Nephrectomy grossing, Prostate grossing

1. NEPHRECTOMY
SPECIMEN
GROSSING
DR.POOJA DWIVEDI
DEPARTMENT OF PATHOLOGY
KING GEORGE’S MEDICAL UNIVERSITY, LUCKNOW
LIVE TO SERVE! Sincerity Service Sacrifice!

2. KIDNEY:INTRODUCTION
Nephrectomy specimens are most important in
view of Renal cell carcinoma which is most
common primary malignant tumour of kidney.
Classification of kidney neoplasms is based on
combination of histological,genetic and
immunohistochemical features.

3. Surgical Anatomy:
Kidneys are paired abdominal organs situated on each
flanks retroperitoneally.
Normal adult kidney measurements:
10 to 13cm long
5 to 7.5 cm wide
150grams weight
#Each kidney enclosed in transparent membrane called
RENAL CAPSULE.
One side of kidney is convex and other side is concave
indented,giving it a bean shape appearance.

5. On cutting,kidney Is divided into two main areas:
Renal cortex-lighter outer area
Renal medulla- Darker inner area
Within medulla there are cone shape sections known as RENAL
PYRAMIDS.
Area between renal pyramids called RENAL COLUMNS.
Collecting system of is comprised of minor and major calyces
which finally joins to form PELVIS which continues as URETER.
RENAL SINUS: concave cavity within kidneyoccupied by renal
pelvis,renal calyces,blood vessels,nerves and fat.

9. TYPES OF SPECIMEN:
RADICAL NEPHRECTOMY
PARTIAL NEPHRECTOMY

10. RADICAL NEPHRECTOMY
Radical nephrectomy consists of Kidney,most of
the Ureter,Renal vein and artery,perinephric fat
and Gerota’s fascia.
Adrenal gland may or may not present.

12. PARTIAL NEPHRECTOMY
Partial nephrectomy is
usually performed for
clinical stage T1a tumour
Vascular and ureteral
structures generally do
not accompany partial
nephrectomy specimens.
Perinephric soft tissue will
also usually not be
included.

14. FIXATION OF SPECIMEN
Routine fixation is done in
10% buffered formalin
after bivalving the kidney.

16. STEPS IN GROSSING:
Firstly establish the
size,location and
completeness of
resection of tumour
with respect to 3
regions:
Kidney
Renal Hilum
Perinephric tissue

17. RADICAL NEPHRECTOMY
1# Weigh measure entire specimen.
2# Don’t strip off perinephric tissue and renal capsule until their
relation to tumour is determined.
3# Ureter is used to orient the specimen.
4# Ureter arises from medial aspect of kidney and point inferiorly in
continuity with Renal Pelvis at HILUM-anterior to posterior: Renal
Vein, Renal Artery, Renal Pelvis.
5# Shave the ureter,renal vein and artery and submit these sections.
6# Record if any tumour emboli seen at renal vein cut margin.
7# Open ureter,vessels and bivalve the kidney.

19. 8# Describe the tumour as:
Measure size.
Location in terms of upper pole lower pole
Arise from CORTEX or MEDULLA.
Tumour colour.
Any area of haemorrhage and necrosis.
Mension gross capsular invasion:submit section from area of
suspected PERINEPHRIC FAT invasion.
Note and sample area with a homogenous,tan buldging
surface so called FISH FLESH QUALITY,which represent
sarcomatoid dedifferentiation.

21. 9# Describe the hilum:vessel patency,number and
size,color,and lymph nodes.
10# Describe perinephric fat,look for involvement of
ADRENAL GLAND.
11# Serially section the sinus fat at 5mm intervals,and
2 section from interface between the tumour and
sinus tissues.
12# Dissect out perihilar and hilar lymph nodes.

22. SECTIONS TO BE SUBMITTED:
1) Tumour with area of
haemorrhage,necrosis and adjoining renal
parenchyma.
2) Tumour showing FISH FLESH area.
3) Tumour with pelvicalyceal system and
hilar structures.
4) Tumour with renal capsule and if
infiltrated-with perinephric fat.
5) Radial margin of external inked surface.
6) Renal vein section if involved.

23. 7) Ureteric cut margin.
8) Vascular cut margin.
9) Renal sinus.
10) Hilar lymph nodes.
11) Adrenal gland.
12) Unremarkable renal
parenchyma.

24. KEEP CALM !!!
STAY TUNED…

25. PROSTATE

26. INRODUCTION:
PROSTATE are resected for tumours-RADICAL
PROSTATECTOMY
 less commonly for BENIGN HYPERPLASIA-SUPRAPUBIC
PROSTATECTOMY
Transurethral resection of prostate(TURP) are performed to
relieve urinary obstruction,generally for benign disease.
Prostate adenocarcinoma is one of the most frequently
diagnosed carcinoma in men.
Occurs at an increasing rate with advancing age.
At time of diagnosis,prostate cancer may be organ
confined,locally advance or more commonly metastatic
disease.

27. SURGICAL ANATOMY
Prostate is a walnut size gland,located between bladder
and penis.
Prostate is just anterior to the rectum.
Apex is the inferior portion of prostate ,continues with
striated sphincter.
Base is the superior portion and continuous with bladder
neck.
It has 2 lateral surface on either side.

31. Zones in Prostate: 3 zones
CENTRAL ZONE:1-5% of prostate cancers from this
zone
Cone shape region
surrounds ejaculatory ducts.
PERIPHERAL ZONE:70% prostate adenocarcinoma
arise from this zone
posterolateral prostate which
forms majority of prostatic glandular
tissue.
TRANSITIONAL ZONE:20% of prostatic cancers arise from TZ
TZ surrounds prostatic urethra proximal to
veru montanum.

35. TYPES OF SPECIMEN
Radical Prostatectomy
Transurethral Resection of Prostate(TURP)
Suprapubic Prostatectomy or Retropubic Simple
Prostatectomy(Enucleation) for BPH

36. TRANSURETHRAL RESECTION OF PROSTATE
In this multiple fragments are curetted from central transition zone
of prostate in order to relieve obstruction.
For prostate cancer diagnosis,criteria for “Clinically Significant”
prostate cancer have included extent,gradeand age of patient but
no universally accepted definition.
A quarter to third of incidentally found prostate carcinoma will
progress if followed for 10 years.
Likelihood of finding carcinoma on TURP specimen depend on
amount of tissue from TURP.
In some studies limited sampling from prostate has been effective
in detecting all carcinomas defined to be clinically important.

37. CAP recommends examining specimens weighing 12
grams or less in their entirety.
For larger specimens,the first 12 grams should be
submitted (in 6 to 8 cassettes)
Then with one more cassette for each additional 5
grams of tissue.
If firm yellow or yellow orange chips are present,they
should be submitted,as these chips are more likely to
contain carcinoma.

40. Recommendations for submission of
entire specimen:
Patient <60 yrs age.(small low grade carcinoma is
significant in this age.)
Patient with elevated PSA.(may have centrally
located carcinoma.)

41. Steps in grossing:
Weigh the specimen.
Record the dimensions in aggregate.
Describe the fragments including colour(grey/tan-
normal,yellow-tumour),consistency(rubbery-normal,hard-
tumour) and all areas with different
appearance;necrosis,hemorrhage.
Ink the outer surface of specimen identifying surgical margins.
Submit the entire specimen if possible,upto 12 blocks.
For larger specimen follow the protocol.
If carcinoma is present on initial slides,and involves <5% of
tissues,all the remaining tissue is generally submitted.

42. Since the carcinoma tend to be near the capsule and
the clinician may take smaller slices to avoid going
through the capsule,
smaller fragments may be more likely to contain
carcinoma.
For cases with 1 to 2 cassettes,order 2 levels.for 3 or
more cassettes order one level
The proportion of prostatic tissue involve by
tumour(<5% or >5%) is reported.
The number of chips with tumour and total number
of chips also be reported.

43. RADICAL PROSTATECTOMY

44. RADICAL PROSTATECTOMY:
Steps in Grossing
Weigh and measure the prostate gland in 3D:also measure
seminal vesicles.
Orient the specimen and ink the outer aspect of prostate
identifying surgical margin prior to grossing.
After appropriate fixation and inking transect the distal apical
segment.
And serially section it perpendicular to inked surface.
The basal(bladder neck) aspect is commonly doughnut shape
and irregular.
Transect the base from main specimen and serially slice it.

45. Take transverse section of entire prostate.

46. Describe as per:
Any dominant/grossly seen tumour nodule.
Note their size no. and consistency.
If any tumour nodule buldges beyond the contours
of gland,note its location.

47. At the level of seminal vesicle base,includes sections of
prostate along with base of both the seminal vesicles to
look for any direct invasion.
As per grossing protocol entire specimen should be
submitted.
For partial or subtotal submission of specimen,a systematic
approach to include the posterolateral peripheral zone
should be used.
All lymph nodes accompanying the radical prostatectomy
should be submitted for histological analysis after noting
their number,size of LN and their appearance on cut
section.

48. SECTIONS TO BE SUBMITTED:
Apex:entire distal margin
of prostate is taken as a
thick section and then
devided perpendicular to
cut margin so as to look
for exact distance of
tumour(radial) 0n
microscopy.

50. Beginning from apex,the entire prostate need to be
submitted.
Bilateral seminal vesicle.
Sections to include base of vesicle with prostate in
one section.
Base is submitted similar to apex.
Pelvic lymph nodes,right and left.

53. THANK YOU!
PresentedBy:
DR. POOJA DWIVEDI