HANDLING AND PROCESSING
RADICAL PROSTATECTOMY SPECIMEN.
DRAFT COPY ONLY.
(Procedure 166).
http://www.netautopsy.org/axsop/axsop166.htm


NEXT PAGE
PREVIOUS PAGE
RETURN TO TABLE OF CONTENTS

United States Government Work, uncopyrighted, public-domain, DRAFT COPY ONLY. This document does not necessarily represent the views or policies of any United States Government agency. This document is provided "as is", without warranty of any kind, express or implied, including but not limited to the warranties of merchantability, fitness for a particular purpose and non-infringement. In no event shall the authors be liable for any claim, damages or other liability, whether in an action of contract, tort or otherwise, arising from, out of, or in connection with the document or the use or other dealings made with the document.



PRINCIPLE OF THE TEST.


A radical prostatectomy is performed for known or suspected cancer, or other clinical indication, and received in surgical pathology for evaluation. The specimen should be oriented, evaluated grossly, surgical margins inked, and any gross abnormalities described thoroughly. The final report should reflect an adequate sampling of tissue, and should include the size and TNM stage of any tumor.



SPECIMEN REQUIRED.


Tissue Specimen and filled-out Tissue Examination Form (USSF515).



REAGENTS, INSTRUMENTATION.


1. Dissection Instruments.



STEP-BY-STEP DESCRIPTION.


1. A radical prostatectomy is performed for known or suspected cancer, or other clinical indication, and received in surgical pathology for evaluation. The specimen should be oriented, evaluated grossly, surgical margins inked, and any gross abnormalities described thoroughly. The final report should reflect an adequate sampling of tissue, and should include the size and TNM stage of any tumor.

2. Fix the prostate overnight for better, thinner sectioning.

3. Orient the prostate by locating the seminal vesicles and vasa deferentia. These structures sit along the posterior aspect of the base of the prostate (proximal prostate).

4. The base (proximal end) of the prostate is broad and flat. The anterior aspect is adjacent to the urinary bladder. The posterior aspect is adjacent to the rectum. The apex (distal end) of the prostate is narrow and cone-shaped. The urethra may be probed from anterior to posterior.

5. Weigh and measure the prostate.

6. Palpate the prostate for areas of induration.

7. Paint the surface of the prostate with ink.

8. The distal/apical margin of the prostate may be submitted as a 2 mm thinly shaved, en-face section, perpendicular to the axis of the urethra. This donut-shaped section may have to be halved or quartered to fit into standard tissue blocks.

9. Alternatively, the distal/apical margin of the prostate may be amputated 1 cm from the apex, and sectioned into thin slices (2 mm) perpendicular to the axis of the urethra. We prefer the latter method.

10. Apical sections are taken to assess the neck of the bladder, so that inking the outside of the prostate is important. Proximal (basal) margins are also taken.

11. Seminal vesicles are evaluated by passing a section through the base of the seminal vesicle where it joins the prostate.

12. Serially section the prostate perpendicular to the posterior surface of the prostate, carefully preserving the periprostatic capsule, which must be oriented to assess possible periprostatic extension of tumor. It is easiest if the posterior aspect sits flat upon the dissection table.

13. Lay out the sections from apex to base. With the posterior surface down, the urethral section is ∩-shaped. Describe the size and appearance of any lesions. Grossly, cancer is hard and homogenous, whereas non-neoplastic prostate tissue is spongy and cystic. Most cancers arise in the posterior and posterolateral parts of the gland.

14. In prostatectomies removed for urethral obstruction rather than cancer (prostate enucleation), the seminal vesicles may not be included, and orientation is more difficult.

15. In transurethral resections, prostate chips should be submitted as at least six cassettes, or until one-third of the prostate chips have been submitted, whichever is greater.

16. In patients over 65 years old, or if cancer is detected in the original specimen, then the entire enucleation or prostate chips should be submitted, so that the volume of cancer can be assessed. At the Baltimore VAMHCS, approximately 15% of prostate specimens not removed for cancer have unsuspected cancer.



17. FIGURE 166.001.0. Radical Prostatectomy Specimen.
Radical Prostatectomy Specimen.



18. SAMPLE DICTATION. 
  PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
                 
  1.  SPECIMEN #1 IS RECEIVED FRESH AND IS SUBSEQUENTLY FIXED IN
  FORMALIN OVERNIGHT, LABELED WITH THE PATIENT'S IDENTIFICATION AND
  "PROSTATE GLAND".  IT CONSISTS OF ONE INTACT PROSTATE GLAND WITH
  ATTACHED BILATERAL VASA DEFERENTIA AND SEMINAL VESICLES, WEIGHING ...
  GRAMS AND MEASURING ... CM FROM BASE TO APEX, ... CM FROM THE TIP OF
  THE SEMINAL VESICLES TO THE APEX, ... CM LEFT TO RIGHT, AND ... CM
  ANTERIOR TO POSTERIOR.  THE EXTERNAL SURFACE IS DULL RED-BROWN AND
  UNREMARKABLE.  THE CUT SURFACE OF THE PROSTATE VARIES FROM FIRM TO
  RUBBERY, AND IS NODULAR, LIGHT TAN AND YELLOW.  ILL-DEFINED, DIFFUSE
  YELLOW STREAKS ARE NOTED WITHIN THE PROSTATE GLAND.  NO DISCRETE
  MASSES OR LESIONS ARE NOTED.  THE RIGHT ANTERIOR SURFACE IS INKED
  BLUE, THE LEFT ANTERIOR SURFACE IS INKED BLACK, AND THE POSTERIOR
  SURFACE IS INKED GREEN.  THE SPECIMEN IS SERIALLY SECTIONED AND EVERY
  OTHER SECTION IS SUBMITTED.
               
  SUMMARY OF SECTIONS:
             
  1-1,  PROXIMAL URETHRAL MARGIN, EN FACE, 1 PIECE.
            
  1-2,  LEFT VAS DEFERENS MARGIN AND SEMINAL VESICLE WITH PROSTATE, 2 PIECES.
          
  1-3,  RIGHT VAS DEFERENS MARGIN AND SEMINAL VESICLE WITH PROSTATE, 2 PIECES.
                  
  1-4,  LEFT PROSTATE AT BASE, 1 PIECE.
           
  1-5,  RIGHT PROSTATE AT BASE, 1 PIECE.
           
  1-6,  LEFT PROSTATE DISTAL TO 1-4, 1 PIECE.
             
  1-7,  POSTERIOR ONE HALF OF 1-6, 2 PIECES.
            
  1-8,  RIGHT PROSTATE DISTAL TO 1-5, 1 PIECE.
            
  1-9,  POSTERIOR ONE HALF OF 1-8, 1 PIECE.
              
  1-10,  LEFT PROSTATE DISTAL TO 1-6, 2 PIECES.
          
  1-11,  POSTERIOR ONE HALF OF 1-10, 1 PIECE.
          
  1-12,  RIGHT PROSTATE DISTAL TO 1-8, 1 PIECE.
             
  1-13,  POSTERIOR ONE HALF OF 1-12, 1 PIECE.
            
  1-14,  LEFT DISTAL URETHRAL MARGIN, SECTIONED, 3 PIECES.
              
  1-15,  LEFT DISTAL URETHRAL MARGIN, SECTIONED, 6 PIECES.
            
  1-16,  RIGHT DISTAL URETHRAL MARGIN, SECTIONED, 8 PIECES.
          
  1-17,  RIGHT DISTAL URETHRAL MARGIN, SECTIONED, 7 PIECES.



19. SAMPLE AJCC/UICC CHECKLIST. 
     TUMOR QUANTITATION:
     PROPORTION (PERCENT) OF PROSTATE INVOLVED BY TUMOR:  20%.
                       
     EXTRAPROSTATIC EXTENSION:  ABSENT.
              
     SEMINAL VESICLE INVASION:  ABSENT.
                    
     MARGINS:  NEGATIVE.
                       
     PERINEURAL INVASION:  PRESENT.
                                       
     VENOUS (LARGE VESSEL) INVASION:  ABSENT.
                 
     LYMPHATIC (SMALL VESSEL) INVASION:  ABSENT.
            
     TNM STAGE:  pT2N0MX.

20. TNM STAGING.


TUMOR STAGING:
T1a ... Not palpable; <5% of resected tissue.
T1b ... Not palpable; >5% of resected tissue.
T1c ... Not palpable; positive needle biopsy only.
T2a ... Confined to prostate; < half lobe.
T2b ... Confined to prostate; 1/2 - 1 lobe.
T2c ... Confined to prostate; both lobes.
T3a ... Unilateral extracapsular extension.
T3b ... Bilateral extracapsular extension.
T3c ... Involves seminal vesicle.
T4a ... Bladder neck, external sphincter, rectum.
T4b ... Levator muscles, pelvic wall.

NODAL STAGING:
N0 ... None.
N1 ... Single lymph node <2 cm.
N2 ... Single lymph node 2-5 cm; or multiple lymph nodes all <5 cm.
N3 ... Any lymph node >5 cm.

METASTASIS STAGING:
M0 ... No metastases.
M1 ... Distant metastases.





REFERENCES.


1. Rosai J.
Rosai and Ackerman's Surgical Pathology. Ninth Edition.
St Louis: C.V. Mosby. 2004;:.
ISBN: 0323013422, 3080 pages.

2. Mills SE, Carter D, Greenson JK, Oberman HA, Reuter VE, Stoler MH, eds.
Sternberg's Diagnostic Surgical Pathology. Fourth Edition.
New York: Lippincott Williams & Wilkins. 2004;:.
ISBN: 0781740517, 3089 pages.

3. Westra WH, Hruban RH, Phelps TH, Isacson C.
Surgical Pathology Dissection. An Illustrated Guide. Second Edition. With a Forward by Askin FB.
New York: Springer. 2002.
ISBN 0-387-95559-3, 258 pages.

4. Lester SC.
Manual of Surgical Pathology.
New York: Churchill Livingstone. A Harcourt Health Sciences Company. 2001;:.
ISBN 0-443-07918-8, 336 pages.

5. Sinard JH.
Outlines in Pathology.
Philadelphia: W.B.Saunders Company. A Harcourt Health Sciences Company. 1996.
ISBN 0-7216-6341-9, 229 pages.

6. American Joint Committee on Cancer.
AJCC Cancer Staging Manual. Sixth Edition.
New York: Springer. 2002.
ISBN 0-387-95271-3, 421 pages.