Grossing of Hysterectomies Specimen.pptx

Grossing hysterectomy specimen, lovely read

1. Grossing of Hysterectomy Specimen By Dr. Samuel Adebudo Registrar, Department of Anatomic Pathology, UBTH

2. OUTLINE INTRODUCTION GROSSING PROCEDURE OF THE UTERUS GROSSING PROCEDURE OF THE OVARY GROSSING PROCEDURE OF THE FALLOPIAN TUBE CONCLUSION

3. INTRODUCTION Hysterectomy is a surgical procedure to remove all or part of the uterus. Hysterectomies can be performed by either the abdominal or the vaginal route Supra-cervical hysterectomies - The corpus is separated from the cervix and the latter is left in place

4. INTRODUCTION Depending on the age of the patient and the nature of the disease, abdominal hysterectomies may be accompanied by unilateral or bilateral adnexectomy and by the removal of regional lymph nodes.

5. PROCEDURE Check the patient history found on the requisition or in the patient’s chart/case file Type of hysterectomy : total? radical? With salpingo -oophorectomy Detach the adnexa but keep track of which is anterior and which is posterior Describe Shape of uterus: deformed? Sub- serosal bulges? Serosa : fibrous adhesions Ink the anterior and posterior surfaces different colors/make a cut on the anterior surface Weigh the specimen and adnexa (if included)

6. PROCEDURE Open it by cutting with scissors through both lateral walls, from the cervix to the uterine cornua (3 and 9 o’clock), Make a mark as to which half is anterior (e.g. by cutting a small wedge on one side ) Identify and Describe Wall: thickness, abnormalities Endometrium: appearance; thickness; polyps? (size, shape);cysts? Cervix: appearance of exocervix , squamocolumnar junction, endocervical canal; erosions? polyps? cysts? Myoma : number, location ( subserosal , intramural, submucosal ); size; sessile or pedunculated ? hemorrhage, necrosis, or calcification? ulceration of overlying endometrium?

7. PROCEDURE Make additional cuts through any large mass in the wall Make parallel transverse sections through each half, about 1 cm apart, beginning at the upper level of the endocervical canal and stopping short of completing them on one side to keep them together, and examine carefully each surface

8. PROCEDURE Make several sections of the cervix along the endocervical canal Make at least one cross section of every myoma present and examine carefully; larger myomata need additional cuts

9. Hysterectomy : Anterior and posterior. This side-by-side picture of both anterior and posterior aspects of a uterus shows the greater inferior extent of the smooth serosal surface on the posterior side

10. The uterus is sectioned along the lateral uterine walls (3 and 9 o’clock). Sectioning this way will provide the best visualization of the endometrial cavity, lower uterine segment

11. The uterus is sectioned along the lateral uterine walls (3 and 9 o’clock). Sectioning this way will provide the best visualization of the endometrial cavity, lower uterine segment

12. Submucosal leiomyoma. Many nodules can be seen in this bisected uterus, including submucosal leiomyomata located immediately beneath the endometrial lining

13. Make parallel transverse sections through each half, about 1 cm apart, beginning at the upper level of the endocervical canal and stopping short of completing them on one side to keep them together, and examine carefully each surface

14. PROCEDURE Sections for histology Cervix: O ne section from anterior half and O ne from posterior half Corpus: A t least two sections taken close to fundus and including endometrium, good portion of myometrium, and, if thickness permits, serosa; A dditional sections from any grossly abnormal areas

15. PROCEDURE Sections for histology Myoma : at least one section per myoma , up to three; sections from any grossly abnormal area (e.g. soft, fleshy, necrotic, cystic) Cervical or endometrial polyps: to be submitted in entirety unless extremely large

16. Hysterectomy : Serial sectioning and intramural leiomyomas . Serial sections of the uterus are taken horizontally (transversely) from the superior aspect to the inferior. The myometrium in these sections is remarkable for several intramural leiomyomas

17. Uterus – Hysterectomy For Cervical Carcinoma (In Situ Or Invasive) Procedure If lymph nodes are included (radical hysterectomy ), dissect while fresh and separate into left and right obturator , interiliac , and left and right iliac (high nodes) groups (not all of these groups will be present in every specimen) Measure and weigh the specimen; orient as to anterior and posterior sides . Amputate the cervix from the corpus about 2.5 cm above the external os with a sharp knife

18. Uterus – Hysterectomy For Cervical Carcinoma (In Situ Or Invasive) Description Cervix : color of epithelium; presence of irregularities, erosions , healed or recent lacerations, masses (size, shape, location ), cysts (size, content), previous biopsy, or conization sites Rest of uterus: As earlier described Lymph nodes, if present: approximate number; gross appearance ; seem involved by tumor?

19. Uterus – hysterectomy for cervical carcinoma (in situ or invasive) Handle the uterus as initially described as well as the tubes and ovaries, if present . Open the cervix with scissors through the endocervical canal at the 12 o’clock position and carefully pin stretched specimen on a corkboard with the mucosal side up. Be careful to avoid tearing or rubbing the epithelial surface

20. Uterus – Hysterectomy For Cervical Carcinoma (In Situ Or Invasive) PROCEDURE Fix by floating for several hours or overnight with the tissue on the underside of the corkboard in a formalin container Paint the vaginal surgical margin with India ink Cut the entire cervix by making parallel longitudinal sections, 2–3 mm apart, along the plane of the endocervical canal starting at the 12 o’clock position and moving clockwise. Sections should be taken in such a way that the epithelium (including the squamo -columnar junction) is present in each section.

21. Uterus – hysterectomy for cervical carcinoma (in situ or invasive) Sections for histology Cervix : all tissue is submitted (except for trimming of stroma ) and identified separately as follows: Sections from 12 to 3 o’clock Sections from 3 to 6 o’clock Sections from 6 to 9 o’clock Sections from 9 to 12 o’clock If an accurate mapping of the lesions is desired, identify sequentially each section with a letter, beginning from the 12 o’clock position )

22. Uterus – hysterectomy for cervical carcinoma (in situ or invasive) Sections for histology Vaginal cuff (entire line of resection) Left soft tissue (for invasive cases only Right soft tissue (for invasive cases only) Rest of uterus: As earlier described Ovaries and tubes Lymph nodes, if present: Left obturator Right obturator Interiliac Left iliac (high nodes) Right iliac (high nodes)

23. Uterus – Hysterectomy For Endometrial Hyperplasia Or Carcinoma Description Type of operation: radical? total? with salpingectomy and oophorectomy ? Tumor : exact location; size; appearance (solid, papillary, ulcerated , necrotic, hemorrhagic); color; extent of endometrial extensions; presence of myometrial , serosal , parametrial (soft tissue), venous, cervical, or tubal extension Rest of uterus: As described earlier Ovaries and tubes: see respective instructions Lymph nodes, if present: approximate number; gross appearance ; seem involved by tumor?

24. Uterus – Hysterectomy For Endometrial Hyperplasia Or Carcinoma PROCEDURE If lymph nodes are included (radical hysterectomy), dissect while fresh and separate into left and right obturator , interiliac , and left and right iliac (high nodes) groups (not all of these groups will be present in every specimen) Open and fix the uterus as earlier explained If ovaries and tubes are present, handle according to respective instructions

25. Uterus – Hysterectomy For Endometrial Hyperplasia Or Carcinoma PROCEDURE M easure the deepest point of myometrial invasion. Measure the myometrial thickness. A trabeculated myometrial cut surface may indicate adenomyosis . For endometrial tumors, submit representative sections (at least one section per centimeter of tumor), to include full thickness sections at the deepest point of invasion If the cervix is grossly involved with carcinoma, submit at least two representative sections of tumor involving the cervix . It is important that the sections of the cervix include the full thickness of the cervical wall and the ectocervical or vaginal cuff margin.

26. Uterus – hysterectomy for endometrial hyperplasia or carcinoma Sections For Histology If there is obvious tumor present: Three sections, one of which should be through area of deepest invasion and be complete sections from surface of endometrium through serosa (if too thick for a cassette, divide in half and identify both halves appropriately) Two sections from non-neoplastic endometrium; do not need to be through entire wall Soft tissue from left and right parametria

27. Uterus – hysterectomy for endometrial hyperplasia or carcinoma Procedure & Sections For Histology If no obvious tumor present (previous irradiation, very superficial carcinoma, endometrial hyperplasia): Sample entire endometrium by making complete transverse parallel sections, 2–3 mm apart, of both uterine halves; one section should comprise entire thickness of organ, from mucosa to serosa; trim away from all others deepest two-thirds of myometrium. Label separately as anterior and posterior halves Rest of uterus: as earlier described Ovaries and tubes: As will be described Lymph nodes, if present: Left obturator , Right obturator , Interiliac , Left iliac (high nodes), Right iliac (high nodes)

28. Endometrial carcinoma. A mass can be seen filling the entire endometrial cavity. The lower uterine segment and cervix appear grossly uninvolved , but representative sections should always be taken to rule out microscopic involvement by the tumor

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30. Ovary – O ophorectomy Oophorectomies may be total or partial The most common type of conservative operation is the removal of an ovarian cyst with preservation of the uninvolved parenchyma (ovarian cystectomy). Procedure Measure the organ. Weigh it if it is obviously abnormal If the specimen is received fresh: Normal-sized or nearly normal-sized organ: bivalve and fix for several hours Enlarged organ: make several cuts and fix for several hours Description Size and shape; weight, if enlarged Capsule : thickened? adhesions? hemorrhage? rupture? External surface smooth or irregular?

31. Ovary – oophorectomy Cut section: character of cortex, medulla, and hilum; cysts (size and content); corpus luteum ? calcification? hemorrhage? Tumors : size ; external appearance: smooth or papillary? Solid or cystic? content of cystic masses; hemorrhage, necrosis, or calcification?

32. Ovary – oophorectomy Sections for histology For incidental oophorectomies: one sagittal section of each entire ovary, labeled as to side For cysts: up to three sections of cyst wall (particularly from areas with papillary appearance) For tumors: T hree sections or one section for each centimeter of tumor, whichever is greater O ne section of non-neoplastic ovary , if identifiable

33. Fallopian tubes – salpingectomy Salpingectomy may be performed by itself in the case of fallopian tube pathology or – more often – as part of a total abdominal hysterectomy with unilateral or bilateral salpingo -oophorectomy . Surgical Grossing Procedure Fix the specimen before sectioning. If the tubes are attached to the uterus, they should be fixed in that position Measure the length and greatest diameter If the tube is relatively normal in size, serially section at 5 mm intervals and examine. Make the cuts incomplete so that the pieces remain attached by the serosa If the tube is obviously enlarged, make one complete longitudinal section, followed by parallel sections, if necessary

34. Fallopian tubes – salpingectomy Description Length and greatest diameter Serosa : fibrin? hemorrhage? fibrous adhesions to ovary or other organs? Wall : abnormally thick? ruptured? Mucosa : atrophic? hyperplastic? appearance of fimbriated end; inverted ? Lumen : patent? dilated? content; diameter, if abnormally large Masses : size, appearance, invasion Cysts in paraovarian region: diameter, thickness of wall, content ; sessile or pedunculated ? In cases of suspected ectopic pregnancy: embryo or placenta identified ? amount of hemorrhage; rupture

35. Fallopian tubes – salpingectomy

36. Fallopian tubes – salpingectomy Sections for histology For incidental tubes without gross abnormalities: three cross-sections of each tube, taken from the proximal, mid, and distal portions, submitted in the same cassette. For tubes with suspected ectopic pregnancy: submit any tissue with gross appearance of products of conception. If none is grossly identified, submit several sections from the wall in the area of hemorrhage as well as several from the intraluminal clot . If products of conception are not identified microscopically, submit additional sections

37. Fallopian tubes – salpingectomy Sections for histology For tubes with other lesions: as many as needed to adequately examine any abnormal areas. If tumor is present, at least three sections must be taken to include grossly uninvolved mucosa

38. Conclusion Accurate grossing of specimens is a prerequisite for making accurate diagnosis which will in turn assist the clinician in making right decisions in the management of patients. Hence we should continue to consolidate on our knowledge of grossing surgical specimens.

39. REFFERENCES Rosai J, Ackerman, L. V, Rosai , J.(2011). Rosai and Ackerman’s Surgical pathology 10 th edition ; Edinburgh Mosby Monica B. Lemos , Ekene Okoye editors ( 2019) ; Atlas of Surgical Pathology Grossing; Switzerland G A Springer Nature

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