• Diagnostic biopsy

• Therapeutic resections

• Obstetrical specimens.

Section Codes

It is important that every department settle on a numbering system that is clear and used consistently throughout the specimen. The most common systems in use today are computer generated, providing the accession number for the overall case, the container sub-number for each portion of the specimen when it is received in multiple parts, an identifier for each paraffin block, the level within each paraffin block, and the type of stain used with any given slide.

Most systems use a one- or two-letter prefix to identify the general type of case received (S = surgical, C = cytology, A = autopsy), followed by a two-digit number designating the year (00 = 2000), followed by a sequential digit number. One system, in common use worldwide, then assigns a unique letter to each container received, starting at the beginning of the alphabet, i.e., ‘A.’ Each block sampled from that specimen/container then receives a sequential number, e.g., A1, A2, . . . An. Each subsequent specimen/container receives the next available letter, e.g., B, with multiple blocks from the container having sequential numbers, B1 . . . Bn. If multiple levels of a single paraffin block are made, a practice for cervical biopsies in many institutions, the letter ‘L’ is appended with the designation of the slide level, e.g., -L2 for the second level of the block. Thus a typical specimen number might be SG-00-02167 B4-L2, which translates to ‘Surgical specimen of a gynecologic nature, received in year 2000, accession number 2167, container B, fourth block taken from specimen B, and second slide prepared from that paraffin block.’ Variants of the above system typically utilize letters in upper and lower case, Roman numerals, and Arabic numbers, usually in some combination and defined sequence. Of course, multiple numbering systems exist, and it is not the purpose of this chapter to pick which is best; the purpose is rather to help ensure clarity in whatever system is used.

Location of Section Codes in the Report

Most pathologists prefer a section code summary at the end of the gross text while some prefer entering block codes within the gross text. In either case, the report must be clear, both to the pathologist and to any person who at a later time will need to utilize the report. Block summaries, if used, may duplicate substantial parts of the gross, but cannot be used in its place. Including the block submission within the body of the gross description may be easier and more efficient for the person cutting in the specimen: ‘The borders in one region are sharp and distinct from the surrounding myometrium (Block B10) while elsewhere it blends into the adjacent myometrium (Block B11).’ However, having a section key at the end of the dictation may make histologic examination easier and more efficient. If the block codes are listed sequentially at the end of the report, the specific site and feature identified require presentation in sufficient detail so that the reader can easily link the gross description with the slide. Using the example above, it would be inappropriate for the coding block at the end to state that B10 and B11 are myometrium as it is unclear which section has the sharp borders and which has blurred borders. A section code at the end might better read, ‘B10 Myometrium, sharply circumscribed medial border, B11 Myometrium, blurred indistinct borders.’

Specimen and Site Identification

Regardless of the section code method used, it is critical that the reader can link the tissues received to the sections processed and both to the final diagnoses. For example, four cervical biopsies from the same patient are received in separate containers, but from the same operation. Information on the requisition slip indicates that the colposcopically directed specimens are from 3, 6, 9, and 12 o’clock, respectively. In this example, the accession number might be SG-00-02167, and the containers labeled A, B, C, and D, respectively. Since the paraffin block usually is identified solely by the code, then this same code should appear throughout. Thus, the gross might read ‘A. 3:00 bx’ (the wording exactly replicating what the clinician wrote on the container itself) while the final diagnosis would include ‘A. Cervix, Biopsy at 3 o’clock: Diagnostic finding.’ Obviously, the label on the slide must provide all of the necessary identifiers.

A most perplexing problem we encounter in referred specimens is where the label assigned to the container in the gross description differs from that given in the microscopic description to that given in the final diagnosis. For example, the container might be ‘A’ in the gross description, which refers to a specimen consisting of uterus, ovaries, and fallopian tubes, whereas the final diagnosis is ‘1. Endometriosis of the ovary.’ Such cases require substantial effort on the part of the consultant pathologist to determine (and sometimes guess) which gross description truly belongs to which slide and both to the listed final diagnosis.

Gross Description

If possible, describe specimens received in the fresh state before fixation. Formalin alters natural color and consistency of tissue. The opening sentence of the gross description should indicate how the tissue is received (fresh or fixed) and labeled. Does the specimen received correspond with its label? For example, the container received states ‘Uterus, tubes, and ovaries,’ yet the left adnexa is absent. Such a gross description might read, ‘Received fresh is a uterus and right ovary and fallopian tube. The left ovary and fallopian tube are absent.’ Give measurements and weights of the individual diseased organs (e.g., ‘the 710 g, 18 × 15 × 8 cm uterus’). Conglomerate measurements and weights are meaningless (uterus, tubes, and ovaries which together weigh 710 g and measure 18 × 15 × 8 cm) since they are ambiguous as to the role played by each organ and where the pathology resides.

The gross description should proceed in an orderly fashion, focusing on the primary lesion. Several common methods are in use. In one, the pathology in any given container/specimen is emphasized first. This highlights the pathology and de-emphasizes the normal. In practice, descriptions are full but economical in words and space. The second method is to follow a routine pattern whereby the same order is followed in every case, e.g., ovary, fallopian tube, uterine corpus, cervix, etc. This method, while usually easier for the novice, lends itself to loquacious reports filled with tedious description. All too often the true pathology is treated least well or even inadequately, as it is buried deep in the description. Not uncommonly, such travelogues lead to reports several pages long, but with a description of the tumor under several lines in toto. With the novice, detailed descriptions force careful examination, but, with experience, can be refined to a more concise and readable form.

Avoid elaborate descriptions of normal incidental anatomy. In a radical hysterectomy for cervical cancer, there is no need for an overly elaborate description of a normal fallopian tube. The following is excessive, ‘7 cm long, elongate structure with a 1 mm internal diameter and 4 mm external diameter with a tan, smooth, glistening serosa, a 2 mm thick wall, and a lumen without identifiable abnormality.’ Simply ‘the fallopian tube is 7 cm long, 4 mm in diameter and unremarkable’ will do.

Similarly, we believe experience should allow the pathologist to describe grossly obvious lesions in diagnostic terms rather than nonspecific and frequently long-winded descriptions, a practice with which many also disagree. Leiomyoma, or, where useful, the diagnostic term with one or two adjectives (‘well-circumscribed, whorled leiomyoma lacking hemorrhage or necrosis’), is far more useful than the excessive description (‘numerous, discrete, circumscribed, rounded lesions with a bulging whorled cut surface, white in color, and compressing the adjacent myometrium’), which is tedious to read. At worst the description is vague (‘rounded lesions’). Purposeful uncertainty, where it exists, can also be introduced with adjectives (‘5 cm soft, focally necrotic leiomyomatous nodule with irregular borders suspicious for sarcomatous change’).

The gross description, especially of small specimens, should conclude by stating how much of the tissue has been processed for microscopic examination. This is especially important in the case of endometrial curettings removed for a suspected intrauterine pregnancy where neither chorionic villi nor other tissues of fetal origin are found and all of the tissue has been submitted. Specify the number of each type of block sampled and from where each was obtained. An example of a useful gross description is ‘The endometrium, which is 2 mm thick, discloses no obvious tumor. The entire endometrium including the superficial myometrium is blocked and submitted in toto.’

Inking

Application of ink, often in multiple colors, can be useful to identify various surgical margins, which on histologic sections is helpful to determine if the lesion is truly present at the margin or is present only where the tissue has been cut on a bias, thus simulating a margin (ink absent). If used, apply ink sparingly and blot dry to prevent spillover or running. Acetone or distilled white vinegar can be used to set the ink. As inking is a procedure all too often done indiscriminately, determine first whether it is even useful. There is no need to ink a uterine serosa in cases of cervical squamous intraepithelial lesions (SIL) or in cases where the endometrial cancer is small and noninvasive and the serosa is obviously normal and uninvolved. Ink sometimes is helpful (and sometimes the only clue) in identifying the surface of the ovary when replaced by tumor. Ensure also that the ink does not inadvertently conceal disease, e.g., endometriosis or a metastasis on the serosa.

Drawings and Photographs

The inclusion of drawings and/or photographs may simplify portrayal of complicated relationships and permits better orientation, especially of surgical resection margins. Today, most photographs use digital technology. Document scanners can also be used for this purpose and can create surprisingly high-quality images. Block diagrams made from digital photographs or Xerox copies are particularly useful in complex cases. In the absence of actual photographs, diagrammatic drawings of the specimen and sections taken can also be helpful.

Fixatives

Formalin-based fixatives are generally the most practical and commonly used today. Tissue submitted in blocks for processing should be less than 3 mm thick. Thicker fragments are difficult to dehydrate and inhibit paraffin infiltration, thus leading to suboptimal slides. Sometimes, it is much easier to cut sections from tissue that has been fixed for several hours instead of attempting to cut 3 mm thick slices directly from a fresh specimen. Large specimens should be cross sectioned and cut at intervals 1 cm thick or less. This permits adequate penetration by formalin, after which the tissue can be trimmed into 3 mm thick sections. For large specimens, e.g., uteri removed for leiomyomata, placing the tissue blocks into cassettes (with all labeling complete) and retaining them in the fluid fixative for an extra day facilitates better sections. If fresh or frozen tissue is required for special studies, this should be collected prior to fixation.

Number of Sections Required

Judging what must be sampled to optimally examine a specimen is one of the more controversial subjects not only in gynecologic pathology, but in all branches of surgical pathology. In general, the authors believe that far too many blocks are usually taken, adding expense without furthering diagnostic information gained. A useful exercise is to determine what single slide would be taken if the entire prosection permitted were limited to the single slide. This forces thinking about which single slide would demonstrate the lesion as well as pertinent margins or neighboring relations. Such forethought often has a major influence on how a specimen is opened and/or sampled. For example, an excisional biopsy of vulvar tumor might be best sampled by six equidistant perpendicular blocks sampling the central tumor, deep margin, and lateral margins rather than eight parallel lateral margins, shave margins of the base, and only several of the tumor. Leiomyomas/equivocal leiomyosarcomas should include not only the tumor but also the border with neighboring tissue and margins if possible. Endometrial tumors can easily be sampled to include the adjacent ‘normal’ endometrium.

Synoptic Checklists

As the complexity of information contained in reports increases and tumor cases are accessioned into trials with specific entry criteria, checklists are being used with increasing frequency to record and evaluate the details of operative and pathologic findings consistently. A full listing of College of American Pathologists specimen processing protocols, including synoptic checklists, is available online at www.cap.org.

Excisional Biopsies

Biopsies of the vulva should be handled like skin biopsies. Assess the deep and lateral resection margins. If the surgeon has placed a suture for orientation, inking (often in several colors) facilitates recognition on microscopic examination.⁴

Wide Local Excision

In general, wide local excisions are performed for noninvasive neoplasms such as vulvar intraepithelial neoplasm (VIN) 3 or Paget disease of the vulva, as well as superficially invasive (less than 1 mm) stage 1 carcinomas. Lymph node dissections are added for stage 1B carcinomas (greater than 1 mm invasive). Orientation is critical in these specimens and, if not clearly indicated, consultation with the surgeon may be required. Operative specimens often include labia minora and majora, clitoris, perineal body, and perianal tissue (Figure 35.1). Describe and measure the lesions, distances to resection margins, and the anatomic structures involved. Examine the coloration and surface texture carefully as intraepithelial lesions are subtle, typically red-brown to white and roughened.

As intraepithelial lesions are often multifocal and difficult to discern macroscopically, all surgical peripheral and deep resection margins should be evaluated microscopically. Sections parallel to margins (‘tangential’) may be taken to evaluate the excision lines; however, one difficulty commonly encountered in parallel sections for evaluation of margins is to determine if tumor found in the slide truly involves the margin or was from the inner face, and therefore not a true representation of the margin.

For discrete tumors, such as squamous cell carcinoma, multiple full thickness sections perpendicular to the skin surface and radiating outward from the lesion are advantageous as the central lesion, margins, and intervening areas can be included in one slide and tumor close to the margin is easy to evaluate (Figure 35.2). Facilitate sectioning by pinning the specimen on a corkboard or a block of paraffin and fix for several hours or overnight. Diagrams or photographs are often useful.

Skinning Vulvectomy

This is by definition a superficial excision of the vulvar skin at the level of the dermis, meaning it is performed almost entirely for noninvasive neoplasms (VIN 3 and Paget disease). The gross description and sections taken will be similar to those of wide local excision.

Simple (or Total) Vulvectomy

This includes the entire vulva and subcutaneous fat (dissection to deep fascia). It is typically performed for noninvasive neoplasms that widely involve the vulva. Pin, fix, and section the specimen at 0.5 cm intervals to evaluate for invasive carcinoma. Typically, the extent of Paget disease exceeds that visible macroscopically as occult foci are often present within normal-appearing skin. The resection margins must be thoroughly evaluated.2,5

Radical Vulvectomy

Radical vulvectomy consists of vulva excised to the deep fascia of the thigh, the periosteum of the pubis, and the inferior fascia of the urogenital diaphragm. It is most commonly performed together with at least an inguinal lymph node dissection, which may be included en bloc with the vulvectomy. Total radical vulvectomies have largely been replaced in favor of more limited excisions, but sufficient to completely excise the primary tumor with a minimum 2 cm margin. Radical total vulvectomies are now performed primarily for large and/or aggressive tumors. The gross description should include the size, location, depth of invasion, and all resection margins, including perianal and vaginal margins. Sections should include the tumor, showing the maximum depth of invasion, labia majora and minora, clitoris, distal urethra, resection margins including the vaginal margin, and all lymph nodes. Separate lymph nodes into superficial and deep groups, and submit all lymph nodes entirely for histologic examination (unless grossly positive; in that case a representative section is sufficient). Invasive vulvar neoplasms are typically solitary in contrast to intraepithelial lesions, which are often multifocal. Consequently, evaluation of resection margins can be largely limited to the margins closest to the tumor. The report should include microscopic diagnosis, tumor grade, dimensions, location and maximum depth of invasion, presence of lymphatic invasion, number and location of involved lymph nodes, and distance to resection margins. Diagrams and/or photographs may be useful aids.