PULMONARY PATHOLOGY GROSSING GUIDELINES

Specimen Type: LUNG/ PLEURAL BIOPSY

NOTE: An open lung biopsy, other than performed for a neoplastic mass, is often a medical urgency, done in very ill or dying patients, when the clinicians need a tissue diagnosis to guide potential life-saving therapy for the patient. It is our responsibility to assure that the specimen is studied properly. This includes proper microbiologic studies, touch-preps, E.M., freezing, use of special fixatives, cytogenetics, etc. You should be aware of the clinical differential diagnosis so you can determine which studies are indicated.

If neoplasm is clearly present the specimen need not be handled as a rush. You may place 1 mm cube in E.M. fixative and do a touch prep. If lymphoma is clinically suspected, please request lymphoma work up from the hemepath team.If the biopsy is performed to assess for pulmonary hemorrhage or collagen vascular disease, place a small piece in Zeus fixative and place in the appropriate container in the fridge (this is required for immunofluorescence studies).

Cassette Submission:All tissue submitted – ALL OF THESE BIOPSIES ARE RUSH SPECIMENS

-Lung-1 (BROWN or GREEN): biopsies for neoplasm (4 slides; 4 sections per slide, 2 microns)

  • 1,4 H&E
  • 2,3 unstained (IHC)

-Lung-2 (BROWN or GREEN): biopsies for infectious disease (4 slides; 4 sections per slide, 2 microns)

  • 1,4 H&E
  • 2 GMS
  • 3 AFB (no gram stain)

-Lung-3 (BROWN or GREEN): biopsies for transplant and other immunocompromised hosts (8 slides; 4 sections per slide, 2 microns)

  • 1,8 H&E
  • 2 AFB
  • 3 Trichrome
  • 4 Methenamine silver
  • 5 CMV
  • 6 Negative control for CMV
  • 7 unstained

-Lung-4 (BROWN or GREEN): biopsies with no information (4 slides; 4 sections per slide, 2 microns

  • 1,4 H&E
  • 2, 3 unstained (IHC)

-Lung-5 (BROWN or GREEN): open biopsy (6 slides from one block only; 1 H&E of other blocks)

  • 1 H&E
  • 2 AFB
  • 3 GMS
  • 4,5,6 unstained

Procedure:

  1. Measure to the mm.
  2. Describe pleural surfaces, noting color and granularity. Describe state of inflation and consistency.
  3. If possible, perfuse the specimen with 10% formaldehyde and section the specimen after several hours of fixation. Small wedge biopsies of lung can be shaken vigorously in formalin to expand alveoli.
  4. Describe parenchyma, noting color, size, consistency, content of airways and focal lesions.
  5. If received very late in the day, such that adequate fixation is a concern, one cassette of the most abnormal tissue should be processed, and the remainder may be held overnight.
  6. If fixation is not an issue, the specimen should be entirely embedded and submitted the day received.
  7. In any type of case, special stains need not be done on all blocks, only the one that is most abnormal grossly.
  8. Special stains for infectious diseases should be ordered
  9. Submit entire specimen if small or representative sections if large.

Gross Template:

Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram, *** x *** x *** cm lung biopsy. There is a *** cm in length staple line present at the resection margin. The pleural surface is [intact/ruptured/smooth/glistening/roughened]. There is a [minimal, moderate, extensive] amount of anthracotic pigmentation. Sectioning reveals [describe all lesions including size, color, involvement of pleura, and distance from margin]. The remaining lung parenchyma is [emphysematous/spongiform/fibrotic/unremarkable]. Representative sections are submitted [number of cassettes].

Ink Key:

Blue-stapled resection margin

Green-pleura overlying mass, if applicable

Specimen Type: PLEURECTOMY

Note: Please weigh all mesothelioma cases and thoroughly search the tissue for pericardium, diaphragm, and other soft tissue and take sections to show mass involvement of these tissues.

Gross Template:

Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram, *** x *** x *** cm aggregate of multiple portions of [describe color, consistency, shape of pleura] tissue. The specimen is serially sectioned to reveal [describe cut surfaces, comment on other tissue present if identified- diaphragm, pericardium, etc]. Representative sections are submitted [number of cassettes].

Cassette Submission: Entirely submit specimen if less than 3 cassettes. If too large, provide representative sections in 3 cassettes.

Specimen Type: WEDGE RESECTION

Procedure:

  1. Describe nature of the specimen (entire lung, lobe, wedge resection).
  2. Weigh, measure to the mm and photograph
  3. Describe pleural surface, noting color, granularity, presence of adhesions, retraction, tumor. Describe state of inflation and consistency.
  4. Inflate the specimen with 10% formaldehyde. Margins should be inked. After fixation, serially section the specimen.
  5. Describe cut surface of lung, noting color and consistency and focal lesions. For tumors, describe size, color, consistency, location, relationship to bronchi and closest distance to pleura and margin or resection. Photograph all tumors.
  6. Describe lymph nodes, noting location, range of sizes and appearance of cut surface.

Gross Template:

Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram, *** x *** x *** cm [intact/previously incised] lung wedge resection. There is a *** cm in length staple line present at the resection margin. The pleura is [intact/ruptured/smooth/glistening/roughened/puckered]. There is a [minimal, moderate, extensive] amount of anthracotic pigmentation.Sectioning reveals [describe all lesions including size, color, involvement of pleura, and distance from stapled resection margin]. The remaining lung parenchyma is [emphysematous/spongiform/fibrotic/unremarkable]. Representative sections are submitted [number of cassettes].

Ink key:

Blue-stapled resection margin

Green- puckered pleura overlying lesion

Cassette Submission: Entirely submit specimen if less than 3 cassettes. If more than 3cassettes, representatively sample as below:

-Perpendicular section(s) from margin

-One section per 1 cm of tumor

  • Show relationship to pleura/unremarkable parenchyma/margin)

Specimen Type: LOBECTOMY/ PNEUMONECTOMY

Procedure:

Please note that as part of our research studies we are collecting fresh neoplasm for tissue banking. Please cooperate. Please make sure there is enough neoplasm for diagnostic evaluation. The rest may be collected for research studies.

  1. Describe nature of the specimen (entire lung, lobe, wedge resection).
  2. Weigh, measure to the mm and photograph
  3. Describe pleural surface, noting color, granularity, presence of adhesions, retraction, tumor. Describe state of inflation and consistency.
  4. Inflate the specimen with 10% formaldehyde. Margins should be inked. After fixation, serially section the specimen.
  5. Describe cut surface of lung, noting color and consistency and focal lesions. For tumors, describe size, color, consistency, location, relationship to bronchi and closest distance to pleura and margin or resection. Photograph all tumors.
  6. Describe lymph nodes, noting location, range of sizes and appearance of cut surface.
  7. Submit sections as follows:

COMMENT: Please do not submit entire tumor specimen if possible. The wet tissue can be resubmitted for EM studies, if necessary or used for research.

a)3-4 sections of tumor or 1 section per centimeter if tumor is large

b)One section demonstrating closest approach to pleura (order EMT stain on this section)

c)One section demonstrating most central aspect.

d)Bronchial margin of resection. If tumor is more than 2 cm from margin, take section of entire circumference. If tumor is less than 2 cm from margin, take one or more sections perpendicular to inked margin.

e)Pulmonary vascular margins of resection.

f)One section of uninvolved parenchyma (including bronchi).

g)Sections of any other lesions.

h)All lymph nodes.

Gross Template:

Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram, *** x *** x *** cm [intact/previously incised] [left/right] [upper, lower, middle][lobectomy pneumonectomy]. The bronchus/bronchi measure(s)*** cm in length x*** cm in diameter. The vascular margin(s) measures*** cm in length x*** cm in diameter.

The pleurais [intact/ruptured/smooth/glistening/roughened/puckered]. There is a [minimal, moderate, extensive] amount of anthracotic pigmentation. Sectioning reveals [describe all lesions including size, color, involvement of pleura, and distance from margins- bronchovascular, stapled margin, and pleura]. The endothelium of the vasculature is [tan-yellow and smooth or remarkable for calcifications]. The mucosa of the bronchi is [tan-yellow, corrugated, and grossly unremarkable or remarkable for-describe presence of lesion].

The remaining lung parenchyma is [emphysematous/spongiform/fibrotic/unremarkable]. [Describe number/size of lymph nodes if identified- indicate if hilar or intraparenchymal- and color/consistency]. Gross photographs are taken. Representative sections are submitted [number of cassettes].

Ink key:

Blue-stapled resection margin

Green- puckered pleura overlying lesion

Cassette Submission: 10-15 cassettes

-Bronchial resection margin

  • Submit shave if tumor is greater than 2 cm away from the margin
  • Submit 1 or 2 perpendicular sections of margin if tumor is less than 2 cm away from the margin (often centrally located tumors such as SCC)

-Pulmonary vascular resection margins, shave

-3-4 sections of tumoror 1 section per centimeter if tumor is large

-One section of pleura closest to tumor (if not previously submitted)

  • Order EMT stain on this section

-One cassette of uninvolved lung (including bronchi)

-Submit all lymph nodes

  • Indicate hilar vs intraparenchymal LN[WWD1]

Specimen Type: TRANSPLANT PNEUMONECTOMY

Gross Template:

Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram, *** x *** x *** cm [intact/previously incised] [left/right] pneumonectomy. The bronchus measures*** cm in length x*** cm in diameter. The artery measures*** cm in length x*** cm in diameter.

The pleurais [smooth/glistening/roughened/remarkable for adhesions]. There is a [minimal, moderate, extensive] amount of anthracotic pigmentation. Sectioning reveals [describe location of emphysematous changes and fibrosis: peripheral or central; and which lobes are involved: upper, lower, etc]. The endothelium of the vasculature is [tan-yellow and smooth or remarkable for calcifications]. The mucosa of the bronchi is [tan-yellow, corrugated, and grossly unremarkable or remarkable for-describe presence of lesion].

[Describe number/size of lymph nodes if identified- indicate if hilar or intraparenchymal- and color/consistency]. Gross photographs are taken. Representative sections are submitted [number of cassettes].

Cassette Submission: 8-10 cassettes per lung (16-20 total)

-Bronchovascular margins, shave

-Submit representative hilar and intraparenchymal lymph nodes

-Submit 2 sections per lobe (6 sections of each lung)

  • One section of peripheral parenchyma to include pleura
  • One section of central parenchyma
  • Submit 6 sections of left and right lungs- submit central and peripheral middle left lung parenchyma
  • Take sections to include interface between fibrosis and unremarkable lung parenchyma

THYMUS

Specimen Type: RESECTION (partial/total thymectomy)

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “***”, and received [fresh/in formalin] is a ***gram, *** x *** x *** cm [partial/total] thymectomy. [Describe orientation if provided]. Sectioning reveals [describe any lesions present including size, color, external appearance, relationship to capsule, calcification, necrosis, relationship to uninvolved thymus]. The remaining cut surfaces are [yellow, smooth, lobulated, fatty, unremarkable]. The adherent adipose tissue is dissected through for lymph nodes. [Describe number/size of lymph nodes identified]. Representative sections are submitted [describe cassette submission].

Ink Key:

Black- external surface (if un-oriented and for tumor)

[Additional ink may be required if oriented for margin assessment]

Cassette Submission: 10-12 cassettes

-One cassette if incidentally removed

-One cassette per 1 cm of lesion/tumor

  • Show relationship to capsule
  • Show relationship to unremarkable parenchyma

-One cassette of unremarkable parenchyma

-Submit all lymph nodes identified

-Submit representative sections of other structures present (pleura, pericardium, etc.)

[WWD1]This is repetitive