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1. GASTROINTESTINAL TRACT GROSSING (OESOPHAGUS, STOMACH, INTESTINE ) P r e s e nt e r : Avadh Sharma Moderator : Dr Mura d Ahmad

2. INTRODUCTION AND SURGICAL ANATOMY RATIONAL TYPES OF SPECIMEN FIXATION ANF STEPS IN GROSSING SAMPLE DICTATION

3. OESOPHAGUS 25 cms in length. from lower end of pharynx (C6) to cardiac end of stomach (T11). Three normal anatomic constrictions Pharyngo- oesophageal jn (C6), 15 cms from the upper incisors. Arch of aota and left main bronchus (T4) , 25 cms from upper incisors Pierces diaphragm (T10), 40 cms .(LES)

4. RATIONALE Grossing a oesophagectomy specimen correctly provides information regarding tumour size, the depth of invasion, involvement of adventitia and serosa, the status of the proximal, distal and circumferential margins and the lymph nodal status. All these factors are of immense importance in prognosis and deciding further treatment.

5. Types of Specimens

6. FIXATION Oesophagectomy specimens contract immediately after surgical resection and should be promptly fixed. Open the stomach along the gastric resection margin by cutting out the staples as close to the specimen as possible. Insert cotton soaked with formalin into the stomach and, if possible, into the oesophagus . Take a deep tray and allow the specimen to fix overnight in 10% buffered formalin

7. BIOPSY Biopsies are commonly performed for evaluation of heartburn (e.g., due to reflux or ulcers in immunocompromised patients), for the evaluation of dysphagia (usually secondary to strictures or tumors) surveillance for dysplasia in patients known to have Barrett’s esophagus.

8. PROCESSING THE SPECIMEN 1. Record: Number of fragments Aggregate dimensions Greatest dimension of largest fragment Record the shape of the fragments – needle cores or small irregular fragments. 3. Record the color and consistency of the fragments. Small biopsy specimens should not be cut or inked. If the specimen is large enough to orient (e.g., colon polyps, skin, or temporal arteries), see the specific section concerning this type of biopsy. All fragments are submitted and embeded so that the mucosal side is at right angles to the cutting surface.

9. OESOPHAGECTOMIES

10. Steps in Grossing 1. State the type of specimen. 2. Measure the length, circumference and wall thickness of the oesophagus and the length of the stomach along the lesser and greater curvatures. 3.Examine the external surface of the oesophagus for any obvious abnormality. 4.Open the esophagus longitudinally from one end to the other and in presence of tumor, the specimen is cut opposite the tumor. Extend the cut along the greater curvature of the stomach if it is included in the specimen .

11. 5. The perioesophageal fat along with lymph nodes are dissected from the specimen. The lymph nodes are divided as proximal and distal groups in relation to the tumor when obvious. 6. Paint the external/ advential surface of the oesophagus with ink 7. Identify the slices bearing the tumour . Note Appearance of tumour : ulcerative, polypoidal etc Dimension of tumour Depth of invasion Distance of the tumour from the proximal, distal and resection margins, gastroesophageal junction. Any perforation

12. 8. Look for the abnormality in the rest of the oesophagus , the cardiooesophageal junction and the stomach mucosa. 9. After the tumour sections have been submitted, dissect out the paraoesophageal nodes that are present along with the specimen. Also dissect out the lymph nodes along the cardio- oesophageal junction and the greater and lesser curvature of the stomach.

13. SECTIONS SUBMITTED Tumour , minimum of 4 sections. To include maximum depth of tumor infiltration To include interface with adjacent proximal esophagus To include interface with adjacent distal esophagus b. Two transverse bits from proximal and distal esophagus when there is no gross pathology c. Proximal resection margin d. Distal resection margin e. Cardio- oesophageal junction f. Any other obviously abnormal looking area

14. g. random sections from stomach one from anterior wall one from posterior wall . h. One half each of all lymph nodes submitted. Paraoesophageal nodes, cardiooesophageal junction nodes, lesser curvature nodes and greater curvature· nodes.

15. For tumours situated at the cardiooesophageal junction . A tumour , where the epicenter is within 5 cm of the cardio- oesophageal junction and which extends into the oesophagus , is classified and staged according to the oesophageal scheme . All other tumours with an epicenter in the stomach greater than 5 cm from the cardio- oesophageal junction or those within 5 cm of the cardiooesophageal junction without extension into the oesophagus are staged using the gastric carcinoma scheme.

16. GROSS DIFFERENTIAL DIAGNOSIS ADENOCARCINOMA at or just above the GE juction typically tan-pink, polypoid, and may be ulcerated. may tunnel underneath the overlying uninvolved mucosa and show up on your microscopic sections far from the tumor .

17. SQUAMOUS CELL CARCINOMA at any level of the esophagus, more common in middle and lower thirds . Grossly circumferential constricting lesion, with sharply demarcated margins. fungating ulcerated diffuse thickening with narrowing of the lumen.

18. LEIOMYOMA subepithelial nature Well circumscribed, pink to white, polypoid mass. Smooth overlying mucosa smooth, concave junction between the mass and the surrounding mucosa.

19. BARRETTS MUCOSA pale pink-red and finely granular. squamous mucosa which is white, smooth and glistening. usually found close to the GE junction, but can occur elsewhere.

20. Tumor after treatment : areas of shallow ulceration, thickened wall or irregular, granular appearing squamous mucosa. If a tumor is not readily identified, the entire gastroesophageal junction needs to be submitted to look for residual tumor . H/O High grade Dysplasia/carcinoma in situ on a previous biopsy and no tumor is grossly identified: The gastroesophageal junction mucosa should be blocked and submitted in toto .

21. SAMPLE DICTATION Received fresh sample labeled as “esophagus” is an esophagectomy and partial gastrectomy specimen consisting of esophagus (15 cm in length × 4 cm in circumference) and stomach (5 cm in length × 12 cm in circumference). There is a 3.5 × 3 cm tan/pink, firm, centrally ulcerated tumor mass arising just proximal to, and partially involving, the gastroesophageal junction. The tumor invades into and focally through the muscularis propria into adjacent soft tissue .

22. SAMPLE DICTATION The tumor is 12 cm from the proximal margin and 5 cm from the distal margin . The esophageal mucosa adjacent to the tumor is tan/pink and finely granular and extends to within 5 cm of the proximal resection margin. The remainder of the mucosal surfaces are unremarkable. Five lymph nodes are found in the surrounding soft tissue, the largest measuring 1 cm in greatest dimension. This node is very firm and white.

23. STOMACH • It is a muscular sac. • It is a J-shaped. It occupies the left upper quadrant, epigastric, and umbilical regions, and much of it lies under cover of the ribs. • Stomach located at level of T10 and L3 vertebral.

24. The stomach is divided into four regions: cardia, which surrounds the opening of the esophagus into the stomach. fundus of stomach, which is the area above the level of the cardial orifice. body of stomach, which is the largest region of the stomach. pyloric part, which is divided into the pyloric antrum and pyloric canal and is the distal end of the stomach.

25. Other features of the stomach include: • The greater curvature, which is a point of attachment for the gastrosplenic ligament and the greater omentum • The lesser curvature, which is a point of attachment for the lesser omentum .

26. TYPES OF SPECIMEN

27. BIOPSIES Note the number and color of the tissue fragments. They need to be separated from underlying filter paper/cardboard on which they were sent or fixed. Measurement: Note, the largest and the smallest of the fragments in greatest dimension. All submitted.

28. FIXATION Measure - length of greater curvature, lesser curvature, esophageal and duodenal cuffs (if present), gastric wall thickness. Probe with finger to locate the lesion Open specimen along the greater curvature. Once the stomach is opened, evaluate each of the three layers of the stomach—the mucosa, wall, and serosa.

29. Examine for small mucosal erosions and irregularities ; also for intramural and subserosal nodules. Examine in fresh state dissect omentum & lymph nodes if any Photograph Pin on corkboard, mucosa side up. Fix overnight

30. In case the tumour involves greater curvature , the· cut should be taken in a wide arc curving around the tumour . If a large tumour sits on the greater curvature , stomach can be opened along the lesser curvature. The main point of concern here is that the relationship of tumour with the serosa should not be violated while opening the stomach

31. Most common indications are malignancy or peptic ulcer disease

32. Gastrectomy Specimen (for Peptic Ulcer) Examine the specimen in the fresh state. The resected portion normally includes the antrum, pylorus and portion of the first part of duodenum. Examine the mucosa for ulcer— location, no. of ulcers size, depth of penetration, shape, margins(sharp or irregular), borders (smooth flat or heaped-up), base (clean or shaggy) + of large vessels or perforation at base

33. Measure the distance of the ulcer from the closest proximal and distal surgical margins. Cut through the center of the ulcer along its long axis to see the base of the ulcer for fibrosis and presence of large vessels, if any. Examine the rest of the mucosa for edema, hemorrhage, atrophy, erosions, any mucosal irregularities and nodules if any. Dissect the lymph nodes and group them separately. Measure the greatest dimension of the largest and the smallest lymph nodes of each group.

34. SECTIONS SUBMITTED Ulcer - Four sections, also to include the center of the lesion Lesser curvature - two sections Greater curvature – two sections Pylorus and Duodenum – two sections including line of resection Two sections from the rest of the stomach showing any mucosal lesion if present . Lymph nodes , depending on the number. section entire lymph node if less than 5 mm. Bisect and take one-half if more than 5 mm in size.

35. BENIGN ULCER Young Males Lesser curvature of pylorus Usually <4 cm Clear base Folds radiating from margins Flat margins Sharply punched out

36. MALIGNANT ULCER Older Greater curvature >4 cm Necrotic h’gic base Interrupted folds Heaped margins Irregular lesion

37. Gastrectomy Specimen (for Malignant Lesion) 1. Examine the opened out specimen for tumor and observe the following features: • Type (ulcerative, ulceroproliferative or polypoid) • Location (whether on lesser or greature curvature) • Size • Note the distance from the closest proximal and distal surgical margins . 2. Cut through the tumor along its long axis and note the extent of infiltration. Measure the maximum depth of infiltration.

38. 3. Examine the rest of the mucosa for edema, hemorrhage, mucosal nodules, mucosal irregularities 4. Mark the proximal and distal surgical margins with India ink 5. Identify the lymph node groups as cardiac, greater curvature, lesser curvature, pyloric and omental nodes. Note the number in each of the groups and measure the greatest dimension of the largest and the smallest lymph nodes in each group.

39. SECTIONS From tumour :- 4 sections through wall including tumour border and adjacent mucosa. When the stomach appears diffusely thickened by an infiltrative process (e.g., linitis plastica ) submit sections from all four regions of the stomach Non neoplastic mucosa : mid stomach, 2 sections Proximal line of resection along lesser curvature: 2 sections Proximal line of resection along greater curvature: 2 sections pylorus and duodenum, if present): 2 sections.

40. 6. Spleen , if present 7. Pancreas, if present 8. Lymph nodes: a Pyloric b Lesser curvature c Greater curvature d Omentum e Perisplenic Sections are taken perpendicular to mucosal folds , at margin shave section can be taken when tumour is far off from margin

41. If thorough mapping of mucosal abnormalities is desired such as in case of intestinal metaplasia, dysplasia, regenarative atypia, a Swiss roll technique (where mucosa alone is shaved off from the underlying muscle layer and rolled up) should be used to cover a large mucosal surface in a minimum number of blocks.

42. GASTRIC CA Gastric Carcinomas of Intestinal Type usually arise in the antrum. The edges are usually heaped up and serpiginous with a central ulcer bed. Polypoid and villous architecture may be present. Diffuse Type (Signet Ring Cell Carcinomas) are usually located in the prepyloric region or body of the stomach. In this the wall of the stomach is markedly thickened due to the infiltrative nature of the malignant cells (termed “ linitis plastica ”)

43. GIST It arise from the specialized interstitial cells of Cajal in the muscularis propria. The cut surface is tan and lacks the whorled appearance of smooth muscle tumors. Most arise in the stomach with fewer in small intestine, colon or rectum, or esophagus . The risk of malignant behavior is related to location (gastric tumors are less likely to behave in a malignant fashion), size, and mitotic rate

44. CARCINOID Sharply outlined, covered by flattened mucosa, resemble polyps

45. INTESTINE

46. Intestine is a tubular organ from the stomach to the anus It is divided into small & large intestine

47. The small intestine consists of the duodenum, jejunum and ileum. It extends from the distal end of the pyloric canal to the ileocaecal valve overall length of 5 metres (3–7 metres ) in the living adult.

48. Large intestine : it begins in the right iliac fossa as the caecum which becomes the ascending colon & bends to the left forming the hepatic flexure and becomes the transverse colon . It reaches the left hypochondrium, curves inferiorly to form the splenic flexure (left colic flexure) and becomes the descending colon , which proceeds through the left lumbar and iliac regions to become the sigmoid colon in the left iliac fossa. The sigmoid colon descends deep into the pelvis and becomes the rectum which ends in the anal canal a t the level of the pelvic floor. The large intestine is approximately 1.5 m long in adults , although there is considerable variation in its length.

49. Identification of resected specimen To differentiate large intestine from small intestine Large intestine has- Larger diameter: Taeniae coli Haustras Appendices epiploicae

50. Mucosal fold of small intestine is stretched entirely across the entire circumference of bowel while that of large intestine is discontinuous

51. TYPES OF SPECIMEN Biopsy B . Polypectomy C. Endoscopic mucosal resection-  technique used for the staging and treatment of superficial neoplasms of the gastrointestinal tract.  Single or multiple fragments; described, entire specimen is serially sectioned & submitted

52. D. Bowel resections Total colectomy Right hemicolectomy – terminal ileum with ileo- cecal valve, cecum and colon up to hepatic flexure along with attached appendix and mesentery Left hemicolectomy includes colon from splenic flexure to sigmoid Tranverse colectomy (hepatic to splenic flexure)

53. BIOPSY

54. Finger like- normal mucosal pattern Leaf like -normal, malabsorption syndrome, giardiasis Cerebriform - proliferative haemorrhagic enteropathy Flat – coeliac sprue, megaloblastic anaemia, radiation enteropathy

55. INTESTINAL POLYP

56. STEPS IN GROSSING The key to orienting the polyp is to find its stalk. After finding the stalk, mark its base Nature of specimen: polypectomy/fragments. Dimensions : maximum dimension; length of stalk, diameter of base. Externalsurface : ulcerated/smooth/lobulated/villous/fronded, etc. Cut surface : cysts, mucus, haemorrhage, necrosis.

57. place the specimen in formalin for fixation Once fixed, the specimen should be sectioned in a way to show the relationship of the stalk to the head of the polyp. this is usually best demonstrated by trisecting the polyp into two lateral caps and one median section that includes the stalk and the center of the head.

58. For long polyp with long stalk> 1cm The median section should demonstrate the largest cross-sectional area of the head of the polyp, its interface with the stalk, and the surgical margin. To avoid missing a small focus of carcinoma, submit the entire specimen.

59. Polyp with short or no stalk Identify surgical section Cut in 2 half longitudinally

60. Intestinal resection for NON-NEOPLASTIC disease

61. SPECIMEN FIXATION- 2 methods cut longitudinally through the anti- mesentric border. Remove the mesentry & submit for HPE open & rinse specimen by anisotonic solution pin on corkboard fix overnight Wash out contents by normal saline Tie on one end fill the lumen with formalin Tie other end fix overnight open longitudinally

62. Specimen Photography Photographs of the specimen should be taken to document further the gross findings, especially the distribution and nature of the mucosal alterations . Photograph the specimen after it has been opened and fixed. Always position the specimen anatomically on the photography table.

63. STEPS IN GROSSING Orient the specimen. Identify and measure the specimen-look for appendix in particular. Describe the external surface - congestion, exudate, perforation, hemorrhage, stricture, tubercles, adhesions. Describe the mucosal aspect - presence of edema, hemorrage , ulceration, gangrene, stricture, tubercles, perforation.

64. TISSUE SAMPLING In inflammatory changes in the specimen , all areas of the bowel should be sampled submit representative sections at10-cm intervals , beginning at the distal to proximal end of specimen in a step-wise fashion. By this mucosa is well sampled and also provides infor sections of any focal lesions such as ulcers or polyps should be submitted the mesentery for lymph nodes, submit sections of mesenteric blood vessels and of any focal lesions. Sections should be longitudinal (exception linear ulcer is best demonstrated by a transverse section through the bowel).

65. Colon with Ulcerative colitis

66. Colon with Crohns disease showing patchy distribution of affected colon and mucosal erythema

67. Feature Ulcerative colitis Crohn disease Distribution Diffuse, continuous Focal (skip), segmental Depth of involvement Mucosa, submucosa Transmural Mucosal appearance Irregular ulcers, friable, atrophy Cobblestoning Bowel wall Thin Thickened or normal Creeping fat Absent Common Stricture Usually absent Maybe Fistula Usually absent Maybe Fissuring Usually absent Common Ileal involvement <10% (backwash) Common Upper GI involvement Usually no Maybe Rectal involvement 100% ~15% Anal involvement 5–10% ~75% Well-formed granuloma Absent Common Transmural lymphoid aggregates Absent Common

68. Macroscopic description Dimensions: Length of intussusception; distance of apex from distal resection margin; distance of neck from proximal margin; diameter of lumen. Opened bowel : Type of intussusception - ileoileal /ileocolic/ colocolic . Appearance of the mucosa ; state of the underlying wall; ischaemia. Look for a causative lesion: foreign body, polyp, diverticulum, various tumours, ileal lymphoid hyperplasia, appendix. In young children, a cause is often not found. Sampling Apex of intussusception, including possible causative lesion. Demonstrate intussusception if possible. Margins are important if there is ischaemia

69. ILEOSTOMY

70. ILEOSTOMY: SECTIONING : Open the stapled end by cutting beneath the staples. Cut through the osteomy site. Take sections so that both the skin and mucosa are included.

71. Intestinal resection for NEOPLASTIC disease

72. STEPS IN GROSSING Orient the specimen Measure the length and diameter of the specimen Describe the external surface and look for nodularity, strictures, perforation, adhesions or exudate. Palpate the segment. localise the tumour . Cut the intestine from opposite end tumour . if tumour not grossly palpated , then simply open on anti- mesentric border. Rinse off the intestinal contents by isotonic saline.

73. Tumour - dimensions, configuration : endophytic, pedunculated, sessile Appearance ( fungating,polypoid,stenosis,ulceration,necrosis , hemorrhage). location relative to margin deepest gross penetration a/w bowel perforation or not Rest of the mucosa such as edema, ulceration, hemorrhage or polyps. Look for satellite nodules , invasion to vessels or adjacent organs Note the distance from tumour to soft tissue k/a circumferential radial margin

74. Lymph nodes Dissect the lymph node & remove mesentry while specimen is in fresh state Number: Size of the largest Location: around the tumor, proximal and distal to the tumor Look for and sample any lymphnode adjacent to the point of ligation of vascular pedicle k/a- highest lymph node Also examine the vessels in mesentry for thrombi & submit it

75. SECTIONS SUBMITTED at least five sections of the tumour (or more for large tumours ), if size permits, to include where applicable: the deepest tumour penetration into or through the bowel wall involvement of the peritoneal surface involvement of any adjacent organs if macroscopic tumour is <30 mm from the proximal or distal margins, appropriate section to show the closest approximation to that margin a section of tumour and adjacent mucosa, to include any precursor polyp , if present a section of normal-appearing intestine

76. all lymph nodes identified (whole node if <4 mm; central block through longest axis for larger nodes) any other macroscopic abnormalities a section of appendix if present (right hemicolectomy). In such specimens, a section from terminal ileum is only considered essential if there are macroscopic abnormalities in the ileum or the tumour is close to this proximal longitudinal margin.

77. NEOPLASTIC DISEASE

78. Serosal and Non-peritoneal resection margin involvement by tumour is important because of... Serosal involvement ( peritoneal surface) denotes stage T4 tumour , it does predict subsequent intraperitoneal recurrence and is a strong independent prognostic parameter. Circumferential margin ( Non – Peritoneal) involvement in the rectum carries a high risk of local recurrence and needs adjuvant Radiotherapy with an associated mortality rate of 90%.

79. MARGINS OF RECTAL SPECIMEN ANTEROR POSTERIOR

80. CIRCUMFERENTIAL RADIAL MARGIN (CRM) This margin represents the bare area in the connective tissue at the surgical plane of excision that is not covered by a peritoneal surface . Its extent varies greatly according to the site of the tumour. Low rectal tumours will be completely surrounded by a circumferential, non-peritonealised margin, upper rectal tumours have a nonperitonealised margin posteriorly and laterally and a peritonealised surface anteriorly.

81. Radial margin depends on the location of the tumour relative to peritoneal reflections . Tumour beneath the anterior peritoneal reflection have a CRM, while those that are not entirely beneath the anterior reflection have a NON-CRM

82. TYPES OF SPECIMEN Low Anterior Resection : for tumours in the upper 2/3 rd of rectum. Abdominoperineal resection (sigmoid colon, rectum and anus). It is used to resect tumours of distal 1/3 rd of rectum or anal canal. Total mesorectal excision

83. MESORECTUM: fatty connective tissue layer, measuring 2-3cm in thickness, with associated vessels, lymphatics and LN, which surrounds the rectum. Total Mesorectal Excision (TME): It is the removal of the mesorectum en bloc with the rectal tumour , It forms the current therapeutic 'gold standard' for rectal tumours. A good quality TME reduces the possibility of loco regional relapse. Assessment of quality of TME by pathologist is important as it provides prognostic information to identify those patients who are more likely to experience tumour recurrence .

84. MESORECTAL EXCISIONS

85. STEPS IN GROSSING Measure: length and greatest diameter. Orient the specimen Photograph the specimen Important step unique to rectum specimens: Evaluate the excision of the mesorectum ( mesorectal envelope) Describe as complete, nearly complete, or incomplete . Look for the presence of tumour site perforation before inking. Paint the non- peritonealised surface with ink with special reinforcement to the NPS related to the tumour . Do not paint the serosa

86. Ink: to designate the anterior and posterior mesorectal envelope, peritoneal surface. Open up the specimen longitudinally and gently remove blood, stool or necrotic debris Pin on corkboard and fix overnight. Grossing In Identify the type of resection : abdominoperineal resection (APR), low anterior resection, rectosigmoidectomy . Identify sigmoid and rectum – measure from rectosigmoid junction.

87. Tumor Size Shape (fungating, polypoid, flat) Surface (ulcerated, necrotic) Color Location distance from dentate line, state tumor is located “in the rectum”, or “at the anorectal junction”, etc.) Distance from proximal and distal margins of resection If prior chemo-radiation has been given, there may not be an identifiable mass. In this case, describe the area of induration and/or ulceration. Serially section the tumor full thickness , into approximately 5 mm thick sections, transverse to the longitudinal axis of the specimen Measure distance from lesion to mesorectal radial margin

88. Rectal and anal mucosa : Dentate line : It divides the anal canal into into upper two thirds and lower one third. It is located at the inferior limit of the anal valves.

89. SECTIONS SUBMITTED Sections of tumor (3), including junction of carcinoma with normal mucosa on at least one, and full depth (with inked margin), including serosa on at least two sections. Other lesions, if any. One section of uninvolved mucosa Margins of resection, proximal and distal. Circumferential margin Lymph nodes; remember to get at least 12 to avoid understaging . Measure the enlarged lymph nodes and note if they seem involved by tumor. Submit all other nodes entirely.