Partial Penectomy

Successful local control by partial penectomy depends on division of the penis 2 cm proximal to the gross tumour extent. During the operation the skin is incised circumferentially and the cavernous bodies are divided sharply to the urethra. The dorsal vessels are then ligated and the urethra is dissected proximally and distally to attain a 1 cm redundancy. After a dorsal urethrotomy a skin-to-urethra anastomosis is performed and the redundant skin approximated dorsally to complete the closure.

Clinical Presentation

Patients with liver disease may be asymptomatic. The most common clinical sign is jaundice, although other stigmata of hepatocellular disease such as spider naevi, finger-clubbing, gynecomastia, etc. may also be present. If the jaundice is obstructive then the patient will have dark urine and pale faeces. Weight loss, anorexia and anaemia may suggest an underlying malignancy. Fever and rigors may be seen if an abscess is present. Hepatomegaly (enlarged liver) may be encountered in numerous...

Biopsy Specimens

Fine needle aspiration (FNA) cytology has only a very limited role in the diagnosis of primary bone tumours. Bones are obviously deep-seated and due to the hard nature of the tissue do not avail themselves to aspiration cytology. Although this technique is very well established in breast and head and neck pathology it has almost no role to play in the diagnosis of primary bone tumours. Occasionally, radiologically guided fine needle aspiration can be performed where metastatic disease is...

Tumourlike Conditions

Postoperative necrobiotic granulomas seen following transurethral surgery with diathermy. Microscopy reveals central necrosis with peripheral palisading of histiocyes and occasional giant cells. Postoperative spindle cell nodule nodular bladder masses seen up to several months following surgery. Histology shows interlacing fascicles of mitotically active bland spindle cells resembling leiomyosarcoma. Clinical history is most important. Behaviour is benign with spontaneous resolution in many...

Special Sites

Hair hair samples should be plucked, not cut, from the patient and sent unfixed to the laboratory. The hair is mounted unfixed on glass slides and examined for hair shaft anomalies, or to look at the hair roots and count the telogen anagen ratio - this requires a minimum of 50 hairs. Scanning electron microscopy provides more information in patients with hair shaft anomalies and picks up more subtle changes than those seen at light microscopy. Nails fragments of nails may be submitted for...

Resection Specimens

abrading the cortical surface should be avoided in order to preserve the mesothelial lining. each ovary is weighed (g) and measured in three dimensions (cm) and if necessary photographed. The presence of fallopian tubes is confirmed and they are measured. the cortical surfaces of the ovaries may be inked but in general this is not necessary. the cortical surface of each ovary is closely inspected around the whole circumference. The presence of obvious tumour deposits on the capsular surface or...

Proximal Extrahepatic Bile Duct Cancer Resection

bile duct segment - site common bile duct common hepatic duct right or left hepatic duct cystic duct. and maximum dimension (cm) of lesion. tumour - maximum dimension (cm). - site common bile duct common hepatic duct right or left hepatic duct cystic duct intraduct mural extramural involvement of liver. - appearance hepatic resection - segment(s). - dimensions (cm) and maximum dimension (cm) of tumour present. biliary stent - not present present placement (within or outside the lumen). gall...

Procedure

open the pharynx longitudinally with scissors and identify site of tumour. ink the external and mucosal resection margins. slice into 4 mm-thick slices transversely. - length and width of specimen (cm). - dimensions (cm) of mucosal defects and other specimens. maximum depth from reconstructed mucosal surface (cm). distances to closest mucosal and deep surgical margins (cm). mucosal abnormalities. plaque-like ulcerated fungating usual type SCC. warty well-differentiated SC, verrucous carcinoma....

Nonneoplastic Lesions Liver Cysts

Liver cysts may be congenital or acquired (e.g., neoplastic, inflammatory infective, traumatic, etc.). When surgery is to be carried out for a liver cyst an extensive preoperative clinical and radiological work-up is required to ascertain, as closely as possible, its aetiology. An initial thorough laparotomy examination is undertaken. For non-infective cysts, the cyst is opened and the contents aspirated and sent for cytological and microbiological examination. The cyst wall can then be excised...

Nonneoplastic Conditions

Epididymitis primary cause of epididymal obstruction and usually related to cystitis, prostatitis or urethritis that spreads through the vas deferens or lymphatics. It may cause testicular ischaemia and necrosis. Causes include chlamydia trachomatis, neisseria gonorrhoea, E-coli, pseudomonas, other urinary tract infection organisms and rarely tuberculosis and brucellosis. Cysts of epididymal appendix and epididymal cysts the former can twist, necrose and present with pain while the latter form...

Neoplastic Lesions

The key to successful hepatic resection of malignant disease is careful patient selection. In general A primary liver tumour may be considered for resection if it involves a single lobe and there is no invasion of the portal vein or inferior vena cava. There should be little evidence of cirrhosis in the surrounding liver. A solitary metastatic deposit (the vast majority of which will be from a primary colorectal carcinoma) localised to a single lobe may be considered for resection. There should...

Lymphovascular Supply

The internal pudendal artery gives off a branch which provides part of the blood supply to the vulva, which is also contributed to by branches from the femoral artery. The venous drainage follows the arterial blood supply. The lymphatic drainage of each side of the vulva is largely to the ipsilateral inguinal and femoral lymph nodes although some contralateral drainage occurs. Most of the lymphatic drainage is to the superficial inguinal lymph nodes and therefore these are usually the first...

Lymphovascular Drainage

The face, oral tissues and tongue possess many lymphatic channels and display a variable pattern of lymphatic drainage. In general, the tissues of the anterior face and lips drain to lymph nodes in the submental and submandibular regions. The tissues of the lateral face, eyelids and anterior portion of the scalp and external ear drain to lymph nodes around the parotid region. The tissues of the posterior scalp and behind the ear tend to drain to retroauricular and suboccipital lymph nodes....

Iris

Small biopsies of the iris may be taken to confirm and or treat a clinical diagnosis of malignant melanoma. Pigmented lesions of the iris are most often benign naevi. However, serial clinical observations may identify lesions that are growing rapidly, particularly when they involve the filtration angle, have an irregular pattern of growth and show changes in pigmentation. In the laboratory, one uses a dissecting microscope to attempt to orientate the small specimen especially if the operative...

Insitu Hybridisation including FISH

This technique has been regarded as a research tool but improved technologies (proprietary kits and integrated instruments for automated immunohistochemistry and in-situ hybridisation) are leading to clinical applications. In-situ hybridisation may be used to detect viral nucleic acid, examples being the detection of EBV in post-transplant lymphoproliferative disorders or HPV subtyping in cervical biopsies. In-situ hybridisation for k and light chain mRNA may have advantages over conventional...

Initial procedure

palpate and locate the tumour through the perinephric fat. if there seems to be a penetrating tumour, ink the surface prior to opening the perirenal fat capsule. This helps to distinguish true tumour penetration of the perirenal fat and margins from the relatively common finding of elevation of the capsule by a protruding lobulated tumour margin. Ink also the parenchymal kidney resection margin in partial nephrectomy for renal tumours. the initial incision should pass through the midline of...

Histopathology Report

Final reports of oral mucosal resection specimens should include details on the specimen type, side and tissues present. the type of tumour present - SCC variants include basaloid, adenosquamous, spindle cell, verrucous adenocarcinoma (salivary gland types). the grade of tumour assessed at the invasive front. cohesive or non-cohesive patterns (more metastasis with non-cohesive). the extent of local spread. the distance of tumour from the nearest mucosal margin. the distance of the tumour from...

Disorders of the Pericardium

Acute pericarditis due to infection caused by viruses or bacteria. Viruses include coxsackie B, echoviruses, influenza, mumps and Epstein-Barr virus. Bacterial pericarditis may be due to Staphylococcus aureus, Streptococci or Haemophilus influenza. Tuberculous pericarditis usually becomes chronic. Acute pericarditis can also be secondary to acute rheumatic fever, myocardial infarction, connective tissue disorders such as systemic lupus erythematosus and rheumatoid disease, uraemia, renal...

Clinical Investigations

Thyroid function is routinely assessed by measuring blood levels of thyroid stimulating hormone (TSH) and, if appropriate, the levels of thyroxine and triiodothyronine in patients with thyroid gland disease, including those with neoplastic conditions. Occasionally calcitonin levels are measured. Elevated plasma thyroglobulin (and calcitonin in medullary thyroid carcinoma) following ablative therapy for malignant disease can indicate recurrence or metastasis. Autoantibodies to thyroglobulin,...

Blocks for histology

The histology should represent the tumour, its deepest extent, the relationship to the bony, mucosal and deep soft tissue margins and changes in adjacent tissues (Figures 13.3, 14.1 and 14.2). Lateral wall of maxillary sinus Upper buccal sulcus Lateral wall of maxillary sinus Upper buccal sulcus Figure 14.1. Left maxillectomy specimen for carcinoma. Suggested siting and orientation of tissue blocks for maxillectomy specimens. (a) View of palatal aspect. (b) View from lateral aspect. (c) View of...

Blocks for Histology Figure

trim off any excess mesenteric fat and only process that which appears abnormal. process in one cassette a 1-1.5 cm longitudinal slice from the tip along with a transverse section from the base. serially section the rest of the appendix transversely at 3 mm intervals with a sharp scalpel. sample five to six slices, approximately one slice per 1-1.5 cm length and process in a separate cassette from that of the tip base. sample any area of mural thinning or focal lesion as indicated by gross...

Blocks for histology Figure 302

sample proximal (base) and distal (apical) margins as described. sample the seminal vesicles at their bases (junction with the prostate) and the vasa deferentia at their limits. each serial section is bisected into right and left halves (and if necessary into superior and inferior quadrants) to fit into routine cassettes and the entire gland processed for histological examination, labelling each block carefully to aid microscopic interpretation. alternatively, some pathologists prefer to...

Blocks for histology Figure 293

transverse section the urethral and ureteric limits. if bilateral ureteric limits are submitted separately, measure the two lengths and sample the proximal surgical margin of each (if orientated by the surgeon), then serially section the remainder and process separately. sample at least four blocks of tumour to demonstrate depth of invasion, distance to perivesical soft tissue margins and relationship to adjacent mucosa, ureters, prostate or other organs. sample any suspicious background...

Benign Conditions

As alluded to above, surgery for chronic peptic ulceration is now unusual. It aims to remove the gastric ulcer and the gastrin-producing G cells that drive acid secretion. This is accomplished by a Bilroth I distal gastrectomy with a gastroduodenal anastomosis (Figure 2.3). Alternatively, blockage of gastric innervation is achieved by transecting the vagus nerve trunks as they emerge through the diaphragmatic hiatus (truncal vagotomy) resulting in reduced gastric secretions and motility....

Anatomy

The external nose contains the right and left nostrils (or nares), each communicating with the nasal cavities via a slight dilatation just inside the nostril called the nasal vestibule. Bone from the frontal, maxillary and nasal bones supports the upper one-third of the external nose while cartilage supports the lower two-thirds. Each nasal cavity extends posteriorly from just behind the nasal vestibule, through the opening called the anterior choana, to communicate with the nasopharynx via the...

Special Techniques and Considerations

Immunofluorescence immunofluorescent examinations are required for the diagnosis of chronic blistering diseases and are useful in connective tissue diseases. The site of biopsy is important for immunofluorescence, particularly in the blistering disorders. In dermatitis herpetiformis a biopsy for immunofluorescence should be taken from clinically normal skin away from the area of blistering. In the other blistering disorders, perilesional skin is submitted. The skin should have an intact...

Neoplastic Conditions

Benign tumours these are rare, e.g., granular cell tumour. Human papilloma virus (HPV) a common aetiological agent associated with a spectrum of anal viral lesions, preneoplasia (anal intraepithelial neoplasia - AIN) and carcinoma, as well as concurrent lesions of the uterine cervix. HPV subtypes 16 18 are particularly neoplasia-progressive in this viral - AIN - carcinoma sequence. Anal margin perianal skin carcinoma commonly well-differentiated keratinising squamous carcinoma with predisposing...

Omentum and Peritoneum

The omental fat and peritoneal serosa may be involved by various inflammatory and neoplastic disorders. Inflammation acute due to appendicitis or a perforated viscus (GU, diverticulitis), or granulomatous, e.g., tuberculosis, fungal peritonitis (chronic ambulatory peritoneal dialysis (CAPD)) or after previous surgery. CAPD can also be associated with the rare condition of fibrous or scle-rosing peritonitis. Infarction spontaneous, idiopathic omental infarction in the right iliac fossa mimicking...

Inflammatory Lesions

Balanitis circumscripta plasmacellularis ( Zoon's balantitis) occurs in uncircumcised men with an unknown aetiology (possibly autoimmune). It consists grossly of well-defined brown red plaques, solitary or multiple, and clinically resembles erythroplasia of Queyrat. Balanitis xerotica obliterans (BXO) this is the male equivalent of lichen sclerosus et atroph-icus of vulva. It may cause narrowing of the urethral meatus or phimosis. There is a weak association with carcinoma of the foreskin. The...

Pathological Conditions

A variety of tumours, both benign and malignant, may arise within the retroperitoneum. The commoner lesions are discussed here. Liposarcoma arising within the retroperitoneal fat, well-differentiated liposarcoma, particularly the sclerosing subtype, represents one of the commonest histological subtypes. There is a very low risk of metastasis with this type of lesion, which indeed has been described as an atypical lipoma at other sites. However, such lesions can be difficult to excise from the...

Adult Tumours

Oncocytoma represents 4 of renal tumours and usually occurs in adults over 50 as an incidental finding. It has a benign behaviour if strict diagnostic criteria are followed. Grossly it is circumscribed, brown-yellow, with a stellate central scar in larger lesions. It may be bilateral or multifocal and can invade the renal capsule. Histologically it has a sheeted or nested pattern of uniform cells with intensely eosinophilic and coarse granular cytoplasm. Patterns not allowed include papillary...

Benign Tumours

Fibroadenoma this is the commonest benign tumour of the breast, most often encountered in premenopausal women who present with a palpable, painless and mobile discrete lump. Nonoperative diagnosis can be confidently made by the triple approach except in large lesions where excision may be advised to exclude a low-grade phyllodes tumour. Proliferative lesions (radial scar complex sclerosing lesion, intraduct papilloma, nipple adenoma, myoepithelioma) these lesions are due to epithelial...

Specimen Handling

usually multiple fragments, free floating in fixative, non-orientated. place in cassette between foam insert pads or loosely wrap in moist filter paper. align in the block at the embedding stage as this facilitates microscopic assessment and fragments are not missed. separate specimens use separate cassettes and site identification labels appropriate to the request form information. cut through multiple levels. this allows better assessment of mucosal architecture and site distribution of...

Anterior Mediastinal Masses

Neurogenic tumours-neurofibroma, neurilemmoma (schwannoma),ganglioneuroma, ganglioneuroblastoma, malignant schwannoma, neuroblastoma, paraganglioma Unilocular thymic cysts of developmental origin and occur more often in the neck than the mediastinum. The lining may be flattened, cuboidal, columnar or (rarely) squamous epithelium with thymic tissue in the wall. Multilocular thymic cysts acquired and thought to be secondary to inflammation. Some cases are seen in HIV infection. They can mimic an...

The Core Data in Histopathology Specimens

Specimen dissection must be geared to provide information relevant to the clinician who is managing the patient. Reports must be timely, i.e., prompt, but in the context of an adequate period of fixation so that acquisition of accurate data is not compromised. The report content must not only come to an interpretationally accurate diagnosis but also be qualified by assessment of various prognostic indicators. In the field of surgical cancer pathology this is reflected by the trend towards...

Gastrointestinal Specimens

Albores-Saavedra J, Henson DE, Klimstra DS. Tumors of the gall bladder, extrahepatic bile ducts and ampulla of vater. Atlas of tumor pathology. 3rd series. Fascicle 27. Washington AFIP, 2000 Bateman AC. How to handle and report pancreatic specimens. CPD Cellular Pathology 2001 3 94-98 Beckingham IJ (ed). ABC of liver, pancreas and gall bladder diseases. London BMJ Books, 2001 Biddlestone LR, Bailey TA, Whittles CE, Shepherd NA. The clinical and molecular pathology of Barrett's oesophagus. In...

Dissection

Cancer resections for optimal demonstration of the deepest point of tumour spread, its relationship to the CRM and correlation with ELUS CT cross sectional imaging multiple, serial, 3-4 mm thick slices of the cancer in the transverse axis are recommended. The slices can then be laid out in sequence and a photographic or digital record provided. Generally, four or five blocks of the tumour and wall are selected to adequately define the pT stage. Some pathologists leave the tumour segment...

Resections Specimens

Corpus Carcinom

The uterus is usually removed together with the cervix as part of a hysterectomy. Occasionally the cervix is left in situ and a subtotal hysterectomy is performed. Myomectomies may also be performed, especially for uterine fibroids. the specimen is weighed g . the specimen is measured in three dimensions cm , i.e., superior to inferior, medial to lateral, anterior to posterior. the specimen is orientated. The peritoneal reflection extends lower on the posterior aspect of the uterus than...

Surgical Pathology Specimens Laboratory Protocols

Punch Biopsy Alopecia

Punch, ellipse or shave biopsy embedded intact. Figure 37.1. Punch, ellipse or shave biopsy embedded intact. Figure 37.2. Punch, shave or ellipse bisected and embedded. Figure 37.2. Punch, shave or ellipse bisected and embedded. Diagnostic punch biopsy diagnostic punch biopsies come in a variety of sizes ranging from 2 mm to 8 mm. The smaller-sized punch biopsies are usually for diagnostic purposes. The size of the punch is recorded and a description of any lesion seen. Small...

Resection in Neoplastic Conditions

Right Colectomy

Adenomatous polyps as discussed above, the majority of adenomatous lesions can be removed by endoscopic techniques. However, large sessile polyps gt 5 cm in diameter and occupying more than one third of the colon circumference should be removed by a localised resection. Sessile adenomas in the rectum can be removed by transanal submucosal resection. In this procedure adrenaline solution is infiltrated into the submucosa around the lesion and the mucosa is incised rectal stump CIBD, diversion...

Pelvic and Retroperitoneal Specimens

ACTH adrenocorticotrophic hormone MEN multiple endocrine neoplasia syndrome RPLND retroperitoneal lymph node dissection basal cell papilloma seborrhoeic keratosis dysplastic atypical melanocytic naevus pityriasis lichenoides et varioliformis acuta pruritic urticarial papules and plaques of pregnancy

Resection in Nonneoplastic Conditions

Colectomy With Hartmann Pouch

Hartmann's procedure - this is one of the most commonly used emergency operations for colorectal disease. Although this was initially devised for the elective treatment of proximal rectal tumours, it is now usually used in the emergency setting to treat conditions such as perforated diverticular disease most commonly , perforated tumour, etc. The procedure itself is defined as resection of the sigmoid colon and a variable length of proximal rectum if required with the fashioning of a terminal...

Abdominal Wall and Umbilicus

Various conditions can affect the abdominal wall and result in both FNAC and histopathology specimens. Secondary carcinoma commonly due to either gastrointestinal or gynaecological cancer involvement, can be by direct spread at presentation or because of a subsequent metastatic recurrence. The former is not infrequently seen with a perforated bowel cancer and the inner layers of the abdominal wall may be dissected off separately or in continuity with it. The latter tends to be encountered as an...