Surgical Pathology Dissection: An Illustrated Guide, Second . - Patologi
Surgical PathologyDissection:An Illustrated Guide,Second EditionWilliam H. Westra, M.D., et al.Springer
Surgical Pathology DissectionSecond Edition
Surgical PathologyDissectionAn Illustrated GuideSecond EditionWilliam H. Westra, M.D.Ralph H. Hruban, M.D.Department of PathologyThe Johns Hopkins UniversitySchool of MedicineBaltimore, MarylandDepartment of PathologyThe Johns Hopkins UniversitySchool of MedicineBaltimore, MarylandTimothy H. Phelps, M.S.Christina Isacson, M.D.Department of Art as Applied to MedicineThe Johns Hopkins UniversitySchool of MedicineBaltimore, MarylandDepartment of PathologyVirginia Mason Medical CenterSeattle, WashingtonWith Forewords by Frederic B. Askin, M.D.With 58 Illustrations
William H. Westra, M.D.Department of PathologyThe Johns Hopkins HospitalThe Weinberg Cancer Building, Room 2242401 North BroadwayBaltimore, MD 21231-2410, USARalph H. Hruban, M.D.Department of PathologyThe Johns Hopkins HospitalThe Weinberg Cancer Building,Room 2242401 North BroadwayBaltimore, MD 21231-2410, USATimothy H. Phelps, M.S.Department of Art as Appliedto MedicineThe Johns Hopkins UniversitySchool of Medicine1830 East Monument Street,Suite 7000Baltimore, MD 21205-2100, USAChristina Isacson, M.D.Department of PathologyVirginia Mason Medical Center1100 Ninth Avenue, C6-PathSeattle, WA 98101, USACover illustration: Extrahepatic biliary tract resection for carcinoma of the common bile duct.Illustration by Timothy H. Phelps.Library of Congress Cataloging-in-Publication DataSurgical pathology dissection: an illustrated guide/[edited by] William H. Westra . . .[et al.].—2nd ed.p.; cm.Includes bibliographical references and index.ISBN 0-387-95559-3 (s/c: alk. paper)1. Pathology, Surgical—Laboratory manuals. 2. Human dissection—Laboratory manuals. I. Westra, William H.[DNLM: 1. Pathology, Surgical—Laboratory Manuals.2. Dissection—Laboratory Manuals. WO 142 S9615 2002]RD57. S87. 2002617′.07—dc212002029448ISBN 0-387-95559-3Printed on acid-free paper.쑕 2003, 1996 Springer-Verlag New York, Inc.All rights reserved. This work may not be translated or copied in whole or in part without thewritten permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, NewYork, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis.Use in connection with any form of information storage and retrieval, electronic adaptation,computer software, or by similar or dissimilar methodology now known or hereafter developedis forbidden.The use in this publication of trade names, trademarks, service marks, and similar terms, even ifthey are not identified as such, is not to be taken as an expression of opinion as to whether ornot they are subject to proprietary rights.While the advice and information in this book are believed to be true and accurate at the dateof going to press, neither the authors nor the editors nor the publisher can accept any legalresponsibility for any errors or omissions that may be made. The publisher makes no warranty,express or implied, with respect to the material contained herein.Printed in the United States of America.9 8 7 6 5 4 3 2SPIN 10888565www.springer-ny.comSpringer-Verlag New York Berlin HeidelbergA member of BertelsmannSpringer Science Business Media GmbH
To the Breakfast Club. Fond memories of hooping it up.To the team: Sharon, Caryn, Janine, and Willem.William H. WestraTo my wonderful wife, Claire, and our three terrific children, Zoe,Emily, and Carolyn.Ralph H. HrubanTo my wife, Lyn, for her ever-present love and support; my twochildren, Katie and Kevin, who bring me great and constant joy;my art instructors of the past for all they have shared with me; and,particularly and most importantly, my Father; and in loving memoryof my Mother.Timothy H. PhelpsTo my sisters, Charlotte and Patty.Christina Isacson
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Foreword to the Second EditionIt is a pleasure, an honor, and a distinct privilege to write the foreword forthe second edition of Surgical Pathology Dissection: An Illustrated Guide. I amdelighted to see that my predictions were accurate in regard to this effectiveand useful book. It has become an extremely popular dissection manualwith regard to both its text and illustrative material. In fact, the manual andits medical illustrator, Timothy H. Phelps, received the Illustrated BookAward from the Association of Medical Illustrators in 1996. Pathologistreviewers have uniformly characterized the text as valuable and inclusivewhile still leaving room for individual variation in specimen handling.Just as our other clinical colleagues continually endeavor to improve patient care by adding new diagnostic tests and techniques, it is incumbent onanatomic pathologists to do the same. The authors’ goal in the developmentof the second edition of this manual was not to replace the first editionbut, rather, to build on its strength. In this second edition, one finds theaddition of new coauthors with recognized expertise in their respective fieldsof interest. These coauthors have provided chapters on contemporarytopics not covered in the first edition and new illustrations (the specifics arelisted in the Preface). In addition, a number of the original illustrations,such as the breast specimen dissection, have been significantly revised andimproved. In an attempt to provide more uniform description and tumorstaging, the existing chapters have been updated to conform with the recentlypublished College of American Pathologists (CAP) and Association of Directors of Anatomic and Surgical Pathology (ADASP) guidelines.The basic goals for the first edition have been retained: to provide anaccurate, concept-oriented, easy-to-use manual that provides a logical,concise approach to the most commonly encountered specimens. Althoughnew authors and new material have been added, the basic solid frameworkof the manual persists. I am confident that the second edition providessignificant improvements and that this manual will continue to be a mainstayin the anatomic pathology armamentarium.Frederic B. Askin, M.D.Professor of PathologyThe Johns Hopkins UniversitySchool of MedicineandDirector of Surgical PathologyThe Johns Hopkins HospitalBaltimore, MD 21231-2410, USAvii
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Foreword to the First EditionThe modern surgical pathology cutting room is replete with tools of theelectronic age. Computers, automatic cassette labelers, bar coding, and evenelectronic voice-recognition systems are available to help the surgical pathologist be an effective, efficient, and highly productive cog in the machinery ofhealthcare delivery. In spite of this automated armamentarium, much of ourability to render diagnoses rests with the surgical pathology ‘‘cutters.’’ Thesepersonnel need to be trained to handle surgical specimens consistently andappropriately, with the goal of providing optimal diagnostic informationand adequate pathologic correlation with clinical and radiologic findings.This dissection manual is an outgrowth of what Waldemar Schmidthas called the ‘‘oral tradition’’ of surgical pathology. Traditionally, the seniorpathologist passed down to the trainee an individual accumulation of expertise on the handling of specimens. This transfer of information was oftenrandom and based solely on the specific case at hand. Now, despite theimportance of training personnel, the exigencies of modern practice limitthe amount of time available for individual training, and so most laboratorieshave developed their own local manual. Unfortunately, many of these manuals are incomplete or not user-friendly.Drs. Hruban, Westra, and Isacson have prepared this manual with thehelp of a distinguished and talented medical artist. Timothy H. Phelps’s penand ink drawings bring a unique vitality and multidimensional effect to thereader throughout the manual as dissection techniques are explained andillustrated. The editors and contributors have effectively shared their talentsand experience by providing general principles that can be employed toresolve even the most complex problems in dissection and effective tissuesampling. The methods are broadly applicable and unusually easy to follow.This text should be at hand in all surgical pathology laboratories, whereit will be useful to a wide variety of personnel including staff pathologists,residents, pathologist’s assistants, histotechnologists, and other laboratorypersonnel. It is highly likely that many surgeons would also benefit fromuse of this manual, through which they can gain an understanding of howspecimens are dissected and can become familiar with the way in whichmargin and tumor sampling are carried out.This is a very practical manual. The authors discuss the clinically important features of various types of specimens and lesions in each organsystem. They instruct the prosector in every instance as to what information isneeded to provide the clearest clinical picture. I suspect that this work willix
xForeword to the First Editionbe most valuable to the surgical pathology cutter late in the evening or onweekends, when the redoubtable oral historian of surgical pathology is notavailable. This manual should serve as a cornerstone on which to build astable but malleable standard of excellence in the surgical pathology cutting room.Frederic B. Askin, M.D.Professor of PathologyThe Johns Hopkins UniversitySchool of MedicineandDirector of Surgical PathologyThe Johns Hopkins HospitalBaltimore, MD 21231-2410, USA
PrefaceOur goal in writing the first edition of Surgical Pathology Dissection: AnIllustrated Guide was to create a user-friendly, hands-on guide for the dissection of surgical pathology specimens. To do this, we brought a team ofsurgical pathologists with a broad range of expertise together with TimothyH. Phelps, one of the leading medical illustrators in the United States. In sodoing, we believe we created a manual that provides a logical, conciseapproach to the most commonly encountered specimens. In the yearssince the first edition was published, Surgical Pathology Dissection: An Illustrated Guide has emerged as the standard in the field, and in 1996, TimothyH. Phelps was awarded the Illustrated Book Award from the Associationof Medical Illustrators for his artwork in the book.We have made a number of significant improvements in the second editionof Surgical Pathology Dissection: An Illustrated Guide. First, new coauthorswere asked to join the existing team to add a fresh perspective to keychapters. For example, Elizabeth Montgomery, Robb E. Wilentz, MichaelTorbenson, Susan Abraham, E. Rene Rodriguez, and Pedram Argani havehelped update key chapters on the digestive system, heart, and breast.Second, new chapters, including chapters on transplantation and sentinellymph nodes, have been added, reflecting emerging trends in surgical pathology practice. Importantly, these new chapters retain the user-friendlystyle characteristic of the first edition. Third, new illustrations, includingthose for dissection of an explanted heart, craniofacial bones, and sentinellymph nodes, have been added. In addition, a number of the original illustrations, such as for the dissection of breast specimens, have been significantlyrevised and improved. Fourth, updates to existing chapters, particularlywhere they were needed to conform to the more recently published Collegeof American Pathologists (CAP) and Association of Directors of Anatomicand Surgical Pathology (ADASP) guidelines, have been made. Thesechanges were made with the goal of keeping Surgical Pathology Dissection:An Illustrated Guide user-friendly and up to date. Each chapter thereforecontinues to include descriptions and illustrations of the mechanics involvedwhen handling each specimen as well as a conceptual framework for questions to keep in mind during the dissection. At the end of each chapter, thesection entitled “Important Issues to Address in Your Pathology Report”helps guide the user to the key information needed to stage most tumorsaccurately.xi
xiiPrefaceFinally, to reflect the equal contributions of the two first authors, Drs.Westra and Hruban have switched places in authorship, and Dr. Westrais now the first author on the second edition.We believe the second edition is a significant improvement over the firstedition, and we continue to hope that this illustrated guide will make thedissection of any specimen an important and enjoyable endeavor.William H. Westra, M.D.Ralph H. Hruban, M.D.Timothy H. Phelps, M.S.Christina Isacson, M.D.
AcknowledgmentsThe authors thank Amanda Lietman and Sandy Markowitz for their superbassistance in preparing, proofreading, and editing this manual and for theirpatience and understanding. It is impossible to praise their talents andefforts enough. The authors also thank Drs. Frederic B. Askin and GroverM. Hutchins for their constructive criticism of the book and Drs. MichaelBorowitz, Joseph Califano, David Eisele, Jonathan Epstein, Kristin Fiebelkorn, Stanley R. Hamilton, Zdenek Hruban, Wayne Koch, Ralph Kuncl,Robert Kurman, and Charles Yeo for sharing their expertise. The authorsalso thank Claire E. Hruban.William H. Westra, M.D.Ralph H. Hruban, M.D.Timothy H. Phelps, M.S.Christina Isacson, M.D.xiii
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ContentsForeword to the Second Edition .Foreword to the First Edition .Preface .Acknowledgments .Contributors .viiixxixiiixixI. General Approach and TechniquesChapter 1General Approach to Surgical Pathology Specimens .2Chapter 2Laboratory Techniques . 14William M. Fox III and Robert H. Rosa, Jr.Chapter 3Tissue Collection for Molecular Genetic Analysis . 22Chapter 4Photography . 26Norman J. BarkerII. Lymph Nodes for Metastatic TumorsChapter 5Lymph Nodes . 34III. The Head and NeckChapter 6Larynx. 38Chapter 7Major Salivary Glands . 43Chapter 8Complex Specimens . 44Chapter 9Maxilla. 48James J. SciubbaChapter 10 Radical Neck Dissection. 54IV. The Digestive SystemChapter 11 Esophagus. 58Elizabeth MontgomeryChapter 12 Stomach . 62Elizabeth Montgomeryxv
xviContentsChapter 13 Non-Neoplastic Intestinal Disease . 66Robb E. WilentzChapter 14 Neoplastic Intestinal Disease. 70Elizabeth MontgomeryChapter 15 Appendix . 74Elizabeth MontgomeryChapter 16 Liver. 76Michael S. TorbensonChapter 17 Gallbladder and Extrahepatic Biliary System . 82Susan AbrahamChapter 18 Pancreas. 88V. The Cardiovascular/Respiratory SystemChapter 19 Heart, Heart Valves, and Vessels . 94E. Rene RodriguezChapter 20 Lungs . 102Chapter 21 Transplantation . 110VI. Bone, Soft Tissue, and SkinChapter 22 Bone . 114Edward F. McCarthy, Jr.Chapter 23 Soft Tissue, Nerves, and Muscle . 120Elizabeth MontgomeryChapter 24 Skin . 124Thomas D. HornVII. The BreastChapter 25 Breast . 132Pedram ArganiVIII. The Female Genital SystemChapter 26 Vulva . 142Chapter 27 Uterus, Cervix, and Vagina . 146Chapter 28 Ovary and Fallopian Tube. 160Chapter 29 Products of Conception and Placentas. 166
ContentsIX. The Urinary Tract and Male Genital SystemChapter 30 Penis. 172Chapter 31 Prostate. 176Chapter 32 Testis . 180Chapter 33 Kidney . 184Chapter 34 Bladder . 188X. The Ocular SystemChapter 35 Eye.Robert H. Rosa, Jr., and W. Richard Green194XI. The Endocrine SystemChapter 36 Thyroid. 202Chapter 37 Parathyroid Glands . 206Chapter 38 Adrenal Glands. 208XII. Pediatric TumorsChapter 39 Pediatric Tumors . 212Elizabeth J. PerlmanXIII. The Central Nervous SystemChapter 40 Brain and Spinal Cord. 218Peter C. BurgerXIV. The Hematopoietic and Lymphatic SystemChapter 41 Lymph Nodes .224Chapter 42 Spleen . 228Chapter 43 Thymus. 231Chapter 44 Bone Marrow. 232XV. Odds and EndsChapter 45 Common Uncomplicated Specimens . 236Closing Comments. 239References. 240Suggested Web Sites and Suggested Readings . 242Index. 253xvii
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ContributorsSusan Abraham, M.D.Assistant Professor of Pathology, Division of Gastrointestinal/Liver Pathology, The Johns Hopkins School of Medicine, Baltimore, MD 21287-6971, USAPedram Argani, M.D.Assistant Professor of Pathology, The Johns Hopkins University School ofMedicine, Baltimore, MD 21231-2410, USAFrederic B. Askin, M.D.Professor of Pathology, The Johns Hopkins University School of Medicine;and Director of Surgical Pathology, The Johns Hopkins Hospital, Baltimore, MD 21231-2410, USANorman J. Barker, M.S., R.B.P.Assistant Professor of Pathology and Art as Applied to Medicine andDirector of Pathology Photography, The Johns Hopkins University Schoolof Medicine, Baltimore, MD 21287-6971, USAPeter C. Burger, M.D.Professor of Pathology, Oncology, and Neurosurgery, The Johns HopkinsUniversity School of Medicine, Baltimore, MD 21287-6971, USAWilliam M. Fox III, B.S., M.S., P.A.-C.Mercy Medical Center, Baltimore, MD 20201, USAW. Richard Green, M.D.International Order of Odd Fellows Professor of Ophthalmology, and Professor of Pathology, the Wilmer Ophthalmological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-6971, USAThomas D. Horn, M.D.Professor of Dermatology and Pathology, and Chairman, Department ofDermatology, University of Arkansas for Medical Sciences, Little Rock,AR 72205, USARalph H. Hruban, M.D.Professor of Pathology and Oncology, The Johns Hopkins University Schoolof Medicine; and Director, Division of Gastrointestinal/Liver Pathology, TheJohns Hopkins Hospital, Baltimore, MD 21231-2410, USAxix
xxContributorsChristina Isacson, M.D.Pathologist and Deputy Chief of Pathology, Virginia Mason Medical Center,Seattle, WA 98101-0900, USAEdward F. McCarthy, Jr., M.D.Professor of Pathology and Orthopedic Surgery, The Johns Hopkins University School of Medicine; and Director, Bone Histomorphometry Laboratory,The Johns Hopkins Hospital, Baltimore, MD 21231-2410, USAElizabeth Montgomery, M.D.Associate Professor of Pathology, Division of Gastrointestinal/Liver Pathology, The Johns Hopkins School of Medicine, Baltimore, MD 21205-2410, USAElizabeth J. Perlman, M.D.Professor of Pathology, Northwestern University; and Head, Department ofPathology, Children’s Memorial Hospital, Chicago, IL 60614, USATimothy H. Phelps, M.S., FAMI, C.M.I.Associate Professor of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USAE. Rene Rodriguez, M.D.Associate Professor of Pathology, The Johns Hopkins School of Medicine;and Director, Clinical Services Cardiovascular Pathology, The Johns Hopkins Hospital, Baltimore, MD 21205-2410, USARobert H. Rosa, Jr., M.D.Associate Professor, Departments of Ophthalmology and Pathology, Scottand White Clinic, Texas A&M University System Health Science Center,Temple, TX 76508, USAJames J. Sciubba, D.M.D., Ph.D.Professor of Otolaryngology, Head and Neck Surgery, Pathology, and Dermatology, The Johns Hopkins University School of Medicine, Baltimore, MD21287-6971, USAMichael S. Torbenson, M.D.Instructor of Pathology, Division of Gastrointestinal/Liver Pathology, TheJohns Hopkins School of Medicine, Baltimore, MD 21205-2410, USAWilliam H. Westra, M.D.Associate Professor of Pathology and Otolaryngology, Head and NeckSurgery, The Johns Hopkins University School of Medicine, Baltimore,MD 21231-2410, USARobb E. Wilentz, M.D.Assistant Professor of Pathology, Division of Gastrointestinal/Liver Pathology, The Johns Hopkins School of Medicine, Baltimore, MD 21205-2410, USA
IGeneral Approachand Techniques
1General Approach toSurgical Pathology SpecimensSafety in the SurgicalPathology LaboratoryThe key to safety in the surgical pathology laboratory is to recognize that this area is a dangerousplace. A variety of noxious chemicals are routinely used in the surgical pathology laboratory,and tissues infected with the human immunodeficiency virus (HIV), hepatitis viruses, mycobacteria, and other agents enter through its doors ona daily basis. Not only are these infectious agentspresent in the laboratory, but their transmissionis also facilitated by the frequent handling ofbloody tissues and the routine use of surgicalblades, knives, saws, and other sharp instruments. Clearly, the surgical pathology laboratoryis no place to ‘‘let down one’s guard’’ by becoming careless or distracted. Rather, safety in thework area should become an ingrained habit, anduniversal precautions should be exercised withall specimens.Protective GearThe prosector should regard all tissues as potentially infectious, not just those tissues removedfrom patients known to have an infectious disease. For the protection of oneself and for thesafety of others, the prosector should wear protective gear in the cutting area at all times.Protective gear prevents contact of potentiallyinfectious materials with the skin and mucousmembranes, and it diminishes the transfer ofinfectious material outside of the surgical pathology laboratory. At the very least, protectivegear should include surgical scrubs, waterproof2shoe coverings, a surgical gown and/or waterproof forearm wraps, gloves, a cap, a mask, andeye protection. A waterproof apron should alsobe worn to prevent the absorption of fluidsonto the clothing and skin. Hands should beprotected by well-fitting surgical gloves. Toprevent seepage of fluids, two pairs of gloves arepreferred to one pair, and these gloves shouldbe changed frequently. Keep in mind that eventwo pairs of gloves will not protect against punctures and cuts. Fine mesh metallic or syntheticgloves that are cut-resistant are recommendedin those instances where one is unfamiliar withthe use of a sharp instrument or when one isdissecting a specimen with sharp edges (e.g., abone resection). Soiled or bloody garments andcoverings should not be worn outside of thecutting area.Disposal of Instruments and Trash,and Storage of SpecimensIn order to avoid inadvertent wounds, thereshould be no more than one blade in the dissection field at any one time. Needles, razor blades,scalpel blades, and other sharp disposable objects should be promptly discarded into appropriate containers following their use. Trash itemssoiled with blood or other potentially infectiousmaterials should be discarded into designatedbiohazard containers located in the cutting area.Upon completion of the dissection, the specimenshould be stored in a container with adequateformalin. Specimen containers should be wipedclean of any potentially infectious materials,securely closed to prevent leakage, accuratelylabeled, and stored in a designated storage area.
1. General ApproachIn cases of known viral hepatitis, HIV infection, ortuberculosis, the cutting area should be washedclean and wiped with a disinfectant such as dilutebleach, and a biohazard label should be affixedto the specimen container.Radioactive SpecimensWith the increasing use of radioactive materialsas a means to identify sentinel lymph nodes, theproper handling of radioactive materials hasbecome an increasing concern in the surgical pathology laboratory. Although the risk of significant radiation exposure associated with thesesentinel lymph nodes is believed to be very low,each institution should nonetheless develop written procedures for handling all radioactive specimens. These procedures should be developed inconjunction with the institution’s radiation safetyofficer and should encompass issues related tothe labeling, transportation, processing, storage,and disposal of radioactive specimens. The radiation safety officer is also responsible for trainingpathology personnel regarding safety issues. Donot be shy about contacting your institution’s radiation safety office if you have questions aboutgeneral policy issues or specific concerns regarding a radioactive specimen.Fundamentals of DissectionAt first glance the challenges facing the surgicalpathology cutter appear almost insurmountable.The types of specimens that come across the cutting table seem endlessly diverse, and the complexity of these specimens may at times beperplexing. To top it off, each specimen, whethera simple needle biopsy or a convoluted compositeresection, must be handled with equal care andprecision. How then does one confidently andeffectively function in the surgical pathologylaboratory, given the bewildering diversity andcomplexity of specimens that enter its doors?Where does one even begin?For any specimen, the best place to begin is atthe end. Even before making the first cut, taketime to visualize the end result of your work,the surgical pathology report. Consider the issues that need to be addressed in that report, andthen plan a dissection of the specimen that willhelp address these important issues. While it istrue that no two specimens are exactly alike, youwill find that the questions they pose are remarkably similar. Even the most complex of specimenscan be reduced to three fundamental issues: Whatstructures are present? What is the nature of the pathologic process? How extensive is that process? If youare not familiar with the important issues for agiven organ, the Association of Directors of Anatomic and Surgical Pathology have an excellentwebsite that summarizes the important diagnostic and prognostic issues for many of the majortumor types (www.panix.com/ adasp/). Regardless of the complexity or novelty of the specimen, these issues can be efficiently addressed bya systematic four-step approach. By masteringthese four fundamental steps of surgical dissection, the surgical pathology cutter will be wellequipped to tackle even the most intimidating ofspecimens with confidence.Step 1. Specimen OrientationIf the surgical pathology report is the end resultof the dissection, specimen orientation might beregarded as a road map by which to reach thatultimate destination. With orientation, an otherwise confusing conglomerate of tissue is placedin its proper clinical and anatomic context andappreciated as a structural unit. Then a propercourse of dissection can be chartered. Withoutorientation, specimen dissection can proceedspeedily but may never reach its desired aims.The Requisition FormOrientation is usually thought of in terms of thestructural anatomy of the specimen. Whilethese anatomic considerations ce
Surgical Pathology Dissection An Illustrated Guide Second Edition William H. Westra, M.D. Ralph H. Hruban, M.D. Department of Pathology Department of Pathology The Johns Hopkins University The Johns Hopkins University School of Medicine School of Medicine Baltimore, Maryland Baltimore, Maryland Timothy H. Phelps, M.S. Christina Isacson, M.D.
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Surgical Pathology 183 2008 Surveys & Anatomic Pathology Education Programs.cap.org Program PIP Challenges per Shipment Surgical pathology case review for one pathologist 10 Product Information The Performance Improvement Program in Surgical Pathology (PIP) is designed by pathologists for the
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