Surgical Pathology Dissection

Springer Science+ Business Media, LLC

Surgical Pathology Dissection An Illustrated Guide

Ralph H. Hruban, M.D. Department of Pathology The Johns Hopkins University School of Medicine Baltimore, MD

Timothy H. Phelps, M.S. Department of Art as Applied to Medicine The Johns Hopkins University School of Medicine Baltimore, MD

William H. Westra, M.D. Department of Pathology The Johns Hopkins University School of Medicine Baltimore, MD

Christina Isacson, M.D. Department of Pathology The Johns Hopkins University School of Medicine Baltimore, MD

With a Foreword by Frederic B. Askin, M.D.

Springer

Ralph H. Hruban, M.D. Department of Pathology Meyer 7-181 The Johns Hopkins Hospital 600 North Wolfe Street Baltimore,MD2~~~,USA

Timothy H. Phelps, M.S. Department of Art as Applied to Medicine The Johns Hopkins University School of Medicine 1830 East Monument Street, Suite 7000 Baltimore, MD 21205-2100, USA

William H. Westra, M.D. Department of Pathology Meyer7-181 The Johns Hopkins Hospital 600 North Wolfe Street Baltimore. MD 2~-6971. USA

Christina Isacson, M.D. Department of Pathology Vt.rginia. Mason Medical Center 1100 Ninth Avenue, C6-Path Seattle, WA 98101, USA

CD'Dtr iUustration: Pancreaticoduodenectomy for cancer of the pancreas. A single section can be taken to demonstrate the relationship of the carcinoma to the pancreas, to the bile duct, to the ampulla of Vater, and to the duodenum. lliustration by Timothy H. Phelps.

With 50 lliustrations Library of Congress Cataloging-in-Publication Data Surgical pathology dissection : an illustrated guide I Ralph H.

Hruban ... et al.; foreword by Frederic B. Askin. p. em.

Includes bibliographical references. ISBN 978-0-387-94567-5 ISBN 978-1-4757-2548-3 (eBook) DOI 10.1007/978-1-4757-2548-3 1. Pathology, Surgical-Laboratory manuals. 2. Human dissection­

-Laboratory manuals. I. Hruban, Ralph H. [DNLM: 1. Pathology, Surgical-laboratory manuals.

2. Dissection-laboratory manuals. WO 142 59615 1995] RD57.587 1995

617'.07-dc20 DNLM/DLC for Library of Congress 95-24467

Printed on add-free paper.

© 1996 Springer Science+Business Media New York Originally published by Springer-Verlag New York, Inc. in 1996

All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher Springer Science+Business Media, LLC, except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or here­after developed is forbidden. The use of general desaiptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no war­ranty, express or implied, with respect to the material contained herein.

Production managed by Terry Kornak; manufacturing supervised by Jacqui Ashri. Typeset by Bytheway Typesetting Services, Inc., Norwich, NY.

9 8 7 6 5 4 3 2

ISBN 978-0-387-94567-5 SPIN 10842292

To the Breakfast Club. Fond memories of hooping it up.

To my wonderful wife, Claire, and our three terrific children, Zoe, Emily, and Carolyn

Ralph H. Hruban

To Mike, brother and friend William H. Westra

To my wife Lyn, for her ever present love and support; my two children, Katie and Kevin, who bring me great and constant joy; to my art instructors of the past for all they have shared with me; and particularly and most importantly, my Father; and in loving mem­ory of my Mother

Timothy H. Phelps

To my parents for all their love and encouragement Christina Isacson

Foreword

The modem surgical pathology cutting room is replete with tools of the electronic age. Computers, automatic cassette labelers, bar coding, and even electronic voice-recognition systems are available to help the surgical pathologist be an effective, efficient, and highly productive cog in the machinery of health care delivery. In spite of this automated armamentar­ium, much of our ability to render diagnoses rests with the surgical pathol­ogy ''cutters.'' These personnel need to be trained to handle surgical speci­mens consistently and appropriately, with the goal of providing optimal diagnostic information and adequate pathologic correlation with clinical and radiologic findings.

This dissection manual is an outgrowth of what Waldemar Schmidt has called the "oral tradition" of surgical pathology. Traditionally, the senior pathologist passed down to the trainee an individual accumulation of ex­pertise on the handling of specimens. This transfer of information was often random and based solely on the specific case at hand. Now, despite the importance of training personnel, the exigencies of modem practice limit the amount of time available for individual training, and so most laboratories have developed their own local manual. Unfortunately, many of these manuals are incomplete or not user-friendly.

Drs. Hruban, Westra, and Isacson have prepared this manual with the help of a distinguished and talented medical artist. Tim Phelps's pen and ink drawings bring a unique vitality and multidimensional effect to the reader throughout the manual as dissection techniques are explained and illustrated. The editors and contributors have effectively shared their tal­ents and experience by providing general principles that can be employed to resolve even the most complex problems in dissection and effective tissue sampling. The methods are broadly applicable and unusually easy to follow.

This text should be at hand in all surgical pathology laboratories, where it will be useful to a wide variety of personnel including staff pathologists, residents, pathologist's assistants, histotechnologists, and other laboratory personnel. It is highly likely that many surgeons would also benefit from use of this manual, through which they can gain an understanding of how specimens are dissected and can become familiar with the way in which margin and tumor sampling are carried out.

This is a very practical manual. The authors discuss the clinically impor­tant features of various types of specimens and lesions in each organ sys­tem. They instruct the prosector in every instance as to what information is needed to provide the clearest clinical picture. I suspect that this work

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will be most valuable to the surgical pathology cutter late in the evening or on weekends, when the redoubtable oral historian of surgical pathology is not available. This manual should serve as a cornerstone on which to build a stable but malleable standard of excellence in the surgical pathology cutting room.

Frederic B. Askin, M.D. Professor of Pathology

The Johns Hopkins University School of Medicine

and Director of Surgical Pathology

The Johns Hopkins Hospital Baltimore, MD 21287-6971, USA

Preface

Our goal in writing this book is to provide an illustrated, hands-on guide for the dissection of surgical pathology specimens. It is intended for use by anyone involved in the gross evaluation and handling of surgical tissues, whether they be technicians, pathologist's assistants, medical students, residents, or staff pathologists. Several outstanding dissection manuals, such as Schmidt's Principles and Techniques of Surgical Pathology (1983), pro­vide a comprehensive approach to the evaluation of pathology specimens, but their practical utility in the daily hustle and bustle of a laboratory can be limited. It is our impression that there is a need for an illustrated manual that provides a logical and concise approach to the most commonly en­countered specimens.

This guide begins with an overview of how to approach any surgical pathology specimen and follows with a description of laboratory tech­niques and photography. The remainder of the manual is arranged by organ system. All ranges of specimen types are described, from biopsies to total resections. Each chapter includes a description and illustration of the mechanics involved in handling a specimen as well as a conceptual framework for questions to keep in mind during the dissection. At the end of each chapter, the section entitled ''Important Issues to Address in Your Surgical Pathology Report" includes most of the information needed to provide accurate TNM (the International Union Against Cancer's Clinical Stage Oassification of Malignant Tumors) and FIGO (Federation Intema­tionale de Gynecologie et d'Obstetrique) staging for the majority of tu­mors. The reader may choose to read this manual straight through in its entirety; however, the chapters can also be read selectively, as dictated by the type of specimen encountered. The illustrations are intended to stand on their own and can be easily displayed at the work station. We hope that this illustrated guide will make the dissection of any specimen an informative and enjoyable endeavor.

Ralph H. Hruban, M.D. William H. Westra, M.D.

Timothy H. Phelps, MS Christina Isacson, M.D.

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X

Acknowledgments

The authors thank Amanda Lietman for her superb assistance in prepar­ing, proofreading, and editing this manual and for her patience and under­standing. It is impossible to praise her talents and efforts enough. The authors also thank Drs. Frederic B. Askin and Grover M. Hutchins for their constructive criticism of the book and Drs. Michael Borowitz, David Eisele, Jonathan Epstein, Kristin Fiebelkorn, Stanley R. Hamilton, Zdenek Hruban, Wayne Koch, Ralph Kuncl, Robert Kurman, and Charles Yeo for sharing their expertise. The authors also thank Jane Day, Oaire E. Hruban, and Cheryl Dewyre.

Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Frederic B. Askin

Preface.................................................................................... ix Acknowledgments.................................................................... x Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Chapter 1 Chapter2

Chapter3

Chapter4 ChapterS Chapter6 Chapter7

ChapterS Chapter9 Chapter10 Chapterll Chapter12 Chapter13 Chapter 14 Chapter 15

I. General Approach and Techniques

General Approach to Surgical Pathology Specimens ..... . Laboratory Techniques ............................................ .

William M. Fox, III and Robert H. Rosa, ]r. Photography ......................................................... .

NoTmlln ]. Barker

IT. The Head and Neck

Larynx ................................................................. . Salivary Glands ..................................................... . Complex Specimens ............................................... . Radical Neck Dissection ........................................... .

ill. The Digestive System

2 14

22

30 35 36 40

Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Stomach................................................................ 48 Non-neoplastic Intestinal Disease............................... 52 Neoplastic Intestinal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Appendix ... ....... ....... ..... .. .. .. ... . ... ....... .. ...... ..... ....... 60 Liver..................................................................... 62 Gallbladder............................................................ 68 Pancreas................................................................ 72

IV. The Cardiovascular/Respiratory System

Chapter 16 Heart Valves and Vessels.......................................... 78 Chapter 17 Lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

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xii Contents

V. Bone, Soft Tissue, and Skin

Chapter 18 Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Edward F. McCarthy, Jr.

Chapter 19 Soft Tissue, Nerves, and Muscle . .. . . . . . . . .. . . . . .. . .. . . . . . . . . . . . 96 Chapter 20 Skin...................................................................... 100

Thomas D. Horn

VI. The Breast

Chapter 21 Breast.................................................................... 106

VIT. The Female Genital System

Chapter 22 Vulva.................................................................... 112 Chapter 23 Uterus, Cervix, and Vagina....................................... 116 Chapter 24 Ovary and Fallopian Tube......................................... 130 Chapter 25 Products of Conception and Placentas......................... 136

VITI. The Urinary Tract and Male Genital System

Chapter 26 Penis..................................................................... 142 Chapter 27 Prostate................................................................. 146 Chapter 28 Testis.................................................................... 150 Chapter 29 Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Chapter 30 Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

IX. The Ocular System

Chapter 31 Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Robert H. Rosa, Jr. and W. Richard Green

X. The Endocrine System

Chapter 32 Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Chapter 33 Parathyroid Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Chapter 34 Adrenal Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 178

XI. Pediatric Tumors

Chapter 35 Pediatric Tumors..................................................... 182 Elizabeth J. Perlman

XII. The Central Nervous System

Chapter 36 Brain and Spinal Cord.............................................. 186 Peter C. Burger

XIII. The Hematopoietic and Lymphatic System

Chapter 37 Lymph Nodes . . . . . . . . . .. . . ... . . .. . . . . . . . . . . . .. . . .. .. . . . . . . . . . . . . . . . . . 192 Chapter 38 Spleen................................................................... 196 Chapter 39 Thymus ................................................................. 199 Chapter 40 Bone Marrow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

XIV. Odds and Ends

Chapter 41 Common Uncomplicated Specimens........................... 204

Oosing Comments . . . . . . . . . . . . . . . . . .. . . .. . . . .. . . . . . . . . . . . . . . . . . . .. .. . . . . .. . . . . . . . . . . . 207 References............................................................................... 208 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Contents xiii

Contributors

Frederic B. Askin, M.D. Professor of Pathology, The Johns Hopkins University School of Medicine; and Director of Surgical Pathology, The Johns Hopkins Hospital, Balti­more, MD 21287-6971, USA

Norman f. Barker, M.S., R.B.P. Assistant Professor of Pathology and Art as Applied to Medicine; and Assistant Director of Pathology Photography, The Johns Hopkins Univer­sity School of Medicine, Baltimore, MD 21287-6971, USA

Peter C. Burger, M.D. Professor of Pathology, Oncology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-6971, USA

William M. Fox, III, B.S., M.S. Pathologist Assistant, The Johns Hopkins Hospital, Baltimore, MD 21287-6971, USA

W. Richard Green, M.D. International Order of Odd Fellows Professor of Ophthalmology; and Pro­fessor of Pathology, the Wilmer Ophthalmological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-6971, USA

Thomas D. Horn, M.D. Associate Professor of Dermatology and Pathology, The Johns Hopkins University School of Medicine; and Director of Dermatopathology, The Johns Hopkins Hospital, Baltimore, MD 21287-6971, USA

Ralph H. Hruban, M.D. Associate Professor of Pathology and Oncology, The Johns Hopkins Uni­versity School of Medicine; Assistant Professor of Otolaryngology, Head and Neck Surgery, The Johns Hopkins University School of Medicine; and Director, Division of Cardiovascular-Respiratory Pathology, The Johns Hopkins Hospital, Baltimore, MD 21287-6971, USA

Christina Isacson, M.D. Fellow in Gynecologic Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-6971, USA

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xvi Contributors

Edward F. McCarthy, Jr., M.D. Associate Professor of Pathology and Orthopedic Surgery, The Johns Hop­kins University School of Medicine; and Director, Bone Histomorphometry Laboratory, The Johns Hopkins Hospital, Baltimore, MD 21287-6971, USA

Elizabeth J. Perlman, M.D. Assistant Professor of Pathology, The Johns Hopkins University School of Medicine; and Director, Division of Pediatric Pathology, The Johns Hop­kins Hospital, Baltimore, MD 21287-6971, USA

Timothy H. Phelps, M.S., FAMI, C.M.I. Associate Professor of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-6971, USA

Robert H. Rosa, Jr., M.D. Fellow in Ophthalmic Pathology, The Wilmer Ophthalmological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-6971, USA

William H. Westra, M.D. Assistant Professor of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-6971, USA