upper lobe
d Upper division, lingular, upper lobe
e Lower division, lingular, upper lobe
f Anterior basal bronchus, lower lobe
g Middle basal bronchus, lower lobe
h Posterior basal bronchus, lower lobe
i Apical bronchus, lower lobe
Lymph node – biopsy
Procedure
1 If the lymph node is received in the fresh state, cut
2–3 mm slices perpendicular to the long axis and:
a Take a small portion for culture and if an infectious
disease is suspected or needs to be ruled out
b Make four imprints of the cut surface on alcohol-cleaned
slides, fix in methanol, and stain two with hematoxylin–
eosin and two with Wright stain. See instructions for
Imprints (touch preparations)
c Place one of the slices in B5 fixative and submit for
histology
d In cases of suspected hematolymphoid disorders, submit
tissue for cell markers (by flow cytometry), cytogenetics,
and molecular genetics (see respective sections for
instructions)
JACKSON AND HUBER’S NOMENCLATURE
a Apical bronchus, upper lobe
b Anterior bronchus, upper lobe
c Posterior bronchus, upper lobe
d Medial division, middle lobe
e Lateral division, middle lobe
f Anterior basal bronchus, lower lobe
g Lateral basal bronchus, lower lobe
h Posterior basal bronchus, lower lobe
i Medial basal bronchus, lower lobe
j Superior bronchus, lower lobe
a Superior division, upper lobe
b Apical posterior, upper lobe
c Anterior bronchus, upper lobe
d Superior lingular, inferior division, upper lobe
e Inferior lingular, inferior division, upper lobe
f Anterior-medial basal, lower lobe
g Lateral basal, lower lobe
h Posterior basal, lower lobe
i Superior bronchus, lower lobe
e If additional tissue is available, fix in formalin, and submit
for histology
2 If the specimen is received already fixed in formalin, cut in
3 mm slices and submit representative sections
Description
1 State whether node received fresh or fixed
2 Size of node and condition of capsule
3 Appearance of cut surface: color, nodularity, hemorrhage,
necrosis
Sections for histology
Cross-sections of node, including at least portion of capsule: one to
three sections depending on size of node
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 Appendix E
Lymph node dissection –
general instructions
Procedure
1 Dissect the node-containing fat from the organ in the fresh
state, using forceps and sharp scissors. Make the fat dissection
as close as possible to the wall of the organ; this is where
most lymph nodes are located. Divide them in groups
according to specific instructions
2 Two options are available:
a Search the fat for nodes while specimen is fresh, under a
strong light and with the use of scissors, forceps, and
scalpel. Avoid crushing the nodes by rough palpation. If
insufficient nodes are identified, contact the senior
pathologist or surgeon
b Fix overnight in formalin or Carnoy solution, and search
for nodes the next day. The latter fixative is preferred
because it clears the fat somewhat
Description
1 Number of nodes in each group
2 Size of largest node in each group
3 Appearance; obvious involvement by tumor?
Sections for histology
1 All lymph nodes should be submitted for histology
2 Small nodes (up to 3 mm in thickness after fat is removed)
are submitted as a single piece
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3 Several small node groups may be submitted in the same
cassette
4 Larger nodes are bisected and, if necessary, further
sectioned into 2–3 mm slices. A slice as large as will fit the
cassette should be submitted for each one of these larger
nodes1
5 Store the remainder in the formalin container, properly
identified as belonging to lymph node group
1 The alternative would be to submit the entirety of these large nodes,
but the number of additional metastases found seems too small to
justify the considerably higher cost involved (Niemann TH, Yilmaz AG,
Marsh Jr WL, Lucas JG. A half node or a whole node. A comparison of
methods for submitting lymph nodes. Am J Clin Pathol 1998, 109:
571–576.)
Lymph node dissection – axillary
See under Breast – mastectomy
Lymph node dissection – inguinal
1 All lymph nodes are submitted as a single group unless the
surgeon has submitted the superficial and deep groups
separately. A minimum of 12 lymph nodes should be found
2 A cross-section of the internal saphenous vein also should be
submitted for histology
 Lymph node dissection – radical neck

Lymph node dissection –
radical neck
The standard radical neck dissection includes removal of cervical
lymph nodes, sternomastoid muscle, internal jugular vein, spinal
accessory nerve, and submaxillary gland; the tail of the parotid is
sometimes also included.
In the modified radical neck dissection (also known as functional
or Bocca neck dissection), the sternomastoid muscle, spinal acces-
sory nerve, and internal jugular vein are spared.
The extended radical neck dissection includes, in addition to the
structures removed in the standard operation, the excision of retro-
pharyngeal, paratracheal, parotid, suboccipital, and/or upper medi-
astinal lymph nodes.
In the regional (partial or selective) neck dissection, only the
station of lymph nodes thought to represent the first metastatic
station is removed.
The instructions following are devised for the standard radical
neck dissection and need to be modified for the other three. Because
of the lack of anatomic landmarks in the modified and regional
procedures, the labeling of the lymph nodes according to groups
needs to be done by the surgeon. The same applies to the extra
lymph node groups removed in the extended operation.
Procedure
1 Orient the specimen and divide it into submaxillary gland,
platysma, sternomastoid muscle, internal jugular veins, and
node-containing fat
2 Divide the lymph nodes into six groups depending on
whether they are on the upper or lower portion of the
specimen and on their relationship with the sternomastoid
muscle (see accompanying drawing). A minimum of 40
lymph nodes should be found1
Description
1 Site and type of primary neoplasm (see specific
instructions)
2 Length of sternomastoid muscle
3 Jugular vein included? length? invaded by tumor?
4 Presence of tumor in lymph nodes, submaxillary gland, soft
tissue, or muscle
5 Size of the largest node
Sections for histology
1 Superior anterior cervical lymph nodes
2 Superior jugular cervical lymph nodes
3 Superior posterior cervical lymph nodes
4 Inferior anterior cervical lymph nodes
5 Inferior jugular cervical lymph nodes
6 Inferior posterior cervical lymph nodes
7 Submaxillary gland
8 Jugular vein
9 Sternocleidomastoid muscle
10 Thyroid gland, if present
1 Other pathologists use an alternative scheme in which lymph nodes are
divided into five regions: anterior (submental and submandibular), superior
jugular, middle jugular, inferior jugular, and posterior (posterior triangle)
(Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW.
Standardizing neck dissection terminology. Arch Otolaryngol Head Neck
Surg 1991, 117: 601–605.)

Portion of Superior Superior

Platysma lower parotid Sternomastoid Sternomastoid Parotid jugular anterior

Superior
posterior

Inferior
posterior Inferior
jugular

Inferior
Omohyoid anterior

Superficial view Deep view

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 Appendix E

Lymph node dissection

– retroperitoneal
1 For the proper evaluation of this specimen, it is essential for
the surgeon to divide the lymph nodes into groups at the Suprahilar
time the dissection is performed and submit them to the
laboratory in separate containers. In most institutions,
urologic surgeons divide the node groups as follows:
• Suprahilar (above level of renal artery)
• Superior interaortocaval Superior
• Pericaval interaortocaval
• Periaortic
Para-aortic
• Common iliac (usually excised only on side of tumor)
2 If the specimen is submitted as a single piece, it is necessary
to identify, with the help of the surgeon, the upper and lower Paracaval Inferior
borders and the periaortic and pericaval regions. When this is interaortocaval
established, the lymph nodes can be divided in the following
groups: Common iliac
• Superior periaortic (tumor side)
• Middle periaortic
• Inferior periaortic
• Superior pericaval
• Middle pericaval
• Inferior pericaval
• Common iliac (specify side)
3 If the surgeon is unavailable or unable to orient the specimen,
all lymph nodes are submitted as one group. A minimum of
25 lymph nodes should be found

Molecular diagnosis – sampling Orbital exenteration

Evaluation of tissue using molecular techniques has become a very Procedure
important diagnostic procedure, particularly for the evaluation of
hematolymphoid processes and many solid tumors, particularly of 1 Pin down the elliptic piece of orbicular skin, and fix overnight
soft tissue type. at 4°C
Sample 1 cm3 of fresh tumor tissue (or as much as available), 2 Paint the surgical margins with India ink
drop in a Petri dish having in its bottom a layer of filter paper wet 3 Take surgical margins; cutaneous, soft tissue, optic nerve
(not overly soaked) with saline solution, and submit to appropriate 4 Cut skin, soft tissue, and ocular globe
laboratory immediately. If prompt transportation is not feasible,
freeze at –70°C until time of use.
Description
Needle biopsies 1 Skin: shape and length; appearance; if lesion present: size,
shape, depth of invasion, color
Procedure 2 Soft tissues
1 Remove the tissue from the fixative without squeezing it with 3 Ocular globe: dimensions, appearance, length of optic nerve
a forceps; do not use toothed forceps; handle the tissue in (see under Eyes – enucleation)
such a manner as to keep it intact; do not cut it transversely
but rather coil it inside the cassette if overly long
2 Always search the container, including the undersurface of the Sections for histology
lid, for tiny fragments of tissue that may be overlooked
3 Carefully wrap the tissue in a tea bag, without squeezing For skin tumors
4 If the amount of the tissue core permits (a core over 1 cm 1 Tumor: three sections
long or two tissue cores) and if it would be anticipated that a 2 Cutaneous surgical margins (superior, inferior, internal, and
fat stain may be useful, save a 3–5 mm portion in formalin external)
3 Soft tissue surgical margins
Description 4 Ocular globe
1 Length and diameter of core; number of fragments; color
2 Homogeneity or lack of it
For ocular tumors
1 Globe with tumor
Sections for histology
2 Orbital soft tissue adjacent to tumor
All material received (except if fat stains desired, see under Procedure) 3 Surgical margin of optic nerve
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