Gastrointestinalpathology Grossing Guidelines

GASTROINTESTINALPATHOLOGY GROSSING GUIDELINES

Specimen Type: EMR

Note:Please page/notify the GI biopsy fellow on service to review the gross specimen

Procedure:

Measure and provide orientation.
If unoriented -- ink should be applied on the peripheral and deep margins (1 color only)
If oriented, ink peripheral margins differentially (similar to skin specimen; e.g., 12-3:00 blue, 3-6:00 green, 6-9:00 purple, 9-12:00 orange, deep- black) and indicate orientation in the cassette summary
Section at 2mm intervals
If a gross lesion is identified- section along the axis to allow for evaluation of the lesion to the nearest peripheral margin:

If no gross lesion is identified OR if the lesion appears to completely involve all margins, section along the long axis. Take perpendicular sections of the first and last slices to allow for complete evaluation of the margins:

Gross Template:Labeled with the patient’s name ***, medical record number ***, designated ***, and received [fresh/in formalin] is an [oriented/unoriented]EMRmeasuring *** x *** cm , excised to a depth of *** cm. [Describeorientation]. [Describe any lesions – including size, type, borders, color,shape, distance to all margins]. The specimen is sectioned [provide orientation if applicable] to reveal [describe cut surface]. The specimen is entirely submitted.

The specimen is entirely submitted in [describe cassette submission].

Cassette Submission: 5-10 cassettes

-Submit levels sequentially into cassettes

-Multiple levels can be placed into the same cassette

-The cassette key should clearly indicate what is submitted (ie, A1: level one, perpendicularly, A2: next 3 serial slices, A3: Next 2 serial slices, A4: last slice, perpendicularly sectioned)

Sample Cassette Submission

A1One end, perpendicular

A2- A4 Central sections (lesion: -A3-A4)

A5Opposite end, perpendicular

STOMAS

Specimen Type: END STOMA

Procedure:

Measure the length and diameter or circumference of bowel.
Measure the location (distance from the closest bowel margin) and diameter of stoma opening.
Describe the presence or absence of skin at stoma opening, and the width of skin if present

Gross Template:

Labeled with the patient’s name ***, medical record number ***, designated ***, and received [fresh/in formalin] is an [intact, disrupted]end ileostomy. The bowel measures *** cm in length x *** cmin diameter. There is a *** cm stomal diameter. Mesenteric/pericolic fat extends up to *** cm from the bowel wall.

The serosa is remarkable for [describe adhesions, plaques, full-thickness defects or is smooth, tan, glistening, and unremarkable]. There [is/ is no] skin present at the stoma site. Mucosa at the stoma site is [red, granular, hemorrhagic, ulcerated] and extends up to *** cm above the surrounding tissue.The remaining mucosa is [pink-tan, red, granular, hemorrhagic ulcerated]. Representative sections are submitted.

Cassette Submission: 1-2 cassettes (additional cassette(s) if necessary to demonstrate pathology)

- Stapled resection margin, shave

- Unremarkable bowel in relation to stoma and skin, if present

Specimen Type: LOOP ILEOSTOMY

Procedure:

Measure the length and diameter or circumference of bowel.
Measure the location (distance from the closest bowel margin) and diameter of stoma opening.
Describe the presence or absence of skin at stoma opening, and the width of skin if present

Gross Template:

Labeled with the patient’s name ***, medical record number ***, designated “***”, and received [fresh/in formalin] is an [intact, disrupted]loop ileostomy. The bowel measures *** cm in length x *** cm in diameter, with a stoma located in the midportion. The longer limb measures *** cm in length. The shorter limb measures *** cm in length . There is a ***cm stomal diameter. Fat extends up to *** cm from the bowel wall.

Cassette Submission: 2 cassettes (additional cassette(s) if necessary to demonstrate pathology)

- Longer limb in relation to stoma and skin

- Shorter limb in relation to stoma and skin

- Stapled resection margins, shave

ESOPHAGUS

Specimen Type: ESOPHAGECTOMY

Procedure:

- Portions of the esophagus are usually resected to remove neoplasms, and less frequently because of strictures.

Measure length of segment and diameter or circumference. Make sure to stretch the esophagus when measuring its length because it shrinks.
Measure the length of attached proximal stomach, and its diameter or circumference at the distal gastric margin (if present).
Ink external surface of the esophagus at the lesional site.
Describe external surface noting areas of retraction, induration, extension of tumor, perforation, presence of enlarged lymph nodes.
Open esophagus longitudinally. Record thickness of wall. Describe appearance of the mucosa, noting any areas of ulceration, glandular mucosa (which appears pink or tan), tumors, and the degree of narrowing of the lumen caused by such lesions.
Measure and describe appearance (size, color, texture) of ulcers, tumors and strictured segments. Measure the distance from such lesions to the margins of resection and/or GE junction.
Stretch and pin the opened esophagus on a board and fix in 10% formaldehyde. If the tumor is large, make several cuts to allow proper fixation.
After fixation, cut through tumor or ulcer to assess depth of invasion through esophageal wall.
If no tumor is grossly identified (which is often the case after neoadjuvant therapy of the GEJ tumors), then generally the entire ulcerated area is blocked off and submitted.

Gross Template:

Labeled with the patient’s name ***, medical record number ***, designated ***, and received [fresh/in formalin] is an [intact/disrupted] esophagectomy with [two stapled ends, one opened and one stapled end, etc.]. [Indicate orientation, if provided]. The esophagus measures *** cm in length x *** cm in average open circumference [provide range if there is a significant variation], with a *** cm average wall thickness.[Describe other adherent structures-parietal pleura].

All identified lymph nodes are entirely submitted. [The tumor/fibrotic area is entirely submitted(if applicable, otherwise skip to next sentence)] Representative sections of the remaining specimen are submitted.

Ink key:

Black –esophageal adventitial margin

[Additional inking description if proximal/distal margins taken perpendicularly]

Cassette Submission: 15-20 cassettes

-Proximal resection margin, shave

Submit perpendicular section if lesion is close to margin

-Distal resection margin, shave

Submit perpendicular section if lesion is close to margin

-One cassette per 1 cm of lesion (OR at least 5 sections of tumor)

Show maximum depth of invasion
Show nearest approach of tumor to esophageal adventitial margin
Show relationship to unremarkable mucosa

-One cassette of uninvolved esophagus

-Cassettes sampling any additional pathology in the gross description (ulcers, polyps, etc.)

-Submit all lymph nodes identified and adventitial soft tissue

Separate gastric and esophageal lymph nodes

-Note: If no gross tumor is present, block out ulcerated/fibrotic area and entirely submit

Specimen Type: ESOPHAGOGASTRECTOMY

Procedure:

- Portions of the esophagus are usually resected to remove neoplasms, and less frequently because of strictures.

Measure length of segment and diameter or circumference. Make sure to stretch the esophagus when measuring its length because it shrinks.
Measure the length of attached proximal stomach, and its diameter or circumference at the distal gastric margin.
Ink external surface of the esophagus at the lesional site.
Describe external surface noting areas of retraction, induration, extension of tumor, perforation, presence of enlarged lymph nodes.
Open esophagus longitudinally. Record thickness of wall. Describe appearance of the mucosa, noting any areas of ulceration, glandular mucosa (which appears pink or tan), tumors, and the degree of narrowing of the lumen caused by such lesions.
Measure and describe appearance (size, color, texture) of ulcers, tumors and strictured segments. Measure the distance from such lesions to the margins of resection and/or GE junction.
Stretch and pin the opened esophagus on a board and fix in 10% formaldehyde. If the tumor is large, make several cuts to allow proper fixation.
After fixation, cut through tumor or ulcer to assess depth of invasion through esophageal wall.
If no tumor is grossly identified (which is often the case after neoadjuvant therapy of the GEJ tumors), then generally the entire ulcerated area is blocked off and submitted.

Gross Template:

Labeled with the patient’s name ***, medical record number ***, designated ***, and received [fresh/in formalin] is an [intact/disrupted] esophagogastrectomy with [two stapled ends, one opened and one stapled end, etc.]. [Indicate orientation, if provided]. The esophagus measures *** cm in length x *** cm in average open circumference [provide range if there is a significant variation], with a *** cm average wall thickness.There is a ***cm open circumference at the gastroesophageal junction. Adventitial soft tissue extends up to ***from the esophageal wall. The stomach measures *** cm in length along the greater curvature, ***cm in length along the lesser curvature, *** cm in open circumference at the distal resection margin, and ***cm in average wall thickness. The attached gastric fibroadipose tissue measures *** x *** x *** cm.[Describe other adherent structures].

The serosal surface is remarkable for [describe, if applicable]. The mucosal surface is remarkable for a [describe lesion: size (__ x __ x __ cm), shape (e.g. polypoid, ulcerated, fungating), color, consistency (e.g. soft, firm, friable), associated ulceration]. Sectioning reveals thelesionhas a [describe cut surface of lesion and maximum thickness]. The center of the lesion is located [at, proximal to, distal to] the gastroesophageal junction.The lesionmeasures***cm from the proximal margin, *** cm from the gastric margin, ***cm from the esophageal adventitial margin, ***cm from the margin of greater curvature of fat (if applicable), and ***cm from the margin of lesser curvature fat (if applicable).

The remainder of the esophageal mucosa is [tan and glistening with unremarkable longitudinal folds or describe any additional lesions, such as ulcers/erosions, polyps, anastomoses, smooth areas with loss of folds, fibrotic areas, etc.]. The remainder of the gastric mucosa is [tan, rugated, glistening, and unremarkable or describe any additional lesions, such as ulcers/erosions, polyps, smooth areas with loss of folds, fibrotic areas, etc.]. ***of lymph nodes are identified ranging from *** to *** cm in greatest dimension.

Ink key:

Black –esophageal adventitial margin

Blue – gastric serosa adjacent to tumor

[Additional inking description if proximal/distal margins taken perpendicularly]

Cassette Submission: 15-20 cassettes

-Proximal resection margin, shave

Submit perpendicular section if lesion is close to margin

-Distal resection margin, shave

Submit perpendicular section if lesion is close to margin

-One cassette per 1 cm of lesion (OR at least 5 sections of tumor)

Show maximum depth of invasion
Show nearest approach of tumor to esophageal adventitial margin
Show relationship to unremarkable mucosa

-One cassette of uninvolved esophagus

-One cassette of uninvolved stomach

-Cassettes sampling any additional pathology in the gross description (ulcers, polyps, etc.)

-Submit all lymph nodes identified and adventitial soft tissue

Separate gastric and esophageal lymph nodes

-Note: If no gross tumor is present, block out ulcerated/fibrotic area and entirely submit

STOMACH

Specimen Type: SLEEVE GASTRECTOMY

Procedure:

Measure the length and range of diameter or circumference of resected portion of stomach.
Describe the appearance of serosa and mucosa

Gross Template:

Labeled with the patient’s name ***, medical record number ***, designated ***, and received [fresh/in formalin] is an [intact, disrupted]sleeve gastrectomy measuring [__x__x__] cm. There is a ***cm in length staple line at the resection margin. Perigastric fibroadipose tissue extends up to ***cm from the gastric wall.

The serosal surface is remarkable for [describe adhesions, plaques, full-thickness defects (perforations or enterotomies) or is smooth, tan, glistening, and unremarkable]. The mucosal surface is remarkable for [describe ulcers/erosions/polyps/loss of folds/nodularity or is pink, rugated, glistening, and unremarkable]. Representative sections are submitted.

Cassette Submission: 1 cassette (additional cassette(s) if necessary to demonstrate pathology)

-Submit two representative sections of stomach wall

Include area of congestion

Specimen Type: GASTRECTOMY (PARTIAL OR TOTAL)

Procedure:

Describe the type of resection (total, partial) and indicate any additional organs (such as omentum, distal esophagus, proximal duodenum) which are included with the specimen.
Describe the serosal surface, noting color, granularity, presence of adhesions, scarring, or perforation.
Open the specimen along the greater curvature unless lesion is located along the greater curvature. In that case, the specimen should be opened along the lesser curvature.
Measure the specimen along the greater and lesser curvatures, the circumference of the proximal and distal margins.
Measure the thickness of the gastric wall and note its consistency.
Describe the mucosal surface, noting any ulcers, tumors, or other lesions.
Description of tumors should include location, size, distance from margins of resection, consistency, outline and depth of penetration into wall. Where no discrete tumor is found, the nature and extent of any indurated areas should be described. Descriptions of ulcers should include location, size, distance from margins, appearance of the ulcer base and the surrounding mucosa, and depth of penetration into wall.
Ink the outer serosal surface overlying the lesion.
Measure the size of omentum, particularly the width from gastric wall. Identify the lesser and greater omental resection margins. Describe the distance of lesion from the closest omental margin.
Dissect lymph nodes from the specimen, from greater curvature, less curvature, cardia and pylorus, keeping groups of nodes separate.

Gross Template:

Labeled with the patient’s name ***, medical record number ***, designated ***, and received [fresh/in formalin] is a [partial/total] gastrectomy measuring ***cm in length along the greater curvature, ***cm in length along the lesser curvature, with a ***cm average open circumference [include open circumference of pylorus if present]. Thewall thickness ranges from ***cm in the [location] to ***cm in the [location]. Attached greater omental adipose tissue measures*** x *** x *** cm and lesser omental adipose tissue measures*** x *** x *** cm. [If a portion of esophagus and/or duodenum is present, mention and measure.]

The serosal surface is remarkable for [describe, if applicable]. The mucosal surface is remarkable for a [describe lesion: size (__ x __ x __ cm), shape (e.g. polypoid, ulcerated, fungating), color, consistency (e.g. soft, firm, friable)] located in the [antrum/body/fundus]. Sectioning reveals the [lesion/mass] has a [describe color, consistency] cut surface and grossly [is superficial, extends into the bowel wall, extends through the bowel wall into the fibroadipose tissue]. The [lesion/mass] measures***cm from the serosa and ***cm from the nearest omental resection margin, [if applicable].

The remainder of the serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions, such as adhesions, plaques, enterotomies, etc.]. The remainder of the gastric mucosa is [tan, rugated, glistening, and unremarkable or describe any additional lesions, such as ulcers/erosions, polyps, smooth areas with loss of folds, fibrotic areas, etc.]. The gastric wall ranges from *** – ***cm in thickness.[Describe any attached duodenum or esophagus] ***of lymph nodes are identified ranging from *** to *** cm in greatest dimension.

All identified lymph nodes are entirely submitted. [The tumor/fibrotic area is entirely submitted(if applicable, otherwise skip to next sentence)] Representative sections are otherwise submitted.

Ink key:

Blue – gastric serosa adjacent to tumor

[Additional inking description of any radial/omental margin that may be present]

[Additional inking description if proximal/distal margins taken perpendicularly]

Cassette Submission:

Ulcer: 5-10 cassettes:

-If ulcer is small, entirely submit

-If ulcer is large submit representative sections

Including adjacent unremarkable mucosa

-Uninvolved body and antrum

-Lymph nodes

Tumor: 15-20 cassettes

-Proximal resection margin (en face)

Submit perpendicular section if lesion close to margin

-Distal resection margin (en face)

Submit perpendicular section if lesion close to margin

-Omental margin

-One cassette per 1 cm of lesion (OR at least five sections of tumor OR if small enough, entirely submit)

Show maximum depth of invasion
Show nearest approach of tumor to gastric serosa
Show nearest approach of tumor to radial margin, if applicable
If lesion is a small ulcer – the entire area can be submitted
If lesion is a large ulcer – submit representative sections with relationship to adjacent mucosa
Show relationship to unremarkable mucosa

-Uninvolved body and antrum proximal and distal to tumor

Important because gastric neoplasms often invade extensively beyond normal appearing mucosa

-Cassettes sampling any additional pathology in the gross description (ulcers, polyps, etc.)

-Any attached organs

-Submit all lymph nodes identified (16 nodes are suggested)

Separate lesser curvature and greater curvature lymph nodes

-Note: If no gross tumor is present, block out ulcerated/fibrotic area and entirely submit

-Note: If a lymphoma is suspected, take fresh samples for flow cytometry and cytogenetic studies. A quick frozen section can be used to decide if this is necessary or not. If frozen shows definite carcinoma these steps can be avoided.

SMALL BOWEL

Specimen Type: SMALL BOWEL (for TUMOR)

Procedure:

Measure the length and range of diameter or circumference.
Describe serosal surface, noting color, granularity, presence of indurated or retracted areas, perforation, and presence of enlarged lymph nodes.

3. Measure the width of attached mesentery. Note any enlarged lymph nodes and thrombosed vessels or other vascular abnormalities. Identify the mesenteric margin.