BONE AND SOFT TISSUE PATHOLOGY GROSSING GUIDELINES
- NOTE: Document in your cassette summary which cassettes (for each specimen part) are submitted for decal
- Ex: Representative sections are submitted (A1, A3; B2-B4; C3-C4 following decalcification).
- Ex: Representative sections are submitted:
- A1- bone (decal)
- A2- skin resection margin, perpendicular
- B2- tibia shave (decal)
BONE
Specimen Type: BONE BIOPSY (morphometry studies)
NOTE: DO NOT DECALCIFY THESE SPECIMENS
Bone biopsies, usually from the iliac crest, are sometimes taken to aid in the diagnosis of certain metabolic disease such as osteomalacia, osteoporosis, etc. In most cases the patient has been given tetracycline beforehand (tetracycline labeling). These specimens need to be handled differently than other routine bone specimens. Most importantly, they MUST NOT BE DECALCIFIED! When the specimen arrives in Surgical Pathology, the request form should state that the specimen is to be processed for bone morphometry. It may simply state that the patient has been “tetracycline labeled”. It may instruct you to notify Dr. Goodman’s lab. In any event, if you see such a specimen, do not process it in the normal manner because it must not be decalcified. Here are the steps to follow to insure the proper handling of these specimens:
- Place the specimen in 10% buffered formalin.
- Call the Bone Morphometry Lab (Dr. Goodman) at ext. 47510, or 62650, and ask them to come and collect the specimen. (Do not accession the specimen at this time).
Once this specimen has been evaluated in the Bone Morphometry Lab, a stained slide and a copy of their report will be sent back to Surgical Pathology. The case should be accessioned at this time. The slides will then be examined by a member of the Surgical Pathology faculty.
Occasionally two specimens will be provided - one for bone morphometry studies, and one for examination in surgical pathology. In this case, the specimen submitted for examination in surgical pathology will be handled like any other bone specimen. A copy of the request form will then be sent with the specimen for bone morphometry. The surgical pathologist will then examine the specimen for malignancy or other pathology. A comment will be made on the report stating that “results of bone morphometry studies are pending will be reported separately”. When bone morphometry studies are completed Dr. Goodman’s report should be added to the surgical pathology report as an addendum. If you have any questions regarding these specimens, please page Dr. Nelson (11361).
Specimen Type: TOTAL KNEE ARTHROPLASTY
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [total/partial/unilateral] knee arthroplasty received in multiple portions ranging from ***to***cm in maximum dimension, amounting in aggregate to ***x***x***cm. [Describe any recognizable portions of bone –tibial plateau, femoral condyles, posterior patella, etc.] [Describe soft tissue components present-meniscus, fibroadipose tissue, synovium]. The articular surface is [smooth/eburnation/osteophytes/eroded/remarkable for a thinning of articular cartilage]. The bone is sectioned to reveal [describe cut surfaces]. Representative sections are submitted following decalcification [describe cassette submission].
Cassette Submission: 2 cassettes
- One cassette of soft tissue (meniscus, synovium)
- One cassette of bone with eburnation (following decalcification)
- Submit more cassettes if lesion/mass is identified
Specimen Type: TOTAL HIP ARTHROPLASTY
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [partial/total] hip arthroplasty. The femoral head measures *** x *** x *** cm. The [attached/detached]femoral neck measures ***cm in length x ***cm in diameter. [Describe the resection margin- smooth/ragged and hemorrhagic/fractured]. The articular surface is [smooth/eburnation/osteophytes/eroded/presence of avulsion]. Sectioning reveals [describe cut surfaces-necrosis, infarct, subchondral cysts, osteochondral lipping]. Representative sections are submitted following decalcification[describe cassette submission].
Cassette Submission: 3 cassettes
- One section of soft tissue (synovium)
- One section of the base of the specimen (femoral neck)
- One cassette of bone (following decalcification)
- Articular surface and subarticular bone with eburnation
- Submit more cassettes if lesion/mass is identified
Specimen Type: DIGIT (NON TUMOR)
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] are [describe digits receivedand if amputate or disarticulated] measuring***cm in length x ***cm in diameter. The skin is [describe any lesions present/location/distance to margins]. The underlying bone is [describe cut surfaces and any areas of softening]. Representative sections are submitted following decalcification[describe cassette submission].
Cassette Submission: 3-4 cassettes
- Skin/soft tissue resection margin, representative perpendicular sections
- Bone resection margin, shave (not a margin if digit is articulated)
- 1-2 cassettes of skin lesions with underlying bone
Specimen Type: BONE RESECTION (FOR TUMOR)
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is an [above-knee disarticulation, hip disarticulation, etc.] measuring ***cm in length x***cm in diameter. The specimen is remarkable for [describe lesion/location/extent/vascular involvement/skip metastases/distance from each margin/extension into soft tissue/necrosis %/appearance]. The adherent soft tissue is dissected through for lymph nodes. [Describe number/size of lymph nodes identified].A gross photograph is taken. Representative sections are submitted following decalcificationin [describe cassette submission].
Cassette Submission: 15-20 cassettes
- Note: Consult pathologist before grossing
- One section per 1 cm of tumor/mass/lesion
- Show relationship to cortex, medulla, adjacent joint/soft tissue
- Submit one full cross section of the resection (provide map of sections)
- Soft tissue resection margin (en face)
- Skin resection margin (en face)
- Vascular resection margin (en face)
- Bone resection margin (en face)
- Submit all lymph nodes identified
- Note: When submitting large fatty tumors, be sure to cut the sections very thin (no thicker than a nickel) in order to have proper processing
1. Ewing's sarcoma, lymphoma, myeloma
2.Osseofibrous dysplasia, adamantinoma
3.Osteoid osteoma
4.Fibrous dysplasia
5.Chondromyxoid fibroma
6.Nonossifying fibroma
7.Bone cyst, osteoblastoma
8.Osteochondroma
9.Osteosarcoma
10.Enchondroma, chondrosarcoma
11.Giant cell tumor
12.Chondroblastoma
Specimen Type: LOWER/UPPER EXTREMITY (NON TUMOR)
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin]] is an [above-knee disarticulation, hip disarticulation, etc.] measuring ***cm in length x ***cm in diameter. The attached [foot/hand] measures ***x***x***cm and has [number of digits present, indicate absent digits or prior amputation site]. The skin is remarkable for [describe any lesions present/location/distance to margins]. The underlying bone is [describe cut surfaces]. The vasculature is dissected out to reveal [describe patency/calcifications/stenosis]. No additional lesions are grossly identified. Representative sections are submitted following decalcification[describe cassette submission].
Cassette Submission: 6-8 cassettes
- Skin/soft tissue/muscle/neurovascular bundle resection margin (en face)
- Bone resection margin (en face)
- If the proximal bone margin appears viable and normal – a section of the proximal bone may be omitted
- 1-2 cassettes of vasculature
- 1-2 cassettes of skin lesions with underlying bone
- Section of bone from affected area (rule out osteomyelitis)
Specimen Type: LOWER/UPPER EXTREMITY (AMPUTATION FOR TUMOR)
NOTE: Consult with the attending pathologist or contact the BST fellow before grossing.
Often, these specimens have been previously diagnosed and treated. For this reason, the importance of precise dissection to reveal structural relationships outweighs the need for expediency. There are two methods commonly used to process the specimen. If you are unsure of which method to use, please check with the attending physician before proceeding.
The first method is the more standard method used for most specimens and involves removing the soft tissue portion of the tumor and fixing it and sectioning (or sectioning and fixing if appropriate) it as you would other specimens. After fixation, thorough dissection of the soft tissue portion of the specimen is completed. This includes the careful measurement of the dimensions of any tumor, and its relationship to underlying bone and adjacent soft tissue structures and vasculature. The relationship of the tumor to the previous biopsy site is noted. Also noted is the relationship of the tumor to the proximal soft tissue surgical margins. Dissection of the neurovascular structures is carried out, as well as identification of lymph nodes. At this point, the following sections should be submitted for processing:
- representative sections of the distal and/or proximal soft tissue margins including nerve, artery, vein, lymph nodes, muscle, and synovium if present.
- sections of any additional lymph nodes identified.
- representative sections of tumor including relationship to adjacent tissue.
- sections of any other unusual appearing tissue.
After thorough dissection of the soft tissue portion has been completed, the soft tissue portion of the specimen is removed from the specimen. The bony portion of the specimen is examined and described further. Using the band saw, a cross section or sections of the proximal bony margin is taken. If there is a distal bony margin, a section of the distal bony surgical margin is also taken. The specimen is then carefully serially sectioned along the long axis. A description of the appearance of the longitudinally sectioned bone is necessary at this time. Important points to note include the size of the tumor, as well as the location, such as intramedullary, cortical, diaphyseal, metaphyseal, etc. It is important to mention extent of spread within the bone itself, for example extension through the epiphyseal plate, expansion through the cortex, involvement of the periosteum, etc. Always note the gross distance of the tumor from the closest proximal or distal margin. For patients who received prior treatment, one of the most important assessments is the amount of tumor necrosis by gross and microscopic examinations. For this reason, the amount and the type of necrosis (solid, cystic, mixed) by gross examination should be indicated. For further microscopic determinations, an entire longitudinal slice of the tumor is submitted for histologic study. A diagram of the longitudinal section of the bone displaying the location and extent of the tumor is sometimes useful. This diagram may also be used to show where various sections were taken. At this point the following sections should be submitted for processing:
- proximal (and distal) bony margins.
- representative tumor (should include a complete longitudinal sample of the tumor).
- any other interesting or unusual sections.
The second method of processing involves freezing the specimen. For some specimens it is helpful to freeze the specimen before fixing and sectioning. An example of such a specimen would be a treated osteosarcoma of the distal femur. Freezing the specimen prior to cutting makes the specimen firm and easier to cut while holding the tumor together (much like a giant frozen section). Sometimes you will want to freeze the entire specimen. Other times it will be easier to disarticulate the uninvolved portions of the specimen, and sample, examine, and remove excess soft tissue before freezing the involved portion of the specimen. Check with your attending pathologist before processing to know which method would be most appropriate for an individual specimen.
All portions of the specimen should be stored until the final diagnosis has been made.
It should be obvious that careful planning and experience are necessary to properly describe, and dissect these specimens. For that reason, do not hesitate to ask for guidance from somebody with experience in this type of dissection before and during the process!
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is an [above-knee disarticulation, hip disarticulation, etc.] measuring***x***x*** cm. The skin surface is remarkable for [describe any lesions present/location/distance to margins]. The underlying bone is [describe cut surfaces]. The vasculature is remarkable for [describe patency/calcifications/stenosis]. The adherent soft tissue is dissected through for lymph nodes. [Describe number/size of lymph nodes identified]. Representative sections are submitted following decalcificationin [describe cassette submission].
Cassette Submission: Described previously
Specimen Type: INCIDENTAL RIBS
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] are [number] of portions of bone ranging from *** to***cm in maximum dimension, amounting in aggregate to ***x***x*** cm. The bone is sectioned to reveal [describe cut surfaces]. [No abnormalities are identified/a gross abnormality is identified]. Representative sections are submitted following decalcificationin [describe cassette submission].
Cassette Submission:
- 1 cassette with representative sections
* If specimen is “first rib” please place in designated area as many patients come and pick up these specimens.
SOFT TISSUE
Specimen Type: DISCS
Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] are *** of fragments of tan-white cartilaginous tissue ranging from [***-***cm] in maximum dimension, amounting in aggregate to *** x *** x *** cm. Representative sections are submitted in [describe cassette submission].
Cassette Submission: 1 cassette
- Submit more cassettes if lesion/mass is identified
- Decalcify if necessary
Specimen Type: SYNOVIUM
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] are *** of fragments of pink-tan, soft tissue ranging from *** to ***cm in maximum dimension, amounting in aggregate to***x***x***cm. [Describe any gross abnormalities]. Representative sections are submitted in [describe cassette submission].
Cassette Submission: 1 cassette
- Submit more cassettes if lesion/mass is identified
Specimen Type: LIPOMA
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [tan-yellow, lobulated] portion of fibroadipose tissue measuring ***x***x***cm. Sectioning reveals [describe cut surfaces, noting whether hemorrhage or necrosis is identified]. Representative sections are submitted in [describe cassette submission].
Cassette Submission: 5-6 cassettes
- DO NOT ink these specimens
- Submit one section per 1 cm of the mass/lesion
- Note: For cord lipomas, submit as follows:
- 1 cassette for 1-2 cm lipoma (2 sections)
- 2 cassettes for a 2-4 cm lipoma (2 sections each cassette)
Specimen Type: RESECTION
Gross Template:
Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [tan-yellow, lobulated, soft, fragmented] mass measuring ***x***x***cm. [An overlying skin ellipse is present measuring ***x***x*** cm. [Describe orientation if provided].
The specimen is sectioned to reveal [describe lesion/location/extent/vascular involvement/distance from each margin/extension into adjacent structures/necrosis %/appearance/borders]. [Note presence of infiltration of adjacent tissue by tumor and of vascular invasion by tumor]. The remaining cut surfaces are [describe remaining tissue]. The adjacent tissue is dissected through for lymph nodes. [Number] lymph nodes are identified. Representative sections are submitted [describe cassette submission].
Ink key:
Consult with attending to determine if ink is necessary
Cassette Submission: 15-20 cassettes
- Submit one section per 1 cm of mass/lesion
- Show relationship to all margins
- Show relationship to adjacent structures
- Show relationship to overlying skin (if present)
- Show zones of filtration
- Submit all lymph nodes (if present)
- Note: Submit a sample of tumor for E.M. and cytogenetics as appropriate.