(Atlas of Anatomic Pathology) Monica B. Lemos, Ekene Okoye - Atlas of Surgical Pathology Grossing-Springer International Publishing (2019)

Monica B.
Lemos
Ekene Okoye
Editors
Atlas of
Surgical Pathology
Grossing
123
Atlas of Anatomic Pathology
Series Editor
Liang Cheng
Indianapolis, Indiana, USA
This Atlas series is intended as a “first knowledge base” in the quest for diagnosis of usual and
unusual diseases. Each atlas will offer the reader a quick reference guide for diagnosis and
classification of a wide spectrum of benign, congenital, inflammatory, nonneoplastic, and
neoplastic lesions in various organ systems. Normal and variations of “normal” histology will
also be illustrated. Each atlas will focus on visual diagnostic criteria and differential diagnosis.
It will be organized to provide quick access to images of lesions in specific organs or sites. Each
atlas will adapt the well-known and widely accepted terminology, nomenclature, classification
schemes, and staging algorithms. Each volume in this series will be authored by nationally and
internationally recognized pathologists. Each volume will follow the same organizational
structure. The first Section will include normal histology and normal variations. The second
Section will cover congenital defects and malformations. The third Section will cover benign
and inflammatory lesions. The fourth Section will cover benign tumors and benign mimickers
of cancer. The last Section will cover malignant neoplasms. Special emphasis will be placed on
normal histology, gross anatomy, and gross lesion appearances since these are generally lacking
or inadequately illustrated in current textbooks. The detailed figure legends will concisely
summarize the critical information and visual diagnostic criteria that the pathologist must
recognize, understand, and accurately interpret to arrive at a correct diagnosis. This book series
is intended chiefly for use by pathologists in training and practicing surgical pathologists in
their daily practice. The atlas series will also be a useful resource for medical students,
cytotechnologists, pathologist assistants, and other medical professionals with special interest
in anatomic pathology. Trainees, students, and readers at all levels of expertise will learn,
understand, and gain insights into the complexities of disease processes through this
comprehensive resource. Macroscopic and histological images are aesthetically pleasing in
many ways. This new series will serve as a virtual pathology museum for the edification of our
readers.
More information about this series at http://www.springer.com/series/10144

Monica B. Lemos • Ekene Okoye
Editors
Atlas of Surgical Pathology

Grossing
Editors
Monica B. Lemos Ekene Okoye
Houston Methodist Hospital Houston Methodist Hospital
Houston, TX Houston, TX
USA USA
ISSN 2625-3372 ISSN 2625-3380 (electronic)

Atlas of Anatomic Pathology
ISBN 978-3-030-20838-7 ISBN 978-3-030-20839-4 (eBook)
https://doi.org/10.1007/978-3-030-20839-4
© Springer Nature Switzerland AG 2019

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The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
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This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
My special thank you to my son, Jaymesson Bezerra,
for being with me in my moments of fear and
frustration, for always showing me the light at
the end of the tunnel.
Monica B. Lemos
To my beloved family – Chike, Chiamaka, Nkechi, and

Oluchi – for their love and support. To my amazing
mentors and colleagues in pathology, and to all the
wonderful residents and fellows I have had the
fortune of working with.
Ekene Okoye
Series Preface
One Picture Is Worth Ten Thousand Words

— Frederick Barnard, 1927
Remarkable progress has been made in anatomic and surgical pathology during the last
10 years. The ability of surgical pathologists to reach a definite diagnosis is now enhanced by
immunohistochemical and molecular techniques. Many new clinically important histopatho-
logic entities and variants have been described using these techniques. Established diagnostic
entities are more fully defined for virtually every organ system. The emergence of personalized
medicine has also created a paradigm shift in surgical pathology. Both promptness and preci-
sion are required of modern pathologists. Newer diagnostic tests in anatomic pathology, how-
ever, cannot benefit the patient unless the pathologist recognizes the lesion and requests the
necessary special studies. An up-to-date Atlas encompassing the full spectrum of benign and
malignant lesions, their variants, and evidence-based diagnostic criteria for each organ system
is needed. This Atlas is not intended as a comprehensive source of detailed clinical information
concerning the entities shown. Clinical and therapeutic guidelines are served admirably by a
large number of excellent textbooks. This Atlas, however, is intended as a “first knowledge
base” in the quest for definitive and efficient diagnosis of both usual and unusual diseases.
The Atlas of Anatomic Pathology is presented to the reader as a quick reference guide for
diagnosis and classification of benign, congenital, inflammatory, nonneoplastic, and neoplastic
lesions organized by organ systems. Normal and variations of “normal” histology are illus-
trated for each organ. The Atlas focuses on visual diagnostic criteria and differential diagnosis.
The organization is intended to provide quick access to images and confirmatory tests for each
specific organ or site. The Atlas adopts the well-known and widely accepted terminology,
nomenclature, classification schemes, and staging algorithms.
This book series is intended chiefly for use by pathologists in training and practicing surgi-
cal pathologists in their daily practice. It is also a useful resource for medical students, cyto-
technologists, pathologist assistants, and other medical professionals with special interest in
anatomic pathology. We hope that our trainees, students, and readers at all levels of expertise
will learn, understand, and gain insight into the pathophysiology of disease processes through
this comprehensive resource. Macroscopic and histological images are aesthetically pleasing
in many ways. We hope that the new series will serve as a virtual pathology museum for the
edification of our readers.
Indianapolis, IN, USA Liang Cheng, MD
vii
Preface
The idea for this book came from Dr. Alberto Ayala, my mentor. He called me into his office
and said “Monica, you should write a grossing manual.” Immediately my answer was “I don’t
know how to do that!” He said very calmly, “Just put on paper everything that you have been
teaching the residents.” At first, I freaked out; I did not want to disappoint him. But then I
started to think about it, and the first idea that came to my mind was the image of a specimen
with a white background, giving the resident, PA, or fellow that would open this book the
impression that the specimen was right there in front of them. The second idea was that it
should be predominantly pictures, following a step-by-step approach, trying to lessen the fear
of a person who is just beginning to gross specimens, and also lessen doubts they might have
about more complex specimens. The idea is to gross in a simple and efficient way. Knowing
how to gross thoroughly and efficiently is incredibly important.
The focus of this Atlas is intentionally on the images of actual gross specimens, as opposed
to solely illustrations of gross specimens. The images highlight key features of various types
of gross specimens. The use of actual gross images will allow the reader to more readily apply
the grossing tips to actual specimens that they encounter at the grossing bench. This book
contains many grossing tips, as well as sample dictations, that complement and complete the
visual grossing lessons this book provides.
The goal of this book is to help pathology trainees (residents, fellows, pathology assistant
students) learn how to gross a variety of specimens, and to give more experienced practitio-
ner’s additional ideas for how to gross in the most efficient manner. Thus in addition to pathol-
ogy trainees, we hope that attending pathologists and practicing pathologist assistants may
also benefit from this book.
Finally, always think about how you would like a case to be grossed as if the patient were a
member of your own family. With that thought in mind, you will always perform a gross
examination with care and efficiency.
Houston, TX, USA Monica B. Lemos

Ekene Okoye
ix
Acknowledgments
Teaching residents has become my heart. Working as a PA in Houston Methodist Hospital and
also continuing part time at MD Anderson is for me the basis of my accomplishments. Along
the path I met people who gave me so much knowledge and support for everything that I have
achieved as a PA. Thank you to all the residents and fellows along these 4 years (2012–2016):
Drs. Sergio Pina, Miguelina De La Garza, Daniel Wimmer, Jana Wimmer, Nicole Nelles,
Suzanne Crumley, Natasha Golardi, Andreia Barbieri, Ziad El-Zaatari, and Ahmed Shehabeldin.
To the Department of Pathology and Genomic Medicine at Houston Methodist Hospital for all
the amazing support from the attendings: Drs. Alberto Ayala, Dina Mody, Steven Shen, Patricia
Chevez Barrios, April Ewton, Ekene Okoye, Blythe Gorman, Mary Schwartz, Donna Coffey
(for her unconditional friendship and support), Michael Deavers, Roberto Barrios, and Mukul
Divatia (for his vast knowledge and for always going completely out of his way to help me).
Also, thank you to the attendings from MD Anderson who became part of my life: Drs. Aysegul
Sahin, Nour Sneige, Patricia Troncoso, Elvio Silva, Victor Prieto, Fraser Symmans, and Stanley
Hamilton. I also thank Dr. Michelle Williams for her guidance. And especially to the person
who started my history in this country, Dr. Janet Brunner.
Many thanks to Dr. Ziad El-Zaatari for his great assistance and work on the digital image
editing for this book. We greatly thank Dr. Sasha Pejerrey for her assistance.
I especially want to thank Dr. Alberto Ayala. This book is your idea, the seed that you
planted with love and care. The only thing I want is for you to be proud. Thank you for believ-
ing in me, for pushing me through my fears, and for holding my hand through my career. You
are a real teacher, a teacher and mentor of us all, the example of character, knowledge, patient
care, love, and dedication. As a daughter to a father, I want to say with all my heart: Thank you,
Dr. Ayala.
Monica B. Lemos
xi
Contents
1 Skin�� 1
Monica B. Lemos and Patricia Chevez-Barrios
2 Breast�� 5
Monica B. Lemos and Nour Sneige
3 Head and Neck �� 13
Monica B. Lemos and Alberto Ayala
4 Gastrointestinal Tract�� 27
Monica B. Lemos and Mary Schwartz
5 Hepatobiliary and Pancreas�� 43
6 Genitourinary�� 55
Monica B. Lemos and Steven Shen
7 Female Reproductive Tract �� 67
Monica B. Lemos, Donna Coffey, and Michael Deavers
8 Lung�� 83
Monica B. Lemos and Roberto Barrios
9 Bone and Soft Tissue�� 89
Monica B. Lemos and Michael Deavers
Index�� 95
xiii
Contributors
Alberto Ayala, MD Department of Pathology and Genomic Medicine, Houston Methodist

Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
Roberto Barrios, MD Department of Pathology and Genomic Medicine, Houston Methodist
Patricia Chevez-Barrios, MD Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
Donna Coffey, MD Department of Pathology and Genomic Medicine, Houston Methodist
Michael Deavers, MD Department of Pathology and Genomic Medicine, Houston Methodist
Ziad El-Zaatari, MD Department of Pathology and Genomic Medicine, Houston Methodist
Monica B. Lemos, MD Department of Pathology and Genomic Medicine, Houston Methodist
Mary Schwartz, MD Department of Pathology and Genomic Medicine, Houston Methodist
Steven Shen, MD, PhD Department of Pathology and Genomic Medicine, Houston Methodist
Nour Sneige, MD Department of Pathology and Genomic Medicine, Houston Methodist
xv
Skin
1
Monica B. Lemos and Patricia Chevez-Barrios
Dermatologic specimens, including skin biopsies and skin to aid in a more localized and precise re-excision, if neces-
excisions, are commonly encountered in the surgical pathol- sary (Figs. 1.4, 1.5 and 1.6).
ogy grossing suite. This chapter focuses on skin excisions In addition to proper orientation, accurate measurement
and provides instruction on how to properly handle such of the size of the lesion and the distance from the lesion to
specimens. the peripheral and deep margins is essential.
Skin Excision Sample Dictation: Skin Excision
Skin excisions are performed primarily for complete removal Received fresh/in formalin and labeled as “_____” is a tan-
of a lesion and to ensure accurate diagnosis of the lesion in white/brown, oriented/unoriented, irregular/oval/circular/
question. Skin excisions are often in the shape of a circle or elliptical skin excision (____ × ____ × ____ cm).
ellipse, but they can have irregular or non-symmetrical The surface of the skin shows a ____ cm ulcer/healed
shapes. (For specimens with complex shapes, a picture or scar/macule/papule/nodule or multiple pigmented lesion(s)
diagram made before sectioning can be a useful tool). (____ to ____ cm), that is/are centrally/peripherally located,
Margins include all of the soft tissue that was cut by the sur- abutting the peripheral edges/deep margin in the superior/
geon deep to the skin surface. inferior aspect of the specimen.
Orientation is often indicated by the surgeon with The specimen is serially sectioned from lateral to medial
sutures. It is frequently designated in terms of clock posi- and the cut surface is yellow-tan/tan-white and unremarkable
tions (1 o’clock to 12 o’clock all around). Typically, 12 (or) includes a tan-white/black lesion (____ cm) present
o’clock is at the superior-most portion, 3 o’clock and 9 ____ cm from the superior margin, ____ cm from the infe-
o’clock are at the medial and lateral positions, and 6 o’clock rior margin, and ____ cm from the deep margin.
is at the inferior-most portion (Figs. 1.1, 1.2 and 1.3). The specimen is submitted sequentially from lateral to
Inking is performed in such a way that this orientation can medial into cassettes A1–A12 in its entirety.
be reconstructed while examining the specimen microscop-
Ink code:
ically, so that if microscopic lesions are detected close to or
involving a specific margin, the location of the positive • Superior – Blue
margin can be accurately conveyed to the surgeon, in order • Inferior – Orange
M. B. Lemos (*)
Department of Pathology and Genomic Medicine, Houston
e-mail: [email protected]
P. Chevez-Barrios
© Springer Nature Switzerland AG 2019 1

M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_1
2 M. B. Lemos and P. Chevez-Barrios
Fig. 1.1 Skin excision:

orientation. The excision
specimen is oriented with a
long stitch placed by the
surgeon at 12 o’clock and a
short stitch at 9 o’clock. An
ulcerated lesion can be clearly
seen at the center, with a
surrounding area of normal
skin extending to the margins
circumferentially
Fig. 1.2 Skin ellipse. A skin

excision in the shape of an
ellipse. This specimen is
oriented and grossed in the
same manner as a circular
skin excision (see Fig. 1.1),
with the additional step of
submitting the tips of the
ellipse separately
1 Skin 3
Fig. 1.3 Skin excision with

scarred and pigmented
lesions. Lesions on the
surface of skin excisions can
have varied appearances. In
addition to pigmented lesions,
this specimen includes a
depressed area representing
the possible site of a scar
Fig. 1.4 Skin excision:

inking. The right and left
halves of the skin excision
specimen are inked with
separate colors. In this
picture, the specimen is
oriented with the skin surface
facing down. The margins on
any skin excision specimen
include all the surfaces of the
soft tissue deep to the
superficial skin surface
4 M. B. Lemos and P. Chevez-Barrios
Fig. 1.5 Skin excision: Sectioning. Sections are taken here sequen- medial. Sections can be bisected to fit into individual cassettes. Sutures
tially from 9 o’clock to 3 o’clock, perpendicular to the inked superior should be removed before submitting sections in cassettes. The tips or
and inferior halves. Sections are submitted sequentially from lateral to peripheral-most sections should be placed ink side up in the cassette
Fig. 1.6 Irregular skin excision. This irregularly shaped skin excision margins were inked differentially, and the specimen was serially sec-
was oriented by the surgeon’s sutures with a short suture on the superior tioned from lateral to medial, perpendicular to the superior/inferior
aspect and a long suture on the medial aspect. The superior and inferior halves
Suggested Reading Smith-Zagone MJ, Schwartz MR. Frozen section of skin specimens.
Arch Pathol Lab Med. 2005;129:1536–43.
Weinstein MC, Brodell RT, Bordeaux J, Honda K. The art and science of
Bell WC, Young ES, Billings PE, Grizzle WE. The efficient operation of the
surgical margins for the dermatopathologist. Am J Dermatopathol.
surgical pathology gross room. Biotech Histochem. 2008;83:71–82.
2012;34:737–45.
Ghauri RR, Gunter AA, Weber RA. Frozen section analysis in the man-
agement of skin cancers. Ann Plast Surg. 1999;43:156–60.
Breast
2
Monica B. Lemos and Nour Sneige
Breast cancer, one of the most commonly diagnosed cancers, Mastectomy

accounts for 30% of all new cancer diagnoses in women.
Therefore, breast specimens, including breast biopsies, Mastectomy is performed for malignant lesions of the breast
lumpectomies, and mastectomies, are commonly encoun- that are not amenable to localized excisions (see
tered in the surgical pathology grossing suite. This chapter Lumpectomy), or on an elective basis for other indications.
examines the proper handling of mastectomy and lumpec- At our institution, margins of mastectomy specimens with
tomy specimens, as well as sentinel lymph nodes. tumors, are grossly assessed during intraoperative consulta-
There are multiple types of mastectomy procedures. A tion, making careful attention and quick mastery of orienta-
total simple mastectomy removes the whole breast and most tion and grossing techniques essential.
of the overlying skin, including the nipple. A modified radi-
cal mastectomy is similar to a simple mastectomy, but
includes an axillary dissection. A radical mastectomy Grossing Tips: Mastectomy
includes removal of the whole breast, overlying skin and
nipple, pectoralis muscles, and axillary lymph nodes. • When the specimen is received, first note the laterality
(Though previously widespread, radical mastectomies now (right or left) and orientation of the mastectomy specimen
are rarely performed.) More modern mastectomy methods (e.g., short stitch, superior; long stitch, lateral).
include skin-sparing mastectomies, which removes the • Imagine the patient in front of the prosector in order to see
breast tissue, nipple, and areola only, as well as nipple- the correct orientation. For example, lateral will be on the
sparing mastectomies, which removes the breast tissue with- left-hand side for a right breast and on the right-hand side
out removing the overlying skin or nipple. for a left breast (with superior being up in both examples)
Lumpectomy procedures remove a portion of the breast (Fig. 2.1).
and are performed for removal of both palpable and non- • Once the correct orientation is certain, ink the superior
palpable breast lesions. Breast-conserving therapy is becom- and inferior halves of the specimen, each a different color
ing more common, as many women with breast cancer are (Fig. 2.2).
candidates for this therapy, which includes a partial breast • Next, flip the breast so that the deep surface now faces the
excision (i.e., lumpectomy), usually with subsequent radia- prosector and superior is still upwards.
tion therapy. Survival outcomes are similar between patients • The deep surface of the specimen can now be inked. This
undergoing breast-conserving therapy with radiation therapy surface is usually flatter than its surroundings.
versus patients who have a mastectomy. • With the breast still flipped, section the breast from lateral
Axillary lymph node sampling, most commonly in the to medial (right breast) or medial to lateral (left breast)
form of sentinel lymph node biopsy, is a standard staging (Fig. 2.3).
modality. Instruction on how to handle these specimens is • Lay out the slices as they are cut from lateral to medial
also included in this chapter. (right breast), or medial to lateral (left breast), keeping
track of the orientation of the slices.
• Number the slices (Fig. 2.4).
M. B. Lemos (*) · N. Sneige • Grossly locate any tumor(s) and measure the closest dis-
Department of Pathology and Genomic Medicine, Houston tance to each of the margins.

6 M. B. Lemos and N. Sneige
Fig. 2.1 Right mastectomy: Orientation. The mastectomy specimen respect to the medial and lateral sides in a left mastectomy specimen.
consists of four quadrants in addition to superior, inferior, medial, and The nipple (or the base of nipple excision in nipple-sparing mastecto-
lateral sides. The specimen pictured also includes an axillary tail. The mies) is considered the center point around which the four quadrants
orientation can be described by clock positions, with 12 o’clock superi- are arranged. This orientation scheme is used to describe the position of
orly, 3 o’clock medially, 6 o’clock inferiorly, and 9 o’clock laterally. masses or other breast lesions
Note that the 3 o’clock and 9 o’clock positions would be switched with
Fig. 2.2 Mastectomy: Inking of margins. Three margins should be should then be flipped and the deep surface inked. (Black, shown here,
inked on a mastectomy specimen: superior, inferior, and deep. The is a common choice.) In a nipple-sparing mastectomy, the nipple area
superior and inferior halves are inked different colors. The specimen should also be inked
2 Breast 7
Fig. 2.3 Sectioning a

mastectomy. The mastectomy
specimen should be sliced
along the long axis (medial to
lateral, or lateral to medial),
with the deep aspect always
facing the prosector. The
slices should be made as thin
as possible so that lesions on
the cut surface can be
effectively detected. To cut
effectively and keep track of
orientation, always slice the
breast with the skin
(superficial aspect) facing
down on the cutting board and
the superior aspect directed
upwards
Fig. 2.4 Mastectomy slices. Thinly sliced sections are laid out from lateral to medial and numbered sequentially. Now, the cut surface can be
examined for the presence of lesions and their proximity with respect to the inked margins
• Take sections sequentially according to the slice numbers _____ × _____ × _____ cm). Attached to the specimen
and document the slice number from which each section there is a _____ × _____ cm tan white/brown ellipse of
was taken in the dictation (Note: Sequential sectioning skin. The nipple and areola complex are grossly unremark-
can help determine tumor size when tumors are detected able (or the nipple is inverted). The nipple is _____ cm in
microscopically.) diameter.
• In some cases, it can be very helpful to make a diagram of The breast is serially sectioned sequentially from
where sections were taken, so when viewing slides micro- medial to lateral (left breast)/lateral to medial (right breast)
scopically it can be precisely known where in the breast into _____ slices. The nipple is located in slice number
the section is from. This is also known as “mapping” of _____. The cut surface reveals on slice numbers _____,
breast sections (Fig. 2.5). _____, and _____ in the (UOQ/LOQ/UIQ/LIQ/UC/LC)∗∗
• The nipple, if included, should be submitted. Transect the a tan/white irregular firm mass with areas of fat necrosis.
nipple and base of the nipple from the breast. Then tran- There is a surgical clip (shape, location/slice number) that
sect the base of the nipple from the everted portion of the has been removed. The lesion is _____ cm from the supe-
nipple (after transecting, the base will have a circular, disc rior margin, _____ cm from the inferior margin, _____ cm
like shape). Then serially section the remainder of the from the deep margin, and _____ cm from the skin. The
nipple (everted part of the nipple). Submit the base of the remainder of the parenchyma is fibrous-fatty tissue
nipple and the serial sections of everted portion nipple in (_____% fibrous, _____% fatty) with multiple cysts rang-
two separate cassettes. ing from 0.2 to 0.4 cm and filled with tan brown dense
• For axillary dissections, a minimum of ten lymph nodes fluid.
should be found.
Ink code:
Sample Dictation: Mastectomy • Superior – Blue

• Inferior – Orange
Received fresh labeled as “right/left mastectomy” is an ori- • Deep – Black
ented right/left mastectomy specimen (_____ grams,
Fig. 2.5 Mapping a mastectomy. Breast slices can be mapped to show photocopy is annotated with the location of each section submitted, as
the locations of submitted sections. A photocopy of the breast slices is well as inked resection margins. (In this image, blue = superior, black =
taken by placing the slices between two clear plastic sheets; then the deep, and orange = inferior.)
2 Breast 9
Section code: Grossing Tips: Lumpectomy
Slice 8 • When the specimen is received, first note the laterality

• A1 – Junction of lower and upper aspect- central breast (right or left) and orientation of the lumpectomy specimen
• A2–A4 – Upper central (e.g., short stitch, superior; long stitch, lateral) (Fig. 2.6).
Slice 9 • Once the correct orientation is certain, ink the superior,
• A5–A7 – Upper outer quadrant (UOQ) inferior, superficial, medial, lateral and deep aspects each
• A8 – Lower outer quadrant (LOQ) a different color (Fig. 2.7).
Slice 10 • Section the breast lateral to medial (right breast) or medial
• A9 – Upper outer quadrant (UOQ) to lateral (left breast) (Fig. 2.8).
• A10 – Upper outer quadrant (UOQ); area with clip • Lay out the slices as they are cut from lateral to medial
• A11 – Lower outer quadrant (LOQ) (right breast) or medial to lateral (left breast), keeping
Slice 11 track of the orientation of the slices.
• A12–15 – Upper outer quadrant (UOQ) • Number the slices.
• A16 – Junction of lower and upper aspect- outer breast • Grossly locate any tumor(s) and measure the closest dis-
Slice12 tance to each of the margins.
• A17–20 – Upper outer quadrant (UOQ) • At our institution, in most cases, lumpectomy specimens
Etc. are submitted entirely. The specimen can be submitted
sequentially according to the slice number. Document the
∗∗UOQ – upper outer quadrant; UIQ – upper inner quad- slice the sections are taken from.
rant; LOQ – lower outer quadrant; LIQ – lower inner quad- • Just as in mastectomy specimens, mapping out where sec-
rant; UC – upper central; LC – lower central tions are taken from in a lumpectomy specimen can be
extremely helpful (Fig. 2.9). See Sect. 2.1.1 above.
Lumpectomy
Sample Dictation: Lumpectomy
A lumpectomy consists of removal of only a portion of the
breast. In many cases, the margins of resection in these speci- Received fresh labeled as “____” is an oriented (_____
mens are assessed during intraoperative consultation, simi- grams, _____ × _____ × _____ cm), right/left lumpectomy
larly to mastectomy specimens. The gross examination of specimen. A needle localization wire is present within the
lumpectomy specimens is similar to that of mastectomy speci- specimen, and the specimen is submitted for Faxitron
mens, however there are important differences as noted below. imaging.
Fig. 2.6 Lumpectomy with localization wire. A needle localization machine (Hologic; Marlborough, MA) before sectioning to confirm
wire is protruding from the surface of this oriented lumpectomy speci- radiographically the presence of a tumor localization clip. The actual
men. At our institution, lumpectomies are first placed in a Faxitron tumor, as well as calcifications, can also be seen on the x-ray images
Fig. 2.7 Lumpectomy:
Inking. There are six margins,
corresponding to the six faces
of a cube: superior, inferior,
medial, lateral, superficial,
and deep. Each margin is
inked in a different color
Fig. 2.8 Lumpectomy: Sections, clip localization, and margin assess- be found and removed before submitting sections. (This also applies to
ment. Thin slices are made from lateral to medial and are numbered clips in mastectomies.) The closest distance of the tumor to each of the
(top). The localization clip placed in a lumpectomy (bottom left) should lumpectomy margins (bottom right) should be measured and recorded
2 Breast 11
Fig. 2.9 Mapping lumpectomy sections. One can use the scheme in this image to submit the sections for a lumpectomy
• A6 – Superficial
The specimen is serially sectioned from lateral to medial
• A7 – Deep
(right lumpectomy), or medial to lateral (left lumpectomy)
• A8 – Inferior superficial
into ____ slices. The cut surface reveals in slice numbers
• A9 – Inferior deep
____, ____, and ____, a ____ × ____ × ____ cm mass
Slice 3
[describe the mass here]. The mass is associated with a surgi-
• A10 – …
cal clip in slice ____. The mass is ____ cm from the superior
Etc.
margin, ____ cm from the superficial margin, ____ cm from
the inferior margin, ____ cm from the deep margin, ____ cm
from the most lateral margin, and ____ cm from the most
medial margin. The remainder of the breast parenchyma is Sentinel Lymph Nodes
fibro-fatty tissue (____% fibrous, ____% fatty).
Sentinel lymph nodes are often removed and sent for intra-
Ink code:
operative consultation for both mastectomy and lumpectomy
• Superior – Blue specimens (Fig. 2.10). The objective is to assess for meta-
• Superficial – Yellow static tumor deposits in the sentinel lymph nodes, to help
• Inferior – Green determine whether to perform an axillary dissection in
• Lateral – Red patients with breast malignancies.
• Medial – Orange
• Deep – Black
Grossing Tips: Sentinel Lymph Nodes
Section code:
• For sentinel lymph nodes (or generally for lymph nodes
Slice 1 (Most lateral or most medial) from any body site), never put more than one bisected or
• A1–A3 – In perpendicular sections serially sectioned lymph node piece from a different
Slice 2 lymph node in a single cassette. This can lead to confu-
• A4 – Superior superficial sion when lymph nodes are positive. For example, if two
• A5 – Superior deep lymph nodes are bisected and placed in the same cassette,
Fig. 2.10 Grossing sentinel lymph nodes for intraoperative consul- to a slide. The lymph node slices are then flipped, and the opposite
tation. The lymph node is separated from surrounding fat, then seri- surfaces of each lymph node piece are touched to another slide.
ally sectioned along its long axis into thin slices. Next, touch Slides are immediately placed into alcohol (to avoid air-drying arti-
preparations are performed by touching the lymph node cut surface fact) and then stained
and two of four fragments are microscopically positive, it Goodman S, O’Connor A, Kandil D, Khan A. The ever-changing role
of sentinel lymph node biopsy in the management of breast cancer.
would not be possible to determine whether this repre-
Arch Pathol Lab Med. 2014;138:57–64. https://doi.org/10.5858/
sents one or two positive lymph nodes. arpa.2012-0441-RA.
• Serially section the lymph node along the long axis. Lemos M, Sahin A. Surgical margin evaluation. In: Babiera GV,
• Touch slices to a glass slide, and also touch the opposite Skoracki RJ, Esteva FJ, editors. Advanced therapy of breast dis-
ease. 3rd ed. Shelton: People’s Medical Publishing House; 2012.
surface of the slices to another glass slide.
p. 569–80.
• Place slides in alcohol immediately, followed by routine Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J
H&E staining. Clin. 2019;69:7–34. https://doi.org/10.3322/caac.21551.
• Placing the slides in alcohol immediately after a touch Stolnicu S. Prognostic and predictive factors in breast carcinoma. In:
Stolnicu S, Alvarado-Cabrero I, editors. Practical atlas of breast
imprint is made will help avoid air-drying artifact, which
pathology. Springer International Publishing; 2018. p. 327–56.
can hinder microscopic interpretation. https://doi.org/10.1007/978-3-319-93257-6.
Valencia-Cedillo R. Sampling and evaluation of the breast surgical
specimens. In: Stolnicu S, Alvarado-Cabrero I, editors. Practical
Suggested Reading atlas of breast pathology. Springer International Publishing; 2018.
p. 475–89. https://doi.org/10.1007/978-3-319-93257-6.
Agarwal S, Pappas L, Neumayer L, Kokeny K, Agarwal J. Effect of Zahoor S, Haji A, Battoo A, Qurieshi M, Mir W, Shah M. Sentinel
breast conservation therapy vs. mastectomy on disease-specific sur- lymph node biopsy in breast cancer: a clinical review and update.
vival for early-stage breast cancer. JAMA Surg. 2014;149:267–74. J Breast Cancer. 2017;20:217–27. https://doi.org/10.4048/
https://doi.org/10.1001/jamasurg.2013.3049. jbc.2017.20.3.217.
Head and Neck
3
Monica B. Lemos and Alberto Ayala
The head and neck region, with its many organs and struc- imen is serially sectioned showing a tan-pink rubbery cut
tures, is divided into different areas, which include the oral surface. Tan-yellow granules are identified in crypts. No
cavity, pharynx, larynx, paranasal sinuses and nasal cavity. gross lesions are identified.
Head and neck pathology specimens encountered in the sur-
Sections Code:
gical pathology suite range from routine tonsil specimens to
complex specimens such as a laryngectomy. When handling
• A1 – Tonsil, representative section
head and neck specimens, an appreciation of the anatomic
landmarks is essential, and understanding the anatomic ori-
entation before specimen sectioning begins is particularly
Glossectomy
critical. A systematic approach to complex specimens will
aid in providing a thorough and complete gross examination,
Before sectioning a glossectomy specimen, the orientation of
and will help to ease any anxiety that may arise in the face of
the specimen, as designated by the surgeon, should be prop-
potentially intimidating specimens. This chapter discusses
erly understood (ie, anterior/posterior aspects). After inking
the gross examination of a variety of head and neck speci-
the resection margins, the specimen is serially sectioned
mens, as well as thyroid specimens, and includes a stepwise
(Fig. 3.4).
and straightforward approach to grossing laryngectomy
specimens.
Uvulectomy
Tonsillectomy Grossing of a uvula specimen (Fig. 3.5) is usually
straightforward.
Tonsillectomy specimens commonly have a cerebriform
appearance. After examination of the outer surface, the spec-
imen is serially sectioned (Figs. 3.1, 3.2 and 3.3).
Sample Dictation: Uvula
Received is a tan-pink smooth and glistening conical portion

Sample Dictation: Tonsillectomy of tissue (____ × ____ × ____ cm). The base of the specimen
is inked blue. The uvula is bisected, and the cut surface is
Received fresh/in formalin labeled as “_____” is a tan-pink
tan-pink and rubbery. [Describe any lesions]. The specimen
ovoid lobulated tonsil (____ × _____ × _____ cm). The spec-
is entirely submitted in cassette A1.
M. B. Lemos (*)
Floor of the Mouth
Resected specimens from the floor of the mouth should be
A. Ayala
Department of Pathology and Genomic Medicine, Houston properly oriented and inked (Figs. 3.6 and 3.7) before being
Methodist Hospital, Houston, TX, USA sequentially sectioned (Fig. 3.8).

14 M. B. Lemos and A. Ayala
Fig. 3.1 Tonsillectomy specimens. Right and left tonsils are shown. Note the “cerebriform” appearance and the tan-yellow “sulfur” granules,
representing Actinomyces bacterial colonies, which are commonly seen in tonsils
Fig. 3.2 Sectioned tonsils. Note the tan-pink cut surface and tan-yellow “sulfur” granules present within tonsillar crypts
3 Head and Neck 15
Fig. 3.3 Tonsil with

papilloma. This tonsil has a
papilloma in addition to the
frequently identified “sulfur”
granules
Fig. 3.4 Glossectomy. An ulcerated, mucosal-based lesion makes up (not shown is the resected surface deep to the mucosa). The medial and
the majority of the surface of this glossectomy specimen. Resection lateral halves of the specimen are inked two different colors. The speci-
margins are present circumferentially, in addition to the deep margin men is serially sectioned from anterior to posterior
Salivary Gland
Parotid glands and submandibular glands may be received as

part of a neck dissection, or received individually. All sali-
vary glands should be weighed, if received individually, and
not as part of a neck dissection. This section will focus on
how to handle salivary glands when received separately, and
not as part of a neck dissection.
If there is a history of tumor, or if after palpation of the
gland, a mass is felt, the outer surface of the gland should be
inked one color, before serially sectioning (Figs. 3.9, 3.10
and 3.11).
Thyroidectomy
Grossing Tips: Thyroidectomy
Fig. 3.5 Uvula. To gross this specimen, simply ink the base (resection • Always weigh thyroid specimens (total or partial) in addi-
margin), bisect, describe the cut surface and any lesions, and submit tion to measuring their dimensions.
entirely
Fig. 3.6 Floor of the mouth. This resection of a floor of the mouth tially along all the clock positions in addition to the deep margin (which
lesion is oriented by the surgeon with a long stitch at 12 o’clock and a is not shown and is on the resected surface deep to the mucosa)
short stitch at 3 o’clock. Resection margins are present circumferen-
3 Head and Neck 17
Fig. 3.7 Floor of the mouth: Margins. The left and right halves of the gin section. The margins are shaved circumferentially with care to
specimen are inked with two different colors. Dots are placed along the include a portion of mucosa in each section
various o’clock positions to give a more precise location for each mar-
Fig. 3.8 Floor of the mouth:

Sectioning. After submitting
the margins, the specimen is
sectioned sequentially along
the 12 to 6 o’clock direction.
Serial sections should be
examined for depth of
invasion of the lesion. If a
frozen section is requested
and the lesion comes close to
the deep margin, an additional
section of the deepest
invasion may be required. The
specimen should be submitted
entirely and sequentially from
12 to 6 o’clock
Fig. 3.9 Submandibular gland. This submandibular gland resection lymph nodes. In this case, there was no history of tumor, and no mass
specimen included attached fibroadipose tissue. The specimen should was palpated, thus the outer surface of the specimen was not inked. The
be first weighed. Note the ovoid, lobulated, and smooth surface of the gland tissue is subsequently serially sectioned to look for lesions. In this
submandibular gland, which is different from the more rough and irreg- case, serial sections of the submandibular gland showed an unremark-
ular surface of a parotid gland. The fat should be sectioned to look for able cut surface
Fig. 3.10 Parotid gland. Shown here is a parotid gland and following case, there was no history of tumor, and no mass was palpated, so the
serial sections. Before sectioning, the specimen should be weighed and outer surface was not inked before the specimen was serially sectioned.
palpated for any masses. Note the rough and irregular surface. In this The cut surface of this serially sectioned parotid is grossly unremarkable
• The convex side is anterior; the concave side is posterior • Nodules may have areas of hemorrhage due to degenera-
(Fig. 3.12). tive change or due to prior fine needle aspiration
• Ink the anterior surface, posterior surface, and isthmus • Note if the nodule is encapsulated or not. For encapsu-
each a different color (Fig. 3.13). lated nodules, it is important that sections include the
• It is useful to use the same colors consistently to ink thy- entire capsule (capsular-parenchymal interface).
roid specimens. That way, if the ink code is lost, one will • Papillary thyroid carcinomas often have a gray-white or
still know which colors were used for each part of the tan-brown cut surface. Associated calcifications may also
specimen. be noted, as well as cystic change.
• Section the specimen from superior to inferior (Fig. 3.14). • Follicular carcinomas are encapsulated and have a thicker
• Keep the sections laid out as corresponds to the normal capsule than adenomas.
thyroid (i.e., superior up and inferior down, with the left • Submit sections in sequential order from most superior to
lobe sections on the left and the right lobe sections on the inferior, even if the sections are only representative
right) (Fig. 3.15). sections.
• Examine the cut surface for any nodules and describe the
appearance of any noted nodules.
3 Head and Neck 19
Fig. 3.11 Parotid gland with tumor. The cut surface of this parotid gland shows a tumor, which is distinct from the grossly normal surrounding
cut surface. Note that the outer surface of the parotid has been inked (black)
Fig. 3.12 Total thyroidectomy. Note the positions of right and left lobes and the isthmus. Also, note that the posterior surface is more roughened
and concave than the anterior thyroid surface
Sample Dictation: Thyroid The specimen is serially sectioned and in the superior/mid
portion/inferior aspect of the left/right thyroid lobe, there is a
Received fresh/in formalin labeled as “______” is a total thy- ______ cm tan-gray/yellow, firm/gelatinous/calcified nod-
roidectomy specimen (or right/left thyroid lobe) (_____ ule, well-circumscribed nodule (or multiple nodules ranging
grams, ____ × ____ × ____ cm right lobe, ____ × ____ × ____ from ____ cm to ____ cm in greatest dimension). The
left lobe, and ____ × ____ × ____ cm isthmus). The capsular remainder of the thyroid parenchyma is dark-red and
surface is intact/disrupted. homogeneous.
Fig. 3.13 Total thyroidectomy: Inking. The anterior surface of both right and left lobes is inked blue, except for the isthmus, which is inked red.
The posterior surface of both right and left lobes is inked black, except for the isthmus, which is again inked red
Fig. 3.14 Total
thyroidectomy: Sectioning.
Sectioning of the thyroid is
done from superior to inferior
while keeping track of
sections from each lobe (right,
left, or isthmus). Depending
on the type of case, the
specimen may be submitted
entirely or representative
sections may be taken. In this
particular case, there was a
diagnosis of papillary thyroid
carcinoma, thus the entire
thyroid was submitted
3 Head and Neck 21
Fig. 3.15 Thyroid nodules. Thyroid nodules with various gross appearances
Fig. 3.16 Laryngectomy: Anterior aspect (post-formalin fixation) and should also be inked a third color. This specimen includes a tracheos-
inking. The anterior right surface of the laryngectomy is inked one tomy site, which is inked in yellow around the skin
color, and the anterior left side is inked another color. The epiglottis
Ink Code: Laryngectomy
• Blue – Anterior thyroid surface Grossing Tips: Laryngectomy

• Black – Posterior thyroid surface
• Red – Anterior and posterior isthmus • Ink the left and right anterior surfaces (Fig. 3.16) and the
left and right posterior surfaces (Figs. 3.17 and 3.18) with
Section Code: four separate colors.
Serial sections from superior to inferior, as follows: • If a tracheostomy is present, ink the resection margin
there with an additional color.
• A1–A11 – Left lobe, from superior to inferior sequentially • If the thyroid is present, keep it attached, and ink its left
• A12–18 – Isthmus from left to right and right anterior surfaces (as one would ink a specimen
• A19–29 – Right lobe, from superior to inferior sequentially without a thyroid).
Fig. 3.17 Laryngectomy: Posterior aspect (fresh, pre-formalin fixation). The posterior aspect of the laryngectomy specimen includes the struc-
tures and margins shown
Fig. 3.18 Laryngectomy:
Posterior aspect inking. The
laryngectomy is opened with
a longitudinal cut along the
middle of the posterior
surface. Similar to the anterior
side, the left posterior surface
in inked one color and the
right posterior surface is
inked another color. The
tracheal margin is inked in a
third color
3 Head and Neck 23
• If a thyroid is present, include it in the sections to evaluate This makes it easier to identify true and false vocal cords
invasion into the thyroid. microscopically.
• Open the specimen along its posterior surface. Cut along
the midline (Fig. 3.19). Sample Dictation: Laryngectomy
• Look for abnormalities or tumor, and if present, measure
the size and comment on the location. Received fresh labeled as “____” is a total laryngectomy
• Take the tracheal margin for frozen section. specimen (___ × ___ × ___ cm) including a hyoid bone
• Also, take sections of the right and left mucosal margins. (___ × ___ × ___). A right/left/right and left thyroid lobe is
• Place a wooden stick to keep the specimen open as it fixes attached to the specimen (___ × ___ × ___). On the anterior
(Fig. 3.20). aspect is a tracheostomy site with tan white/brown skin
• After fixing, take serial perpendicular sections of the epi- (___ cm length and ___ cm width). The specimen is opened
glottis and serial perpendicular transglottic sections. posteriorly and shows a ___ × ___ × ___ cm gray-white fri-
Mark slices with tumor or any other abnormalities with a able/ulcerated/nodule/lesion located at the supraglottis/glot-
broken wooden stick. This will make it easy to keep track tis/subglottis and ___ cm above/below the commissure, ___
of which areas are abnormal and should be submitted. cm from the distal tracheal margin, and ___ cm from the
• Separate the sections to those that are supraglottic/glottic mucosal margin. The tumor grossly appears/does not appear
and subglottic, and submit sequentially as follows: to infiltrate into the lamina propria and appears/does not
–– Posterior left: submit from mid to lateral appear to infiltrate the thyroid. The lesion does/does not
–– Anterior left: submit from lateral to mid grossly involve the true/false vocal cord(s). The remainder of
–– Anterior right: submit from mid to lateral the mucosa is tan/pink and unremarkable/with edema etc.
–– Posterior right: submit from lateral to mid Ink code:
• If a tumor is located posteriorly, near the pyriform sinus,
take sections horizontally and submit from superior to • Blue – Right anterior surface of larynx
inferior in that area (Fig. 3.21). • Black – Left anterior surface of larynx
• In sections of the supraglottis/glottis, place a dot of ink on • Red – Epiglottis
each section to indicate the supraglottic aspect (Fig. 3.22). • Yellow – Tracheostomy site
Fig. 3.19 Laryngectomy: Opened view. Note the normal anatomic located beneath the epiglottis. Note the formalin-fixed and sectioned
structures seen on the inside of this opened laryngectomy. The subglot- specimen to the right, which separates epiglottis, supraglottis/glottis,
tis is located approximately 1 cm below the commissure. A tumor is and subglottis
Fig. 3.20 Laryngectomy: Opened view after fixation. The opened laryngectomy specimen is held open with a small wooden stick and fixed in
formalin overnight. Note again the anatomic structures
Fig. 3.21 Laryngectomy: Sectioning. Serial sections are made across the tumor in the pyriform sinus
3 Head and Neck 25
Fig. 3.22 Laryngectomy: Sections. Sections are divided into those tumor. Also, the sections of supraglottis/glottis are inked with a dot on
from the epiglottis, supraglottis/glottis, and subglottis. Supraglottis/ their superior aspect (supraglottic surface) to help keep track of their
glottis sections are made to include both true and false vocal cords. orientation
Note the wooden stick pieces placed to keep track of the sections with
• Orange – Left posterior surface Suggested Reading

• Red – Right posterior surface
• Purple – Tracheal margin Faquin W. The thyroid gland: recurring problems in histologic and
cytologic evaluation. Arch Pathol Lab Med. 2008;132(4):622–32.
Gnepp DR, Barnes L, Crissman J, Zarbo R. Recommendations for the
Section Code: reporting of larynx specimens containing laryngeal neoplasms. Am
J Clin Pathol. 1998;110:137–9.
• A1 – Epiglottis, representative sections Helliwell TR, Giles TE. Pathological aspects of the assessment of head
and neck cancers: United Kingdom National Multidisciplinary
• A2–A4 – Supraglottis and glottis, posterior left, submit- Guidelines. J Laryngol Otol. 2016;130(Suppl S2):S59–65. https://
ted from mid to lateral doi.org/10.1017/S0022215116000451.
• A5–A8 – Supraglottis and glottis, anterior left, submitted Hiatt JL, Gartner LP. Palate, pharynx, and larynx. In: Textbook of head
from lateral to mid and neck anatomy. 4th ed. Philadelphia: Lippincott Williams &
Wilkins; 2009. p. 243–62.
• A9–A15 – Supraglottis and glottis, anterior right, submit- Lydiatt WM, Patel SG, Ridge JA, O’Sullivan B, Shah JP. Staging head
ted from mid to lateral and neck cancers. In: Amin MB, editor-in-chief. AJCC cancer
• A16–A20 – Supraglottis and glottis, posterior right, sub- staging manual. 8th ed. Chicago: American College of Surgeons;
mitted from lateral to mid 2018.p. 55–65. https://doi.org/10.1007/978-3-319-40618-3.
• A21–A24 – Subglottis, representative sections, posterior
left, submitted from mid to lateral
• A25–A29 – Subglottis, representative sections, anterior
left, submitted from lateral to mid
• A30–A33 – Subglottis, representative sections, anterior
right, submitted from mid to lateral
• A34–A39 – Subglottis, representative sections, posterior
right, submitted from lateral to mid
Gastrointestinal Tract
4
Gastrointestinal tract specimens are among those most com- The specimen is opened through the greater curvature and
monly received in the surgical pathology grossing suite. reveals a ___ × ___ cm friable/fungating/polypoid firm
Besides the numerous gastrointestinal tract biopsy speci- tumor located on the greater/lesser curvature or in the cardia/
mens, many of the more common larger routine specimens fundus/antrum/pre-pyloric region. The tumor is ___ cm from
come from the gastrointestinal tract, including appendec- the proximal margin and ___ cm from the distal margin. The
tomy, cholecystectomy, and colectomy specimens. Standard tumor grossly invades/does not invade through the muscula-
gross evaluation and sectioning is recommended, regardless ris propria and invades/does not invade into the perigastric
of the apparent presence or absence of a neoplastic lesion. soft tissue. The remainder of the mucosa is unremarkable,
This procedure ensures that if an unexpected neoplasm is with normal folds. In the attached perigastric adipose tissue
discovered microscopically, the important information are __# lymph nodes ranging in size from ___ to ___ cm.
needed, such as margin status, will be documented. This
Ink code:
chapter provides instruction on grossing many of the various
types of gastrointestinal tract specimens that may be encoun- • Blue – Proximal margin
tered in the surgical pathology grossing suite. • Black – Distal margin
Section code:
Esophagogastrectomy
• A1 – Proximal margin
Specimens include portions of the esophagus and stomach • A2 – Distal margin
(Figs. 4.1 and 4.2). • A3–A10 – Tumor
• A11 – Normal stomach
• A12 – Lymph nodes
Sample Dictation: Gastrectomy
Received fresh/in formalin labeled as “_____” is a total/sub- Sample Dictation: Esophagectomy

total gastrectomy specimen. The specimen measures ___ cm
along the greater curvature and ___ cm along the lesser cur- Received fresh/in formalin labeled as “____” is an esopha-
vature. The circumference ranges from ___ cm at the proxi- gectomy specimen (___ cm in length and ___ cm in circum-
mal margin to ___ cm at the distal margin. A portion of the ference) with a small attached portion of stomach (___ cm in
duodenum is present (___ cm in length and ___ cm in cir- length and ___ cm in circumference). The serosal surface is
cumference). The serosal surface is tan-pink smooth and tan-pink and smooth with attached adipose tissue.
glistening/includes an area of adhesions or perforation (areas The mucosal surface reveals a ___ × ___ cm tan/tan-gray
of adhesions or perforation are inked ___). The wall thick- firm friable/fungating mass located at the gastroesophageal
ness is ___ cm. junction, which invades/does not invade the muscularis pro-
pria and soft tissue. The tumor is ___ cm from the proximal
M. B. Lemos (*) · M. Schwartz margin and ___ cm from the distal margin. The remainder of
Department of Pathology and Genomic Medicine, Houston the mucosa is unremarkable. The stomach mucosa is tan/pale
Methodist Hospital, Houston, TX, USA tan/erythematous with normal folds. In the paraesophageal

28 M. B. Lemos and M. Schwartz
Fig. 4.1 Esophagogastrectomy. Note the presence of esophagus and a portion of the proximal stomach with staples along the surgical resection
margin. Cut directly under the staples and ink this resection margin
Fig. 4.2 Esophagogastrectomy: Opened. The stomach should be geal junction. Take longitudinal sections of the area with a tumor. Also
opened along the greater curvature. Note the esophageal mucosa and a submit the proximal and distal margins
rugated portion of gastric mucosa. There is a tumor at the gastroesopha-
4 Gastrointestinal Tract 29
tissue, __# of lymph nodes are identified ranging from ___ to intestinal neoplasms, and bowel injuries, among others. After
___ cm. In the paragastric tissue, __# lymph nodes are iden- reversal of an ileostomy, an ileostomy specimen may be
tified ranging from ___ to ___ cm. received in the surgical pathology grossing suite (Figs. 4.3
and 4.4).
Ink code:
• Blue – Proximal (esophageal) margin

• Black – Distal (stapled gastric) margin Sample Dictation: Ileostomy
Section code: Received fresh/in formalin and labeled as “_____” is an ile-

ostomy specimen (____ cm length, ____ cm circumference).
• A1 – Proximal margin An ostomy site is present (____ cm diameter). A tan-gray
• A2 – Distal margin rim of skin surrounding the ostomy site is present (____ cm
• A3–A10 – Tumor width). The serosa is tan-white. The mucosa is tan with nor-
• A11–A12 – Normal esophagus mal folds, and no gross lesions are identified. The wall of the
• A15 – Stomach mucosa bowel is ____ cm thick.
Section code:
Ileostomy • A1, A2 – Margins

• A3–A4 – Representative sections
Various bowel conditions may require a temporary ileos-
tomy. Such conditions include inflammatory bowel disease,
Fig. 4.3 Ileostomy. This specimen consists of a portion of bowel with a rim of skin. Measure the ostomy site diameter and the rim of skin sur-
rounding the ostomy site
Fig. 4.4 Ileostomy: Sectioning. Open the stapled end by cutting beneath the staples. Cut through the ostomy site. Take sections so that both the
skin and mucosa are included
Small Bowel • Ink the proximal and distal margins different colors.
• After opening the colon, determine the location of the
A portion of the small bowel may be resected because of a tumor and its size and distance from margins (Figs. 4.8
tumor (Figs. 4.5 and 4.6) or diverticulum (Fig. 4.7), among and 4.9).
other indications. • Take the fat off the serosa, except for the fat in the area of
tumor. Keep separate the fat proximal to the tumor and the
fat distal to the tumor (Fig. 4.10).
Large Bowel • Take longitudinal sections (i.e., parallel to the length of
the colon) of tumor to help show the relationship of the
Segments of the large bowel may be resected because of tumor to the adjacent normal bowel and other adjacent
tumors (Figs. 4.8, 4.9, 4.10, 4.11, 4.12 and 4.13), diverticuli- structures (Fig. 4.11).
tis (Figs. 4.14, 4.15, 4.16 and 4.17), inflammatory bowel dis- • Be sure to include sections of the deepest gross invasion
ease (Figs. 4.18, 4.19 and 4.20), or ischemia (Figs. 4.21 and of the tumor (e.g., into the muscle wall or pericolonic
4.22), among other indications. fat).
• If the tumor is very close to the proximal or distal margin
of resection, take perpendicular sections to include the
Grossing Tips: Large Bowel margin as well as the tumor. Otherwise (if the tumor is
further away from the margins), submit the margins en
Colon with a neoplasm: face (Figs. 4.12 and 4.13).
• Look for lymph nodes in the fat and submit separately
• Ink the serosal surface and fat overlying the tumor to aid those from the proximal fat, the distal fat, and the peritu-
in the determination of the extent of invasion of the tumor moral fat.
into the colonic wall upon microscopic examination.
Fig. 4.5 Small bowel: Resection of subserosal tumor. Note the peritonealized surface and both the bowel and tumor resection margins
Fig. 4.6 Small bowel: Inking and sectioning of subserosal tumor. The The tumor is then serially sectioned. Note the change in the appearance
soft tissue resection margin adjacent to the tumor is inked one color, of the bowel mucosal surface in the area involved by the tumor
and the peritoneal surface adjacent to the tumor is inked another color.
Fig. 4.7 Meckel’s diverticulum. Intact (left) and bisected (right) Meckel’s diverticulum specimen. There is an area of gastric-type mucosa that can
be appreciated grossly and microscopically. (H&E image courtesy of Andreia Barbieri, MD, Houston Methodist Hospital)
Fig. 4.8 Right hemicolectomy. This specimen includes a portion of the its distance to proximal and distal margins should be recorded. It is also
ileum, cecum, and right colon. An exophytic mass is located adjacent to helpful to ink the proximal and distal margins before taking sections
the ileocecal valve in the cecum. The position of the tumor, its size, and
Fig. 4.9 Right
hemicolectomy: Inking.
Inking the serosa and
pericolonic fat overlying the
tumor helps when assessing
the depth of tumor invasion
Fig. 4.10 Rectum: Radial margin. The radial margin is the non-peritonealized bare area of the rectum, located anteriorly and posteriorly. This
represents tissue through which the surgeon has cut
Fig. 4.11 Colon tumor: Longitudinal sectioning. Longitudinal sections help show the relationship of the tumor to adjacent structures. This can be
especially important when the tumor is very close to one of the margins
Fig. 4.12 Rectum with anal mucosa and dentate line. The anatomy of should be noted whether any tumor in this area crosses or involves the
the dentate line is demonstrated in this gross image and corresponding dentate line, as does the tumor in this specimen. (Sketch courtesy of
sketch. The dentate line divides the upper two thirds and lower one third Ahmed Shehabeldin, MD, Houston Methodist Hospital.)
of the anal canal; it is located at the inferior limit of the anal valves. It
Fig. 4.13 Colon tumor:

Depth of invasion. It is
important to assess the depth
of invasion of colon tumors
grossly and to submit sections
of the deepest areas seen.
Sectioning this tumor shows
grossly apparent invasion into
the fat and a lymph node
grossly positive for metastasis
Colon with diverticula: tion (patchy vs. continuous) of mucosal changes (mucosal
eryhthema, ulceration, pseudopolyps, etc); as well as the
• Before cutting into the specimen, look carefully at the presence or absence of strictures (Fig. 4.18, 4.19 and
outside surface for areas of serosal exudate or adhesions 4.20).
(Figs. 4.14 and 4.15). These areas could represent sites of • Make sure to evaluate for any nodules or massess.
perforation. • Numerous lymph nodes are often present in the peri-
• If an area of adhesion is identified, ink this area, but intestinal adipose tissue. It is not uncommon to identify
remove the non-inflamed adipose tissue. dozens of lymph nodes, in cases of inflammatory bowel
• Take longitudinal sections, as this helps to identify the disease.
diverticula (Figs. 4.16 and 4.17).
Colon with ischemia:
Colon with inflammatory bowel disease:
• Evaluate the serosal surface and note for changes in color.
• In cases of inflammatory bowel disease (ulcerative colitis The serosal surface is often dark, and has a dusky apper-
and Crohn’s disease), make sure to document the distribu- ance (Fig. 4.21)
Fig. 4.14 Diverticulitis. When grossing a colon with diverticular disease, identify areas of adhesions or exudate on the surface first. These areas
may represent sites of diverticular rupture or colon perforation
Fig. 4.15 Diverticulitis:
Adhesions. Seen here are
adhesions on the surface of a
colon with diverticulitis
Fig. 4.16 Diverticular
disease: Mucosal surface.
Several diverticular openings
are apparent on the mucosal
surface of this segment of
bowel
Fig. 4.17 Diverticula: Sections. Longitudinal sections need to be taken to identify and submit diverticula. Once identified, submit diverticula for
microscopic examination. These sections should include the entire depth of the diverticulum into the colonic wall
Fig. 4.18 Colon with

ulcerative colitis. Note the
multiple pseudopolyps and
diffuse mucosal involvement
of the large bowel

Crohn’s disease. Note the
patchy distribution of affected
colon and mucosal erythema.
Also seen is the “cobblestone”
mucosa characteristic of
Crohn’s disease

Crohn’s disease: Stricture.
Strictures such as this are
common findings in Crohn’s
disease
Fig. 4.21 Bowel with adhesed ovary. This bowel shows features of ischemia and has a dusky serosal surface, as well as serosal exudates.
Extensive adhesions are present, including adhesion of an ovary. Due to the dense adhesions, the ovary was surgically resected along with the colon
• Evaluate for any adhesions, serosal exudate, or perforations. Note the adhesed ovary in Figs. 4.21 and 4.22. The area
• Examine the appearance of the mucosa, noting if the of adhesion between the ovary and colon is inked green.
mucosal folds appear depressed, flattened, or discolored. In addition to submiting bowel margins and represena-
• Examine the blood vessels to evaluate for any grossly tive sections of bowel wall, sections at the site of adhe-
obvious sites of thrombosis or other vascular lesion. sions are taken to microscopicaly examine the
• In some cases of ischemia with associated rupture and relationship between the colon and ovary.
adhesions, there may be adhesions to other structures.
Fig. 4.22 Bowel with adhesed ovary: Opened. The area of adhesions is inked in green, after which the ovary is bisected and examined. In this
case, the ovary happened to be cystic
ample Dictation: Right Hemicolectomy/

S Section code:
Ileocolectomy
• A1 – Proximal margin∗
Received fresh/in formalin and labeled as “_____” is a seg- • A2 – Distal margin∗
ment of terminal ileum (____ cm length, _____ cm circum- • A3 – Radial/mesenteric margin
ference), cecum (____ × ____ cm) and right colon (____ cm • A4 – Tip of the appendix, bisected
length, ____ cm circumference). An appendix is present • A5 – Representative cross-sections of appendix
(____ cm length, ____ cm circumference) (or the appendix • A6–A10 – Mass
is not identified). The serosal surface is tan-pink and smooth/ • A11 – Polyp #1
with an area of adhesion measuring ___ × ___ cm and located • A12 – Polyp #2
___ cm from the proximal margin and ___ cm from the distal • A13 – Non-neoplastic right colon, representative
margin. There is attached adipose tissue along the entire section
length of the specimen. • A14–A16 – Lymph nodes from adipose tissue proximal to
A fungating/ulcerated and firm tan-brown mass tumor
(____ × ____ × ____ cm) is located in the cecum/ileocecal • A17–A19 – Lymph nodes from peritumoral adipose
valve/ascending colon. The tumor grossly invades/does not tissue
invade the muscularis propria/pericolic fat. The tumor is • A20–A22 – Lymph nodes from adipose tissue distal to
located ____ cm from the proximal margin and ____ cm tumor
from the distal margin.
There are ____ # polyps (____ cm to ____ cm in greatest ∗Note: Submit margin(s) perpendicularly, if close to the
dimension) located in _____, and are present ____ cm from tumor.
the tumor and _____ cm from the closest margin. __# possible
lymph nodes are identified in the pericolic adipose tissue.
Sample Dictation: Low Anterior Resection
Ink code:
Received fresh/in formalin labeled as “____” is a segment
• Black – Radial or mesenteric margin of sigmoid colon (____ cm length, ____ cm circumfer-
• Blue – Serosa underlying tumor ence), a segment of rectum (____ cm length, ____ cm cir-
• Orange – Proximal margin cumference) with perirectal and mesenteric adipose tissue.
• Green – Distal margin The serosal surface is tan-pink, and an area of adhesion is
identified measuring ____ × ____ cm and ____ cm from • A12 – Polyp #2

the proximal margin and ____ cm from the distal margin. • A13 – Non-neoplastic sigmoid colon, representative
Perirectal and mesenteric adipose tissue is present. section
A ____ × ____ × ____ cm firm tan-brown and ulcerated/ • A14 – Non-neoplastic rectum, representative section
fungating mass is located in the sigmoid colon/rectum, and is • A15–A16 – Lymph nodes from adipose tissue proximal to
____ cm from the proximal margin, ____ cm from the distal tumor
margin, and ____ cm from the radial margin. The tumor • A17–A19 – Lymph nodes from peritumoral adipose
grossly invades/does not invade the muscularis propria/peri- tissue
colic adipose tissue. • A20–A22 – Lymph nodes from adipose tissue distal to
There are ____ # polyps (____ cm to ____ cm in greatest tumor
dimension) located in _____ and present ____ cm from the
tumor, and _____ cm to the closest margin. __# possible ∗Note: If the tumor is very close to the margins, take per-
lymph nodes are identified in the pericolic adipose tissue. pendicular sections.
Ink code:
Appendectomy
• Black – Radial margin
• Blue – Proximal margin
Figure 4.23 illustrates the grossing of an appendix. Serosal
• Orange – Distal margin
exudate (Fig. 4.24) is not always seen.
Section code:
• A1 – Proximal margin Sample Dictation: Appendix

• A2 – Distal margin
• A3 – Radial margin (if rectal tumor) Received fresh/in formalin and labeled as “______” is an
• A4–A10 – Mass appendectomy specimen with a small amount of peri-
• A11 – Polyp #1 appendiceal fat. The appendix is ____ cm in length and
Fig. 4.23 Appendectomy. When received, measure the appendix and serially section the appendix and submit representative cross-sections. If
always ink the proximal margin. Then examine the serosal surface for the appendix appears grossly normal but appendicitis is suspected clini-
abnormalities, including exudate and perforation. The distal tip should cally, the entire appendix should be submitted for microscopic examina-
be bisected and submitted entirely. Also submit the inked proximal mar- tion. In these images, note the blue ink on the proximal margin, the
gin. (This can be submitted in the same cassette as the tip.). Finally, presence of a fecalith within the lumen, and the bisected appendix tip
Fig. 4.24 Appendix:
Purulent serosal exudate.
Note the presence of
tan-white exudate material at
the tip of this appendectomy
specimen
Fig. 4.25 Polypectomy. Seen here is a polyp with its stalk. The base of Alternatively, both ends of the polyp can be submitted in a single cas-
the polyp (tip of the stalk) should be inked. When no stalk is present, sette, as long as it is indicated in which cassettes the ends are
ink the base of the polyp. The polyp is serially sectioned parallel to the submitted
stalk and submitted sequentially from one end to the opposite end.
____ cm in diameter. The proximal margin is inked blue. The Polypectomy

outer appendiceal surface is tan-pink and smooth/with areas
of serosal exudate. The specimen is serially sectioned, and Figure 4.25 illustrates the grossing of a polyp, including
the lumen ranges from ____ cm to _____ cm in diameter. No serial sectioning.
fecaliths or perforations are present (or the lumen is partially
filled with fecaliths or purulent material).
Ink code: Sample Dictation: Polypectomy
• Blue – Proximal margin Received fresh/in formalin and labeled “polyp” is a tan-pink/
red-brown polyp measuring __ × ___ × ___ cm with a stalk
Section code: present measuring ____ cm in diameter and ____ cm in
length. The base of the polyp is inked blue. The specimen is
• A1 – Tip of the appendix bisected and entirely submitted; serially sectioned. The cut surface is tan-pink and rubbery/
proximal margin ink side down slightly friable. It is entirely submitted sequentially from one
• A2 – Representative cross-sections of appendix end to the opposite end in cassettes A1–A__.
Suggested Reading Poulin EJ, Shen J, Gierut JJ, Haigis KM. Pathology and molecular
pathology of colorectal cancer. In: Loda M, Mucci L, Mittelstadt
M, Van Hemelrijck M, Cotter M, editors. Pathology and
Burroughs SH, Williams GT. Examination of large intestine resection epidemiology of cancer. Cham: Springer; 2017. p. 409–46. https://
specimens. J Clin Pathol. 2000;53:344–9. https://doi.org/10.1136/ doi.org/10.1007/978-3-319-35153-7_22.
jcp.53.5.344. Royston D, Warren B. Pathology of anorectal and colonic speci-
Glickman JN, Odze RD. Epithelial neoplasms of the esophagus. In: mens. In: Givel JC, Mortensen N, Roche B, editors. Anorectal and
Odze RD, Goldblum JR, editors. Surgical pathology of the GI colonic diseases. Berlin: Springer; 2010. p. 81–115. https://doi.
tract, liver biliary tract and pancreas. Philadelphia: Elsevier; 2015. org/10.1007/978-3-540-69419-9_7.
p. 674–709. Shen S, Haupt B, Ro J, Baily HR, Schwartz M. Number of lymph
Plesec TP, Owens SR. Inflammatory and neoplastic disorders of the nodes examined and associated clinicopathologic factors in colorec-
anal canal. In: Odze RD, Goldblum JR, editors. Surgical pathol- tal carcinoma. Arch Pathol Lab Med. 2009;133:781–6. https://doi.
ogy of the GI tract, liver biliary tract and pancreas. Philadelphia: org/10.1043/1543-2165-133.5.781.
Elsevier; 2015. p. 887–918.
Hepatobiliary and Pancreas
5
The volume of hepatobiliary and pancreatic specimens Sample Dictation: Hepatectomy

received in the surgical pathology grossing suite is highly
dependent on the individual hospital practice setting. Some Received fresh/in formalin is a hepatectomy specimen
of these specimens, such as pancreaticoduodenectomy speci- (____ grams, ____ × ____ × ____ cm) with an attached
mens, can be very complex. A pancreaticoduodenectomy intact gallbladder (____ cm length, ____ cm maximum
procedure, also known as a Whipple procedure, includes circumference).
resection of the head of the pancreas, a portion of the bile The liver capsule is red-brown and smooth (or, for a cir-
duct, a portion of the distal stomach, and a portion of the rhotic liver, diffusely nodular with nodules ranging from
duodenum. Whipple procedures are typically performed for ____ cm to ____ cm). There is a ____ cm retracted area on
resection of tumors in the head of the pancreas, distal com- the surface. The specimen is serially sectioned, and there is a
mon bile duct, or ampulla of Vater. Whipple procedure speci- ____ × ____ × ____ cm tan-gray mass located in segment #
mens are one of the most anxiety-inducing specimens ____ (describe any additional characteristics of the mass
encountered by pathology trainees and practitioners unfamil- such as areas of necrosis, hemorrhage, calcification, etc.).
iar with such specimens. In practice settings where these sur- The mass is ____ cm from the capsular surface.
geries are performed infrequently, acquiring confidence in The gallbladder surface is tan-pink with a ____ cm cystic
handling such specimens may be challenging. This chapter duct. There is dark green bile within the gallbladder lumen.
outlines step-by-step procedures on how to handle hepatobi- The mucosa is green with yellow-speckled areas, consistent
liary and pancreatic specimens, including pancreaticoduode- with cholesterolosis (or velvety green and trabeculated). The
nectomy specimens, and gives helpful tips on how to properly wall of the gallbladder is ____ cm thick.
orient these specimens upon their receipt in the grossing
Ink code:
suite.
• Black – Segment VIII surface
• Purple – Segment II surface
Hepatectomy • Orange – Segment III surface
• Red – Segment IV surface
Grossing Tips: Hepatectomy
• Yellow – Segment V surface
• Blue – Segment VI surface
• Draw the outlines of the liver segment surfaces with a
• Green – Segment VII surface
light-colored ink (yellow works best). Then, with a differ-
• No color – Caudate surface
ent color, blot each segment’s surface inside the lines
drawn (Figs. 5.1, 5.2, 5.3, 5.4 and 5.5). This method will
Section code:
reduce the time required to ink the entire liver.
• Do not forget to take vascular and hepatic duct margins • A1 – Hepatic duct and vascular margins
before serially sectioning the liver (Figs. 5.6 and 5.7). • A2–A6 – Lesion in segment # ____
• A7 – Representative section of liver parenchyma from
segment # ____
M. B. Lemos (*) · M. Schwartz
Department of Pathology and Genomic Medicine, Houston • A8 – Representative section of gallbladder

Fig. 5.1 Hepatectomy. Note

the right and left lobes,
falciform ligament, and
caudate lobe, as seen in this
anterior view of a total
hepatectomy specimen
Fig. 5.2 Hepatectomy: Segments in anterior view. The liver is divided Fig. 5.3 Hepatectomy: Segments in posterior view. Note also the posi-
into eight anatomical segments tion of the attached gallbladder
Fig. 5.4 Hepatectomy: Inking (anterior). The liver surface is inked with different colors for each of the anatomic segments. The inking will aid in
describing the location of lesions with respect to the segments after the liver is serially sectioned (see Figs. 5.6 and 5.7)
5 Hepatobiliary and Pancreas 45
Fig. 5.5 Hepatectomy: Inking (posterior). Inking of the liver segments posteriorly, using the same colors as for anterior inking
Fig. 5.6 Hepatectomy: Sectioning. Thin serial sections should be the lesion(s) is located in. This will allow the prosector to pay additional
made to look closely for any abnormality or mass. It is helpful to review attention to this segment(s), in order to identify the radiographically
any available preoperative radiographic imaging of the liver to see if detected lesion(s)
any lesions were identified radiographically, and if so, which segment
Fig. 5.7 Hepatectomy: Serial sections with tumor. After inking the surface of the different liver segments and thinly sectioning the liver, the loca-
tion of any tumor in serial sections can be identified. Note the tan-white mass seen here
Fig. 5.8 Cholecystectomy. This cholecystectomy specimen has a node. Do not forget to assess whether a pericystic lymph node is present
smooth serosal surface, roughened hepatic aspect (where the surgeon before grossing the rest of the gallbladder
dissected the gallbladder off the liver surface), and a pericystic lymph
Cholecystectomy Sample Dictation: Cholecystectomy
After examining the surface of the gallbladder (Fig. 5.8) and Received in formalin labeled “gallbladder” is an intact/pre-
submitting the cystic duct margin (Fig. 5.9), open the gall- viously opened gallbladder (____ cm length and ____ cm
bladder, examine the mucosal surface, and take representa- maximum circumference) with a cystic duct. The serosal
tive sections (Fig. 5.10). surface is tan-green/green, etc. The bile is dark green. The
Fig. 5.9 Cholecystectomy: Cystic duct margin. The cystic duct margin is usually stapled or clipped and should be submitted (en face)
Fig. 5.10 Cholecystectomy: Sectioning. The gallbladder is opened cating cholesterolosis. Representative sections of the gallbladder are
and its contents, which consist of bile and possibly stones, are removed. submitted; these sections are made longitudinally to include the great-
Then the mucosal surface can be examined. This picture shows gall- est surface area possible for examination
bladder mucosa with a characteristic yellow-spotted appearance indi-
mucosa is velvety and green/pink-green and trabeculated/ Whipple Resection

with cholesterolosis/with multiple yellow granular polyps (Pancreaticoduodenectomy)
(____ cm to ____ cm in greatest dimension). The wall of the
gallbladder measures ____ cm in thickness. Multiple green/ Grossing Tips: Whipple Resection
black/yellow-green and smooth/granular/irregularly shaped
gallstones are present (____ to ____ cm in greatest dimen- • When a Whipple resection specimen is received, orient it
sion). A ____ cm tan-pink single lymph node is identified. so that the stomach is on the left-hand side of the prosec-
tor and the duodenum is on the right-hand side (Fig. 5.11).
Section code: When positioned this way, the pancreatic resection mar-
gin will face the prosector.
• A1 – Representative section of the gallbladder (include • Probe the pancreatic duct from the visible pancreatic sur-
cystic duct margin and three sections of gallbladder) face. Ink this surface and submit it for frozen section eval-
• A2 – Lymph node (if present) uation (en face section) in one or two blocks.
Fig. 5.11 Pancreaticoduodenectomy (Whipple procedure) specimen. creatic resection margins are submitted. For the latter, shave the entire
The specimen consists of the pancreas, a portion of the stomach, and the visible pancreatic surface and submit in one or two cassettes (en face
duodenum. The probes seen here are in the pancreatic duct and the section)
common bile duct. For frozen sections, the common bile duct and pan-
Fig. 5.12 Pancreaticoduodenectomy (Whipple procedure) specimen: enteric artery was dissected off by the surgeon. The retroperitoneal mar-
Vascular groove and retroperitoneal margin. The vascular groove is a gin is adjacent to the vascular groove; it can be found using the
linear indentation that represents the area from which the superior mes- technique shown in Fig. 5.13
• It can be helpful for the histotechnologist to know the the prosector’s index finger and thumb is the retroperito-
correct orientation of the section, so leave the probe in neal margin (as shown in Fig. 5.13).
the shaved pancreatic duct as it is placed on the frozen • Keep the specimen oriented as above (with the stomach
chuck. on the left and the duodenum on the right).
• Locate and ink the common bile duct margin. Shave and • Use a different color to ink the vascular groove, which is
submit this margin en face. near the retroperitoneal margin but appears slightly
• To find the retroperitoneal resection margin (Fig. 5.12), depressed or concave.
the prosector should take their left hand and place their • Sometimes the surgeon may request a frozen section of
middle finger over the pancreatic resection margin, place the retroperitoneal margin. In this case, palpate the sur-
their index finger in the vascular groove, and place their face and submit the area that is most firm (where the
thumb on the other end of the pancreas. The area between tumor is closest to the margin).
Fig. 5.13 Pancreaticoduodenectomy (Whipple procedure) specimen: groove. The left thumb should be at the end of the pancreas opposite the
Finding the retroperitoneal margin. The vascular groove is a slightly pancreatic resection margin. The retroperitoneal margin is between the
depressed linear indentation along the pancreas. To find the retroperito- groove (index finger) and the end of the pancreas (thumb). The retro-
neal margin, place the left middle finger over the pancreatic resection peritoneal margin, vascular groove, and pancreatic resection margin
margin (see Fig. 5.11) and the left index finger along the vascular should all be inked different colors
Fig. 5.14 Pancreaticoduodenectomy (Whipple procedure) specimen: extends from the common bile duct throughthe ampulla. The ampulla
Ampulla. After opening the duodenum and stomach, the ampulla is should be the first submitted section following frozen sections and
probed. The ampulla is visible on the mucosal surface, and the probe before further sectioning
• Probe the ampulla and submit it as the first section (after • Open the pancreatic and common bile ducts, and ink their
submission of margins) before grossing further (Fig. 5.14). opened edges each with a different color (Fig. 5.15). Ink
This helps to avoid the possibility of not being able to only the edges and avoid inking over the remainder of the
locate the ampulla later after fixation and sectioning. mucosa. Use the same colors used for the frozen sections
Fig. 5.15 Pancreati
coduodenectomy (Whipple
procedure) specimen: Opened
ducts. The pancreatic and
common bile ducts are
opened and inked at the
opened edges, marking each
with a different color. The
specimen can then be fixed in
formalin before further
sectioning
Fig. 5.16 Pancreaticoduodenectomy (Whipple procedure) specimen: surface and its relationship to adjacent ducts and the duodenum. If a
Sections. The pancreas is horizontally/transversely sectioned, and sec- tumor is not grossly identified, the entire pancreas should be submitted
tions are submitted sequentially. Note the presence of tumor on the cut
of the pancreatic resection and bile duct margins. After Sample Dictation: Whipple Resection
inking, fix the specimen in formalin before taking further
sections. Received fresh labeled as “Whipple” is a Whipple resection
• Transversely section the pancreas, including the attached specimen consisting of stomach (____ cm in length × ____ cm
duodenal mucosa (Fig. 5.16). in circumference), duodenum (____ cm in length × ____ cm in
• Next, examine the sections for tumor (Fig. 5.17). Submit circumference), and pancreatic head (____ × ____ × ____ cm).
sections sequentially and in an order that will help keep The pancreas is serially sectioned and shows a ____ cm
track of the size, location, and extent of the tumor mass obstructing the pancreatic duct (or the pancreatic duct
(Fig. 5.18). is patent). The common bile duct is patent (or there is a
• Take sections of the gastric margin and duodenal margin. ____ cm tan-white area of induration). The mass is ____ cm
• Take representative sections of the stomach and duode- from the pancreatic resection margin and involves/does not
num that are uninvolved by the tumor. involve the ampulla. The bile duct is dilated/not dilated with
• Look for lymph nodes present in the peripancreatic fat. an adjacent ____ cm tan-pink lymph node.
Fig. 5.17 Pancreaticoduodenectomy (Whipple procedure) specimen: Slice. This slice from a Whipple resection shows a close-up view of both the
tumor and the normal pancreas. Also note the common bile duct and pancreatic duct
Fig. 5.18 Pancreaticoduodenectomy (Whipple procedure) specimen: both cases, care is taken to submit sections in such a way that the size,
Submitting sections. The slice on the left is partially submitted (repre- location, and extent of a tumor or any lesion can be reconstructed later.
sentative sections). The slice on the right is completely submitted. In It should be similar to putting together pieces of a puzzle
The mucosa of the duodenum is tan-pink with normal Ink code:

folds. The gastric mucosa is tan-pink and unremarkable.
Identified are ___ # periduodenal lymph nodes ranging from • Violet – Retroperitoneal margin
____ to ____ cm. Also identified are ___ # lymph nodes in the • Blue – Common bile duct margin
adipose tissue adjacent to the pancreas measuring ____ cm. • Black – Pancreatic resection margin
Gross photographs are obtained. • Green – Vascular groove
Section code: ∗The pancreatic resection margin and common bile duct
margin are typically submitted at the time of frozen section.
• AFS 1∗ – Pancreatic resection margin
Thus in this sample dictation, “FS” is added to the section
• AFS 2∗ – Common bile duct margin
code to indicate that these sections were submitted for frozen
• A3 – Ampulla
section.
• A4–A10 – Mass, sequential sections
• A11–A14 – Peripancreatic lymph nodes (specify # in
each cassette) Distal Pancreatectomy
• A15–A19 – Periduodenal lymph nodes (specify # in each
cassette) A distal pancreatectomy specimen may also include the
• A20 – Duodenum margin spleen (Figs. 5.19 and 5.20).
• A21 – Duodenum, representative section
• A22 – Gastric margin
• A23 – Stomach, representative section
Fig. 5.19 Distal
pancreatectomy. The
specimen includes the distal
pancreas and spleen. The
pancreatic resection margin
should be inked and submitted
separately
Fig. 5.20 Distal pancreatectomy: Sections. The pancreas and spleen are transversely sectioned and laid out sequentially. In this picture, a tumor
is visible in the sections of the pancreas
Fig. 5.21 Splenectomy. The intact spleen is weighed and measured, cular margins at the splenic hilum are then submitted. Finally, serial
and the capsule is examined for any lesions or surface disruptions. sections of the spleen are made and the cut surface is examined
Here, a scarred area is identified on an intact splenic capsule. The vas-
Sample Dictation: Distal Pancreatectomy Splenectomy
Received fresh/in formalin is a distal pancreatectomy and Weigh the spleen, and examine the splenic capsule; submit
splenectomy specimen, which consists of the tail of the pan- the hilar vascular margins and serially section the spleen
creas (____ × ____ × ____ cm) and the spleen (Fig. 5.21).
(____ × ____ × ____ cm).
Sections through the soft/firm/cystic pancreas show an
area of fibrosis (or tumor) (____ × ____ cm) located ____ cm
from the resection margin. The lesion does/does not involve
Suggested Reading
the spleen. Saka B, Balci S, Basturk O, Bagci P, Postlewait LM, Maithel S, et al.
The remainder of the pancreatic parenchyma is lobulated/ Pancreatic ductal adenocarcinoma is spread to the peripancreatic
fibrotic. Sections of the spleen are unremarkable, without soft tissue in the majority of resected cases, rendering the AJCC
gross lesions or masses. Several lymph nodes are identified T-stage protocol (7th edition) inapplicable and insignificant: a size-
based staging system (pT1: ≤2, pT2: >2-≤4, pT3: >4 cm) is more
in the fat around the pancreas and the hilar area. valid and clinically relevant. Ann Surg Oncol. 2016;23:2010–8.
Ink code: https://doi.org/10.1245/s10434-016-5093-7.
Soer E, Lodewijk B, Van de Vijver M, Dijk F, Van Velthuysen ML,
Farina-Sarasqueta AF, et al. Dilemmas for the pathologist in
• Blue – Pancreatic resection margin the oncologic assessment of pancreatoduodenectomy speci-
mens. Virchows Arch. 2018;472:533–43. https://doi.org/10.1007/
Section code: s00428-018-2321-5.
Verbeke CS, Gladhaug IP. Resection margin involvement and tumour
• A1 – Pancreatic resection margin origin in pancreatic head cancer. Br J Surg. 2012;99:1036–49.
• A2–A10 – Mass, submitted sequentially https://doi.org/10.1002/bjs.8734.
• A11 – Uninvolved spleen, representative section Verbeke CS. Operative specimen handling and evaluation of resec-
tion margins. In: Kim SW, Yamaue H, editors. Pancreatic can-
• A12 – Uninvolved pancreas, representative section cer: with special focus on topical issues and surgical techniques.
• A13–A15 – Peripancreatic lymph nodes Berlin, Heidelberg: Springer; 2017. p. 67–88. https://doi.
• A16–A20 – Hilar lymph nodes org/10.1007/978-3-662-47181-4_5.
Genitourinary
6
Monica B. Lemos and Steven Shen
Of the various types of genitourinary specimens, nephrec- • If the vascular margins are not easily visible, pull up the
tomy specimens are some of the most common. Nephrectomy area with staples and make a deep en face section. It
specimens may include the entire kidney (radical nephrec- should be possible to cut through and remove all the mar-
tomy) or only a portion of the kidney (partial nephrectomy). gins with this technique.
Total nephrectomy specimens may be received for removal • Check the renal vein for tumor involvement.
of a neoplasm or a non-neoplastic condition. A partial • Ink the outside surface of the kidney closest to where the
nephrectomy is typically performed to remove a mass lesion mass is palpated.
and includes the mass and a small amount of non-neoplastic • Bivalve the kidney (Fig. 6.3).
kidney tissue. Depending on the size and location of the • Describe the location of the tumor with respect to the kid-
tumor, a partial nephrectomy may be preferred, as this tech- ney poles (upper, mid, or lower).
nique allows for the preservation of kidney function and low- • Take a parallel section to look for involvement of the
ers the risk of subsequent chronic kidney disease. renal sinus by the tumor (Fig. 6.4). Make this section
Other types of genitourinary specimens include bladder very thin, so representative sections can be placed in a
resections (cystectomy) and removal of the testis and sper- cassette.
matic cord (orchiectomy). In male patients, the bladder may • Include a section of the tumor with the renal sinus, if the
be received with the prostate (cystoprostatectomy). This tumor is close enough to the renal sinus area (Fig. 6.5).
chapter discusses the proper handling of all of these • Include sections of any areas where perirenal fat or capsu-
specimens. lar invasion is suspected.
• Include a section of the tumor with adjacent normal kid-
ney parenchyma.
Radical Nephrectomy • After taking a parallel section, take perpendicular
sections to complete the gross evaluation and assess
Grossing Tips: Nephrectomy for tumor invasion of the capsule or perirenal fat
(Fig. 6.6).
• First, find the ureter margin. Ink and submit this margin, • Nephrectomy specimens may be received in cases of
and then open the ureter. polycystic kidney disease. In such cases numerous vari-
• The lower pole is identified as the pole toward which the able sized cysts are typically present. It is important to
ureter points as it leaves the hilum (Fig. 6.1). also look for any possible tumors that may also be present
• Find and submit the vascular margins. These are usually (Fig. 6.7).
stapled or clipped (Fig. 6.2). • Make sure to assess whether an adrenal gland is present in
the fat adjacent to the upper pole. Sometimes, only a rim
M. B. Lemos (*) of adrenal is present, so look carefully to ensure it is not
Department of Pathology and Genomic Medicine, Houston missed. Measure and submit any adrenal tissue that is
Methodist Hospital, Houston, TX, USA present.
S. Shen

56 M. B. Lemos and S. Shen
Fig. 6.1 Radical
nephroureterectomy:
Orientation. Use the ureter as
a guide in identifying the
upper and lower poles of the
kidney. The ureter travels
downward, away from the
upper pole and toward the
direction of the lower pole.
The vascular margins are
found in the area where the
ureter inserts into the kidney
and the renal pelvis. These
margins are often stapled or
sutured. (See Fig. 6.2.)
Fig. 6.2 Radical nephroureterectomy: Margins. The ureter and vascu- vascular margins. If only a short segment of the ureter is excised, the
lar margins should be located and submitted before dissection of the ureter margin should still be located in the hilar area where the vessels
kidney. There is usually a staple line or clip, which helps to identify the are also clipped or stapled
6 Genitourinary 57
Fig. 6.3 Radical nephrectomy: Bivalved surface. After bivalving the ible. Because invasion into the perirenal fat, hilum, or renal sinus
kidney along the longitudinal axis, the relationship of the tumor with upstages the tumor, an accurate gross examination is critical
respect to the kidney poles, perirenal fat, renal pelvis, and hilum is vis-
Fig. 6.4 Radical
nephrectomy: Parallel
sectioning. After bivalving the
kidney, a parallel section will
help in further examining the
critical relationship of the
tumor to the hilar fat, renal
sinus, renal pelvis, and
perirenal tissue
Sample Dictation: Radical Nephrectomy lower pole with a heterogeneous golden yellow and
focally hemorrhagic cut surface. The tumor is ____ cm
Received fresh/in formalin is a right/left nephrectomy speci- from the renal pelvis. The tumor pushes against the renal
men with perirenal fat and adrenal gland. The kidney is capsule and appears to invade/not invade the capsule/peri-
___ × ____ × ____ cm and weighs ____ grams, and the adre- renal fat. The tumor protrudes into the renal vein and is
nal gland is ____ × ____ × ____ cm. Extending from the ____ cm from the renal vein margin. The remainder of the
renal pelvis is a ureter measuring ____ cm in length and renal cortex is red-brown with a well-defined cortical
____ cm in diameter. medullary junction. The pelvis and calyces are covered by
The specimen is bivalved, and the cut surface reveals a smooth, glistening mucosa. The adrenal gland/rim of the
____ × ____ × ____ cm mass located in the upper/mid/ adrenal gland is yellow-brown and grossly unremarkable.
Fig. 6.5 Hilar invasion.

Pictured is a tumor with
obvious gross hilar invasion
Fig. 6.6 Radical
nephrectomy: Perpendicular
sectioning. After taking a
parallel section and
examining the relationship of
the tumor to the renal sinus
and hilum, take perpendicular
sections to completely
examine the relationship of
the tumor to the kidney
capsule and perirenal fat
The perirenal adipose tissue is serially sectioned, and __#

of lymph nodes are identified/no lymph nodes are
identified.∗
Section code:
• A1 – Ureter margin
• A2 – Vascular margins
• A3–A4 – Renal sinus/hilar region, in parallel sections
• A5 – Tumor with renal capsule and/or perirenal fat, paral-
lel section
• A6–A15 – Tumor, representative sections, perpendicular
• A16–A18 – Normal kidney parenchyma, representative
sections
• A19 – Renal fat, representative sections (or lymph nodes)
∗Note that most times, no lymph nodes are found. When

lymph nodes are present in the fat, they are most often found
Fig. 6.7 Polycystic kidney. A radical nephrectomy has been performed in the hilar area.
to remove a polycystic kidney, which also happens to have a tumor
6 Genitourinary 59
Sample Dictation: Polycystic Kidney gin. The attached perirenal fat contains/does not contain __#
of lymph nodes.
Received fresh and labeled as “____” is a kidney Gross photographs are taken.
(____ × ____ × ____ cm, weight _____ g) with attached Ink code:
perirenalfat. The specimen has a multinodular surface. The
renal capsule is intact, and a ureter is present, measuring • Blue – Surgical margin
____ cm in length and ___ cm in diameter. The renal artery
and renal vein are identified in the hilum. Section code:
The renal parenchyma is completely replaced by multiple • A1 – Ureter margin
cortical and medullary cysts measuring from ____ cm to • A2 – Vascular margins
____ cm in greatest dimension. The majority of the cysts are • A3–A4 – Renal sinus; hilum
filled with clear to brown fluid. The inner lining of the cysts • A5–A9 – Tumor, representative sections
is tan-red and smooth. The cysts are separated by tan fibrous • A10–A18 – Cysts, representative sections with adjacent
tissue with no/a small amount of normal renal parenchyma normal parenchyma
grossly noted. No papillary or mass lesions are noted (or) a
tumor is present within the upper/lower pole and measures
____ × ____ × ____ cm and is located ____ cm from the Partial Nephrectomy
hilum and invades/does not invade the hilar fat, renal sinus,
renal pelvis, and/or perirenal fat. The renal vein is patent Attention to orientation and inking of the entire resection
and shows no evidence of thrombosis/is invaded/is not margin should precede sequential sectioning of a partial
invaded by the tumor located ____ cm from the ureter mar- nephrectomy specimen (Figs. 6.8 and 6.9).
Fig. 6.8 Partial nephrectomy: Orientation. On the left is the smooth kidney capsular surface; on the right is the rough-appearing kidney parenchy-
mal resection margin. The resection margin should be inked entirely before sectioning the specimen
Fig. 6.9 Partial nephrectomy: Sectioning. Sequential perpendicular sections of the specimen are made to demonstrate the relationship of the
tumor to the inked parenchymal margin. Be sure to identify and submit the tumor closest to the inked resection margin
Cystectomy
This will make it easy to keep track of which areas are
Grossing Tips: Cystectomy abnormal and should be submitted (Fig. 6.13).
• Submit full-thickness sections in areas with a tumor so
that microscopic tumor extension can be properly
• To orient properly, think of the anterior surface of the assessed.
bladder as a rough, large abdomen, whereas the posterior • If a prostate is present (cystoprostatectomy), the prostate
surface is like a smooth, flat back (Fig. 6.10). is typically removed with the seminal vesicles and
• Ink the bladder using four colors for anterior, posterior, grossed separately. (In our institution, this is done by a
left, and right (Fig. 6.11). specifically designated Pathologist Assistant who only
• For bladders received from female patients, extend the ink grosses prostates.) Figure 6.14 however shows an image
to cover the urethra, then shave the urethral margin before of a cystoprostatectomy specimen with both bladder and
proceeding to open the bladder. prostate
• Cut the bladder open with a “Y”-shaped incision from the
base to the dome (Fig. 6.12).
• Find the “bladder mouth,” and the dimples will be where Sample Dictation: Cystectomy
the ureteral orifices are. When probing, direct the probe
horizontally and almost parallel to the bladder mucosa Received is a cystectomy specimen that consists of urinary
surface. bladder (____ × ____ × ____ cm), and attached adipose tis-
• Keep the probes in the ureters, then fix the opened bladder sue (____ × ____ × ____ cm).
overnight. There is an ulcerated/fungating/papillary mass
• While serially sectioning the bladder, mark slices with a (____ × ____ × ____ cm) present in the right/left bladder
tumor or other abnormalities with a broken wooden stick. wall/trigone/dome. Grossly, the mass appears to invade
6 Genitourinary 61
Fig. 6.10 Cystectomy:
Orientation. The anterior
surface of the cystectomy
specimen is rough, and bulges
like a large abdomen. The
posterior surface is smooth
and flat like a back
Fig. 6.11 Cystectomy: Inking. The anterior and posterior surfaces are inked different colors. In addition, the right and left sides of the specimen
are inked with two different colors
into the bladder muscularis propria without extension into left and right ureteral orifices do not show involvement of
the fat. [The prosector should also mention if the tumor the tumor.
involves any of the inked outer margins.] There is a There is a ____ × ____ × ____ cm diverticulum located in
____ × ____ cm erythematous/fibrotic mucosal area the left lateral bladder wall. No involvement of the tumor or
located in the right/left bladder wall/trigone/dome. The other mucosal abnormality is seen in the diverticulum.
Fig. 6.12 Cystectomy: Opening. Cut the bladder open from inferior to ureters, which resembles lips. If these “lips” are found, the openings
superior using a “Y”-shaped incision. After opening, it should resemble should be the two “dimples” at either end (see “Bladder Face” in the
this picture. The ureter orifices may be difficult to identify on the muco- inset). Probe the ureters and allow the bladder to fix before sectioning
sal surface; to aid in finding them, locate the ridge between the two further
Fig. 6.13 Cystectomy: Sectioning. Serially section the bladder sections, in order to keep track of them so that it is easy to submit sec-
sequentially from superior to inferior. Submit sections to show the tions of the ureteral orifices. The ink placed on anterior, posterior, right,
depth of invasion of the tumor and to include any abnormal areas (scar- and left portions of the bladder (see Fig. 6.11) will also help to keep
ring or erythema) that were seen on the mucosal surface. While section- track of the location of any lesion seen on serial sections
ing, keep the probes in the right and left ureteral orifices in the serial
6 Genitourinary 63
Fig. 6.14 Cystopro
statectomy with
verumontanum. In this
cystoprostatectomy specimen,
a tumor involves most of the
mucosal surface of the
bladder. The verumontanum
of the prostate is also visible
Ink code: • Take the spermatic cord margin first, before cutting into
the tumor (to avoid false positive margins due to tumor
• Blue – Anterior contamination).
• Black – Posterior • Bivalve the testis (Fig. 6.16).
• Yellow – Left • Note the size and appearance of the tumor on the cut sur-
• Red – Right face (Fig. 6.17).
• Take parallel sections to see the relationship of the
Section code: tumor to the capsule, normal testis parenchyma, and
epididymis.
• A1 – Urethral margin∗ • After parallel sections, take perpendicular sections.
• A2 – Right ureter, full-thickness
• A3 – Left ureter, full-thickness
• A4–A__ – Sequential full-thickness sections of tumor Sample Dictation: Orchiectomy
• A__–A__ – Erythematous mucosal area
• A__–A__ – Grossly uninvolved bladder, representative Received fresh/in formalin labeled as “_____” is a
sections right/left orchiectomy specimen consisting of testis
• A__–A__ – Dome, representative sections (____ × ____ × ____ cm), epididymis (____ × _____ × ____ cm),
and spermatic cord (____ cm length, ____ cm diameter).
∗Note: If the cystectomy is from a female, shave the ure- The testis is bivalved, and there is a ____ × ____ × ____ cm
thral margin tan-white firm, fleshy, well-circumscribed mass. Focal areas
of necrosis and hemorrhage are present. The tumor does not
grossly extend into the epididymis. The tumor extends
Orchiectomy ____ cm and closely abuts the tunica albuginea.
The remainder of the testicular parenchyma is tan and
Grossing Tips: Orchiectomy unremarkable. The tunica albuginea is tan-white, smooth,
and glistening. The epididymis is unremarkable. The sper-
• Ink the testis and spermatic cord margin different colors matic cord consists of vas deferens, arteries, and veins, and is
(Fig. 6.15). grossly unremarkable.
Fig. 6.15 Orchiectomy. This orchiectomy specimen includes the testis also inked a separate color; this margin is cut and submitted before
and spermatic cord, the surfaces of which are inked different colors. sectioning the testis further
Also note the position of the epididymis. The spermatic cord margin is
Fig. 6.16 Bivalved testis. The testis is bivalved to reveal a tumor

6 Genitourinary 65
Fig. 6.17 Testis cut surface

with tumor. Note the tumor,
which looks different than the
adjacent normal testis
parenchyma. Sections of the
tumor close to the normal
parenchyma, tunica albuginea,
epididymis, and spermatic
cord should be submitted
Ink code: Suggested Reading
• Blue – Spermatic cord resection margin Compérat E, Varinot J, Moroch J, Eymerit-Morin C, Brimo F. A practi-
cal guide to bladder cancer pathology. Nat Rev Urol. 2018;15:143–
54. https://doi.org/10.1038/nrurol.2018.2.
Section code: Grignon DJ, Al-Ahmadie H, Algaba F, Amin MB, Compérat E, Dyrskjøt
L, et al. Tumors of the urinary tract. In: Moch H, Humphrey P,
• A1 – Spermatic cord margin Ulbright T, Reuter V, editors. WHO classification of tumors of
the urinary system and male genital organs. Zurich: International
• A2 – Mid portion of spermatic cord Agency for Research on Cancer (IARC); 2016. p. 77–133.
• A3–A8 – Tumor, representative sections Kunath F, Schmidt S, Krabbe LM, Miernik A, Dahm P, Cleves A, et al.
• A9–A15 – Tumor with adjacent normal parenchyma Partial nephrectomy versus radical nephrectomy for clinical localised
• A16–A21 – Testis normal parenchyma and tunica, repre- renal masses. Cochrane Database Syst Rev. 2017;(5):CD012045.
https://doi.org/10.1002/14651858.CD012045.pub2.
sentative sections Lopez-Beltran A, Bassi P, Pavone-Macaluso M, Monitroni R. Handing
• A22–A24 – Epididymis and pathology reporting of specimens with carcinoma of the urinary
bladder, ureter and renal pelvis. Eur Urol. 2004;45:257–66. https://
doi.org/10.1016/j.eururo.2003.09.018.
Moch H, Amin MB, Argani P, Cheville J, Delahunt B, Martignoni G,
et al. Tumors of the kidney. In: Moch H, Humphrey P, Ulbright
T, Reuter V, editors. WHO classification of tumors of the urinary
system and male genital organs. Zurich: International Agency for
Research on Cancer (IARC); 2016. p. 11–76.
Female Reproductive Tract
7
Monica B. Lemos, Donna Coffey, and Michael Deavers
Gynecologic pathology specimens constitute a sizable per- Hysterectomy

centage of the specimens received in the surgical pathology
grossing suite, as many non-neoplastic and neoplastic condi- Grossing Tips: Hysterectomy
tions of the uterus, ovary, and fallopian tube may require sur-
gical management. Hysterectomy specimens are among the • Check the patient history found on the provided requisi-
most common gynecologic specimens received. The adnexa tion or in the patient’s chart.
(ovary, fallopian tubes and ligaments) may also be removed • Ink the anterior and posterior surfaces different colors
at the same time, depending on the clinical scenario. There (Figs. 7.1 and 7.2).
are various types of hysterectomies. A total simple hysterec- • Weigh the specimen and adnexa (if included). Detach the
tomy, the most common type, includes the uterine corpus adnexa but keep track of which is anterior and which is
and cervix. Total simple hysterectomy specimens are per- posterior.
formed for most endometrial cancers, as well as most non- • Before bivalving the uterus along the lateral uterine walls
cancerous lesions of the uterus. A supracervical hysterectomy (3 and 9 o’clock), shave the posterior cul-de-sac serosa
is less common and includes the uterine corpus only, without (which corresponds to the serosal “tail”), serially section
the cervix. A radical hysterectomy includes the uterine cor- it, and submit it on-edge in the cassette (Fig. 7.3).
pus, cervix, parametrium, and the upper portion of the vagina • Take measurements of the opened endometrial cavity and
(vaginal cuff). This procedure is typically performed for pri- any gross lesions (Figs. 7.4, 7.5 and 7.6).
mary cervical carcinoma or endometrial carcinomas that • Take a vertical/longitudinal section of the lower uterine
extensively involve the cervix or that are centered in the segment and cervix first.
lower uterine segment. • Horizontally (transversely) section each half of the
Other common gynecologic specimens include cervical bivalved uterus into thin slices from the fundus to the
excisions for cervical dysplasia or carcinoma, using a loop lower uterine segment (Fig. 7.7).
electrosurgical excision procedure (LEEP) or cold knife • For uteri with endometrial carcinoma, measure the deep-
cone biopsy. Handling of oophorectomy and vulvectomy est point of myometrial invasion (Fig. 7.8).
specimens will also be discussed. This chapter discusses the • Measure the myometrial thickness. A trabeculated myo-
proper handling of commonly received gynecologic speci- metrial cut surface may indicate adenomyosis.
mens, and addresses clinical situations that require addi- • For endometrial tumors, submit representative sections
tional specimen sampling. (at least one section per centimeter of tumor), to include
full thickness sections at the deepest point of invasion
(Figs. 7.9, 7.10 and 7.11).
• If the cervix is grossly involved with carcinoma, submit at
M. B. Lemos (*) · M. Deavers least two representative sections of tumor involving the
Department of Pathology and Genomic Medicine, Houston cervix. It is important that the sections of the cervix
Methodist Hospital, Houston, TX, USA include the full thickness of the cervical wall and the ecto-
cervical or vaginal cuff margin.
D. Coffey • In cases where the endometrial carcinoma extensively
involves the cervix, a radical hysterectomy may be per-
formed. In such cases, parametrial tissue can be found at

68 M. B. Lemos et al.
Fig. 7.1 Hysterectomy: Anterior. The smooth serosal surface extends aspects are identified, one can infer the laterality of attached adnexa.
lower posteriorly than it does anteriorly. This allows distinction between (Imagine the specimen in the patient either lying towards the prosector
the anterior and posterior uterine surfaces. Once anterior and posterior or facing away from the prosector.)
Fig. 7.2 Hysterectomy: Posterior. The serosal surface extends lower posteriorly, forming a “tail” towards the cervix
7 Female Reproductive Tract 69
Fig. 7.3 Hysterectomy: Anterior and posterior. This side-by-side picture of both anterior and posterior aspects of a uterus shows the greater infe-
rior extent of the smooth serosal surface on the posterior side
Fig. 7.4 Hysterectomy: Bivalved. The uterus is sectioned along the tening, unremarkable endometrial lining. (Compare with the endome-
lateral uterine walls (3 and 9 o’clock). Sectioning this way will provide trium involved by a tumor in Figs. 7.9 and 7.10.) There is a leiomyoma
the best visualization of the endometrial cavity, lower uterine segment, in the superior myometrium
and endocervix. The endometrial cavity here is lined by a smooth, glis-
Fig. 7.5 Supracervical
hysterectomy. This uterus has
been resected above the
cervix; only a stump is
present in the cervical area.
The uterus is markedly
distorted by multiple large
leiomyomas
Fig. 7.6 Submucosal leiomyoma. Many nodules can be seen in this bisected uterus, including submucosal leiomyomas located immediately
beneath the endometrial lining
Fig. 7.7 Hysterectomy: Serial sectioning and intramural leiomyomas. be subserosal (located immediately beneath the serosal surface towards
Serial sections of the uterus are taken horizontally (transversely) from the outer aspect of the uterus). It is important to document any possible
the superior aspect to the inferior. The myometrium in these sections is areas of necrosis or hemorrhage in a suspected smooth muscle
remarkable for several intramural leiomyomas. Leiomyomas can also neoplasm
Fig. 7.8 Hysterectomy with polyp. Two polyps can be seen in this hys- is bivalved (left image). An endometrial polyp is also present within the
terectomy specimen. A cervical polyp is present within the endocervi- endometrial cavity superiorly (right image). Also, note a submucosal
cal canal and can be seen protruding from the cervix before the uterus leiomyoma (right image)
Fig. 7.9 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
Fig. 7.10 Endometrial
carcinoma: Lower uterine
segment section. This figure
demonstrates a longitudinal
section of the lower uterine
segment. Similar longitudinal
sections of the cervix should
also always be taken. Take
these sections first before
serially sectioning (Fig. 7.11),
so as not to forget or
inadvertently section through
the lower uterine segment and
cervix before such sections
can be taken
the lateral aspects of the cervix (3 o’clock and 9 o’clock), • If the tumor does not appear to involve the parametria, the
along with the vaginal cuff. Radical hysterectomy sections may include cervix, parametrium, and parame-
specimens are typically performed in cases of primary trial margins contiguously (as described above), or the
cervical carcinoma. parametrial margins may be taken en face (depending on
• If parametrium is present, measure the size of the parame- the amount of parametrial tissue present), and the remain-
trial tissue on each lateral aspect of the cervix. The para- der of the parametrium may be submitted entirely in a
metrial margins should be inked. If a tumor is near the sequential manner, from lateral to medial.
parametrium, take sections to include the cervix, parame- • If a vaginal cuff is present, ink the cut surface of each
trium, and parametrial margin. quadrant a different color (1 to 3 o’clock, 3 to 6 o’clock,
Fig. 7.11 Hysterectomy with carcinoma: Sectioning. Each anterior and posterior half of the uterus is serially sectioned from the fundus to the
cervix in order to examine the depth of invasion of the tumor or any other lesions within the myometrium
6 to 9 o’clock, and 9 to 12 o’clock) (Fig. 7.12). Shave off in length and ____ cm in diameter, left ovary
each quadrant and submit each in a cassette ink-side ____ × ____ × ____ cm, left fallopian tube ____ cm in length
down, or place on a chuck ink-side up if a frozen section and ____ cm in diameter).
is requested. The uterine serosal surface is tan-pink and smooth (or)
• In benign uteri, or those with carcinoma of a non-serous has tan-white areas of granularity (____ cm). The ectocervix
histotype, representative sections of the fallopian tube, to is white-gray smooth and glistening with a ____ cm cervical
include the entire fimbriated end (longitudinally sec- os/slit-like os. The endometrial cavity is ____ × ____ cm and
tioned), and representative cross-sections of the remain- lined by a ____ cm tan-pink smooth and glistening endome-
der of the tube should be submitted. In cases of uterine trium (or) the endometrial cavity is replaced/partially
serous carcinoma, the SEE-FIM protocol should be per- replaced by a ____ × ____ × ____ cm tan-pink friable mass,
formed (see Fig. 7.19). infiltrating __ cm into a ___ cm thick myometrium. Attached
• The ovaries, if present, should be serially sectioned along to the fundus in the posterior/anterior aspect is a ____ cm
the long axis. Submit sections of any abnormal nodules or tan-pink polyp.
lesions. In benign uteri and endometrial carcinoma of a The myometrium is tan-pink and rubbery/trabeculated
non-serous histotype, representative sections will suffice. and is ____ cm in thickness. Multiple tan-white whorled
In cases of uterine serous carcinoma, the entire ovary intramural/submucosal/subserosal nodules are present.
should be submitted. The cut surfaces of the nodules are grossly unremarkable
without hemorrhage or necrotic areas. The surface of the
right ovary is yellow-tan and convoluted/tan-pink and
Sample Dictation: Hysterectomy smooth. The cut surface shows corpora albicantia ranging
from ____ cm to ____ cm. There are also multiple cysts
Received fresh labeled as “_____” is a total hysterectomy filled with clear fluid/seromucinous fluid and ranging from
specimen/supracervical hysterectomy specimen/hysterec- ____ cm to ____ cm. The surface of the right fallopian
tomy specimen with an amputated cervix (_____ grams, tube is tan-pink and smooth with paratubal cysts present
____ × ____ × ____ cm) with attached bilateral adnexa (right ranging from ____ cm to ____ cm and filled with clear
ovary ____ × ____ × ____ cm, right fallopian tube ____ cm fluid.
Fig. 7.12 Vaginal cuff. Some hysterectomy specimens may be received different colors (in this figure, blue and black, respectively). Single dots
with a vaginal cuff (typically received as part of a radical hysterectomy of different colored ink are placed at intervals indicating clock position
specimen, indicated for some cervical carcinomas). The vaginal cuff around the margin for greater accuracy. The margin is shaved and sub-
margins may also need to be assessed intraoperatively in the frozen sec- mitted from each dot to the next. A diagram (shown to the right) can be
tion suite. In this case, the left and right edges of the margin are inked drawn as a legend of the ink colors used for each section submitted
Ink code: • A___–A___ – Left ovary

• A___–A___ – Left fallopian tube
• Blue – Anterior
• Black – Posterior
Oophorectomy and Salpingectomy
Section code:
Ovary and fallopian tube specimens require the use of some
• A1 – Anterior cervix specific procedures. For ovarian specimens with mass
• A2 – Posterior cervix lesions, the outer surface of the ovary should be inked before
• A3 – Posterior cul-de-sac serosa sectioning. (Figs. 7.13, 7.14, 7.15, 7.16, 7.17, 7.18 and 7.19).
• A4–A7 – Endometrium and myometrium, anterior aspect,
representative sections from fundus to lower uterine
segment Sample Dictation: Cystic Ovary
• A8–A11 – Endometrium and myometrium, posterior
aspect, representative sections from fundus to lower uter- Received fresh and labeled as “_____” is an intact/previ-
ine segment ously opened cystic ovary (____ grams,
• A12–A14 – Representative sections of intramural nodules ____ × ____ × ____ cm). The surface of the specimen is tan-
(for nodules 5 cm or larger, take one section per cm) white to pink and smooth (or with nodules or papillary
• A15–A___ – Right ovary excrescences present).
• A___–A___ – Right fallopian tube
Fig. 7.13 Cystic ovary. This ovary is almost completely replaced by a

cystic lesion. Notice the fallopian tube attached to the cystic ovary. The
presence of the fallopian tube should be noted; detach it before opening
the cyst
Fig. 7.14 Cystic ovary: Inner lining and papillary excrescences. Seen and sections of such areas submitted. Any solid areas should also be
here is the inner lining of an opened ovarian cyst. This inner surface noted and sections submitted
should be carefully evaluated for papillary excrescences (right image)
Fig. 7.15 Cyst roll. The advantage of submitting an ovarian cyst as a thelial lining of the cyst, and thus may hinder microscopic interpreta-
roll is that it maximizes visualization of the greatest surface area of the tion. Therefore, submitting in this manner will depend on the preference
cyst per section submitted. This technique can be used to submit ovar- of the pathologist. An alternative method of sectioning a cystic ovary
ian cysts for frozen (left) as well as permanent (right) sections. The includes submitting longitudinal strips of cyst wall placed in the cas-
disadvantage is that in some cases, this technique may distort the epi- sette on edge
Fig. 7.16 Cystic teratoma.

This ovarian cyst includes a
solid tumor component and a
cystic component with hair,
representing a mature
teratoma. Various elements,
including teeth and bone, can
also be present in teratomas.
Solid portions or any areas
that look different should be
sampled in such cystic ovary
specimens
Fig. 7.17 Ovary: Sectioning. Shown are the intact ovary (left) and serial sections (right). Note the tan-white corpora albicantia seen on the cut
surface
Fig. 7.18 Ovary: Corpora lutea and albicantia. The cut surface of this ovary shows the corpus luteum (golden-yellow and cystic) as well as the
corpora albicantia (white-colored)
Fig. 7.19 Ovary and fallopian tube: SEE-FIM protocol (Sectioning tube may first be opened with scissors, and then additional parallel sec-
and Extensively Examining the FIMbriated End protocol). In patients tions may be made. The remainder of the fallopian tube is sectioned
with BRCA mutations who have undergone prophylactic salpingo- horizontally (“bread loafed”) at intervals of 2–3 mm and submitted
oophorectomy, the fimbriated end of the fallopian tube is amputated at entirely. In this image, the fallopian tube shows small paratubal cysts, a
the infundibulum (distal 2 cm of fallopian tube). The distal 2 cm of the very common finding. In these cases, the ovaries should be serially sec-
fallopian tube is sectioned parallel to the long axis of the tube and sub- tioned at intervals of 2–3 mm along the long axis and submitted entirely
mitted entirely. Alternatively, the distal fimbriated end of the fallopian
Sectioning of the ovary reveals a ____ cm unilocular/ Sample Dictation: Cervical Cone
biloculated/multiloculated cyst(s) ranging from ____ to
____ cm in diameter and filled with yellow, clear, gelatinous Received fresh labeled as “_____” is an oriented conical por-
material (or gray-white paste-like material and hair, in a tion of tissue. The endocervical margin is inked black, and
mature cystic teratoma). The inner lining of the cyst is tan- the ectocervical margin is inked blue. The specimen is radi-
pink and smooth (or tan-pink with papillary excrescences ally sectioned, and the cut surface is pale-tan and rubbery/
measuring up to ____ cm). The thickness of the wall ranges slightly firm. The specimen is entirely submitted sequen-
from ____ to ____ cm. tially from 1 to 12 o’clock in cassettes A1–A12.
Ink code:
• Blue – Entire outer surface of ovary Vulvectomy
Section code: When examining vulvectomy specimens, understanding the

proper orientation is the first crucial step. The specimen
• A1–A10 – Representative sections of cyst wall should then be inked and subsequently sectioned (Figs. 7.22,
• A11–A13 – Papillary excrescences∗ 7.23 and 7.24).
∗Note: Always make sure to submit any areas of papillary

excrescences or solid areas. Sample Dictation: Vulvectomy
Received labeled as “____” is an oriented/unoriented irregu-

Cervical Cone lar piece of vulvar skin with underlying fibroadipose tissue
(____ × ____ × ____ cm). The surface of the specimen
Cone-shaped portions of cervix from cervical cone biopsies reveals an ulcerated/nodular/discolored friable lesion
are inked and radially sectioned (Figs. 7.20 and 7.21). (___ × ___ cm), which is ____ cm from the closest margin
Fig. 7.20 Cervical cone: Oriented specimen. The ectocervical margin cervical mucosa, includes the ectocervical and deep margins; these
and endocervical margins should be identified and inked different col- margins should also be inked a different color. After the margins have
ors. The base of the specimen opposite the cervical opening is the endo- been inked, the specimen is bivalved horizontally along the lateral
cervical margin. The endocervical margin should be inked. The aspect (3 and 9 o’clock), and sections are taken for each clock position
periphery of tissue all around the specimen, excluding the surface ecto- (see Fig. 7.21)
Fig. 7.21 Cervical cone: Radial sectioning. Each half of the bivalved o’clock, A3 = 3 o’clock, and so on until A12). The cuts are made
cone specimen should be sectioned radially. This should result in at towards the center of the cone (similar to sections of a pie)
least 12 cassettes, one for each position (i.e., A1 = 1 o’clock, A2 = 2
Fig. 7.22 Vulvectomy. A

vulvectomy specimen is
shown, which is oriented by
the surgeon with sutures. Note
the lesion in the center, which
appears as a tan-white
discolored area
Fig. 7.23 Vulvectomy: Inking of margins. The margins are inked two placed at various o’clock positions, and the margins are shaved. A dia-
colors on both sides (including the peripheral edges and deep surface) gram is drawn to keep track of the colors used for each position
to indicate 12-3-6 o’clock and 6-9-12 o’clock positions. Then dots are
Ink code:
• Blue – Superior
• Orange – Inferior
or
• Blue – Medial
• Orange – Lateral
or
• Black – 12-3-6 o’clock

• Purple – 6-9-12 o’clock
Fig. 7.24 Larger vulvectomy specimen. Some vulvectomy specimens

include more extensive tissue resection. In such larger vulvectomy
specimens, a more selective strategy of sampling the margin can be Suggested Reading
used. Ink the right and left parts different colors (including the periph-
eral edges and deep surface), but submit only the portion of the Ismill N, Ghorab Z, Covens A, Nofech-Mozes S, Saad R, Khalifa
margin(s) closest to the lesion for frozen section (if the specimen is MA. Intraoperative margin assessment of the radical trach-
received in the frozen section suite). Then make perpendicular sections electomy specimen. Gynecol Oncol. 2009;113:42–6. https://doi.
to evaluate the deepest invasion of the lesion and submit the closest org/10.1016/j.ygyno.2008.12.025.
deep margin. For permanent sections, the complete specimen may be Koc N, Ayas S, Arinkan SA. Comparison of the classical method and
submitted, or only the remainder of the lesion with adjacent normal SEE-FIM protocol in detecting microscopic lesions in fallopian
tissue tubes with gynecological lesions. J Pathol Transl Med. 2018;52:21–
7. https://doi.org/10.4132/jptm.2016.06.17.
Malpica A, Euscher ED, Hecht JL, Ali-Fehmi R, Quick CM, Singh
(e.g., 3 o’clock margin, 6 o’clock margin, deep margin, etc.).
N, et al. Endometrial carcinoma, grossing and processing issues:
The remainder of the surface reveals multiple satellite recommendations of the International Society of Gynecologic
nodules/pigmented lesions ranging from ____ to ____ cm Pathologists. Int J Gynecol Pathol. 2019;38(Suppl 1):S9–24. https://
and located ____ cm from the closest margin(s). doi.org/10.1097/PGP.0000000000000552.
Medeiros F, Muto MG, Lee Y, Elvin JA, Callahan MJ, Feltmate C, et al.
The specimen is inked and serially sectioned sequentially
The tubal fimbria is a preferred site for early adenocarcinoma in
from medial to lateral (or) from 12 o’clock to 6 o’clock and women with familial ovarian cancer syndrome. Am J Surg Pathol.
submitted entirely/representatively, sequentially from 12 2006;30:230–6.
o’clock to 6 o’clock or from medial to lateral in cassettes
A1–A12.
Lung
8
Monica B. Lemos and Roberto Barrios
Pulmonary specimens may be received in the surgical pathol- Lung Lobectomy and Wedge Resections
ogy grossing suite as part of the clinical workup and man-
agement of both neoplastic and non-neoplastic conditions, rossing Tips: Lung Lobectomy and Wedge
G
including infectious processes. Types of lung specimens Resections
commonly encountered include lung biopsies, wedge resec-
tions, lobectomy specimens, and pneumonectomy speci- • When the specimen is received, wear a mask, especially
mens. A lung wedge resection consists of removal of a in cases where tuberculosis infection is possible.
smaller portion of lung tissue; the parenchymal surgical mar- • Weigh the specimen and take bronchial and vascular mar-
gin of resection is typically stapled. A lobectomy specimen gins first.
consists of an entire lung lobe; in such specimens, the key • Check for staple lines. Remove the staples and ink the
margin is the bronchial resection margin. A pneumonectomy lung parenchyma beneath them (Figs. 8.4, 8.5 and 8.6).
specimen consists of the entire lung, which may be received • If received fresh in the frozen section pathology suite,
for a variety of conditions, including neoplastic and non- prepare touch preparation slides on lesions identified
neoplastic processes. In the case of malignancy, a pneumo- (particularly in wedge resections).
nectomy, rather than a smaller resection, may be indicated • If granulomas are found on touch preparation, be sure to
because of the location of a tumor. Pneumonectomy speci- wear a mask, because of the risk of tuberculosis. Frozen
mens may also be encountered in practice settings with a sections will not likely be performed in this case, but if
lung transplantation service. This chapter discusses the han- they are, the cryostat should be promptly decontaminated
dling of pneumonectomy specimens, lobectomy specimens, following any possible exposure.
and wedge resections.
Sample Dictation: Lung Lobectomy

Pneumonectomy
Received fresh labeled as “____” is a right/left upper/mid-
After identifying and submitting the bronchial and vascular dle/lower lobe (____ grams, ___ × ___ × ___ cm). The pleu-
margins, the pneumonectomy specimen is serially sectioned ral surface is dark red and shows a ____ cm area of retraction
(Figs. 8.1, 8.2 and 8.3). or a ____ cm firm area. The remainder of the pleural surface
is smooth and unremarkable. The specimen is serially sec-
tioned along the long axis and shows a white-gray, firm,
well-circumscribed mass ____ cm from the bronchial mar-
gin and ___ cm from the stapled margin. The remainder of
M. B. Lemos (*) the parenchyma is red-pink with scattered black spots rang-
Department of Pathology and Genomic Medicine, Houston ing from 0.1 to 0.3 cm, suggestive of anthracosis.
R. Barrios

84 M. B. Lemos and R. Barrios
Fig. 8.1 Left pneumonectomy. Two lobes (left upper and left lower) are identified in a left pneumonectomy specimen. The resected portions of
bronchus and vessels are seen in the hilar area; these represent margins and should be submitted first before sectioning the rest of the lung
Fig. 8.2 Right pneumonectomy. Three lobes (right upper, right middle, and right lower) are identified in a right pneumonectomy specimen. Again,
the hilar bronchial and vascular margins are identified and should be submitted first
8 Lung 85
Fig. 8.3 Pneumonectomy: Sections. The pneumonectomy is serially sectioned along the long axis, and the cut surface is examined for areas of
fibrosis, tumor, or other abnormalities. Note the areas of fibrosis seen in these sections
Fig. 8.4 Lung lobectomy. A lung lobe resection with a palpable subpleural tumor is pictured. The pleural surface overlying the tumor is inked.
Note that pleural invasion will affect the stage of malignant lung tumors
86 M. B. Lemos and R. Barrios
Fig. 8.5 Lung lobectomy: Bronchial and vascular margins. The bronchial and vascular margins in this lobectomy specimen are stapled (left
image). The staples are removed, and the lumen of the bronchus and vessel can be seen (right image)
Fig. 8.6 Lung wedge resection. A wedge resection typically includes a is visible and is protruding through the pleural surface. Serial sections
parenchymal margin, which should be inked and submitted. This resec- of the wedge are made. The tumor can be seen clearly in these sections,
tion margin is identified by the surgeon’s staples. In this wedge, a tumor which are laid out sequentially
Ink code: • A6–A__ – Tumor

• A__–A__ – Normal parenchyma
• Blue – Retraction (or firm area) of pleural surface
• Orange – Stapled margin
Section code: Suggested Reading

• A1 – Vascular margin Harrison S, Stiles B, Altorki N. What is the role of wedge resection
• A2 – Bronchial margin for T1a lung cancer? J Thorac Dis. 2018;10(Suppl 10):S1157–62.
• A3–A5 – Hilar lymph nodes https://doi.org/10.21037/jtd.2018.03.188.
8 Lung 87
Lackey A, Donington JS. Surgical management of lung cancer. Cham: Springer International Publishing; 2018. p. 79–92. https://
Semin Intervent Radiol. 2013;30:133–40. https://doi.org/10.105 doi.org/10.1007/978-3-319-62941-4.
5/s-0033-1342954. Sienko A, Allen TC, Zander DS, Cagle PT. Frozen section of lung
Ritterhouse L, Sholl LM. The molecular pathology of lung cancer: specimens. Arch Pathol Lab Med. 2005;129:1602–9. https://doi.
pre-analytic considerations. In: Cagle PT, Allen TC, Beasley MB, org/10.1043/1543-2165(2005)129[1602:FSOLS]2.0.CO;2.
et al., editors. Precision molecular pathology of lung cancer. 2nd ed.
Bone and Soft Tissue
9
Monica B. Lemos and Michael Deavers
Acquiring competence in the gross examination of bone and with a hemorrhagic and jagged margin of resection (for his-
soft tissue specimens can be challenging, particularly as tory of fracture). The articular surface varies from smooth to
these specimens are not common. Of the bone specimens focally scratched and pitted. The underlying bone is tan-
that are received in the surgical pathology grossing suite, yellow with hemorrhage at the margin. There is a ____ cm
femoral head and knee arthroplasty specimens are among the tan, pale, wedge-shaped area with detached cartilage (for
most frequent. Such specimens are typically received during cases of avascular necrosis). The cartilage thickness ranges
surgical procedures indicated for osteoarthritis. Other types from ____ to ____ cm.
of bone and soft tissue specimens seen include amputations,
such as below-the-knee and above-the-knee amputations, • A1–A3 – Representative sections following
often due to gangrene. Bone resections for neoplastic condi- decalcification
tions are rare. In such cases, review of the pre-operative
radiographic imaging is essential. Furthermore, in certain
cases, tumor mapping may be required. Knee Arthroplasty
When performing gross examinations of bone specimens,
having appropriate cutting instruments and ensuring proper Specimens obtained during knee arthroplasty are likely to
fixation and adequate decalcification are very important. include both bone and soft tissue (Fig. 9.3).
Inadequate fixation and decalcification can both be problem-
atic and lead to suboptimal sections. This chapter illustrates
examples of various bone specimens and describes the Sample Dictation: Knee Arthroplasty
appropriate handling of such specimens.
Received in formalin and labeled “right/left bone and tissue”
is a ____ × ____ × ____ cm aggregate of irregular to ovoid
Femoral Head portions of tan-yellow bone and gray-white cartilage, in
addition to soft tissue. Tibial plateau and femoral condyle
Thin sections made with a bone saw will include the overly- configurations are present. The bone is partially covered by
ing cartilage and the cortex (Figs. 9.1 and 9.2). concave and convex articular surfaces. The articular surface
varies from smooth to pitted, nodular, and partially eroded.
There are focal areas of eburnation measuring up to ____ cm.
Sample Dictation: Femoral Head Osteophyte formation in the peripheral aspect is identified.
Received in formalin labeled as “right/left femoral head” is a • A1–A2 – Representative sections of bone
femoral head resection specimen (____ × ____ × ____ cm) • A3 – Soft tissue
M. B. Lemos (*) · M. Deavers


90 M. B. Lemos and M. Deavers
Fig. 9.1 Femoral head. This femoral head resection specimen was removed during hip replacement surgery. A thin section is made with a bone
saw through the center of the femoral head, and sections are submitted as shown to include the overlying articular cartilage and cortex
Fig. 9.2 Avascular necrosis.

An area of avascular necrosis
is seen in this femoral head
resection specimen. The
lesion is tan, pale, and
wedge-shaped. Submitted
sections (right) include the
area of avascular necrosis and
detached cartilage
9 Bone and Soft Tissue 91
Fig. 9.3 Knee: Bone and tissue. These fragments of tissue from a knee arthroplasty show areas of eburnation and erosion, characteristic of osteo-
arthritis. Note the femoral condyle and tibial plateau portions of the specimen
Amputations
Grossing Tips: Leg Amputation
• Measure the specimen.

• Check for lesions including ulcers and areas of gangrene.
Measure these lesions and their location with respect to
the resection margin (Figs. 9.7, 9.8 and 9.9).
• Ink the skin and soft tissue resection margins in the area
closest to any noted lesions (Fig. 9.10). Submit representa-
tive sections of skin and soft tissue at the resection margin.
• To assess the bone resection margin, a section of bone at
the margin may be taken, or the bone marrow at the mar-
gin may be scraped, and submitted in a biopsy bag.
Submitting a cut section of the bone resection margin is
preferable in cases of osteomyelitis.
Fig. 9.4 Bone tumor resection. The specimen should be oriented by
the surgeon, usually with sutures. The specimen is inked and oriented • Locate the anterior tibial artery. This can either be found
with different colors. The bone margins should be taken, and then the at the resection margin, or it can be found by making a
specimen should be bivalved (see Fig. 9.5) transverse section on the anterior leg between the tibia
and fibula (Fig. 9.11).
• The artery can likely be found by probing with the finger.
Bone Tumor Resection • The posterior tibial artery can be found easily by palpat-
ing the soft tissue at the resection margin in a below-the-
Bone tumor resection specimens should be oriented, inked, knee amputation. It is often calcified and can thus be
bivalved, and subsequently mapped (Figs. 9.4, 9.5 and 9.6). easily felt.
Fig. 9.5 Bone tumor

resection: Bivalved. The cut
halves of the bone tumor
resection show a tumor that
has eroded and replaced much
of the bone. There are two
bone resection margins, one at
each end of the portion of the
resected bone. These resection
margins should be inked and
submitted in two different
cassettes, which are
subsequently placed into
decalcification solution. Then
the main specimen should be
placed in formalin overnight
before further sectioning
Fig. 9.6 Bone tumor

resection: Mapping. A thin
slice is cut from each side of
the bivalved specimen (see
Fig. 9.5). The slices are then
mapped to show the location
of each submitted section.
After submitting each of the
sections, the cassettes are
placed into decalcification
solution before processing
Fig. 9.7 Above-the-knee amputation. This above-knee amputation

specimen includes the foot, lower leg, and knee
9 Bone and Soft Tissue 93
Fig. 9.8 Above-the-knee amputation: Lesions. Notice the difference

between normal skin, dry scaly skin, and a gangrenous area
Fig. 9.9 Gangrenous toe lesion. Note the black, hard, gangrenous area
on the great toe. There is also skin slippage on portions of the toes
Fig. 9.10 Above-knee amputation: Resection margins. The resection

margins include the soft tissue margin (skin, fat, and muscle) and the
bone resection margin
Fig. 9.11 Anterior tibial artery dissection. The anterior tibial artery has been dissected out and should be opened and assessed for calcification
and/or atherosclerotic stenosis
Fig. 9.12 Popliteal artery

dissection. The popliteal
artery is also dissected out
and opened to assess for
calcification or atherosclerosis
Sample Dictation: Transmetatarsal

Amputation
Received in formalin, labeled “right/left transmetatarsal

amputation” is a ____ × ____ × ____ cm transmetatarsal
amputation specimen with five toes/previously amputated
____ toes. Tan-yellow unremarkable toenails are present.
There is a black ulcerated and gangrenous black lesion on
the dorsal/plantar surface/toe. The lesion is ____ cm from
the soft tissue resection margin.
Ink code:
• Blue – Soft tissue resection margin

• Black – Bone resection margin
Section code:
• A1 – Soft tissue resection margin

• A2 - A3 – Lesions (areas of gangrene, etc.)
Fig. 9.13 Transmetatarsal amputation. Shown is a transmetatarsal • A3 – Anterior vessels
amputation of a gangrenous foot. The skin and soft tissue resection • A4 – Posterior vessels
margins closest to any noted lesion should be inked, and sections should
• A5 – Normal skin
then be taken. The bone resection margin should also be inked and sub-
mitted, particularly in cases of osteomyelitis. Note the absence of the • A6 – Bone resection margin, following decalcification
fifth toe, which in this patient was previously amputated • A7 – Representative sections of bone underlying lesions
(osteomyelitis), perpendicular, following decalcification
• Similarly, the popliteal artery can be easily found by pal-

Suggested Reading
pation of the resection margin in an above-the-knee
amputation (Fig. 9.12). Dimenstein IB. Bone grossing techniques: helpful hints and proce-
• Mention the maximum percent stenosis by any calcifica- dures. Ann Diagn Pathol. 2008;12:191–8. https://doi.org/10.1016/j.
tion or plaque in the vessels. anndiagpath.2007.06.004.
• When there is a history of osteomyelitis, submit a section Khurana JS, Arguello-Guerra V. Grossing of bone and soft tis-
sue (common specimens and procedures). In: Khurana J, edi-
of bone underlying the lesion. tor. Bone pathology. New York: Humana Press; 2009. https://doi.
• In some cases, there has been a previous amputation, so org/10.1007/978-1-59745-347-9_7.
be sure to check for the presence of missing (previously Klein MJ, Memoli VA. Orthopaedic specimen preparation: what pathol-
amputated) toes (Fig. 9.13). ogists should know and do. Semin Diagn Pathol. 2011;28:4–12.
Index
A Cholecystectomy
Amputations cystic duct margin, 46, 47
anterior tibial artery dissection, 91, 93 gallbladder, 46
gangrenous toe lesion, 91, 93 sample dictation, 46, 47
lesions, 91, 93 sectioning, 47
popliteal artery dissection, 94 sections, 46
resection margins, 93 specimen, 46
specimen, 91, 92 Cystectomy
transmetatarsal amputation, 94 inking, 60, 61
Appendectomy, 39, 40 opening, 60, 62
Appendix, 38–40 orientation, 60, 61
Axillary lymph node sampling, 5 sample dictation, 60, 61, 63
sectioning, 60
Cystoprostatectomy, 60, 63
B
Bone and soft tissue
amputations D
lesions, 91, 93 Distal pancreatectomy
anterior tibial artery dissection, 91, 93 distal pancreas and spleen, 52
gangrenous toe lesion, 91, 93 pancreas and spleen, 52
popliteal artery dissection, 94 sample dictation, 53
resection margins, 93 sections, 52
specimen, 91, 92 spleen, 52
transmetatarsal amputation, 94
femoral head
avascular necrosis, 89, 90 E
resection, 89, 90 Esophagogastrectomy
sample dictation, 89 esophagectomy, 27, 29
knee arthroplasty, 89, 91 esophagus, 28
Bone tumor resection gastrectomy, 27
bivalved, 92 stomach, 28
mapping, 92
specimen, 91
Breast F
axillary lymph node sampling, 5 Female reproductive tract
cancer diagnosis, 5 cervical cone
lumpectomy (see Lumpectomy) oriented specimen, 78, 79
mastectomy (see Mastectomy) radial sectioning, 78, 79
sentinel lymph nodes, 11, 12 sample dictation, 78
Breast-conserving therapy, 5 hysterectomy (see Hysterectomy)
oophorectomy (see Oophorectomy)
salpingectomy, 74, 78
C vulvectomy
Cervical cone inking of margins, 78, 80
oriented specimen, 78, 79 larger vulvectomy specimen, 78, 81
radial sectioning, 78, 79 sample dictation, 78, 81
sample dictation, 78 specimen, 78, 80
Follicular carcinomas, 18

https://doi.org/10.1007/978-3-030-20839-4
96 Index
G sectioning, 67, 73
Gastrointestinal tract serial sectioning and intramural leiomyomas, 67, 71
appendectomy, 39, 40 submucosal leiomyoma, 67, 70
esophagogastrectomy supracervical, 67, 70
esophagectomy, 27, 29 total simple hysterectomy, 67
esophagus, 27, 28 vaginal cuff, 72, 74
gastrectomy, 27
stomach, 27, 28
ileostomy, 29 I
ostomy site, 29 Ileocolectomy, 38
sample dictation, 29 Ileostomy, 29
sectioning, 30 ostomy site, 29
large bowel (see Large bowel) sample dictation, 29
polypectomy, 40 sectioning, 30
routine specimens, 27
small bowel
inking, 31 L
Meckel’s diverticulum, 30, 31 Large bowel
subserosal tumor resection, 31 with adhesed ovary, 37, 38
subserosal tumor sectioning, 31 colon tumor
Genitourinary depth of invasion, 30, 34
cystectomy longitudinal sectioning, 30, 33
inking, 60, 61 colon with Crohn’s disease, 34, 36, 37
opening, 60, 62 colon with ulcerative colitis, 34, 36
orientation, 60, 61 diverticulitis, 35
sample dictation, 60, 61, 63 adhesions, 34, 35
sectioning, 60, 62 mucosal surface, 34, 35
cystoprostatectomy, 60 sections, 34, 36
nephrectomy (see Nephrectomy) low anterior resection, 38, 39
orchiectomy rectum
bivalved testis, 63, 64 with anal mucosa and dentate line, 30, 34
sample dictation, 63, 65 radial margin, 30, 33
testis and spermatic cord margin, 63, 64 right hemicolectomy
testis cut surface with tumor, 63, 65 ileum, cecum, and right colon, 30, 32
Glossectomy, 13, 15 inking, 30, 32
sample dictation, 38
serosal surface, 34
H Laryngectomy
Head and neck anterior aspect, 21
floor of the mouth, 13, 16, 17 inking, 21, 22
glossectomy, 13, 15 opened view, 23
laryngectomy (see Laryngectomy) opened view after fixation, 23, 24
salivary gland, 16 posterior aspect, 21, 22
thyroidectomy, 16, 18 sample dictation, 23, 25
tonsillectomy, 13–15 sections, 23–25
uvula, 13, 16 Lobectomy
Hepatectomy bronchial and vascular margins, 86
anterior view grossing tips, 83
inking, 44 lobe resection with palpable subpleural tumor, 85
segments in, 44 sample dictation, 83
total hepatectomy specimen, 44 Lumpectomy
grossing tips, 43 grossing, 9
posterior view inking, 9, 10
inking, 45 with localization wire, 9
segments in, 44 mapping, 9, 11
sample dictation, 43 margins of resection, 9
sectioning, 45 sample dictation, 9, 11
serial sections with tumor, 46 sections, 9, 10
Hilar invasion, 55, 58 survival outcomes, 5
Hysterectomy Lung
adnexa, 67 lobectomy, 83, 85, 86
anterior, 67, 68 pneumonectomy, 83–85
anterior and posterior, 67, 69 wedge resection, 83, 86
bivalved, 67, 69
endometrial carcinoma, 67, 72
with polyp, 67, 71 M
posterior, 67, 68 Mastectomy
radical hysterectomy, 67 grossing, 5, 8
sample dictation, 73, 74 inking of margins, 5, 6

Index 97
mapping, 8 biopsy, 5
margins, 5 grossing, 11, 12
modified radical mastectomy, 5 Skin ellipse, 1, 2
nipple-sparing mastectomy, 5 Skin excision
orientation, 5, 6 clock positions, 1
radical mastectomy, 5 ellipse shape, 1, 2
sample dictation, 8, 9 inking, 1, 3
sectioning, 5, 7 irregular, 1, 4
skin-sparing mastectomy, 5 margins, 1
slices, 5, 7 orientation, 1, 2
total simple mastectomy, 5 pigmented lesion, 1
Meckel’s diverticulum, 31 sample dictation, 1
Myometrium, 71, 73, 74 with scarred and pigmented lesions, 3
sectioning, 1, 4
Small bowel
N inking, 31
Nephrectomy Meckel’s diverticulum, 30
partial nephrectomy subserosal tumor resection, 31
orientation, 59 subserosal tumor sectioning, 31
sectioning, 59, 60 Splenectomy, 53
radical nephrectomy Splenic capsule, 53
bivalved surface, 55, 57 Submandibular glands, 16, 18
Hilar invasion, 55, 58 Supracervical hysterectomy, 67, 70, 73
margins, 55, 56
orientation, 55, 56
parallel sectioning, 55, 57 T
perpendicular sectioning, 55, 58 Thyroid nodules, 18, 21
polycystic kidney, 55, 58, 59 Thyroidectomy
sample dictation, 57, 58 inking, 18, 20
lobes and isthmus positions, 18, 19
sample dictation, 19, 21
O sectioning, 18, 20
Oophorectomy, 67 thyroid nodules, 18, 21
corpora lutea and albicantia, 77 Tonsillectomy
cystic ovary, 75 cerebriform appearance, 13, 14
cyst roll, 76 with papilloma, 13, 15
cystic teratoma, 76 sectioned tonsils, 13, 14
inner lining and papillary excrescences, 75 Tracheostomy, 21, 23
sample dictation, 74, 78 Transmetatarsal amputation, 94
sectioning, 77
Orchiectomy
bivalved testis, 63, 64 U
testis and spermatic cord margin, 63, 64 Uvulectomy, 13, 16
testis cut surface with tumor, 63, 65
V
P Vulvectomy, 67
Pancreaticoduodenectomy, see Whipple resection inking of margins, 78, 80
Parotid glands, 16 larger vulvectomy specimen, 78
Pneumonectomy sample dictation, 78, 81
left pneumonectomy, 84 specimen, 78, 80, 81
right pneumonectomy, 84
sections, 85
specimen, 83 W
Polycystic kidney, 55, 58, 59 Wedge resection, 83, 86
Polyp, 38–4071 Whipple resection
Polypectomy, 40 ampulla, 49
Purulent serosal exudate, 40 duodenum, 48
opened ducts, 49, 50
pancreas, 47, 48
S portion of the stomach, 47, 48
Salivary glands retroperitoneal margin, 48, 49
parotid glands, 16, 18, 19 sample dictation, 50, 52
submandibular glands, 16, 18 sections, 50
Salpingectomy, 74, 78, 79 slice, 50, 51
SEE-FIM protocol, 73, 78 submitting sections, 50, 51
Sentinel lymph nodes vascular groove, 48, 49

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Atlas of Surgical Pathology

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© Springer Nature Switzerland AG 2019

To my beloved family – Chike, Chiamaka, Nkechi, and

One Picture Is Worth Ten Thousand Words

Indianapolis, IN, USA Liang Cheng, MD

Houston, TX, USA Monica B. Lemos

Alberto Ayala, MD Department of Pathology and Genomic Medicine, Houston Methodist

Skin Excision Sample Dictation: Skin Excision

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Fig. 1.1 Skin excision:

Fig. 1.2 Skin ellipse. A skin

Fig. 1.3 Skin excision with

Fig. 1.4 Skin excision:

Breast cancer, one of the most commonly diagnosed cancers, Mastectomy

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Fig. 2.3 Sectioning a

Sample Dictation: Mastectomy • Superior – Blue

Section code: Grossing Tips: Lumpectomy

Slice 8 • When the specimen is received, first note the laterality

Received is a tan-pink smooth and glistening conical portion

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Fig. 3.3 Tonsil with

Parotid glands and submandibular glands may be received as

Grossing Tips: Thyroidectomy

Fig. 3.8 Floor of the mouth:

Ink Code: Laryngectomy

• Blue – Anterior thyroid surface Grossing Tips: Laryngectomy

• Orange – Left posterior surface Suggested Reading

Received fresh/in formalin labeled as “_____” is a total/sub- Sample Dictation: Esophagectomy

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• Blue – Proximal (esophageal) margin

Section code: Received fresh/in formalin and labeled as “_____” is an ile-

Ileostomy • A1, A2 – Margins

Fig. 4.13 Colon tumor:

Fig. 4.18 Colon with

Fig. 4.19 Colon with

Fig. 4.20 Colon with

 ample Dictation: Right Hemicolectomy/

identified measuring ____ × ____ cm and ____ cm from • A12 – Polyp #2

• A1 – Proximal margin Sample Dictation: Appendix

____ cm in diameter. The proximal margin is inked blue. The Polypectomy

The volume of hepatobiliary and pancreatic specimens Sample Dictation: Hepatectomy

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Fig. 5.1 Hepatectomy. Note

Cholecystectomy Sample Dictation: Cholecystectomy

mucosa is velvety and green/pink-green and trabeculated/ Whipple Resection

The mucosa of the duodenum is tan-pink with normal Ink code:

Sample Dictation: Distal Pancreatectomy Splenectomy

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Fig. 6.5 Hilar invasion.

The perirenal adipose tissue is serially sectioned, and __#

∗Note that most times, no lymph nodes are found. When

Fig. 6.16 Bivalved testis. The testis is bivalved to reveal a tumor

Fig. 6.17 Testis cut surface

Ink code: Suggested Reading

Gynecologic pathology specimens constitute a sizable per- Hysterectomy

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Indianapolis, IN, USA Liang Cheng, MD

Houston, TX, USA Monica B. Lemos

Skin Excision Sample Dictation: Skin Excision

Breast cancer, one of the most commonly diagnosed cancers, Mastectomy

Sample Dictation: Mastectomy • Superior – Blue

Section code: Grossing Tips: Lumpectomy

Grossing Tips: Thyroidectomy

Ink Code: Laryngectomy

• Blue – Anterior thyroid surface Grossing Tips: Laryngectomy

Received fresh/in formalin labeled as “_____” is a total/sub- Sample Dictation: Esophagectomy

Ileostomy • A1, A2 – Margins

ample Dictation: Right Hemicolectomy/

identified measuring × cm and cm from • A12 – Polyp #2

• A1 – Proximal margin Sample Dictation: Appendix

____ cm in diameter. The proximal margin is inked blue. The Polypectomy

The volume of hepatobiliary and pancreatic specimens Sample Dictation: Hepatectomy

Cholecystectomy Sample Dictation: Cholecystectomy

mucosa is velvety and green/pink-green and trabeculated/ Whipple Resection

Sample Dictation: Distal Pancreatectomy Splenectomy

Gynecologic pathology specimens constitute a sizable per- Hysterectomy

Ink code: • A_–A_ – Left ovary

• Blue – Entire outer surface of ovary Vulvectomy

Sample Dictation: Lung Lobectomy

Grossing Tips: Leg Amputation

Sample Dictation: Transmetatarsal