What is histopathology[1]

about histopathology and cytopathology

1. How to handle specimen for histopathology By.Dr.Ah.ReshadWajed Pathology Department of NCCP

2. What is Histopathology?

3. What is Histopathology? Histopathology  is the microscopic examination of biological tissues to observe the appearance of diseased cells and tissues in very fine detail. The word "histopathology" is derived from a combination of three Greek words: histos  meaning tissue, pathos  meaning disease or suffering, and logos  which refers to study in this context*. Hence histopathology is the study of microscopic changes or abnormalities in tissues that are caused as a result of diseases

4. General rules for the biopsy Larger the lesion - more numerous biopsies Ulcerated tumor - recommend peripheral biopsy Avoid necrosis and hemorrhage areas All fragments must be sent to the pathology department Not crushing, squeezing, cautery Immediately fix in fixatives Orientating specimen e.g. deep margin, superior and inferior margins by using sutured threads (long, short, black, white)

5. General rules for the biopsy Photography of fresh specimen Never open/cut the specimen Never . . . .Never . . . . .Never split the specimen and send it to different pathology labs

6. How to take a Surgical Specimen?

7. Incisional Biopsy The intent of an incisional biopsy is to sample only a representative portion of the lesion. If the lesion is large or has many differing characteristics, more than one area may require sampling.

8. Indications of incisional biopsy Whenever the lesion is difficult to excise because of its extensive size In cases where appropriate excisional surgical management requires hospitalization or complicated wound management Whenever the exact diagnosis is necessary before larger surgical invasion

9. Incisional biopsy

10. Punch biopsy Another tool that can be used for incisional or excisional purposes. Biopsy is especially well suited for diagnosis of oral manifestations of mucocutaneous and vesiculoulcerative diseases, such as lichen planus, pemphigus, etc.

11. punch biopsy tools

12. Technique of punch biopsy Biopsy punches should range in size from 2-10 mm in diameter. The smaller diameters should be avoided due to the risk of over-manipulating and crushing the tissue. The technique is easily performed with a low incidence of postsurgical morbidity. Suturing in regards to a punch biopsy procedure is usually not required as the surgical wounds heal by secondary intention.

13. Excisional Biopsy Indications: Should be employed with small lesions (Less than 1cm). The lesion on clinical exam appears benign. When complete excision with a margin of normal tissue is possible without mutilation.

14. Excisional biopsy

15. How to send a specimen for Pathology Laboratory?

16. Biopsy Containers information Transparency Lid Leak-proof Wide mouth, flat bottom Size corresponding to specimen volume Label To protect patients from adverse errors made due to improperly labeled specimens, the laboratory policy demands that proper labeling criteria are always met. Every specimen brought to the laboratory must have a label on the container in which it is held.

17. The label must contain the following legible information Patient name Patient medical record number ,with check digit Patient location Collection date and time Specimen type and/or source Test required

18. Handling of the Specimen The surgically resected specimens should submit in a fresh state immediately after resection Should be transported in a glass, plastic, or metal container, or in a plastic bag without the additional of any fluids Avoid wrapping the specimen with gauzes, which tend to produce desiccation If a delay is anticipated in the transport of the specimen, place the container into a refrigerator (4 ℃ ) to slow down the autolysis

19. Most small biopsies should be places in the chosen fixative immediately after they are obtained. Small tissue biopsies to rule out malignancy are usually non-diagnostic if excised by electrocautery , as the presence of epithelial atypical is typically obscure d . Handling of the Specimen

20. If electrocautery is to be used, the incision margin should be far enough away from the interface of the lesion to prevent thermal changes at that interface. Margins of the tissue should be identified to orient the pathologist. A silk suture is often adequate. Illustrations are also very helpful and should be included . Handling of the Specimen

21. Fixation Adequate fixation is a prerequisite to all cell and tissue staining methods, and be completely immersed . The purposes of fixation are: To inhibit autolysis and bacterial overgrowth To prevent solubility of cellular component To preserve their localization at the sites in which they occur in living cells To provide optimal conditions that will permit their visualization with specific indicator reagents The most commonly used fixative in surgical pathology laboratories is Formalin

22. Good fixative is most important in the production of satisfactory results in histopathology Small intestine well preserved Autolyzed Small intestine

23. Fixatives Neutral buffered formalin - fixation time 12-24 hours. Formalin (40% aqueous solution of formaldehyde) - 100ml Sodium dihydrogen orthophosphate (monohydrate) - 4g Disodium hydrogen orthophosphate (anhydrous) - 6.5g Distilled water - 900ml This fixative is suitable for most histological purposes. It is to be preferred to formol -saline (a single 10% solution of formalin in 90% aqueous NaCl ) as formalin pigment is avoided. Specimens may be stored in this fluid. The solution is isotonic.

24. Which information is important for Pathologist?

25. Filling the Request Forms Identified of the patient. I dentified specimen: (gross appearance, cyst, vascular , inking for margin ), type of surgery (biopsy , wide excision ), surgical finding Adequate clinical history ( necessary): prior diagnosis , immune status ( HIV) Prior treatment: radiation, chemotherapy, B one lesion : X-ray finding H ematolg ic disease: CBC , bone marrow F emale reproductive lesion : LMP, hormone H epatitis: LFT Clinical diagnosis or differential diagnosis

26. Rapid diagnosis

27. Cytopathology cytology Study of cells to know the infection,pre malignant and malignant changes 1 types of samples , Gyane (pap smears) 2.Non Gyane (bodyfluids,CSF,urine,pericardial,pleural.asitic.synovial)

28. Procedures done in cytology FNACP (  Fine Needle Aspiration Cytology Histopathology   ) FNAC (Fine Needle Aspiration Cytology ) FNAB ( Fine needle aspiration biopsy) Staining in cytology , H&E Pap ,Dry (rapi) ,Gimes

29. Gyane (pap smears)

30. Non Gyane

31. Frozen section A procedure to perform rapid microscopic analysis of a specimen The examination of tissue while surgery is taking place (evaluation of resection margin of an organ or specimen, mass diagnosis, lymph node metastasis, . . . .) The quality of the frozen section slides is of lower quality than FFPE ( Formalin-Fixed Paraffin-Embedded )tissue The diagnosis can be rendered in many cases

32. Indications for frozen section Benign or malignant lesions Adequacy of surgical margins Metastatic lymph node: sentinel nodes in breast carcinoma Benign VS malignant: not specific diagnosis In case of doubt – wait for permanent section

33. Specimens for frozen section Fresh tissue < 1cm in size is recommended. Put in plastic bag, tightly closed with rubber bands Label on the plastic bag Place the plastic bag in ice Send it to pathology lab immediately

34. Pathology Report “Gold standard in medicine”

35. Pathology Report The examination of a biopsy or surgical specimen by a pathologist The pathologist, a medically qualified specialist who has completed a recognized training program (5~5.5yrs in UK, 4~4.5yrs in Korea, 5 yrs USA) The medical diagnosis is formulated as a Pathology Report The Pathology Report describes the histological findings and the opinion of the pathologist, in the case of cancer this represents the tissue diagnosis required for most treatment protocols

36. Thank you Any Question