Clin Core Lecture 4

Clinical Correlation

A specimen being processed under normal circumstances as standard operating procedures (no time requirement, no add-ons or special requests)

Routine specimen

A specimen with special requirements, specifications or handling (STAT, special handling, add-ons)

Special processing specimen

A muscle biopsy must remain fresh and on ice, which is what kind of handling?

Special handling

what are some examples of add-on tests?

Genomic testing (cytogenetics)

Flow cytometry

Specimens that can be on a short processor (2 hours)

All biopsy types

neuromas

cervical specimens

fibromas

any sample consisting of minute/small fragments (0.4 cm)

Specimens that can be on a medium processor (4-12 hours)

small lipomas

appendicies

gallbladder

tonsils

sinus contents

digit amputations

What usually causes appendicities?

Fecaliths/obstructions

What is a potential cause for appendiceal cancers?

Mucoceles

Who is at risk for appendiceal cancers?

middle-aged individuals

Grossing an appendix for Appendicitis

1. Measure

2. External features

3. CROSS SECTION FROM PROXIMAL TO DISTAL, STOP AT 1 CM FROM DISTAL TIP

4. DO NOT CROSS SECTION THE DISTAL TIP

5. DISTAL DIP MUST BE BISECTED LONGITUDINALLY AND AT LEAST ONE HALF TO BE SUBMITTED

6. NOTE THE CUT SURFACE

7. GIVE MEASUREMENT FOR THE DIAMETER OF THE LUMEN (NORMAL IS PINPOINT)

8. CONTENTS

9. CASSETTE SUMMARY

An appendix mucocele can be indicative of:

invasive adenocarcinoma

What margins must be assessed in an appendix mucocele?

1. proximal resection margin

2. Mesoappendiceal margin (MESENTERIC MARGIN)

3. Serosa (NOT TRUE MARGIN)

Grossing an appendiceal mucocele:

1. measure

2. External finding

3. Ink all margins

4. Remove stable line, SHAVE AND SUBMIT EN FACE

5. Serially cross section from proximal to distal and stop 1 cm from distal dip

6. REMOVE MUCIN FROM LUMIN, DO NOT DISCARD

7. EVALUATE FOR MUCOSA FOR POLYPS OR MASSES

8. TAKE SECTIONS DEMONSTRATING EACH MARGIN IN RELATION TO THE LESION

9. BECAUSE OF MUCIN PRODUCING NEOPLASM, APPENDIX MUST BE EVALUATED TO RULE OUT OCCULT INVASIVE LESION

What might cause cholecystitis?

Stone formation

Obstruction

What age group is at risk for gallbladder cancers?

middle age (50+)

Grossing a gallbladder:

1. Measure

2. Gross findings, external

3. Proximal cystic duct margin, SHAVE MARGIN EN FACE

4. OPEN CYSTIC DUCT

5. DESCRIBE INTERNAL MUCOSAL SURFACES

6. CONTENTS

7. LYMPH NODE, PERICYSTIC

8. CASSETTE SUMMARY

A hyalinized,, calcified gallbladder is called:

Porcelain gallbladder

Porcelain gallbladders are caused by:

Chronic inflammation (scarring)

Due to the increased rick of dysplasia and cancer, a porcelain gladder must:

be entirely submitted (discuss with pathologist)

What is the main goal with toe amputations?

Surgeon wants to remove only portions of the diseased limp from distal to proximal

This is the most common reason for an amputation. Commonly due to diabetes mellitus, heart disease, PBD, atherosclerotic changes.

Vascular insufficiency

This is a bone infection. Characterized by skin sloughing or ulcerated from ischemic disease. The lesion may extend into the underlying bone. Hard to treat.

Osteomyelitis

Explain an amputation:

1. Bone is transected at the margin

2. Sections of the bone margin must be submitted

3. OR YOU CAN SUBMIT MARROW AT THE MARGIN

What is disarticulation?

Separation at the joint

Bone is not cut, NOT TRUE MARGIN

Proximal end is intact and consisting of articular cartilage

Grossing a Digit Amputation:

1. What is present (number of toes, which toes, separate bone fragments)

2. Measure

3. DESCRIBE PROXIMAL END (OSTEOMYELITIS, NECROSIS?)

4. DESCRIBE ANY LESIONS

5. TAKE SECTIONS OF MARGINS

6. TAKE SECTIONS OF SKIN AND UNDERLYING BONE

7. CASSETTE SUMMARY

A trans-metatarsal amputation is the:

amputation of the forefoot

(prior toe amputation, possible)

Metatarsals are transected

COMPLEX GROSS

TRANS-METATARSAL AMPUTION GROSS:

1. What is present

2. measure

3. DESCRIBE SOFT TISSUE MARGIN

4. DESCRIBE BONE AT THE PROXIMAL END

5. DESCRIBE ANY LESIONS, DISCOLORATION (CHANGES LIKE ISCHEMIA)

6. DESCRIBE REMAINING UNINVOLVED SURFACES

7. TAKE SECTIONS OF MARGINS

8. TAKE SECTIONS OF LESION AND UNDERLYING BONE

9. CASSETTE SUMMARY

What are 3 lower extremity amputations?

Foot

Below the knee

Above the knee

What must be submitted in a lower extremity amputation?

vessels at the resection margin, eval for atherosclerosis and proximal occlusion

What specific vessels need to be assessed for stenosis?

1. femoral/popliteal arteries

2. Anterior/posterior tibial arteries

3. Dorsalis pedis artery

How are the vessels submitted for stenosis?

1. Vessels are located, dissected out

2. Serially cross-sectioned from proximal to distal

3. add any stenosis or occlusion in the gross description

Gross procedure for below the knee amp

1. what is present

2. Measurement (foot and leg separate)

3. Describe bone and soft tissue margins

4. DESCRIBE VESSELS AT THE MARGIN (ANTER/POSTERIOR TIBIAL ARTERIES)

5. DESCRIBE ANY LESIONS/ABNORMAL GROSS FINDINGS

6. DISSECT OUT ANTERIOR/POSTERIOR ARTERIES, DORSALIS PEDIS ARTERY

7. WHERE IS THE GREATEST OCCLUSION, WHICH VESSEL, ESTIMATE PERCENTAGE OF OCCLUSION FOR EACH ARTERY

8. CASSETTE SUMMARY

GROSS PROCEDURE FOR ABOVE THE KNEE AMP

1. What is present

2. Measurement

3. Describe bone and soft tissue margin

4. DESCRIBE VESSELS AT MARGIN (FEMORAL POPLITEAL ARTERY)

5. DESCRIBE ANY LESIONS OR GROSS FINDINGS

6. DISSECT OUT THE ANTERIOR, POSTERIOR ARTERIES, DORSALIS PEDIS ARTERY

7. AREA OF GREATEST OCCLUSION, WHICH VESSELS, ESTIMATE A PERCENTAGE OCCLUSION FOR EACH ARTERY

8. CASSETTE SUMMARY