HANDLING AND PROCESSING
COLECTOMY SPECIMEN.
DRAFT COPY ONLY.
(Procedure 168).
http://www.netautopsy.org/axsop/axsop168.htm


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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 colectomy 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 colectomy 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. Orient the specimen. The colon is readily distinguished from the small intestine by its larger diameter, and by the longitudinal muscle bands (taenia coli), sacculations (haustra), and appendices epiploicae. When opened (step 10), the colon shows discontinuous mucosal folds, whereas the small intestine shows continuous mucosal folds that extend around the entire circumference.

3. The cecum, transverse colon and sigmoid colon have a shiny peritoneal surface. The ascending colon, descending colon have a shiny anterior peritoneal surface, and a dull posterior surface of cut fibroadipose tissue, i.e., no peritoneal surface. The rectum has a dull surface of cut fibroadipose tissue all the way around.

4. If the specimen is an ileocolectomy, then there will be a segment of ileum (small intestine), the ileocecal valve, and an appendix, all of which should be noted in the dictation and measured.

5. If only a small segment of small intestine or colon are submitted, then the surgeon should mark one of the surgical margins (proximal, distal) with a suture, and note its position in the Tissue Examination Form.

6. If no orientation is given in the Tissue Examination Form. then this fact should be noted in the dictation, and every effort should be made to determine nearby distinguishing structures or lesions. In some cases where it is clinically relevant, the surgeon should be contacted for additional orientation.

7. Record the length and diameter of the entire specimen, and the distance from the proximal and distal margins from any significant landmarks or structures, such as polyps and tumors.

8. The ascending colon, descending colon, and rectum have a dull surface (i.e., non-peritoneal surface) of cut fibroadipose tissue, and represent deep surgical margins that should be inked.

9. Fix the specimen overnight.

10. Before cutting, note position of any tumor masses by palpation. Cut the bowel along the edge OPPOSITE the main tumor mass. Make an effort to avoid cutting through any tumor masses.

11. If no tumor is appreciated grossly, then open the small intestine along the mesentery; open the colon along the anterior (free) tenia; the rectum along the anterior midline.

12. Describe the tumor in relation to margins, and any landmarks (e.g., appendix, ileocecal valve, pectinate line). Describe the size of the tumor, and configuration (exophytic, endophytic, pedunculated, sessile, infiltrative, annular).

13. Make multiple parallel sections through the tumor at 2-3 mm. Describe depth and relation to muscularis propria and serosa.

14. Describe the mucosa (unremarkable, hemorrhagic, cobblestoned, edematous, etc.), the muscularis propria (thin, thick, diverticula, perforations), and the serosa (shiny, dull, hemorrhage, nodules).

15. Examine lymph nodes on the attached soft tissue or mesentery. Divide the lymph nodes into level 1 (proximal to tumor), level 2 (underneath tumor), and level 3 (distal to tumor).

16. For staging purposes, it is necessary to have at least 13 lymph nodes for microscopic evaluation. If one falls short of this number, then the prosector should submit at least 13 pieces of nodular soft tissue.

17. Submit at least three sections of tumor: from the middle surface, from the lower extent of the tumor, and from the edge of the tumor with normal mucosa.

18. Submit proximal and distal surgical margins. Submit a deep margin underneath the tumor.

19. Sample any other lesions and structures: polyps, diverticula, ileocecal valve, terminal ileum, appendix.



FIGURE 168.001.0. Total colectomy specimen.
Total colectomy specimen.




FIGURE 168.002.0. Right hemicolectomy specimen.
Right hemicolectomy specimen.



SAMPLE DICTATION. 
  PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
                 
  1.  SPECIMEN #1 IS RECEIVED IN FRESH, LABELED WITH THE PATIENT'S
  IDENTIFICATION AND "RIGHT COLON (P)", AND CONSISTS OF ONE RIGHT
  HEMICOLECTOMY SPECIMEN, CONSISTING OF A PORTION OF TERMINAL ILEUM,
  CECUM AND PORTION OF RIGHT COLON, WITH APPENDIX PRESENT.
  THE SPECIMEN MEASURES ... IN LENGTH.  THE SPECIMEN WAS RECEIVED
  PREVIOUSLY OPENED FROM THE OPERATING ROOM.  THE SEROSAL SURFACE
  IS MOSTLY COVERED BY LOBULATED, YELLOW ADIPOSE TISSUE, WITH A
  SMALL AMOUNT OF SMOOTH, GLISTENING, TAN-PINK SEROSA VISIBLE.  THERE IS
  A CIRCULAR, ERYTHEMATOUS, ULCERATED MUCOSAL LESION WITH ROLLED UP
  BORDERS IN THE CECUM.  THE LESION MEASURES ... CM, WITH A CRATER
  DEPTH OF ... CM.  THE CUT SURFACE OF THE LESION IS FLESHY TAN-PINK.
  THE LESION EXTENDS TO A DEPTH OF ... CM, AND APPEARS TO INVADE UP TO,
  BUT NOT THROUGH, THE SEROSA.  THE LESION IS LOCATED ... CM
  FROM THE ILEOCECAL VALVE, ... CM FROM THE PROXIMAL ILEAL MARGIN,
  AND ... CM FROM THE DISTAL COLONIC MARGIN.  THE REMAINING MUCOSA IS
  SMOOTH, GLISTENING AND LIGHT TAN WITH THE NORMAL MUCOSAL FOLDINGS
  NOTED.  A SECOND POLYP-LIKE LESION, MEASURING ... CM IN GREATEST
  DIMENSION, IS LOCATED ... CM FROM THE DISTAL COLONIC MARGIN.  THE
  RADIAL MARGIN IS INKED BLACK AND REPRESENTATIVE SECTIONS ARE SUBMITTED.
                     
  SUMMARY OF SECTION:
                       
  2-1,  PROXIMAL SHAVE MARGIN, 1 PIECE.
                        
  2-2,  DISTAL MARGIN, SHAVE, 1 PIECE.
                       
  2-3,  CECUM MASS, 1 PIECE.
                            
  2-4,  CECUM MASS, WITH ILEOCECAL VALVE, 1 PIECE.
                         
  2-5,  CECAL MASS WITH NORMAL MUCOSA, 1 PIECE.
                           
  2-6,  CECAL MASS WITH RADIAL MARGIN/FAT, 1 PIECE.
                         
  2-7,  POLYP, 1 PIECE.
                        
  2-8,  LYMPH NODES AND PROXIMAL ONE THIRD OF SPECIMEN, MULTIPLE PIECES.
                      
  2-9,  TWO LYMPH NODES AND OVERLYING MASS, ONE TRISECTED AND INKED,
      4 PIECES.
                
  2-10,  TWO LYMPH NODES AND OVERLYING MASS, BOTH BISECTED, ONE INKED
       BLUE, 4 PIECES.
             
  2-11,  POSSIBLE LYMPH NODES AND OVERLYING MASS, MULTIPLE PIECES.
              
  2-12,  LYMPH NODES AND DISTAL THIRD, 5 PIECES.
             
  2-13,  LYMPH NODES AND DISTAL ONE THIRD, MULTIPLE PIECES.
             
  2-14,  APPENDIX, 3 PIECES.



SAMPLE AJCC/UICC PROTOCOL. 
              
     AJCC/UICC PROTOCOL.  RIGHT HEMICOLECTOMY.
                   
     MACROSCOPIC: SPECIMEN TYPE: RIGHT HEMICOLECTOMY.
                        
     TUMOR SITE: ASCENDING COLON.
                         
     TUMOR CONFIGURATION: ULCERATING.
                  
     TUMOR SIZE: 3.8 X 2.9 X 0.8 CM.
                       
     MICROSCOPIC: HISTOLOGIC TYPE: ADENOCARCINOMA.
                     
     HISTOLOGIC GRADE: LOW-GRADE.
                        
     PROXIMAL MARGIN: UNINVOLVED.
                       
     DISTAL MARGIN: UNINVOLVED.
                          
     CIRCUMFERENTIAL MARGIN: UNINVOLVED.
                         
     LYMPHATIC INVASION: ABSENT.
                       
     VENOUS INVASION: ABSENT.
                           
     PERINEURAL INVASION: ABSENT.
                                       
     ADDITIONAL PATHOLOGIC FINDINGS: NONE.
                                  
     PATHOLOGIC STAGING: pT3N1MX.  ONE OF ELEVEN LYMPH NODES INVOLVED.



TNM STAGING.


TUMOR STAGING:
Tis ... Intraepithelial carcinoma or lamina propria invasion.
T1 ... Submucosal invasion.
T2 ... Muscularis propria or subserosal invasion.
T3 ... Subserosal or other pericolic invasion.
T4 ... Adjacent structures or through peritoneum.

NODAL STAGING:
N0 ... None.
N1 ... 1-3 pericolic or perirectal nodes.
N2 ... >4 pericolic or perirectal lymph nodes.
N3 ... Lymph nodes along vascular trunk or apical node involvement.

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



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      16. Maryland Department of Health and Mental Hygiene. Center for Cancer Surveillance and Control.
Colorectal Cancer: Minimal Elements for Screening, Diagnosis, Treatment Follow up, and Education. June, 2005.
Maryland Department of Health and Mental Hygiene. Center for Cancer Surveillance and Control.
201 West Preston Street Baltimore, Maryland 21201. For additional information please contact: Diane Dwyer, MD, ddwyer@dhmh.state.md.us, 410-767-5088
http://www.fha.state.md.us/cancer/html/colcan.html