FRCPath2Macro_Feb 2012 Final

8/2/2019 FRCPath2Macro_Feb 2012 Final

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The FRCPath SurgicalPathology Module

macroscopic specimens

Helen Baker

Consultant Histopathologist


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CASE 1. BreastKey - Wide local excision for mammography screening detected breastlump.Specimen sliced from medial to lateral aspects.Yellow paint - superiorBlue paint - anteriorRed paint - inferior

1) Indicate on the diagram the blocks you would take from thisspecimen.2) What other information would you record before and during specimendissection?3) How would you modify your specimen dissection for a wide local

excision if a tumour mass was not visible and for DCIS?4) How would you deal with:

a) cavity shaves ?b) sentinel lymph nodes ?

5) What additional blocks would you take in a mastectomy case and givetheir rationale?


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CASE 1. Breast

1) Indicate on the diagram the blocks you would takefrom this specimen.

Tumour and involved / nearest margins. Adjacent fibrotictissue. Anterior and posterior to the tumour/DCIS inlarger WLEs to assess extent of DCIS, which canbe more than measured radiologically,macroscopically. Spreads in this plane, along ducts.Any unusual areas and associated margins.


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Case 1

2) What other information would you record before and duringspecimen dissection?

Accompanying X- Ray present or absent. If lesion is

visible in WLE, describe the lesion. Presence of guide-wireand its relation to the lesion.

Weight of specimen, measurement of specimen in threedimensions. Measurement of tumour in three dimensionsand distance to margins. Record abnormal lesions and

relations to margins. Block code essential, +/- diagram.


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Case 1

3) What additional blocks would you take in a mastectomycase and give their rationale

Tumour to give dimensions and relevant margins

Nipple -areolar complex Paget'sAdjacent / ant and post to tumour for accurate sizing

Any abnormal area and margins

Random quadrantic blocks background breast / occultextensive disease


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Case 14) How would you deal with:a) cavity shaves ?

b) sentinel lymph nodes ?

Cavity shave measure, paint , orientate with different colours if

orientated by surgeon. Serially slice, all embed.Sentinel node radioactive time lapse before dissection.

Measure , record if blue, record size of entire tissue and nodesize, serially slice node at 2mm intervals , CAM5.2 or equivalent

marker, levels. Report H& E and immunos in conjunction.


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Common Errors by Candidates

No mention of X-ray

cavity shave limited to block it all

mastectomy: no mention of backgroundbreast; no mention of axillary tail or lymphnodes

cruciate means like a cross

no block code

gigantic blocks; indiscriminate blocks


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CASE 2. Prostate

1) Indicate on the photograph the blocks you would take from thisspecimen

2) What other information would you record prior to and duringspecimen dissection ?

3) How would you deal with accompanying lymphadenectomyspecimens ?

4) What characteristics of the tumour would you reporthistologically ?

5) What immunohistochemical stains may help you in reportingprostatectomy specimens ?


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CASE 2. Prostate

1) Indicate on the photograph the blocks you would take from thisspecimen

2) What other information would you record prior to and duringspecimen dissection ?

3) How would you deal with accompanying lymphadenectomyspecimens ?

4) What characteristics of the tumour would you reporthistologically ?

5) What immunohistochemical stains may help you in reportingprostatectomy specimens ?


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Case 2 - Answers

Vas margins, apex and base margins, seminal vesicles, slice at 3-5mm intervals, whole mount or extensive sampling of CRM

Weight , size, visible tumour location and size, number of slices,photographs if facilities available. Block code.

Identify and separate nodes. Rest of fat to be processed

Type, differentiation, grade, perineural and vascular invasion,location ant, post, central, lateral, multifocal, zones, % glandinvolvement / volume of tumour, breach of margins, extension intofat, seminal vesicles, involve of apical and base blocks, otherorgans

PSA, PSAP confirming prostatic origin. 34BetaE12 or CK5/6 distinguishing invasive from in situ disease. AMACR increasedexpression in cancer and in situ disease. Combined immunos.


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Common Errors by Candidates

block code

gigantic blocks; indiscriminate blocks

other information: no description of visibletumour

not processing fat for lymph nodes

lots of things left out of Minimum Data Set:why block it if youre not going to write aboutit?

immunos: not mentioning prostatic markers


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Case 3

Soft Tissue -


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Case 3 Soft Tissue

What information would you include in your report ?

Macroscopy

Specimen weighed and measured in three dimensions

Plane of section in which tumour located should be recorded

Measurements of tumour to nearest margins, including anteriorand posterior

Dimensions of tumour

Tumour characteristics cystic areas, solid areas,haemorrhage, necrosis assess percentage, different colours,consistencies.


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Case 3 Soft Tissue

Blocks 1 per cm, at leastBlocks from each different area of consistencyBlocks to include nearest marginsSpecimen less than 50mm m.d. all embedHigh grade lesions diagnosed on biopsy may need fewerblocksDedifferentiated liposarcoma, esp. undifferentiated

pleomorphic sarcomas or myxofibrosarcomas innocuousfatty tissue at edge of lesion sampled thoroughly for welldifferentiated liposarcoma areas


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Case 3 Soft Tissue

Minimal info in report:

1 - Size of tumour

2 - Histological type

3 - Grade, FNCLCC;

4 - Tissue planes involved

5 - Tumour invasive edge; pushing/infiltrative

6 - Margins: Distance to the nearest margin

Tissue forming margin e.g. muscle, fascia

7 - Vascular invasion

8 - Genetic findings


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Case 3 Soft Tissue

What advice would you give to clinicians and thelaboratory after removal of resection specimens and corebiopsies ?

Clinicians Biopsies - Fix in formalin promptly

Some tissue can be separated and frozen in liquid nitrogen -genetic studies.

Encourage clinicians to send resections promptly - fresh sampled for genetic studies, better histology

Easier to orientate before fixation


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Case 3 Soft Tissue

Surgeons should be encouraged to orientate specimens in astandard fashion agreed between both the surgeon and thepathologist, and provide diagrams in particularly complexcases.

Laboratory

Promptly inform pathologist of arrival of specimen, so freshtissue can be taken for cytogenetics and the tissue can bepainted and sliced promptly for optimum tissue fixation.

Shallow H&E sections initially with biopsies to preserve tissuewhich may be required for immunohistochemistry and ancillarytests.

Fatty tissue may require extra fixation before processing.


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Case 3 Soft Tissue

What system of grading is used for sarcomas and whathistological parameters are measured ?

French Federation of Cancer Centers System of Grading

Tumour differentiation

Score 1 Sarcoma histologically very similar to normal adultmesenchymal tissue

2 Sarcoma of defined histological subtype (e.g.myxofibrosarcoma)

3 Sarcoma of uncertain type, embryonal and undifferentiatedsarcomas


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Case 3 Soft Tissue

Mitosis countScore 1 09 10 HPF2 1019 10 HPF3 >20 10 HPF

Microscopic tumour necrosisScore 0 - No necrosis1 < 50% tumour necrosis2 > 50% tumour necrosis

Histological gradeGrade 1 Total score 2 or 3Grade 2 Total score 4 or 5Grade 3 Total score 6, 7 or 8


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Common Errors

no vascular invasion

no tissue planes involved

no margins: pushing/infiltrative no type of differentiation

no information about standard gradingsystem

funny sized blocks

no sampling of different areas


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Case 4 Colon


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Briefly note the macroscopic and microscopic featuresyou would record

Macroscopy

Type of resection

Mucosal abnormalities and distribution of disease process proximal, distal, continuous, patchy

Full thickness of wall involved ?

Fat wrapping

Serosal abnormalities

Adhesions/ attached organs

Case 4 Colon


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Macroscopy

Strictures

Tumours

Polyps/ raised areas

Perforations Prominent nodes

Tissue sampling

Proximal and distal resection margins Mapped samples of bowel at regular (at least10cm) intervals

Note if abnormal or normal mucosa

Interfaces between diseased and non diseased areas

Case 4 Colon


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Tissue sampling

Polyps

Raised areas and sampled flat mucosa around them

Strictures

Tumours

Serosal abnormalities

Attached organs

Sample lymph nodes

Case 4 Colon


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Microscopy Active inflammation

LP cellularity

Crypt irregularities

Mucin depletion

Pattern of inflammation mucosal, transmural ulceration deep fissuring, shallow, perforation

patchy, continuous

granulomata

Fibrosis

Dysplasia/ tumours inc staging. DALMs

Margin involvement/ viability

Supervening infections i.e. CMV

Nodes reactive, granulomata

Case 4 Colon


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What disease entities would you be considering with thismacroscopic picture and what clinical information wouldbe optimal before reporting the specimen ?

Idiopathic inflammatory bowel disease Crohn's disease

Ulcerative colitis

Indeterminate colitis

Pseudomembranous / infective

Ischaemia

Demographics

Imaging

Case 4 Colon


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What disease entities would you be considering with thismacroscopic picture and what clinical information wouldbe optimal before reporting the specimen ?

Involved bowel segments Fistulae/ cutaneous manifestations

Other associated diseases

Topical treatment

Arteriopath ?

Recent antibiotics

Foreign travel

Case 4 Colon


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In the presence of dysplasia, what other histologicalinformation should be given ?

Grade Low or high

Sporadic adenoma type flat, tva, va, serrated. DALM need tissue from around to distinguish

Extent of dysplasia

Associated invasive disease

Margins

Case 4 Colon


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Common Errors

no mention of fat wrapping or of skiplesions

Topography no lymph node or appendix block


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Macro Score Summary

15 candidates submitted their macros

13 Pass mark

1 B/L 1 Fail

Overall you did very well!


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Summary

Sections that were well answered: Breast , Prostate + Colon generally answered well.

Sections candidates struggled on:

Soft Tissue case was less well done.

Candidates only answering about Microscopy findings on report + notmentioning Macroscopy.

Summary of common mistakes:

Not using X-rays in DCIS.

Not mentioning vascular invasion. Not mentioning use of immuno in sentinel node protocol.

Lots of people forgot to say they would document color code andblock key on breast + prostate cases.


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Final advice for candidates

Read the question in full and answereach point.

Explanatory notes next to blocks aboutgeneral approach or significance of

taking a specific block helps examinergain an understanding of yourapproach.


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The End

FRCPath2Macro_Feb 2012 Final

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