Selected Biopsy Grossing Techniques

The selected biopsy grossing techniques include only some assorted topics, which are not adequately presented in grossing literature. Actually, they are a sort of grossing remarks, which try to add some details to well known issues to make grossing more diagnostically oriented. These materials certainly reflect my personal experience. They were partially presented during my workshops.

Gynecology

There are four main groups of gynecology biopsies:

Cervical biopsies

Curettage biopsies

Cervical cone biopsies

The Lester’s manual devotes only one line the Cervical Biopsies topic. However, this specimen deserves more than “The color, number of fragments and sizes are noted, and the entire specimen is submitted. But how?

Cervical biopsies arrive in small fragments which usually do not require any section. As a rule, they are in formalin when it is difficult to see the area of the cut, but it is very important for correct embedding to present in the best way the epithelial part. It is necessary to ink the surgical cut area to help the embedding person correctly orient the sample.

 

The sample can be placed in the incision in a foam pad just in the way how it should be embedded. The inked part should be on the side. See the article “Biopsy orientation in the cassette” at the link “Grossing Techniques” of this website and the article Dimenstein IB: Incision in a Foam Pad for Embedding Orientation. The Journal of Histotechnology 2008; 31: 141-142.

Sometimes the sample is so minuscule, that any orientation is impossible. More, often the rest of the content of the container requires filtration as a curettage specimen.

Curettage biopsies endometrial (EMB) and endocervical (ECC) are more difficult than it seems at the first site. The key is in completeness of submission. Filtration of the specimen is obligatory. For many years, I used a diaper pad as the gadget that enhances filtration.

See the articles “Filtration in surgical pathology” at the link “Grossing Techniques” and “Filtration kit for surgical pathology” at the link “Equipment, Instruments, Gadgets”, as well as Dimenstein IB: Baby Diaper Pad for Filtration Biopsies. The Journal of Histotechnology 2006; Vol 29, No. 3. P.204.

Labia biopsy is rather a dermatopathology specimen than gynecology. It should be correctly oriented, preferably by placing in a foam pad incision.

Labia placed in the cassette with foam pad for the best orientation

In my experience, the best way to collect the curettage specimen is wrapping it in lens paper. Other methods (bags, fenestrated cassettes) are less effective due to difficulties during embedding while transferring the specimen in the embedding mold completely.

Products of conception (POC) are substantial part of curettage biopsies. They can be voluminous (in vast majority) or even scarce. The method of collection in SaveGardPower container is not beneficial for surgical pathology grossing. By the way, it is not even satisfactory acceptably in scarce sinus material collection. However, in genecology it is a common practice. Surgical pathology has to adjust methodology for complete and rational submission of the material.

Cervical cone biopsies are in essence surgical procedure of resection due to dysplasia. The main diagnostic targets are transitional zone (squamocolumnar junction and endocervical canal.

I disagree with the methodology of processing described in Lester’s manual as out of touch with modern pathology. For example, scissors take precious material. Only blades should be used. The cone is usually oriented with a 12 o’clock suture. Fixation on the pinned cork is unnecessary for many reasons. The main of them is that it prevents informative inking that is not mentioned at all.

Let’s take “live” specimens on the grossing table. Most of them are irregular in shape and appearance. This is the main difficulty in grossing a cone biopsy specimen.

Cold- knife cervical cone biopsy.

After necessary measurements and description of the cone’s shape (short, long, domed, eccentric), the next step is inking. The latter is underestimated, but it is obligatory. Inking serves more as an orientation (including embedding) mark than margin of excision.

Although one color might be satisfactory, the optimal would be two colors inking to distinguish squamocolumnar junction (the description of the later is very desirable, but practically difficult).

Dissection for blocking is performed after ink is secured. If the endocervical canal is narrow or the cone is rigid, the dissection goes along a orientation probe. Usually a forceps can be inserted.

Although most manuals recommend sequential sectioning clock wise from the orientation suture, I my experience, depending on the concrete shape of the cone, the best way is to divide in two parts along the forceps directly through the suture, then in quarters, and blocking sequentially every quarter while trying to get 2-3 mm thick sections. For orientation during embedding, sections less than 2 mm are difficult due to curling that will provide uneven microsections. In general, a well-shaped block with all layers  (external os, endocervical canal, and portio) on the display is most desirable. Thicker better than thinner. There is not any norm of section (for instance, obligatory 12) depending of the size and shape of the cone.

  

 

  

 

  

Loop Electrocautery Excision Procedure (LEEP)

LEEP cone biopsy can be in one fragment or more (2-4) fragments.

Orientation inking is obligatory although inked area does not represent a real margin due to cauterization. The specimen is rarely oriented by a suture, but sequential blocking (2-3 mm) is appropriate with the presentation of all layers.

 Gastroenterology

Obviously, small biopsies in gastroenterology require a different methodology of grossing than larger biopsies although the goal to provide the pathologist with most informative diagnostic material is the same. The bottom line is that small biopsies (esopagusl, stomach, duodenum, jejunum and colon) should not be treated like a seeds planted in the ground. Every biopsy has an area of the connection with the organ. This area should be recognized. Small gastroenterology biopsies arrive usually in fixative (formalin).  A pin point of tan brown acid formalin hematin (if the fixation is complete) or different variant of discoloration show the area of biopsy procedure. This area in ideal should be on the periphery for embedding. It is not easy but  the grossing should help in this regard although in practice rarely used. Anyway, if it is possible the area of biopsy should not be down or up during embedding. in rare occasion, for example in duodenum biopsy for celiac disease this ought to be done to provide the maximum diagnostically valuable material.

Antrum

Gastric polyps

Duodenum

By the way, below are two similar specimens in handling, but from different areas.

Supraglotic biopsy

The dot looks definite

Bladder biopsies

 

The biopsy area is inked

Endoscopic-polypectomy specimens

The precise description of the size (diameter of the head), ulcerations (if any), surface (smooth, papillary, nodular, cerebriform). The presence of any unusually firm areas is important to notice.

Large polyps (greater than .4 cm)

All polyps, sessile or pedunculated) have a similar methodology of grossing processing.

1/ Identify the surgical line of excision site and ink this area. It is not right to rely on the cautery artefacts to define the excision margin. 2/ Cut longitudinally through it slightly to one side of center, leaving as long as stalk (if any) as will fit into the cassette. 3/ Cut the rest of the polyp into 4 mm slices. It is technically difficult and unwise to try thinner sections unless there are some gadget to immobilize the specimen. Otherwise, the polyp falls apart in small fragment. The main technological feature is immobilization.

Villous rectal polyp

The polyp always falls apart during sectioning. The goal is to minimaze this. The sectioning requires a frech blade, the sharpest. A mold like surface of the cutting board. The section starts in the middle throu the stalk to peripery.

A flat branch paddle forceps is useful, especially if a villous polyp supposed to be cut.

Coral sigmoid polyp require an initial cut through the center, and then to the both sides.

Large polyps (over 3 cm) are extremely rare. A usual rule sounds as one section for every one cm of diameter, but anyway the specimens should be submitted entirely.

Below is an example of a edematous villous colon polyp, which requires cuts along the vessels.

Sessile giant colon polyp

After inking the root, this sessile polyp should be cut in the way to present the main “stem” with subsequent sections along the widest configuration.

Every smal sessile colon polyp ought to be inked at the area of biopsy

The method of Suction Polyp Trap™ does not provide complete submission because some parts of the polyps or other tissue are trapped in the holes of the perforated vials.

Endoscopic mucosal resection

Endoscopic mucosal resections have three functions: diagnostic, potentially therapeutic, and prognostic to determine further treatment. The specimen is represented by a dome-shaped lesion. After formation of a submucosal bulla by injection of saline and epinephrine, the lesion is lifted with grasping forceps and a snare is looped around above the muscularis propria. After strangulation of the mucosa, the specimen is resected with application of electrocautery leaving a nonbleeding ulcer on the wall.  A resection is qualified as complete when all margins including deep and lateral are negative. The initial and last en-face slices should be negative. All technological efforts during grossing are devoted to answer this question. Piecemeal resections are usually difficult to evaluate.

There are steps in grossing processing of the gastric/esophagus/duodenum endoscopic mucosal resection specimen:

a/ measurement, assessment of the lesion;

b/ stretching and pining on wood/cork/wax flat surface;

c/ photography;

d/ inking of deep and lateral margins; in this regard, application of different colored inks is advisable;

e/ fixation in formalin 24 hours;

f/ slicing at 2-3 mm intervals with margins as 2 mm;

g/ submission in coded cassettes for serial sequentially ordered sections.

 Gall bladder

Although a gall bladder is not a biopsy, the grossing person who does biopsies gross usually a gall bladder. It is reasonable to present some practical issues especially due to my personal take of grossing this very frequent specimen.

Under conditions of laparoscopic cholecysectomy, it is reasonable to start from the gall bladder’s neck which is the most frequent area of pathology, including tumors.

The ductus cysticus is incted at the line of resection.

The clamps are taken out.  Although the old manuals recommend to start opening and sections from the fundus, in my experience, it is reasonable to go serially from the neck toward the fundus while separating them in different cassettes. The gall bladder requires at minimum three cassettes although in practice are two. In an remarkable gall bladder, this might be right, but most gall bladders are “unremarkable” due to wrong sections and inexperience of the grossing person.

Gall bladder with diverticulosis and entrapt calculi in the wall, predominately at the fundus. These calculi generate often transitional pain, especially after fat meals due to contractions of the fundus. In the beginning, when the calculi are sharp they are more symptomatic.

 

 

 

2 Responses to Selected Biopsy Grossing Techniques

  1. Dorcas Musvibe says:

    I really found your website very useful. With your permission can I please use some of this information for my portfolio

    Kind regards

    Dprcas

    • izakd says:

      Of course. This is an educational laboratory website. If somebody can use it, the efforts to create and maintain it are justified.
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