Handling Of RadicalHandling Of RadicalProstatectomyProstatectomySpecimensSpecimensAdapted from a review :-Adapted from a review :-Handling of radical prostatectomy specimen.Handling of radical prostatectomy specimen.Histopathology 2012; 60, 118-124Histopathology 2012; 60, 118-124Dept of Oncology-Pathology, Karolinska Institute, stock-Holm, Sweden.Dept of Oncology-Pathology, Karolinska Institute, stock-Holm, Sweden.Thanks to Dr Farzana Habib, our PG TraineeThanks to Dr Farzana Habib, our PG Trainee
BRIEF SUMMARYBRIEF SUMMARY This is a review article by Lars EgevadThis is a review article by Lars Egevad Accurate reporting of radicalAccurate reporting of radicalprostatectomy specimens becoming moreprostatectomy specimens becoming moreimportantimportant Adjuvant therapy given to pts withAdjuvant therapy given to pts withpathological findings indicating a high riskpathological findings indicating a high riskof disease recurrenceof disease recurrence Handling must therefore be standardizedHandling must therefore be standardized Guidelines for gross description, bioGuidelines for gross description, biobanking of fresh tissue, fixation and cuttingbanking of fresh tissue, fixation and cutting
INTRODUCTIONINTRODUCTION Handling of radical prostatectomy specimensHandling of radical prostatectomy specimensis a challenging task for the pathologistis a challenging task for the pathologistbecause: prostate undergoes faster autolysisbecause: prostate undergoes faster autolysisthan most other organsthan most other organs Prostate cancer difficult to identify with nakedProstate cancer difficult to identify with nakedeyeeye Tumors smaller yet more multifocalTumors smaller yet more multifocal Ca very heterogeneous both morphologicallyCa very heterogeneous both morphologicallyand geneticallyand genetically Thus these specimens need to be handledThus these specimens need to be handledwith great care and according to standardizedwith great care and according to standardized
TRANSPORTATION OFTRANSPORTATION OFSPECIMENSPECIMEN Buffered 4% formaldehyde solutionBuffered 4% formaldehyde solution Impairs harvesting of fresh tissueImpairs harvesting of fresh tissue Unfixed material needed for hormonal assays andUnfixed material needed for hormonal assays andmolecular analysesmolecular analyses Volume of formalin 10 times the specimen volumeVolume of formalin 10 times the specimen volume(500ml)(500ml) Proteolytic enzymes in prostatic secretions make itProteolytic enzymes in prostatic secretions make itmore sensitive to autolysis (transported rapidly,more sensitive to autolysis (transported rapidly,kept on ice)kept on ice)
WEIGHING AND MEASURINGWEIGHING AND MEASURING Seminal vesicles and vas deferensSeminal vesicles and vas deferensremoved prior to weighing and measuringremoved prior to weighing and measuring Three dimensionsThree dimensions
HARVESTING OF FRESH TISSUEHARVESTING OF FRESH TISSUE For research purpose, 55.4% academic andFor research purpose, 55.4% academic and7.2% non academic7.2% non academic Several methods have been describedSeveral methods have been described Core biopsiesCore biopsies Shave sections or Punch biopsiesShave sections or Punch biopsies Cytological methodCytological method Freezing of entire sectionFreezing of entire section Freezing of entire slice (liquid nitrogen)Freezing of entire slice (liquid nitrogen) Steu et al recommended precooled isopentaneSteu et al recommended precooled isopentaneor liquid nitrogen rather than CO2 snowor liquid nitrogen rather than CO2 snow Final cutting of the prostate after formalinFinal cutting of the prostate after formalinfixationfixation
FORMALIN FIXATIONFORMALIN FIXATION 2.4mm per 24h2.4mm per 24h < 10mm simple diffusion, > more than 48h< 10mm simple diffusion, > more than 48h Large prostate 6-7cm, several daysLarge prostate 6-7cm, several days Autolytic artefacts impair h/p dx.Autolytic artefacts impair h/p dx. Features of prostate autolysis include retractionFeatures of prostate autolysis include retractionof glandular epithelium from the stroma withof glandular epithelium from the stroma withcollapse of glandular unitscollapse of glandular units Several methodsSeveral methods Formalin injection using 20ml syringeFormalin injection using 20ml syringe Aquarium pump or magnetic stirrerAquarium pump or magnetic stirrer Microwaving for 1-2 minMicrowaving for 1-2 min
INKING AND SLICINGINKING AND SLICING Evaluation of surgical marginsEvaluation of surgical margins Positive surgical margin increasesPositive surgical margin increasesrecurrencerecurrence By definition , cancer glands must reachBy definition , cancer glands must reachink for the margin to be consideredink for the margin to be consideredpositivepositive Minimum 2 different colors for right andMinimum 2 different colors for right andleftleft Adhesion of ink improved by 5% aceticAdhesion of ink improved by 5% aceticacidacid
Sampling with routine sections.Sampling with routine sections.Each transverse slice of prostateEach transverse slice of prostategland (A) is further cut into twogland (A) is further cut into twohalves (B) or four quadrants (C)halves (B) or four quadrants (C)to accommodate the size ofto accommodate the size ofconventional cassettes (D).conventional cassettes (D).The entire prostate was carefullyThe entire prostate was carefullyinked by painting the surface withinked by painting the surface withdifferent colours of ink to ensuredifferent colours of ink to ensureproper orientation and marginproper orientation and marginidentification. The right lobe wasidentification. The right lobe waspainted yellow, and the left lobepainted yellow, and the left lobeblack.black.
SEMINAL VESICLESSEMINAL VESICLES Invasion associated with poor prognosisInvasion associated with poor prognosis Defined as Tumor cells invading theDefined as Tumor cells invading themuscular coat of extra prostatic portion ofmuscular coat of extra prostatic portion ofseminal vesiclesseminal vesicles Embedding of entire seminal vesicles notEmbedding of entire seminal vesicles notmandatory, basal portion and transition tomandatory, basal portion and transition toprostate examined (min requirement)prostate examined (min requirement) Embedding of vasdeferens margin notEmbedding of vasdeferens margin notobligatoryobligatory
FIGURE A, THE PROSTATE SHOULD BE WEIGHED AND MEASURED AFTER THE SEMINAL VESICLES HAVEFIGURE A, THE PROSTATE SHOULD BE WEIGHED AND MEASURED AFTER THE SEMINAL VESICLES HAVEBEEN REMOVED. B, HARVESTING OF FRESH TISSUE BYBEEN REMOVED. B, HARVESTING OF FRESH TISSUE BYSHAVING FROM THE CUT SURFACE. C, HARVESTING OF FRESH TISSUE BY SPLITTING A SLICE OF THESHAVING FROM THE CUT SURFACE. C, HARVESTING OF FRESH TISSUE BY SPLITTING A SLICE OF THEPROSTATE IN SEGMENTS. D, INJECTION OF FORMALIN FOR ENHANCEDPROSTATE IN SEGMENTS. D, INJECTION OF FORMALIN FOR ENHANCEDFIXATION. E, THE PROSTATE MUST BE MOUNTED AND THE CAPSULE PINNED DOWN IF FRESH TISSUE HASFIXATION. E, THE PROSTATE MUST BE MOUNTED AND THE CAPSULE PINNED DOWN IF FRESH TISSUE HASBEEN HARVESTED. F, THE PROSTATE IS INKED WITH ATBEEN HARVESTED. F, THE PROSTATE IS INKED WITH ATLEAST TWO COLOURS AFTER FIXATION.LEAST TWO COLOURS AFTER FIXATION.
TOTAL v/s PARTIALTOTAL v/s PARTIALEMBEDDINGEMBEDDING Prostate cancer not visible at grossProstate cancer not visible at gross Safest method is that entire prostate isSafest method is that entire prostate issubmittedsubmitted Sehdev et al compared 10 protocols forSehdev et al compared 10 protocols forsubtotal embedding, every post. Quadrant andsubtotal embedding, every post. Quadrant andmid ant. Section on each side, saved 7mid ant. Section on each side, saved 7standard blocksstandard blocks Subtotal embedding can decrease the workSubtotal embedding can decrease the workload but additional cutting and new blocksload but additional cutting and new blocksdelays the report and adds further to the workdelays the report and adds further to the work
WHOLE-MOUNT v/sWHOLE-MOUNT v/sSTANDARD SECTIONSSTANDARD SECTIONS Whole-mount sectionsWhole-mount sections• More difficult to makeMore difficult to make• More expensiveMore expensive• Difficult to perform IHCDifficult to perform IHC• Don’t fit into standard slide holdersDon’t fit into standard slide holders Give a better overview and identificationGive a better overview and identificationof multiple tumor foci, lab techs find themof multiple tumor foci, lab techs find themless time consumingless time consumingFigure . A representative whole-mount section of prostateFigure . A representative whole-mount section of prostategland.gland.
Table 1. Obligatory procedures for handling ofTable 1. Obligatory procedures for handling ofradical prostatectomy specimensradical prostatectomy specimens Removal of seminal vesicles before weighing ofRemoval of seminal vesicles before weighing ofprostateprostate Recording of weight of prostateRecording of weight of prostate Recording of three diameters of prostateRecording of three diameters of prostate Inking of prostate with at least two coloursInking of prostate with at least two colours Slicing after full fixationSlicing after full fixation Modified cone method, apexModified cone method, apex Modified cone method, baseModified cone method, base If partial embedding is used, method should beIf partial embedding is used, method should bedocumenteddocumented Embedding of section through the base of theEmbedding of section through the base of theseminal vesicleseminal vesicle
FUTURE PERSPECTIVESFUTURE PERSPECTIVES Clinical managementClinical management Adjuvant treatmentAdjuvant treatment In the near future, h/p examination of theIn the near future, h/p examination of thespecimen will have critical importance forspecimen will have critical importance forpt carept care Fresh tumor tissue for research purposeFresh tumor tissue for research purpose Therefore it is important that standardizedTherefore it is important that standardizedprotocols are developed for the handlingprotocols are developed for the handlingof radical prostatectomy specimensof radical prostatectomy specimens