The FRCPath Surgical Pathology Module

macroscopic specimens
Helen Baker Consultant Histopathologist

CASE 1. Breast
Key - Wide local excision for mammography screening detected breast lump. Specimen sliced from medial to lateral aspects. Yellow paint - superior Blue paint - anterior Red paint - inferior 1) Indicate on the diagram the blocks you would take from this specimen. 2) What other information would you record before and during specimen dissection? 3) How would you modify your specimen dissection for a wide local excision if a tumour mass was not visible and for DCIS? 4) How would you deal with: a) cavity shaves ? b) sentinel lymph nodes ? 5) What additional blocks would you take in a mastectomy case and give their rationale?

CASE 1. Breast
1) Indicate on the diagram the blocks you would take from this specimen. Tumour and involved / nearest margins. Adjacent fibrotic tissue. Anterior and posterior to the tumour/DCIS in larger WLEs to assess extent of DCIS, which can be more than measured radiologically, macroscopically. Spreads in this plane, along ducts. Any unusual areas and associated margins.

Case 1
2) What other information would you record before and during specimen dissection? Accompanying X- Ray present or absent. If lesion is visible in WLE, describe the lesion. Presence of guide-wire and its relation to the lesion. Weight of specimen, measurement of specimen in three dimensions. Measurement of tumour in three dimensions and distance to margins. Record abnormal lesions and relations to margins. Block code essential, +/- diagram.

Case 1
3) What additional blocks would you take in a mastectomy case and give their rationale
Tumour to give dimensions and relevant margins Nipple -areolar complex Paget's Adjacent / ant and post to tumour for accurate sizing Any abnormal area and margins Random quadrantic blocks background breast / occult extensive disease

Case 1
4) How would you deal with: a) cavity shaves ? b) sentinel lymph nodes ? Cavity shave measure, paint , orientate with different colours if orientated by surgeon. Serially slice, all embed. Sentinel node radioactive time lapse before dissection. Measure , record if blue, record size of entire tissue and node size, serially slice node at 2mm intervals , CAM5.2 or equivalent marker, levels. Report H& E and immunos in conjunction.

Common Errors by Candidates

No mention of X-ray cavity shave limited to block it all mastectomy: no mention of background breast; no mention of axillary tail or lymph nodes cruciate means like a cross no block code gigantic blocks; indiscriminate blocks

CASE 2. Prostate
1) Indicate on the photograph the blocks you would take from this specimen 2) What other information would you record prior to and during specimen dissection ? 3) How would you deal with accompanying lymphadenectomy specimens ? 4) What characteristics of the tumour would you report histologically ? 5) What immunohistochemical stains may help you in reporting prostatectomy specimens ?

CASE 2. Prostate
1) Indicate on the photograph the blocks you would take from this specimen 2) What other information would you record prior to and during specimen dissection ? 3) How would you deal with accompanying lymphadenectomy specimens ? 4) What characteristics of the tumour would you report histologically ? 5) What immunohistochemical stains may help you in reporting prostatectomy specimens ?

Case 2 - Answers
Vas margins, apex and base margins, seminal vesicles, slice at 35mm intervals, whole mount or extensive sampling of CRM Weight , size, visible tumour location and size, number of slices, photographs if facilities available. Block code. Identify and separate nodes. Rest of fat to be processed Type, differentiation, grade, perineural and vascular invasion, location ant, post, central, lateral, multifocal, zones, % gland involvement / volume of tumour, breach of margins, extension into fat, seminal vesicles, involve of apical and base blocks, other organs PSA, PSAP confirming prostatic origin. 34BetaE12 or CK5/6 distinguishing invasive from in situ disease. AMACR increased expression in cancer and in situ disease. Combined immunos.

Common Errors by Candidates

block code gigantic blocks; indiscriminate blocks other information: no description of visible tumour not processing fat for lymph nodes lots of things left out of Minimum Data Set: why block it if youre not going to write about it? immunos: not mentioning prostatic markers

Case 3 Soft Tissue -

Case 3 Soft Tissue

What information would you include in your report ? Macroscopy Specimen weighed and measured in three dimensions Plane of section in which tumour located should be recorded Measurements of tumour to nearest margins, including anterior and posterior Dimensions of tumour Tumour characteristics cystic areas, solid areas, haemorrhage, necrosis assess percentage, different colours, consistencies.

Case 3 Soft Tissue

Blocks 1 per cm, at least Blocks from each different area of consistency Blocks to include nearest margins Specimen less than 50mm m.d. all embed High grade lesions diagnosed on biopsy may need fewer blocks Dedifferentiated liposarcoma, esp. undifferentiated pleomorphic sarcomas or myxofibrosarcomas innocuous fatty tissue at edge of lesion sampled thoroughly for well differentiated liposarcoma areas

Case 3 Soft Tissue

Minimal info in report: 1 - Size of tumour 2 - Histological type 3 - Grade, FNCLCC; 4 - Tissue planes involved 5 - Tumour invasive edge; pushing/infiltrative 6 - Margins: Distance to the nearest margin Tissue forming margin e.g. muscle, fascia 7 - Vascular invasion 8 - Genetic findings

Case 3 Soft Tissue

What advice would you give to clinicians and the laboratory after removal of resection specimens and core biopsies ? Clinicians Biopsies - Fix in formalin promptly Some tissue can be separated and frozen in liquid nitrogen genetic studies. Encourage clinicians to send resections promptly - fresh sampled for genetic studies, better histology Easier to orientate before fixation

Case 3 Soft Tissue

Surgeons should be encouraged to orientate specimens in a standard fashion agreed between both the surgeon and the pathologist, and provide diagrams in particularly complex cases. Laboratory Promptly inform pathologist of arrival of specimen, so fresh tissue can be taken for cytogenetics and the tissue can be painted and sliced promptly for optimum tissue fixation. Shallow H&E sections initially with biopsies to preserve tissue which may be required for immunohistochemistry and ancillary tests. Fatty tissue may require extra fixation before processing.

Case 3 Soft Tissue

What system of grading is used for sarcomas and what histological parameters are measured ? French Federation of Cancer Centers System of Grading Tumour differentiation Score 1 Sarcoma histologically very similar to normal adult mesenchymal tissue 2 Sarcoma of dened histological subtype (e.g. myxofibrosarcoma) 3 Sarcoma of uncertain type, embryonal and undifferentiated sarcomas

Case 3 Soft Tissue

Mitosis count Score 1 09 10 HPF 2 1019 10 HPF 3 >20 10 HPF Microscopic tumour necrosis Score 0 - No necrosis 1 < 50% tumour necrosis 2 > 50% tumour necrosis Histological grade Grade 1 Total score 2 or 3 Grade 2 Total score 4 or 5 Grade 3 Total score 6, 7 or 8

Common Errors
no vascular invasion no tissue planes involved no margins: pushing/infiltrative no type of differentiation no information about standard grading system funny sized blocks no sampling of different areas

Case 4 Colon

Case 4 Colon
Briefly note the macroscopic and microscopic features you would record Macroscopy Type of resection Mucosal abnormalities and distribution of disease process proximal, distal, continuous, patchy Full thickness of wall involved ? Fat wrapping Serosal abnormalities Adhesions/ attached organs

Case 4 Colon
Macroscopy Strictures Tumours Polyps/ raised areas Perforations Prominent nodes Tissue sampling Proximal and distal resection margins Mapped samples of bowel at regular (at least10cm) intervals Note if abnormal or normal mucosa Interfaces between diseased and non diseased areas

Case 4 Colon
Tissue sampling Polyps Raised areas and sampled flat mucosa around them Strictures Tumours Serosal abnormalities Attached organs Sample lymph nodes

Case 4 Colon
Microscopy Active inflammation LP cellularity Crypt irregularities Mucin depletion Pattern of inflammation mucosal, transmural ulceration deep fissuring, shallow, perforation patchy, continuous granulomata Fibrosis Dysplasia/ tumours inc staging. DALMs Margin involvement/ viability Supervening infections i.e. CMV Nodes reactive, granulomata

Case 4 Colon
What disease entities would you be considering with this macroscopic picture and what clinical information would be optimal before reporting the specimen ? Idiopathic inflammatory bowel disease Crohn's disease Ulcerative colitis Indeterminate colitis Pseudomembranous / infective Ischaemia Demographics Imaging

Case 4 Colon
What disease entities would you be considering with this macroscopic picture and what clinical information would be optimal before reporting the specimen ? Involved bowel segments Fistulae/ cutaneous manifestations Other associated diseases Topical treatment Arteriopath ? Recent antibiotics Foreign travel

Case 4 Colon
In the presence of dysplasia, what other histological information should be given ? Grade Low or high Sporadic adenoma type flat, tva, va, serrated. DALM need tissue from around to distinguish Extent of dysplasia Associated invasive disease Margins

Common Errors
no mention of fat wrapping or of skip lesions Topography no lymph node or appendix block

Macro Score Summary

15 candidates submitted their macros
13 Pass mark 1 B/L 1 Fail Overall you did very well!

Summary
Sections that were well answered: Breast , Prostate + Colon generally answered well. Sections candidates struggled on: Soft Tissue case was less well done. Candidates only answering about Microscopy findings on report + not mentioning Macroscopy. Summary of common mistakes: Not using X-rays in DCIS. Not mentioning vascular invasion. Not mentioning use of immuno in sentinel node protocol. Lots of people forgot to say they would document color code and block key on breast + prostate cases.

Final advice for candidates

Read the question in full and answer each point. Explanatory notes next to blocks about general approach or significance of taking a specific block helps examiner gain an understanding of your approach.

The End