viewGASTROINTESTINAL PATHOLOGY GROSSING GUIDELINES Specimen Type: EMR (Endoscopic Mucosal Resection) or ESD (Endoscopic Submucosal Resection) Note: Please page/notify the GI biopsy

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GASTROINTESTINAL PATHOLOGY GROSSING GUIDELINES

Specimen Type: EMR (Endoscopic Mucosal Resection) or ESD (Endoscopic Submucosal Resection)

Note: Please page/notify the GI biopsy fellow on service to review the gross specimen

Procedure:

1. Measure and provide orientation.

a. If unoriented -- ink should be applied on the peripheral and deep margins (1 color only)

b. If oriented, ink peripheral margins differentially (similar to skin specimen; e.g., 12-3:00 blue, 3-6:00 green, 6-9:00 purple, 9-12:00 orange, deep- black) and indicate orientation in the cassette summary

2. Section at 2mm intervals

a. If a gross lesion is identified- section along the axis to allow for evaluation of the lesion to the nearest peripheral margin:

b. If no gross lesion is identified OR if the lesion appears to completely involve all margins, section along the long axis. Take perpendicular sections of the first and last slices to allow for complete evaluation of the margins:

Gross Template: Labeled with the patients name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an [oriented/unoriented] EMR measuring *** x *** cm , excised to a depth of *** cm. [Describe orientation]. [Describe any lesions including size, type, borders, color, shape, distance to all margins]. The specimen is sectioned [provide orientation if applicable] to reveal [describe cut surface]. The specimen is entirely submitted.

The specimen is entirely submitted in [describe cassette submission].

Cassette Submission: 5-10 cassettes

Submit levels sequentially into cassettes

Multiple levels can be placed into the same cassette

The cassette key should clearly indicate what is submitted (ie, A1: level one, perpendicularly, A2: next 3 serial slices, A3: Next 2 serial slices, A4: last slice, perpendicularly sectioned)

Sample Cassette Submission

A1One end, perpendicular

A2- A4 Central sections (lesion: -A3-A4)

A5Opposite end, perpendicular

STOMAS

Specimen Type: END STOMA

Procedure:

1. Measure the length and diameter or circumference of bowel.

2. Measure the location (distance from the closest bowel margin) and diameter of stoma opening.

3. Describe the presence or absence of skin at stoma opening, and the width of skin if present

Gross Template:

Labeled with the patients name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an [intact, disrupted] end ileostomy. The bowel measures *** cm in length x *** cmin diameter. There is a *** cm stomal diameter. Mesenteric/pericolic fat extends up to *** cm from the bowel wall.

The serosa is remarkable for [describe adhesions, plaques, full-thickness defects or is smooth, tan, glistening, and unremarkable]. There [is/ is no] skin present at the stoma site. Mucosa at the stoma site is [red, granular, hemorrhagic, ulcerated] and extends up to *** cm above the surrounding tissue. The remaining mucosa is [pink-tan, red, granular, hemorrhagic ulcerated]. Representative sections are submitted.

Cassette Submission: 1-2 cassettes (additional cassette(s) if necessary to demonstrate pathology)

- Stapled resection margin, shave

- Unremarkable bowel in relation to stoma and skin, if present

Specimen Type: LOOP ILEOSTOMY

Procedure:

1. Measure the length and diameter or circumference of bowel.

2. Measure the location (distance from the closest bowel margin) and diameter of stoma opening.

3. Describe the presence or absence of skin at stoma opening, and the width of skin if present.

Gross Template:

Labeled with the patients name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an [intact, disrupted] loop ileostomy. The bowel measures *** cm in length x *** cm in diameter, with a stoma located in the midportion. The longer limb measures *** cm in length. The shorter limb measures *** cm in length . There is a ***cm stomal diameter. Fat extends up to *** cm from the bowel wall.

The serosa is remarkable for [describe adhesions, plaques, full-thickness defects or is smooth, tan, glistening, and unremarkable]. There [is/ is no] skin present at the stoma site. Mucosa at the stoma site is [red, granular, hemorrhagic, ulcerated] and extends up to *** cm above the surrounding tissue. The remaining mucosa is [pink-tan, red, granular, hemorrhagic ulcerated]. Representative sections are submitted.

Cassette Submission: 2 cassettes (additional cassette(s) if necessary to demonstrate pathology)

- Longer limb in relation to stoma and skin

- Shorter limb in relation to stoma and skin

- Stapled resection margins, shave

Specimen Type: ANASTOMOTIC RING/DONUT

Procedure:

1. Measure the length and diameter

a. The donut may come on an EEA (end to end anastomosis) device. There is no need to comment on or photograph the device.

2. Describe the serosa and mucosa.

3. Serially section bowel and describe the thickness and cut surface of the wall

Gross Template:

Labeled with the patients name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an annular fragment of bowel measuring *** cm in length x *** cm in diameter. The serosa is [pink-tan and grossly unremarkable]. The mucosa is [pink-tan and grossly unremarkable]. The specimen is sectioned to reveal [describe cut surface] with a *** cm average wall thickness. No lesions [or describe lesion and/or abnormality present] are grossly identified. Representative sections are submitted.

Cassette Submission: 1 cassette to include representative sections of bowel wall

*If two rings, submit representative sections of each

ESOPHAGUS

Specimen Type: ESOPHAGECTOMY

Procedure:

- Portions of the esophagus are usually resected to remove neoplasms, and less frequently because of strictures.

1. Measure length of segment and diameter or circumference. Make sure to stretch the esophagus when measuring its length because it shrinks.

2. Measure the length of attached proximal stomach, and its diameter or circumference at the distal gastric margin (if present).

3. Ink external surface of the esophagus at the lesional site.

4. Describe external surface noting areas of retraction, induration, extension of tumor, perforation, presence of enlarged lymph nodes.

5. Open esophagus longitudinally. Record thickness of wall. Describe appearance of the mucosa, noting any areas of ulceration, glandular mucosa (which appears pink or tan), tumors, and the degree of narrowing of the lumen caused by such lesions.

6. Measure and describe appearance (size, color, texture) of ulcers, tumors and strictured segments. Measure the distance from such lesions to the margins of resection and/or GE junction.

7. Stretch and pin the opened esophagus on a board and fix in 10% formaldehyde. If the tumor is large, make several cuts to allow proper fixation.

8. After fixation, cut through tumor or ulcer to assess depth of invasion through esophageal wall.

9. If no tumor is grossly identified (which is often the case after neoadjuvant therapy of the GEJ tumors), then generally the entire ulcerated area is blocked off and submitted.

Gross Template:

Labeled with the patients name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an [intact/disrupted] esophagectomy with [two stapled ends, one opened and one stapled end, etc.]. [Indicate orientation, if provided]. The esophagus measures *** cm in length x *** cm in average open circumference [provide range if there is a significant variation], with a *** cm average wall thickness. [Describe other adherent structures-parietal pleura].

The serosal surface is remarkable for [describe, if applicable]. The mucosal surface is remarkable for a [describe lesion: size (__ x __ x __ cm), shape (e.g. polypoid, ulcerated, fungating), color, consistency (e.g. soft, firm, friable), associated ulceration]. Sectioning reveals the lesion has a [describe cut surface of lesion] and a *** cm maximum thickness. The lesion measures *** cm from the proximal margin and *** cm from the esophageal adventitial margin.

The remainder of the esophageal mucosa is [tan and glistening with unremarkable longitudinal folds or describe any additional lesions, such as ulcers/erosions, polyps, anastomoses, smooth areas with loss of folds, fibrotic areas, etc.]. *** of lymph nodes are identified ranging from *** to *** cm in greatest dimension.

All identified lymph nodes are entirely submitted. [The tumor/fibrotic area is entirely submitted (if applicable, otherwise skip to next sentence)] Representative sections of the remaining specimen are submitted.

Ink key:

Black esophageal adventitial margin

[Additional inking description if proximal/distal margins taken perpendicularly]

Cassette Submission: 15-20 cassettes

Proximal resection margin, shave

Submit perpendicular section if lesion is close to margin

Distal resection margin, shave

Submit perpendicular section if lesion is close to margin

One cassette per 1 cm of lesion (OR at least 5 sections of tumor)

Show maximum depth of invasion

Show nearest approach of tumor to esophageal adventitial margin

Show relationship to unremarkable mucosa

One cassette of uninvolved esophagus

Cassettes sampling any additional pathology in the gross description (ulcers, polyps, etc.)

Submit all lymph nodes identified and adv