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 patient’s 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 SubmissionA1 One end, perpendicularA2- A4 Central sections (lesion: -A3-A4)A5 Opposite end, perpendicular

STOMASSpecimen Type: END STOMAProcedure:

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 patient’s 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 ILEOSTOMYProcedure:

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 patient’s 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/DONUTProcedure:

1. Measure the length and diametera. 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 patient’s 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

ESOPHAGUSSpecimen Type: ESOPHAGECTOMYProcedure:

- 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 patient’s 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

o Submit perpendicular section if lesion is close to margin- Distal resection margin, shave

o Submit perpendicular section if lesion is close to margin- One cassette per 1 cm of lesion (OR at least 5 sections of tumor)

o Show maximum depth of invasion Show nearest approach of tumor to esophageal

adventitial margino 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 adventitial soft tissue

o Separate gastric and esophageal lymph nodes- Note: If no gross tumor is present, block out ulcerated/fibrotic

area and entirely submit

Specimen Type: ESOPHAGOGASTRECTOMYProcedure:

- 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.

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 patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an [intact/disrupted] esophagogastrectomy 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. There is a *** cm open circumference at the gastroesophageal junction. Adventitial soft tissue extends up to ***from the esophageal wall. The stomach measures *** cm in length along the greater curvature, *** cm in length along the lesser curvature, *** cm in open circumference at the distal resection margin, and *** cm in average wall thickness. The attached gastric fibroadipose tissue measures *** x *** x *** cm. [Describe other adherent structures].

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 maximum thickness]. The center of the lesion is located [at, proximal to, distal to] the

gastroesophageal junction. The lesion measures *** cm from the proximal margin, *** cm from the gastric margin, *** cm from the esophageal adventitial margin, *** cm from the margin of greater curvature of fat (if applicable), and *** cm from the margin of lesser curvature fat (if applicable).

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.]. The remainder of the gastric mucosa is [tan, rugated, glistening, and unremarkable or describe any additional lesions, such as ulcers/erosions, polyps, 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 Blue – gastric serosa adjacent to tumor[Additional inking description if proximal/distal margins taken perpendicularly]

Cassette Submission: 15-20 cassettes- Proximal resection margin, shave

o Submit perpendicular section if lesion is close to margin- Distal resection margin, shave

o Submit perpendicular section if lesion is close to margin- One cassette per 1 cm of lesion (OR at least 5 sections of tumor)

o Show maximum depth of invasion Show nearest approach of tumor to esophageal

adventitial margino Show relationship to unremarkable mucosa

- One cassette of uninvolved esophagus- One cassette of uninvolved stomach - Cassettes sampling any additional pathology in the gross

description (ulcers, polyps, etc.)- Submit all lymph nodes identified and adventitial soft tissue

o Separate gastric and esophageal lymph nodes- Note: If no gross tumor is present, block out ulcerated/fibrotic

area and entirely submit

STOMACHSpecimen Type: SLEEVE GASTRECTOMYProcedure:

1. Measure the length and range of diameter or circumference of resected portion of stomach.

2. Describe the appearance of serosa and mucosa

Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an [intact, disrupted] sleeve gastrectomy measuring [__x__x__] cm. There is a *** cm in length staple line at the resection margin. Perigastric fibroadipose tissue extends up to *** cm from the gastric wall.

The serosal surface is remarkable for [describe adhesions, plaques, full-thickness defects (perforations or enterotomies) or is smooth, tan, glistening, and unremarkable]. The mucosal surface is remarkable for [describe ulcers/erosions/polyps/loss of folds/nodularity or is pink, rugated, glistening, and unremarkable]. Representative sections are submitted.

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

- Submit two representative sections of stomach wallo Include area of congestion

Specimen Type: GASTRECTOMY (PARTIAL OR TOTAL)Procedure:

1. Describe the type of resection (total, partial) and indicate any additional organs (such as omentum, distal esophagus, proximal duodenum) which are included with the specimen.

2. Describe the serosal surface, noting color, granularity, presence of adhesions, scarring, or perforation.

3. Open the specimen along the greater curvature unless lesion is located along the greater curvature. In that case, the specimen should be opened along the lesser curvature.

4. Measure the specimen along the greater and lesser curvatures, the circumference of the proximal and distal margins.

5. Measure the thickness of the gastric wall and note its consistency.6. Describe the mucosal surface, noting any ulcers, tumors, or other lesions. 7. Description of tumors should include location, size, distance from margins

of resection, consistency, outline and depth of penetration into wall. Where no discrete tumor is found, the nature and extent of any indurated areas should be described. Descriptions of ulcers should include location, size, distance from margins, appearance of the ulcer base and the surrounding mucosa, and depth of penetration into wall.

8. Ink the outer serosal surface overlying the lesion.9. Measure the size of omentum, particularly the width from gastric wall.

Identify the lesser and greater omental resection margins. Describe the distance of lesion from the closest omental margin.

10.Dissect lymph nodes from the specimen, from greater curvature, less curvature, cardia and pylorus, keeping groups of nodes separate.

Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is a [partial/total] gastrectomy measuring *** cm in length along the greater curvature, *** cm in length along the lesser curvature, with a *** cm average open circumference [include open circumference of pylorus if present]. The wall thickness ranges from *** cm in the [location] to *** cm in the [location]. Attached greater omental adipose tissue measures *** x *** x *** cm and lesser omental adipose tissue measures *** x *** x *** cm. [If a portion of esophagus and/or duodenum is present, mention and measure.]

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)] located in the [antrum/body/fundus]. Sectioning reveals the [lesion/mass] has a [describe color, consistency] cut surface and grossly [is superficial, extends into the bowel wall, extends through the bowel wall into the fibroadipose tissue]. The [lesion/mass] measures *** cm from the serosa and *** cm from the nearest omental resection margin, [if applicable].

The remainder of the serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions, such as adhesions, plaques, enterotomies, etc.]. The remainder of the gastric mucosa is [tan, rugated, glistening, and unremarkable or describe any additional lesions, such as ulcers/erosions, polyps, smooth areas with loss of folds, fibrotic areas, etc.]. The gastric wall ranges from *** – *** cm in thickness.[Describe any attached duodenum or esophagus] *** 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 are otherwise submitted.

Ink key:Blue – gastric serosa adjacent to tumor[Additional inking description of any radial/omental margin that may be present][Additional inking description if proximal/distal margins taken perpendicularly]

Cassette Submission:

1. Ulcer: 5-10 cassettes:- If ulcer is small, entirely submit- If ulcer is large submit representative sections

o Including adjacent unremarkable mucosa- Uninvolved body and antrum- Lymph nodes

2. Tumor : 15-20 cassettes- Proximal resection margin (en face)

o Submit perpendicular section if lesion close to margin- Distal resection margin (en face)

o Submit perpendicular section if lesion close to margin- Omental margin- One cassette per 1 cm of lesion (OR at least five sections of tumor

OR if small enough, entirely submit)o Show maximum depth of invasion

Show nearest approach of tumor to gastric serosa Show nearest approach of tumor to radial margin, if

applicable If lesion is a small ulcer – the entire area can be

submitted If lesion is a large ulcer – submit representative

sections with relationship to adjacent mucosao Show relationship to unremarkable mucosa

- Uninvolved body and antrum proximal and distal to tumoro Important because gastric neoplasms often invade

extensively beyond normal appearing mucosa- Cassettes sampling any additional pathology in the gross

description (ulcers, polyps, etc.)- Any attached organs- Submit all lymph nodes identified (16 nodes are suggested)

o Separate lesser curvature and greater curvature lymph nodes

- Note: If no gross tumor is present, block out ulcerated/fibrotic area and entirely submit

- Note: If a lymphoma is suspected, take fresh samples for flow cytometry and cytogenetic studies. A quick frozen section can be used to decide if this is necessary or not. If frozen shows definite carcinoma these steps can be avoided.

SMALL BOWELSpecimen Type: SMALL BOWEL (for TUMOR)Procedure:

1. Measure the length and range of diameter or circumference.2. Describe serosal surface, noting color, granularity, presence of indurated

or retracted areas, perforation, and presence of enlarged lymph nodes.3. Measure the width of attached mesentery. Note any enlarged lymph

nodes and thrombosed vessels or other vascular abnormalities. Identify the mesenteric margin.

3. Open specimen longitudinally along antimesenteric border, avoiding cutting through the tumor.

4. Measure any areas of luminal narrowing/stricture or dilation (length, diameter or circumference, distance to the closest margin), noting relation to tumor.

5. Describe mucosal surface, appearance and size of tumor, including cut surface. Record distance of tumor from resection margins. Note depth of penetration through intestinal wall. If tumor is a polyp, note presence or absence of stalk, configuration.

6. Ink the serosal part outside of the tumor. If tumor grossly puckers the serosa, a section must be taken to show the relationship of the tumor to the inked serosa.

7. Mesenteric margin should be examined grossly and documented.

Gross Template:

Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is a segment of [provide orientation/un-oriented] bowel measuring *** cm in length x *** - *** cm in open circumference with two stapled ends. Mesenteric fibroadipose tissue extends *** cm from the bowel wall.

The serosal is remarkable for [describe, if applicable]. The mucosa is remarkable for a [describe lesion: size (__ x __ x __ cm), shape (e.g. polypoid, ulcerated, fungating), color, consistency (e.g. soft, firm, friable)]. Sectioning reveals the [lesion/mass] has a [describe color, consistency] cut surface and grossly [is superficial, extends into the bowel wall, extends through the bowel wall into the fibroadipose tissue]. The [lesion/mass] measures *** cm from the proximal margin, *** cm from the distal margin, *** cm from the mesenteric margin and *** cm from the serosa [of the bowel wall/of the mesenteric fibroadipose tissue].

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

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

Ink key:Black – mesenteric margin adjacent to tumorBlue –serosa adjacent to tumor[Additional inking description if proximal/distal margins taken perpendicularly]

Cassette Submission: 10-12 cassettes- Proximal resection margin (en face)

o Submit perpendicular section if in relationship to lesion- Distal resection margin (en face)

o Submit perpendicular section if in relationship to lesion- Mesenteric resection margin nearest to tumor (perpendicular

section)- One cassette per 1 cm of lesion

o Show maximum depth of invasiono Show nearest approach to serosao Show relationship to unremarkable mucosao Show relationship to any contiguous or adherent organs

o If lesion is a polyp show the stalk and base in one section if possible

If you need to bisect, maintain relationship of base and bowel wall. You may submit the superficial aspect of the polyp seperately

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

- Submit all lymph nodes identified- Note: When a lymphoma is suspected (frequently intramural),

submit tissue for flow cytometry and cytogenetics studies. Make touch preps from cut surface.

COLONSpecimen Type: COLON RESECTION or TOTAL COLECTOMY (non tumor)Procedure:

A. Diverticular Disease1. Measure length and range of diameter or circumference.2. Describe serosal surface, noting in particular the presence of diverticula,

adhesions, indurated areas, abscesses, or perforations.3. Prior to opening the bowel, the specimen may be flushed with saline and

inflated with formalin, after tying off the ends of the bowel.4. Alternatively the bowel can be opened, pinned out and fixed. The specimen

should be cut serially lengthwise at 0.5-1.0 cm interval. This is the optimal method of demonstrating diverticula.

5. Describe number, location and appearance of diverticula as well as distance to the closest margin. Note if there are any sites of hemorrhage, abscess formation or perforation. The diverticula should be probed to determine if there is perforation if grossly apparent.

6. Describe remainder of mucosal surface, noting any other lesions such as polyps

B. Inflammatory Bowel Disease1. Measure the length and range of diameter or circumference.2. Measure the terminal ileum and right colon separately for right hemicolectomy

specimen. 3. Describe the presence or absence of the appendix for right hemicolectomy

and total colectomy specimens. Measure the length and diameter of the appendix if present.

4. Describe external surface of the bowel, noting color, granularity, indurated areas, perforations, stricture, fistula, anastomoses, distribution of fat, adhesions.

5. Open the specimen longitudinally along the antimesenteric border, and make sure to identify the terminal ileum for total colectomy specimen, which is usually 1-2 cm in length and stapled.

6. Measure thickness of the wall.7. Describe mucosal surface, noting color, ulcers, pseudopolyps, velvety or

indurated areas, cobblestoning. 8. Measure the length, diameter or circumference, wall thickness, location

(distance from the closest margin or ileocecal valve) and appearance of any stenosis/stricture.

9. Describe the length, diameter, location and appearance of fistula.10. Indicate extent of disease involvement, and whether it is diffuse, patchy, focal

or multifocal. Measure the length or area if focal disease, and document the location (distance to closest margin or ileocecal valve).

11.Describe appearance of the mucosa at the resection margins.12.Examine mesenteric tissue for lymph nodes, noting size and appearance of

representative nodes.

C. Familial adenomatous polyposis1. Measure the length and range of diameter or circumference.2. Describe external surface, noting serosal puckering, etc.3. Open the specimen longitudinally.4. Describe mucosal surface, noting polyps, masses. 5. Note estimated numbers of polyps (e.g. <10, 10-50, >100,

innumerable/carpeted with polyps).6. Describe the size range of the polyps. Describe if there is mass lesion(s)

present.7. Indicate extent of involvement by polyps: whether it is diffuse, patchy, focal or

multifocal. Describe the length and location of involved bowel if focal or multifocal.

8. Describe if polyp(s) is present at margin(s) and measure the distance to the closest margin.

9. Examine mesenteric tissue for lymph nodes, noting size and appearance of representative nodes.

D. Trauma (i.e. gunshot wounds)1. Measure the length and diameter or circumference of resected bowel.2. Describe the presence or absence of perforation, and size and location

(distance to the closest margin) of perforation if present.3. Describe other findings, if present, such as hematoma, and their location

and dimension.4. Describe the dimension or width of mesentery.

E. Ischemic Bowel1. Measure the length, diameter or circumference and wall thickness of

resected bowel.2. Describe the color of serosa and mucosa. Measure the length of

discoloration. Describe the color at resection margins.3. Describe the presence or absence of serosal adhesion(s), and the location

(distance to the closest margin) and area of adhesion if present.4. Describe the presence or absence of perforation, and the size and

location (distance to the closest margin) of perforation if present.5. Describe the dimension or width of mesentery, and the presence or

absence of thrombus in mesenteric blood vessels.

Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is a segment of [oriented-provide orientation/un-oriented] bowel measuring *** in length x *** - *** in open circumference with two stapled ends. Fibroadipose tissue extends ***from the bowel wall.

The serosa is remarkable for [describe adhesions, plaques, full-thickness defects (perforations or enterotomies), creeping fat: give the number, size, and relationship to nearest margin]. The mucosal surface is remarkable for a [describe ulcers/erosions/loss of folds/nodularity/perforation/abscess/fistula/anastomosis: give the number, size, and relationship to nearest margin].

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

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

Cassette SubmissionIschemia/volvulus/trauma/obstruction: 2-6 cassettes

- Proximal resection margin, shave- Distal resection margin, shave- 2-3 cassettes of abnormal mucosa

o Perforations/fistulas should be perpendicular sections showing the relationship of uninvolved mucosa to the defect

- 1 cassette of normal mucosa

Inflammatory Bowel Disease (UC and Crohn’s): 10-12 cassettes- Proximal resection margin, shave- Distal resection margin, shave- For diffuse mucosal disease (ulcerative colitis), take 1-2

representative sections (in one cassette) every 10 cm sequentially (either from proximal to distal or vice versa).

o Include transition zone- Representative sections from diseased areas such ulceration,

stricture, adhesion and fistulae. This is usually for Crohn’s disease. In that case, there is no need to take sections every 10 cm.

o Include transition zones of normal and involved areas- Sections of pseudopolyps/polyps. Submit representative polyps

(such as the larger ones) if too many. - A representative section(s) from anastomosis if present. The

location and appearance of anastomosis should be described.- Look carefully for possible dysplasia or carcinoma (e.g. areas of

induration, polyps).- Representative areas of relatively normal mucosa and transitional

areas between relatively normal and dissected bowel.- Sections of the appendix, if present- Representative section(s) of the terminal ileum if it is long enough

(such as that in a right hemicolectomy specimen)- Representative lymph nodes

o In an ulcerative colitis case, lymph nodes are generally inflamed and easy to identify grossly. Avoid the temptation to submit all of the grossly identified lymph nodes. No more than 5 lymph nodes need to be submitted, if there is no cancer.

o Submit no more than 5 lymph nodes

Diverticular Disease: 5-6 cassettes- Proximal and distal resection margins- Representative diverticula

o Including hemorrhagic or indurated areas at bases o Including ones with gross abscess formation and/or

perforation- Few representative lymph nodes

Familial Adenomatous Polyposis: 10-12 cassettes- Look at polyps carefully, if anyone is suspicious for carcinoma,

follow the steps below for neoplastic disease. - If any polyp is suspicious for carcinoma, then that entire polyp

needs to be submitted.- If all polyps appear similar and superficial and none appears to

harbor carcinoma, NOT all of the polyps need to be submitted. Only representative polyps every 10 cm need to be submitted.

- Representative lymph nodes. It is generally a good idea to submit at least 12 lymph nodes even if there is no grossly identified cancer.

Trauma: 2-3 cassettes- Proximal and distal shave margins in one cassette- 1-2 sections to include perforation

Ischemic bowel: 3-5 cassettes

- Proximal and distal shave margins. Both margin shaves can be submitted in one cassette if the specimen is unoriented. Separate in two different cassettes if oriented.

- Two representative sections from grossly most ischemic area(s). If possible, both sections can be submitted in one cassette.

- If more than one segment of bowel is present, two cassettes for each segment: one containing both margins and one cassette containing representative sections from ischemic area(s).

- Two cassettes containing representative sections of large mesenteric blood vessels.

Specimen Type: COLON RESECTION (for TUMOR)Procedure:

1. Measure length and range of diameter or circumference.2. Describe external surface, noting color, granularity, adhesions, fistula,

discontinuous tumor deposits, areas of retraction, induration, stricture, or perforation.

3. Measure the width of attached mesentery if present. Note any enlarged lymph nodes and thrombosed vessels or other vascular abnormalities.

4. Open segment of bowel longitudinally along the antimesenteric border, or opposite the tumor if tumor is located on the antimesenteric border, i.e. try to avoid cutting through the tumor.

5. Measure any areas of luminal narrowing or dilation, noting relation to tumor.

6. Describe tumor, noting size, shape, color, consistency, appearance of cut surface, circumference of the bowel wall involved by the tumor, depth of invasion through bowel wall, and distance from margins of resection (radial/circumferential margin, mesenteric margin, closest proximal or distal margin).a) If resection includes mesorectum, gross evaluation of the intactness of

mesorectum must be included. For rectum, the specimen must also be oriented: anterior, posterior, right lateral, left lateral.

b) For a rectal tumor is close to distal margin, the distance of tumor to the margin should be measured when specimen is stretched. This is usually done during intraoperative gross consultation when specimen is fresh.

c) If the tumor is in a retroperitoneal portion of the bowel (e.g. rectum), radial/retroperitoneal margin must be inked and one or more sections must be obtained (a shaved margin, if tumor is far from the radial margin; and perpendicular sections showing the relationship of the tumor to the inked margin, if tumor is close to the radial margin).

d) If the tumor is in a peritonealized portion of the bowel (e.g. ascending colon), then the serosal surface over the tumor needs to be inked. If tumor grossly puckers the serosa, one or more sections must be taken to show the relationship of the tumor to the inked serosal surface).

e) Mesentric margin is evaluated grossly for tumor involvement for segments with mesentery (transverse and sigmoid colon). The distance of tumor to the mesenteric margin should be described. For other portions of colon (cecum, ascending, descending, and rectum), there is no mesenteric margin. Only radial margin is present, which needs to be examined as described above.

7. Describe the appearance of uninvolved mucosa.8. Describe the size, appearance and location of any additional lesions such

as polyps.9. Dissect mesenteric and pericolorectal adipose tissue for lymph nodes.

Note range of size and appearance of cut surface of lymph nodes.

Gross Template:Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is a [transverse colon, left colon, sigmoid colon, descending colon, total colon, rectosigmoid, other(specify)] . [Indicate orientation if provided]. The colon measures *** cm in length and ranges from *** to *** cm in open circumference, and with a wall thickness ranging from *** to *** cm . [If a portion of small intestine is present, as in a right hemicolectomy, give measurements]. [Mesenteric/pericolic/perirectal fat] extends up to *** cm from the bowel wall. Peritoneum [extends to the distal margin/ terminates *** cm from the distal margin.] Attached omentum measures *** x ***x *** cm. [Describe other attached structures].

The serosa is remarkable for [describe, if applicable]. The mesorectal envelope is [complete/near complete/incomplete] [applicable only to rectal tumors—delete this sentence if not applicable]. The mucosa of the [describe location] is remarkable for a [describe lesion: size (__ x __ x __ cm), shape (e.g. polypoid, ulcerated, fungating), color, consistency (e.g. soft, firm, friable)]. The lesion involves ***% of the circumference of the bowel [describe obstruction or strictures caused by lesion.] Sectioning reveals the [lesion/mass] has a [describe color, consistency] cut surface. The [lesion/mass] [is grossly superficial, extends into the bowel wall, extends through the bowel wall into the fibroadipose tissue (for GISTs or serosa-based lesions indicate layers of bowel wall involved and any associated mucosal ulcertation).] The lesion measures *** cm from the proximal margin, *** cm from the distal margin, *** cm from the [radial/mesenteric] margin [please ask for margin determination if needed], and *** cm from the serosa [of the bowel wall or of the mesenteric/pericolic/perirectal fat].

The remainder of the serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions]. The remainder of the mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions]. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension.

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

Ink key:Black – mesenteric/radial margin overlying lesion Blue – serosa overlying lesion [Additional inking description if proximal/distal margins taken perpendicularly]

Tumor: 15-20 cassettes- Proximal resection margin, shave

o Perpendicular if close to tumor- Distal resection margin, shave

o Perpendicular if close to tumor- Mesenteric/radial resection margin

o Perpendicular section with nearest approach to tumoro OR representative shave

- One cassette per 1 cm of tumor (OR at least 5 sections of tumor)o Show maximum depth of invasiono Show nearest approach to serosao Show relationship to unremarkable mucosao Show relationship to any contiguous or adherent organs

- Radial margin (for segments without mesentery)- If adenomatous polyp with no gross invasion-entirely submit- Cassettes sampling any additional pathology in the gross

description (ulcers, polyps, etc.)- Unremarkable colon

- Note : If no tumor is grossly identified and instead an area of ulceration or scar is present (which is often the case for rectal carcinomas status post neoadjuvant therapy), then the entire ulcer or scar area needs to be submitted.

Specimen Type: RIGHT HEMICOLECTOMY (for tumor)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a(n) [right hemicolectomy or extended right hemicolectomy]. [Indicate orientation if provided]. The colon measures *** cm in length and ranges from *** to *** cm in open circumference and is in continuation with a *** cm in length x *** cm in open circumference segment of terminal ileum. Attached omentum measures *** x *** x *** cm. Mesenteric fat extends up to *** cm from the terminal ileum. Pericolic fat extends up to *** cm from the bowel wall. The attached appendix measures *** cm in length x *** cm in diameter. Mesoappendiceal fibroadipose tissue extends *** cm from the appendix.

The serosa is remarkable for [describe, if applicable]. The mucosa of the [describe location] is remarkable for a [describe lesion: size (__ x __ x __ cm), shape (e.g.

polypoid, ulcerated, fungating), color, consistency (e.g. soft, firm, friable)]. The lesion involves *** %] of the circumference of the bowel [describe obstruction or strictures caused by lesion.] Sectioning reveals the [lesion/mass] has a [describe color, consistency] cut surface. The [lesion/mass] [is grossly superficial, extends into the bowel wall, extends through the bowel wall into the fibroadipose tissue (for GISTs or serosa-based lesions indicate layers of bowel wall involved and any associated mucosal ulcertation).] The lesion measures *** cm from the proximal margin, *** cm from the distal margin, *** cm from the [radial/mesenteric] margin [please ask for margin determination if needed], and *** cm from the serosa [of the bowel wall or of the mesenteric/pericolic/perirectal fat].

The remainder of the serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions]. The remainder of the mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions]. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension.

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

Ink key:Black –radial margin overlying lesion Blue – serosa overlying lesion [Additional inking description if proximal/distal margins taken perpendicularly]

Tumor: 15-20 cassettes- Proximal resection margin, shave (perpendicular if close to tumor)- Distal resection margin, shave (perpendicular if close to tumor)- Mesenteric/radial resection margin (perpendicular section with

nearest approach to tumor)- One cassette per 1 cm of tumor

o Show maximum depth of invasiono Show nearest approach to serosao Show relationship to unremarkable mucosao Show relationship to any contiguous or adherent organs

- If adenomatous polyp with no gross invasion-entirely submit- Cassettes sampling any additional pathology in the gross

description (ulcers, polyps, etc.)- Appendix- 2 cross sections and longitudinally bisected tip- Submit all lymph nodes identified

o Separate lymph nodes into segments of colon

- Note : If no tumor is grossly identified and instead an area of ulceration or scar is present (which is often the case for rectal carcinomas status post neoadjuvant therapy), then the entire ulcer or scar area needs to be submitted.

Specimen Type: LAR (LOW ANTERIOR RESECTION) and APR (ABDOMINO-PERINEAL RESECTION)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an abdomino-perineal resection. [Indicate orientation if provided]. The colon measures *** cm in length from proximal margin to dentate line x *** cm in average open cirucumference and *** cm in open cirucumference at the dentate line. The distance from the dentate line to the margin of resection of perianal skin ranges from *** to *** cm. Pericolic/perirectal fat exends up to *** cm from the bowel wall. The anterior peritoneal reflection is located *** cm from the resection margin of the perianal skin. The mesorectal envelop is [complete, nearly complete, incomplete- describe defects if necessary].

The serosa is remarkable for [describe, if applicable]. The mucosa of the [describe location-sigmoid, rectum, anas, etc.] is remarkable for a [describe lesion: size (__ x __ x __ cm), shape (e.g. polypoid, ulcerated, fungating), color, consistency (e.g. soft, firm, friable)]. The lesion involves***% of the circumference of the bowel [describe obstruction or strictures caused by lesion.] Sectioning reveals the [lesion/mass] has a [describe color, consistency] cut surface. The [lesion/mass] [is grossly superficial, extends into the bowel wall, extends through the bowel wall into the fibroadipose tissue (for GISTs or serosa-based lesions indicate layers of bowel wall involved and any associated mucosal ulcertation).] The lesion measures *** cm from the proximal margin, *** cm from the distal margin, *** cm from the [circumferential radial/mesenteric] margin [please ask for margin determination if needed], and *** cm from the serosa [if located above the level of peritoneal reflection].

The remainder of the serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions]. The remainder of the mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions]. The bowel wall thickness ranges from *** to *** cm. The dentate line ranges from*** to *** cm in thickness. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension.

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

Ink key:Black – mesenteric/radial margin overlying lesion

Blue – serosa overlying lesion [Additional inking description if proximal/distal margins taken perpendicularly]

Tumor: 15-20 cassettes- Proximal resection margin, shave(perpendicular if close to tumor)- Distal resection margin, shave (perpendicular if close to tumor)- Mesenteric/radial resection margin (perpendicular section with

nearest approach to tumor)- One cassette per 1 cm of tumor

o Show maximum depth of invasiono Show nearest approach to serosao Show relationship to unremarkable mucosao Show relationship to any contiguous or adherent organs

- If adenomatous polyp with no gross invasion-entirely submit- Cassettes sampling any additional pathology in the gross

description (ulcers, polyps, etc.)- Submit all lymph nodes identified

o Separate lymph nodes into segments of colon

- Note : If no tumor is grossly identified and instead an area of ulceration or scar is present (which is often the case for rectal carcinomas status post neoadjuvant therapy), then the entire ulcer or scar area needs to be submitted.

APPENDIXSpecimen Type: APPENDECTOMY (NON-TUMOR)Procedure:

1. Measure the length and range of diameter.2. Measure the width of mesoappendix3. Describe the external surface and mesoappendix. Note variation in color,

presence of exudates, signs of perforation, tumors.4. Describe the presence or absence of perforation. Measure the size and

location of perforation if present.5. Section the entire appendix transversely at 3 mm intervals except for the

tip, which is sectioned longitudinally.6. Note wall thickness, state of the lumen, luminal contents (pus, fecaliths,

etc.). Look for tan or yellow nodules within the wall of the appendix especially at the tip (carcinoid tumor). Note size, location, color and consistency of any tumors

Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an [intact/ruptured] appendix measuring *** cm in length x

*** cm in diameter. Attached mesoappendiceal fibroadipose tissue extends *** cm from the wall. There is a *** cm in length staple line at the resection margin. The serosa is [pink-tan and smooth, red, roughened, describe perforation if present and provide location and distance to margin-check for fecalith in lumen]. The mucosa is [pink-tan, reg, granular]. The lumen ranges from *** to *** cm in diameter and contains [purulent fluid, hemorrhagic fluid, fecal material, fecalith]. The wall is [describe cut surface] with a *** cm average thickness. No perforations, lesions, or masses are identified. Representative sections are submitted [describe cassette submission].

Cassette Submission: 2 cassettes (additional cassette(s) if necessary)- Resection margin, shave- This should be in a separate cassette

and should be specified in the cassette summary (it can be put in one cassette with the longitudinal section of the tip)

- Submit one longitudinal section of the tip- Submit two transverse sections from proximal and mid appendix

o Include inflamed areas and/or perforation sites- Suspected appendicitis in which appendix appears grossly

normal – submit the entire appendix- Incidental appendectomy - 2 cross sections and tip.

Specimen Type: APPENDECTOMY (TUMOR)Procedure:1. Measure the length and range of diameter.

2. Measure the width of mesoappendix3. Describe the external surface and mesoappendix. Note variation in color,

presence of exudates, signs of perforation, tumors.4. Describe the presence or absence of perforation. Measure the size and

location of perforation if present.

5. Section the entire appendix transversely at 3 mm intervals except for the tip, which is sectioned longitudinally.

6. Note wall thickness, state of the lumen, luminal contents (pus, fecaliths, etc.). Look for tan or yellow nodules within the wall of the appendix especially at the tip (carcinoid tumor). Note size, location, color and consistency of any tumors

Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an [intact/ruptured] appendix measuring *** cm in length x *** cm in diameter. Attached mesoappendiceal fibroadipose tissue extends *** cm from the wall. There is a *** cm in length staple line at the resection margin. The serosa is [pink-tan and smooth, red, roughened, describe perforation if present and provide location and distance to margin-check for fecalith in lumen, note presence of tumor deposits]. The lumen ranges from *** to *** cm in diameter and contains [purulent fluid, hemorrhagic fluid, fecal material, fecalith]. The mucosa is remarkable for [describe lesion-measure in 2 dimensions, color, shape, and location to margin]. Sectioning reveals the lesion [is grossly superficial, extends into the wall of the appendix, extends to the serosa] and measures *** cm from the serosa.

The remainder of the serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions]. The remainder of the mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions]. *** lymph nodes are identified, ranging from *** to *** cm in greatest dimension. All identified lymph nodes and the resection margin are submitted. Representative sections of the remaining specimen are submitted [describe cassette submission].

Ink key:Blue –mesoappendix overlying lesion

Cassette Submission: 8-10 cassettes- Proximal resection margin, shave

o Perpendicularly section if lesion approaches the margin (ink the margin if this is the case)

- Longitudinally bisected tip- Remaining cross sections, submitted sequentially from proximal to

distalo Only in cases of mucinous neoplasm

- Note: Cases of suspicious or proven appendiceal tumors should typically be submitted entirely. If you have any questions, discuss the case with the assigned pathologist prior to prosecting.

HEMORRHOIDSpecimen Type: HEMORRHOIDECTOMY (Including PPH)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is a hemorrhoidectomy measuring *** x *** x *** cm. The mucosa is [unremarkable, describe lesions if present]. Sectioning reveals [red-brown, hemorrhagic/dilated/thrombosed vessels]. Representative sections are submitted. Cassette Submission: 1-3 cassettes

- Representative section from each tissue fragment, if multiple

PANCREASSpecimen Type : PANCREATICODUODENECTOMY (Whipple Procedure)Procedure:

1. Describe the organs included in the resection. These usually include the pancreatic head, common bile duct (mostly intrapancreatic), and duodenum. Distal potion of stomach may be included for standard Whipple specimens. A portion of superior mesenteric vein (either a patch or a segment) may be included at the vascular groove.

2. Describe the external surfaces of the organs.3. Ink the uncinate margin BLACK. 4. Ink the vascular groove ORANGE. If a portion of superior mesenteric vein

is present, it should be inked with a different color.5. Ink the serosal surface between pancreas and duodenum (posterior) for

duodenal tumors in order to better assess serosal involvement.6. Open the duodenum along the outside of the c-loop.7. Measure the length of the duodenum and circumferences at the proximal

and distal duodenal margins.8. Measure the length and cross diameters of the pancreas.9. Measure the length of the stomach (if present) and circumference at the

proximal margin.10.Measure the size, or length and diameter of attached superior mesenteric

vein.11.Probe the pancreatic and common bile ducts to determine if they are

obstructed. Bivalve the pancreas along the pancreatic and common bile ducts all the way to the ampulla of Vater.

12.Measure the diameter or circumference of the common bile duct and pancreatic duct.

- If the pancreatic duct is patent there is no need to measure the length of the duct as this measurement is the same length of the pancreas

- If the pancreatic duct is obstructed then you may measure the unobstructed length of the duct

13.Describe the size, location, color and consistency of the tumor. Note its relationship to the bile and pancreatic ducts, Ampulla and margins of resection (uncinate, pancreatic neck, vascular groove, and bile duct). Determine if tumor extends beyond confines of the pancreas.

14.Dissect the lymph nodes from peripancreatic soft tissue, the mesentery and attached adipose tissue.

15.Examine each organ included in the resection individually, as detailed elsewhere in the manual.

Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is an [intact/disrupted] [pylorus-preserving whipple/ whipple] [provide orientation]. The pancreatic head measures *** cm in length x *** x*** cm in cross sections. Peripancreatic soft tissue extends up to *** cm from the pancreas. The pancreatic duct [is/is not] obstructed. [If pancreatic duct is obstructed measure the length and diameter; if not obstructed do NOT measure the duct]. The common bile duct measures ***in length x ***in average diameter [describe dilated areas and give range in diameter]. The stomach measures *** x *** x *** cm. The duodenum measures *** cm in length x *** cm in open circumference. The stomach measures *** cm in length x *** cm in open circumference at the proximal resection margin. [If attached gallbladder is present, mention and measure.]

Sectioning the reveals a lesion located in the [pancreatic head, ampulla, periampullary, duodenum]. [Describe lesion – solid vs. cystic, size, shape, color, consistency, location, relationship to main pancreatic duct (abutting/obliterating); if cystic (IPMN-give range and overall dimension and approximate # of cysts), describe cyst lining (specifically mention the relationship of any cyst to the main pancreatic duct [part of the main duct/communicating with the main duct/not communicating with the main duct], loculation (uni-/multiloculated), quantity of fluid within (__mL), quality of fluid within (serous, mucinous, hemorrhagic, purulent), presence or absence of papillary excrescences or solid nodules, and, if present, describe with the same descriptors listed previously]. The lesion [is grossly confined to the pancreas, involves the peripancreatic soft tissue, involves other attached structures-specify]. The common bile duct [is/is not] patent with a [describe mucosal surface (e.g. smooth, roughened, granular, hemorrhagic)], a luminal diameter ranging from *** cm at [location (e.g. distal vs. proximal to the tumor)] to *** cm at [location (e.g. distal vs. proximal to the tumor)], and a wall thickness ranging from *** cm at [location (e.g. distal vs. proximal to the tumor)] to *** cm at [location (e.g. distal vs. proximal to the tumor)]. [If there is a discrete stricture of the duct, additionally describe location, relationship to margins, wall thickness, luminal diameter, and mucosal surface of the stricture.]

The lesion is located *** cm from the pancreatic resection margin, [*** cm from pancreatic duct margin- for IPMNs], *** cm from the common bile duct margin, *** cm from the uncinate margin, *** cm from the vascular groove, *** cm from the proximal [gastric/duodenal] margin, *** cm from the distal duodenal resection margin, and *** cm from the posterior pancreatic fibroadipose tissue. The main pancreatic duct [is/is not] patent with a [describe mucosal surface (e.g. smooth, roughened, granular, hemorrhagic)], and a luminal diameter ranging from *** cm at [location (e.g. distal vs. proximal to the tumor)] to *** cm at [location (e.g. distal vs. proximal to the tumor)], and a wall thickness ranging from *** at [location (e.g. distal vs. proximal to the tumor)] to *** cm at [location (e.g. distal vs. proximal to the tumor)]. [If there is a discrete stricture of the duct, additionally describe location, relationship to margins, wall thickness, luminal diameter, and mucosal surface of the stricture.] The lesion measures *** cm from the main pancreatic duct [or abuts the main pancreatic duct or obliterates the main pancreatic duct for a length of (__ cm) at the (describe location and/or measure distance from applicable margin)].

The remaining pancreatic parenchyma is [lobulated, fibrotic, unremarkable or describe any additional pathology including cysts (see descriptors above), strictures, fat necrosis, additional nodules, etc.]. The remainder of the serosa [tan, smooth, glistening, and unremarkable or describe any additional lesions]. The remainder of the duodenal mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions, such as ulcers/erosions, polyps, smooth areas with loss of folds, etc.]. The remainder of the gastric mucosa is [tan, rugated, glistening, and unremarkable or describe any additional lesions, such as ulcers/erosions, polyps, smooth areas with loss of folds, fibrotic areas, etc.]. [Describe any additional abnormalities of the pancreatic of biliary ductal system, such as the presence of an accessory pancreatic duct, a main pancreatic duct that empties at the minor papilla, a tortuous main pancreatic duct, pancreas divisum, etc.] *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension.

All identified possible lymph nodes are entirely submitted. [The lesion/mass is entirely submitted (if applicable, otherwise skip to next sentence)] The peripancreatic fibroadipose tissue is entirely submitted. Representative sections of the remaining specimen are submitted.

Ink key:Black – uncinate marginBlue – posterior peripancreatic soft tissue Green – anterior peripancreatic soft tissueOrange – vascular groove [Additional inking description for proximal duodenal/gastric and distal duodenal margins, if taken perpendicularly]

[Additional inking description for cystic duct margin and/or common hepatic duct margin, as applicable][Additional inking description if pancreatic duct and bile duct differentially inked- when placing in the same cassette. Histologically, the ducts look the same and they must be inked] Cassette Submission : 20-25 cassettes

- Note: Consult pathologist for assistance with orientation before grossing

- Note: Pancreatic and bile ducts are histologically identical: do not include both in a single section OR if both are present in a single section, ink the mucosal surfaces differentially and note the inking in the ink key or cassette summary.

- Note: sections often taken for frozen section include pancreatic neck (to include duct), proximal margin (gastric or duodenal), and common bile duct margin.

- Gastric resection margin, shave- Duodenal resection margin, shave- Common bile duct resection margin, shave- Uncinate margin – shave off of specimen and entirely submit

(perpendicular sections)o May be able to perpendicularly demonstrate mass in relation

to uncinate margin, if so be sure to submit the remaining margin

- If a solid tumor: one cassette per 1 cm of lesion (at least five sections of mass)

o Show relationship to posterior peripancreatic soft tissue o Show relationship to pancreatic resection margin, if ableo Show relationship to anterior peripancreatic soft tissueo Show relationship to common bile ducto Show relationship to pancreatic ducto Show relationship to ampulla of Vatero Show relationship to peripancreatic soft tissueo Show relationship to overlying duodenumo Show relationship to vascular groove

- If a cystic lesion: entirely embed the lesion (if large lesion-consult with attending)

o Sample any papillary excrescenceso Sample any fibrotic areas or mural noduleso Sample any strictures or areas of wall thickening

- If duodenal or ampullary adenomatous polyp:

o Entirely submit polyp Include relationship to ducts Include relationship to serosal surface of duodenum

(particularly the posterior surface) in a few sections

- One section of ampulla in relation to tumor (in not ampullary lesion)- Any additional lesions in the gross description- One cassette of unremarkable pancreatic parenchyma- One cassette of unremarkable duodenum and stomach- One cassette of unremarkable gallbladder - Submit all lymph nodes identified- Submit all peripancreatic fibroadipose tissue

- Note: If the tumor is ill defined and the tumor size cannot be accurately measured grossly, or a definitive mass lesion cannot be identified, the pancreas should be carefully breadloafed at 0.5 cm intervals. Take one cross section every 1 cm sequentially along the length of pancreas from distal neck margin towards the ampulla so that the tumor size may be estimated on microscopic examination. In that case, please keep remaining pancreatic tissue in order so that additional sections between 2 and 3 cms and between 4 and 5 cms can be taken later on if needed (important for T staging).

Specimen Type : DISTAL PANCREATECTOMYGross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is an [intact/disrupted] distal pancreatectomy [provide orientation]. The distal pancreas measures *** cm in length x *** x *** cm in cross sections. The [attached/ seperately received] spleen weighs [__grams] and measures *** x *** x *** cm. Peripancreatic soft tissue extends up to ***from the pancreas.[Describe any adherent portions of additional organs (e.g. wedge of adherent stomach or colon.] There [is/is no] staple line present at the pancreatic resection margin.

Sectioning the pancreas reveals a lesion located in the [proximal, mid, distal aspect of the pancreas]. [Describe lesion – solid vs. cystic, size, shape, color, consistency, location, relationship to main pancreatic duct (abutting/obliterating); if cystic (IPMN-give range and overall dimension and approximate # of cysts), describe cyst lining (specifically mention the relationship of any cyst to the main pancreatic duct [part of the main duct/communicating with the main duct/not communicating with the main duct], loculation (uni-/multiloculated), quantity of fluid within (__mL), quality of fluid within (serous, mucinous, hemorrhagic, purulent), presence or absence of papillary excrescences or solid nodules, and, if present, describe with the same descriptors listed previously]. The lesion [is grossly confined to the pancreas, involves the peripancreatic soft tissue, involves other attached structures-specify].

The lesion is located *** cm from the pancreatic resection margin, *** cm from the anterior serosal surface, *** cm from the posterior resection margin. The main pancreatic duct [is/is not] patent with a [describe mucosal surface (e.g. smooth, roughened, granular, hemorrhagic)], and a luminal diameter ranging from *** at [location (e.g. distal vs. proximal to the tumor)] to *** cm at [location (e.g. distal vs. proximal to the tumor)], and a wall thickness ranging from *** cm at [location (e.g. distal vs. proximal to the tumor)] to *** cm at [location (e.g. distal vs. proximal to the tumor)]. [If there is a discrete stricture of the duct, additionally describe location, relationship to margins, wall thickness, luminal diameter, and mucosal surface of the stricture.] The lesion measures *** cm from the main pancreatic duct [or abuts the main pancreatic duct or obliterates the main pancreatic duct for a length of (__ cm) at the (describe location and/or measure distance from applicable margin)].

The remaining pancreatic parenchyma is [lobulated, fibrotic, unremarkable or describe any additional pathology including cysts (see descriptors above), strictures, fat necrosis, additional nodules, etc.]. The splenic capsule is [intact/ruptured/roughened]. The spleen is sectioned to reveal [smooth, red, homogeneous, and unremarkable or describe size, shape, color, consistency, # of any nodules] cut surfaces. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension.

All identified possible lymph nodes are entirely submitted. [The lesion/mass is entirely submitted (if applicable, otherwise skip to next sentence)] The peripancreatic fibroadipose tissue is entirely submitted. Representative sections of the remaining specimen are submitted.

Ink key:Blue – anterior surfaceGreen – posterior resection margin[Additional inking description for adherent organ resection margins (e.g. adherent wedge of stomach)][Additional inking description for distal pancreatic margin present (applicable to mid pancreatic resections] Cassette Submission : 10-12 cassettes

- Note: Consult pathologist for assistance with orientation before grossing

- Show relationship to pancreatic resection margin- Show relationship to anterior surface- Show relationship to posterior resection margin- Show relationship to any adherent organs (e.g. adherent wedge of

stomach or colon)- Show relationship to spleen (if applicable)

- If a solid tumor: one cassette per 1 cm of lesion- If a cystic lesion: entirely embed the lesion (typically; discuss with

pathologist for alternate strategies)o Sample any papillary excrescenceso Sample any fibrotic areas or mural noduleso Sample any strictures or areas of wall thickening

- Any additional lesions in the gross description- One cassette of unremarkable pancreatic parenchyma- One cassette of unremarkable spleen - Submit all lymph nodes identified- Submit all peripancreatic fibroadipose tissue

Specimen Type : CENTRAL PANCREATECTOMYGross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is an [intact/disrupted] central pancreatectomy [provide orientation]. The pancreas measures *** cm in length x *** x *** cm in cross sections. Peripancreatic soft tissue extends up to *** cm from the pancreas.[Describe any adherent portions of additional organs (e.g. wedge of adherent stomach or colon.] There [is/is no] staple line present at the pancreatic resection margin(s).

Sectioning the pancreas reveals a lesion located in the [proximal, mid, distal aspect of the pancreas]. [Describe lesion – solid vs. cystic, size, shape, color, consistency, location, relationship to main pancreatic duct (abutting/obliterating); if cystic (IPMN-give range and overall dimension and approximate # of cysts), describe cyst lining (specifically mention the relationship of any cyst to the main pancreatic duct [part of the main duct/communicating with the main duct/not communicating with the main duct], loculation (uni-/multiloculated), quantity of fluid within (__mL), quality of fluid within (serous, mucinous, hemorrhagic, purulent), presence or absence of papillary excrescences or solid nodules, and, if present, describe with the same descriptors listed previously]. The lesion [is grossly confined to the pancreas, involves the peripancreatic soft tissue, involves other attached structures-specify].

The lesion is located *** cm from the proximal pancreatic resection margin, *** cm from the distal pancreatic resection margin, *** cm from the anterior serosal surface, *** cm from the posterior resection margin. The main pancreatic duct [is/is not] patent with a [describe mucosal surface (e.g. smooth, roughened, granular, hemorrhagic)], and a luminal diameter ranging from *** cm at [location (e.g. distal vs. proximal to the tumor)] to *** cm at [location (e.g. distal vs. proximal to the tumor)], and a wall thickness ranging from *** at [location (e.g. distal vs. proximal to the tumor)] to *** cm at [location (e.g. distal vs. proximal to the tumor)]. [If there is a discrete stricture of the duct, additionally describe location, relationship to margins, wall thickness, luminal diameter, and mucosal surface of the stricture.] The lesion measures *** cm from the main pancreatic

duct [or abuts the main pancreatic duct or obliterates the main pancreatic duct for a length of (__ cm) at the (describe location and/or measure distance from applicable margin)].

The remaining pancreatic parenchyma is [lobulated, fibrotic, unremarkable or describe any additional pathology including cysts (see descriptors above), strictures, fat necrosis, additional nodules, etc.]. The splenic capsule is [intact/ruptured/roughened]. The spleen is sectioned to reveal [smooth, red, homogeneous, and unremarkable or describe size, shape, color, consistency, # of any nodules] cut surfaces. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension.

All identified possible lymph nodes are entirely submitted. [The lesion/mass is entirely submitted (if applicable, otherwise skip to next sentence)] The peripancreatic fibroadipose tissue is entirely submitted. Representative sections of the remaining specimen are submitted.

Ink key:Blue-anterior serosal surfaceGreen-posterior resection margin

Cassette Submission : 10-12 cassettes- Note: Consult pathologist for assistance with orientation before

grossing- Show relationship to proximal pancreatic resection margin- Show relationship to distal pancreatic resection margin (applicable

only to mid pancreatic resections)- Show relationship to anterior surface- Show relationship to posterior resection margin- Show relationship to any adherent organs (e.g. adherent wedge of

stomach or colon)- Show relationship to spleen (if applicable)- If a solid tumor: one cassette per 1 cm of lesion- If a cystic lesion: entirely embed the lesion (typically; discuss with

pathologist for alternate strategies)o Sample any papillary excrescenceso Sample any fibrotic areas or mural noduleso Sample any strictures or areas of wall thickening

- Representative sections of all additional lesions in the gross description

- One cassette of unremarkable pancreatic parenchyma- One cassette of unremarkable spleen - Submit all lymph nodes identified

- Submit all peripancretic soft tissue