Gynecologic Pathology Grossing GuidelinesCERVIXSpecimen Type: ENDOCERVICAL CURRETTINGS (ECC)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** x *** x *** cm aggregate of minute red-tan tissue fragments admixed with blood clot. The specimen is entirely submitted [describe cassette summary].Cassette Submission: All tissue submitted

- Note: If received on Teflon or gauze, carefully scrape with a CLEAN blade onto tissue wrap. If free floating in formalin, pour through a nylon biopsy bag

Specimen Type: CERVICAL BIOPSYGross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] are multiple [color, consistency] portions of tissue measuring *** x *** x *** cm in aggregate and ranging from *** cm to *** cm in greatest dimension. The specimen is entirely submitted in [describe cassette summary].Cassette Submission: All tissue submitted

- If necessary section of cervix is taken parallel to the axis of the cervical canal to include squamo-columnar junction. Submit entire specimen.

- If specimens are labeled with specific identification (e.g., anterior lip, posterior lip), submit separately.

Specimen Type: CERVICAL CONEGross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a cold-knife conization of the [cervix/endocervix] measuring *** x *** x *** cm. [Provide orientation if designated]. The external os measures *** cm in diameter and is [patent, stenotic]. The endocervical canal measures *** cm in length. The transformation zone is [distinct, not distinct]. The ectocervical mucosa is [red-brown, smooth,granular]. Sectioning reveals [a tan-white cut suface, presence of lesions]. The specimen is entirely submitted in [describe cassette submission].

Ink key:Blue-endocervical marginBlack-ectocervical and deep (stromal) margin

Cassette Submission: All tissue submitted

- Embed separately (1 radial section per cassette), or up to 4 sections per cassette.

- Label sections in a clockwise manner and maintain the same orientation throughout. (Sections from 12:00 - 3:00; 3:00 - 6:00; 6:00 - 9:00; 9:00 - 12:00)

Specimen Type: LEEP (Loop Electrodiathermy Excisional Procedure) Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a leep conization of the [cervix, endocervix-sometimes refered to as “top hat”] measuring *** x *** x *** cm . [Provide orientation if designated]. The external os measures *** cm in diameter and is [patent, stenotic]. Endocervical tissue [is/is not] identified. The endocervical canal measures *** cm in length. The transformation zone is [distinct, not distinct, not recognized]. The ectocervical mucosa is [red-brown, smooth,granular]. Sectioning reveals [a tan-white cut suface, presence of lesions]. The specimen is entirely submitted in [describe cassette submission].

Ink key:Blue-endocervical marginBlack-ectocervical and deep (stromal) margin

Cassette Submission: All tissue submitted

- Embed separately (1 radial section per cassette), or up to 4 sections per cassette.

- Label sections in a clockwise manner and maintain the same orientation throughout. (Sections from 12:00 - 3:00; 3:00 - 6:00; 6:00 - 9:00; 9:00 - 12:00)

- Note : Usually, three parts consisting of an exocervical portion, an endocervical (“top hat”) portion, and an ECC are included in the specimen, and will not always be oriented.

FALLOPIAN TUBESpecimen Type: LIGATIONGross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a segment of fallopian tube measuring *** cm in length x *** cm in diameter. Fimbriae are [present/absent]. The lumen is patent and measures up to *** cm in diameter. No lesions are identified. Representative sections are submitted [describe cassette submission].Cassette Submission: 1 cassette

- Submit at least 2 complete cross sections, if able- If you do not identify a lumen, submit the entire specimen- If the specimen does not appear to be fallopian tube (i.e. blood

vessel or round ligament) verify attending pathologist immediately.

Specimen Type: ECTOPIC/TUBAL PREGNANCYGross Template:Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [disrupted/intact] salpingectomy measuring *** cm in length x *** cm in diameter. Fimbriae are [present/absent]. The lumen is patent and ranges from *** to *** cm in diameter. There is a [describe rupture- (measure length and width), note associated hemorrhage, blood clot]. The lumen contains [blood, embryo, chorionic vili, other-weigh and measure if appropriate]. Representative sections are submitted [describe cassette submission].Cassette Submission: 3-4 cassettes

- Submit cross sections to demonstrate site of rupture, perpendicular sections

- Submit cross sections to demonstrate uninvolved fallopian tube- If no gestational sac is grossly identified, submit the entire fallopian

tube sequentially

Specimen Type: SALPINGECTOMY (non-neoplastic resection)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [disrupted/intact] salpingectomy measuring *** cm in length x *** cm in diameter. Fimbriae are [present/absent]. The external surface of the fallopian tube is remarkable for [color, texture, adhesions, paratubal cysts]. The specimen is sectioned to reveal [describe luminal contents]. Representative sections are submitted [describe cassette submission].Cassette Submission: 1-2 cassettes

- Grossly unremarkable – submit one representative cross section from proximal, mid, and distal portion and longitudinally bisected fimbriated end

- Adhesions present – submit one section to include adhesions- Sample cystic areas (if present)- BRCA or breast cancer- entirely embed using SEE-FIM protocol

Specimen Type: SALPINGECTOMY (neoplastic resection)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [disrupted/intact] salpingectomy measuring *** cm in length x *** cm in diameter. Fimbriae are [present/absent]. The external surface of the fallopian tube is remarkable for [color, texture, adhesions, paratubal cysts]. The specimen is sectioned to reveal [describe lesion-location, focality, color, circumscription, extension (transmural, % of lumen involved, layers of wall involved]. The remaining mucosa is [describe cut surface]. No additional lesions or masses are identified. Representative sections are submitted [describe cassette submission].Cassette Submission: 8-10 cassettes

- Representative sections of tumor, if present, including one of grossly involved mucosa and one of uninvolved mucosa.

- Representative sections of any cystic lesions.- In a case of primary adenocarcinoma of the fallopian tube, if the

tube is intact, submit section representing deepest invasion in/through wall.

- Submit the surgical margin in a separately designated cassette.- Take gross photographs- BRCA or breast cancer- entirely embed using SEE-FIM protocol

OVARYSpecimen Type: SALPINGO-OOPHRECTOMY (non-neoplastic)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [disrupted/intact] *** gramsalpingo-oophrectomy. The ovary measures *** x *** x *** cm. The fallopian tube measures *** cm in length x *** cm in diameter. Fimbriae are [present/absent].

The ovarian capsule is [smooth, tan-yellow, not extensive tubo-ovarian adhesions if present]. Sectioning the ovary reveal [color/cysts/lining/projections/describe contents/thickness of wall, atrophic changes]. The external surface of the fallopian tube is remarkable for [color, texture, adhesions, paratubal cysts]. Representative sections are submitted [describe cassette submission].Cassette Submission: 2-3 cassettes

- 1 cassette of ovary

- 1 cassette of fallopian tube- BRCA- entirely embed, using SEE-FIM protocol

o This protocol entails submitting the entire fallopian tube as follows: amputate and longitudinally section the infundibulum and fimbrial segment (distal 2 cm) to allow maximal exposure of the tubal plicae. The isthmus and ampulla are cut transversely at 0.2-0.3 cm intervals. In the gross description, mention in the summary of section that the fallopian tube has been submitted in its entirety per the SEE-FIM protocol.

o If ovary is replaced by a large cyst- submit 1 section per 1 cm of the greatest dimension of the ovary

Specimen Type: SALPINGO-OOPHRECTOMY (neoplasm/cysts)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [disrupted/intact] *** gram salpingo-oophrectomy. The ovary measures *** x *** x *** cm. The fallopian tube measures *** cm in length x *** cm in diameter. Fimbriae are [present/absent]. The ovary is [partially, entirely] replaced by a [solid, cystic-unilocular, multicolular-give range and overall size of locules] mass. The mass is approximately [%] solid and [%] cystic. [Cystic component- internal cyst lining, cyst contents, cyst wall thickness]. [Solid component- color, consistent, configuration]. [Describe necrosis, hemorrhage, and calcification].

Residual ovarian parenchyma [is/is not] identified [describe if identified]. [Describe fallopian tube if present]. Representative sections are submitted [describe cassette submission].

Cassette Submission: 10-12 cassettes

- One section for each 1 cm of maximum tumor diameter (For mucinous neoplasms, submit 2 sections for each 1 cm of maximum tumor diameter).

- With cystic lesions, section solid or papillary growths on inside and outside of the cyst wall.

- Section of solid tumor at capsular surface.- Include sections demonstrating relationship of tumor to attached

structures and sections of uninvolved ovarian tissue.

UTERUSSpecimen Type: ENDOMETRIAL BIOPSY/CURRETAGE (EMC/EMB)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** x *** x *** cm aggregate of minute red-tan tissue fragments admixed with [blood clot/blood-tinged mucus]. The specimen is entirely submitted [describe cassette summary].Cassette Submission: All tissue submitted

- Note: If received on Teflon or gauze, carefully scrape with a CLEAN blade onto tissue wrap. If free floating in formalin, pour through a nylon biopsy bag

- If curettage is submitted for incomplete abortion, describe recognizable placental tissue (hydropic villi), fetal parts or degenerate decidua. If the microscopic sections do not show products of conception, submit all tissue.

Specimen Type: MYOMECTOMY (morcellated/laparoscopic)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram, *** x *** x *** cm aggregate of pink-tan, semi-firm irregularly shaped tissue fragments. The fragments range from ***-*** cm in maximum dimension. There are no areas of hemorrhage, necrosis, or calcification. Representative sections are submitted [describe cassette submission].Cassette Submission: 3 cassettes

- Focus on yellow, calcified, or hemorrhagic areas- If small enough-entirely embed

Specimen Type: MORCELLATED LAPRASCOPIC HYSTERECTOMYGross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram morcellated [total/supracervical hysterectomy] received in multiple portions. The portions range from *** to *** cm in maximum dimension and amount in aggregate to *** x *** x *** cm . The [cervix/endocervical stump] measures *** cm in length x *** cm in diameter. There is a *** cm average endometrial thickness. Portions with enodmetirum and serosa have a *** cm average myometrial thickness.

Identifiable serosa is [pink, smooth, glistening]. Identifiable endometrium is [red and thickened, yellow and atrophic, denuded]. The myometrium is [pink-tan, trabeculated, remarkable for cystic spaces (adenomyosis), leiyomyomas-number, size, % the fibroids account for of the total specimen, hemorrhage, necrosis, calcification, location)]. unremarkable/remarkable for leiomyomata]. No lesions or masses are identified. Representative sections are submitted [describe cassette submission].

Cassette Submission: 7-8 cassettes

- 3 cassettes of leiyomyoma if grossly unremarkableo You can add 3 pieces in 1 cassette

- 2 cassettes of endometrium/myometrium/serosa - Anteiror and posterior cervix/upper endocervical stump,

perpendicular

Specimen Type: TOTAL HYSTERECTOMY and SALPINGO-OOPHRECTOMY (benign)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram [intact/previously incised/disrupted] [total/ supracervical hysterectomy/ total hysterectomy and bilateral salpingectomy, hysterectomy and bilateral salpingo-oophrectomy]. The uterus weighs [***grams] and measures [***cm (cornu-cornu) x ***cm (fundus-lower uterine segment) x *** cm (anterior - posterior)]. The cervix measures *** cm in length x *** cm in diameter. The endometrial cavity measures *** cm in length, up to [***cm wide]. The endometrium measures *** cm in average thickness. The myometrium ranges from ***-*** cm in thickness. The right ovary measures [***x***x*** cm]. The left ovary measures [***x***x*** cm]. The right fallopian tube measures *** cm in length [with/without] fimbriae x *** cm in diameter, with a *** cm average luminal diameter. The left fallopian tube measures *** cm in length [with/without] fimbriae x *** cm in diameter, with a *** cm average luminal diameter.

The serosa is [pink, smooth, glistening, unremarkable/has adhesions]. The endometrium is [tan-red, unremarkable, describe presence of lesions/polyps]. The myometrium is [tan-yellow, remarkable for trabeculations, cysts, leiyomoma-(location, size)]. The leiyomyoma are sectioned to reveal [smooth/whorled/nodular cut surfaces, with/without areas of hemorrhage, necrosis, or calcification]. The right and left fallopian tubes are [grossly unremarkable, remarkable for adhesions, show evidence of prior tubal ligation, etc]. The cervix is [grossly unremarkable, presence of Nabothian cysts, lesions]. The right and left ovary are [unremarkable, show atrophic changes, describe presence of lesions]. No lesions or masses are grossly identified. Representative sections are submitted [describe cassette submission].

Cassette Submission:Benign conditions (prolapse, fibroids, adenomyosis): 5-8 cassettes

- Anterior cervix - Posterior cervix - Anterior uterine corpus full thickness (include leiomyomata if

present)

- Posterior uterine corpus full thickness (include leiomyomata if present)

- Right and left fallopian tubeo Two cross sections and fimbriated end

- Right and left ovary- If any polyps are present, submit in entirety

o If you need to transect, keep the relationship of base of the polyp to the endometrium to assess for invasion, if malignant

- Representative sections of leiyomyoma (use judgement)o 3 cassettes if all are grossly unremarkableo Sample as many myomas as possible with emphasis on

larger myomas.o Sections should include periphery of myoma. If submucosal

should include endometrium in section of myoma.o If myomas do not have characteristic appearance and have

any change in color or consistency, should be brought to attention of the pathologist and additional sampling is indicated.

- Note: Supracervical hysterectomy - Ink the resection margin of lower uterine segment at the line of excision.

Specimen Type: TOTAL HYSTERECTOMY and SALPINGO-OOPHRECTOMY (for TUMOR)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram [intact/previously incised/disrupted] [total/ supracervical hysterectomy/ total hysterectomy and bilateral salpingectomy, hysterectomy and bilateral salpingo-oophrectomy]. The uterus weighs [***grams] and measures *** cm (cornu-cornu) x *** cm (fundus-lower uterine segment) x *** cm (anterior - posterior). The cervix measures *** cm in length x *** cm in diameter. The endometrial cavity measures *** cm in length, up to *** cm wide. The endometrium measures *** cm in average thickness. The myometrium ranges from *** to *** cm in thickness. The right ovary measures *** x *** x *** cm. The left ovary measures *** x *** x *** cm. The right fallopian tube measures *** cm in length [with/without] fimbriae x *** cm in diameter, with a *** cm average luminal diameter. The left fallopian tube measures *** cm in length [with/without] fimbriae x *** cm in diameter, with a *** cm average luminal diameter.

The serosa is [pink, smooth, glistening, unremarkable/has adhesions]. The endometrium is tan-red and remarkable for [describe lesion- location (fundus, corpus, lower uterine segment); size (***x***cm in area); color; consistency; configuration (solid, papillary, exophytic, polypoid)]. Sectioning reveals the mass has a [describe cut surface-solid, cystic, etc.]. The mass extends [less than/ greater than] 50% into the myometrium (the mass involves *** cm of the wall where the wall measures *** cm in thickness, in the [location]). The mass [does/does not] involve the lower uterine segement and measures *** cm from the cervical mucosa.

The myometrium is [tan-yellow, remarkable for trabeculations, cysts, leiyomoma-(location, size)]. The leiyomyoma are sectioned to reveal [smooth/whorled/nodular cut surfaces, with/without areas of hemorrhage, necrosis, or calcification]. The cervix is [grossly unremarkable, presence of Nabothian cysts, lesions]. The right and left ovary are [unremarkable, show atrophic changes, describe presence of lesions]. The right and left fallopian tubes are [grossly unremarkable, remarkable for adhesions, show evidence of prior tubal ligation, etc].

No additional lesions or masses are grossly identified. Representative sections are submitted [describe cassette submission].

Ink Key:Black-right paracervical soft tissueBlue-left paracervical soft tissue

Cassette Submission:

- Endometrial hyperplasia: 12-15 cassetteso Anterior cervixo Posterior cervixo Anterior uterine corpus, full thicknesso Posterior uterine corpus, full thicknesso 1 section of funduso Anterior/posterior uterus

If previous material revealed only simple or cystic hyperplasia, submit sections of endometrium, including one full thickness section of uterine wall (3 from each wall).

If previous material revealed complex or atypical simple or complex hyperplasia, submit entire endometrium, including one full thickness of anterior uterine wall and one full thickness of posterior uterine wall

o Right fallopian tube and right ovary (include fimbriae)o Left fallopian tube and left ovary (include fimbriae)

- Malignant conditions (endometrial carcinoma): 15-20 cassetteso Shave and submit right and left parametrial margins if tumor

is > 1cm from margins. Submit perpendicular section of parametrial margins if tumor is < 1cm from margin.

o Anterior cervixo Posterior cervixo 2 sections of anterior uterine corpus full thickness (showing

depth of invasion)o 2 sections of posterior uterine corpus full thickness (showing

depth of invasion)o 1 section of uterine fundus with and without lesiono Tumor with relationship to unremarkable endometriumo Anterior lower uterine segment full thickness, perpendicularo Posterior lower uterine segment full thickness, perpendicularo Right and left fallopian tube

2 cross sections and fimbriated endo Entirely submit both ovaries if grossly unremarkable

If ovaries are large and cyst-filled, submit representative sections

o Submit all lymph nodes (if present)- Malignant conditions (cervical carcinoma): 20-25 cassettes

o Submit entire cervix (in clock wise manner: 12-3:00; 3-6:00; 6-9:00; and 9-12:00)

o Keep vaginal cuff intact if presento Anterior lower uterine corpus segment full thicknesso Posterior lower uterine corpus segment full thicknesso 1 section of uterine fundus o Anterior uterine full thicknesso Posterior uterine full thicknesso Entirely submit both fallopian tubeso Entirely submit both ovaries

If ovaries are large and cyst-filled, submit representative sections

o Submit all parametrium- Cervical neoplasia (in situ or invasive):

o Sections of amputated cervix treated like a cone biopsy, in cases of hysterectomy for intraepithelial neoplasia.

o Measure distance from exocervix to vaginal resection margin and section latter in simple and radical hysterectomy specimens. Shave the entire inked vaginal cuff margin and submit in 4 cassettes (12:00 – 3:00, 3:00 – 6:00, 6:00 – 9:00 and 9:00 – 12:00).

o In radical hysterectomy specimens, ink surgical margins of parametrial and paracervical tissue and section entire right and left parametrial tissue.

o In radical hysterectomy specimens process cervix as in (a) if tumor small, or if a large bulky tumor, selectively section tumor, at least 3 sections, and define depth of invasion and its relation to the surgical margins which have been inked.

o Section deep surgical margin anteriorly and posteriorly in relation to location of bladder and rectum, and label as such.

o Sections of parametria.o Sections of distal vaginal and surgical deep margins to show

the closest relationship between the tumor and these margins.

o Sections of lower uterine segment and fundus to evaluate tumor spread.

o Section of uninvolved endometrium and myometrium, as described under "benign disease".

o Section of all lymph nodes, if present.- Stromal Neoplasm/Sarcoma:

o Submit at least 1 section of tumor per cm tumor diameter.o Sections of adjacent and remote endometrium.

o Sections of adjacent myometrium to determine extent of invasion and possible serosal spread.

o Section of lower uterine segment and cervix nearest to tumor to determine possible spread.

o Section of vaginal margin.o Section entire left and right parametrial tissue.

- Gestational Trophoblastic Tumor:o Multiple sections of trophoblastic tumoro Section to demonstrate deepest invasion into myometrium

(note this in the gross dictation as well, if possible)o Submit fresh material for Cytogenetic analysis and DNA

ploidy by flow cytometry. Both require RPMI tissue medium.

Specimen Type: TOTAL HYSTERECTOMY (for CERVICAL tumor)Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** gram [intact/previously incised/disrupted] [total/ supracervical hysterectomy/ total hysterectomy and bilateral salpingectomy, hysterectomy and bilateral salpingo-oophrectomy]. The uterus weighs [***grams] and measures [***cm (cornu-cornu) x *** cm (fundus-lower uterine segment) x *** cm (anterior - posterior)]. The cervix measures *** cm in length x *** cm in diameter. The cervical cuff extends up to *** cm anteriorly and *** cm posteriorly from the cervix. The endometrial cavity measures *** cm in length, up to *** cm wide. The endometrium measures *** cm in average thickness. The myometrium ranges from *** to *** cm in thickness. The right ovary measures *** x *** x *** cm. The left ovary measures [***x***x*** cm]. The right fallopian tube measures *** cm in length [with/without] fimbriae x *** cm in diameter, with a *** cm average luminal diameter. The left fallopian tube measures *** cm in length [with/without] fimbriae x *** cm in diameter, with a *** cm average luminal diameter.

The cervical mucosa is remarkable for a lesion located in the [anterior/posterior aspect] extending from *** o’clock to *** o’clock, which measures *** x *** cm in surface area. Sectioning reveals the lesion [describe cut surface] and has a *** cm maximum thickness. The lesion measures *** cm from the inked paracervical soft tissue margin. The lesion [does/does not] extend into the vaginal cuff. The lesion [does/does not] extend to the lower uterine segment. The lesion [does/does not] extend into the uterus. [OR if no tumor identified –“The cervix is remarkable for a defect measuring *** cm in diameter which extends *** cm into the cervix. No residual tumor is grossly identified”.]

The uterine serosa is [pink, smooth, glistening, unremarkable/has adhesions]. The endometrium is [tan-red, unremarkable, describe presence of lesions/polyps]. The myometrium is [tan-yellow, remarkable for trabeculations, cysts, leiyomoma-(location, size)]. The right and left ovary are [unremarkable, show atrophic changes, describe presence of lesions]. The right and left fallopian tubes are [grossly unremarkable, remarkable for adhesions, show evidence of prior tubal ligation, etc]. No additional lesions or masses are grossly identified. Representative sections are submitted [describe cassette submission].

Ink Key:Black-rightBlue-left

Cassette Submission: 20-25 cassettes

- Right and left parametrial margins- Anterior vaginal cuff margin- Posterior vaginal cuff margin- Cervix with and without tumor

o Show closest approach to inked soft tissue margin- Anterior and posterior lower uterine segment- Uterine fundus- Right and left fallopian tube

o 2 cross sections and bisected fimbriated end- Right and left ovary

o Representative cross sections if uninvloved- Parametrial soft tissue- All lymph nodes if present

SENTINEL LYMPH NODES Specimen Type: SENTINEL LYMPH NODESUltrastaging of lymph nodes (Sentinel lymph nodes) in gynecologic malignancies:

Lymph nodes being evaluated by “ultrastaging” should be serially sectioned in the longest axis at 2 mm intervals and submitted totally with slips in all cassettes denoting them as “uterus ultrastaging package”. All ultrastaging lymph nodes have three serial H&E sections (serial #1, 3, 5) and three immunoblanks (serial #2, 4, 6) for pancytokeratin (AE1/AE3) on serial #2 and Cytokeratin 7 on serial #4. Serial #6 is the IHC negative control. The ultrastaging lymph node package is done in malignant cases in which lymph nodes are submitted as sentinel lymph nodes.

OMENTUMSpecimen Type: OMENTECTOMY for staging of GYN MALIGNANCIESOmentum must be examined grossly and carefully searched for small (0.4–0.5 cm) foci by the naked eye, palpation, and/or dissection. If macroscopic lesion is not detectable and the patient 3 to 5 sections seem sufficient for appropriate staging.

VAGINASpecimen Type: RESECTION (for tumor) Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a *** x *** cm portion of vagina excised to maximum depth of *** cm. [Provide orientation].

The mucosa is remarkable for a *** cm ulcerated, tan, firm, ill-defined mass is Sectioning reveals the mass extends into the underlying soft tissue and has a maximum depth of *** cm. The mass measures *** cm from the closest margin [indicate margin on clock face].

The uninvolved vaginal mucosa is grossly unremarkable. No lymph nodes are identified within the underlying soft tissue. A gross photograph is taken. Representative sections are submitted [describe cassette submission]. Cassette Submission: 20-25 cassette

- Shave the inked peripheral vaginal margin and submit entirely from 12:00 – 3:00, 3:00 – 6:00, 6:00 – 9:00 and 9:00 – 12:00.

- Thickest portion of lesion to demonstrate maximal invasion as well as thickness of vaginal wall in this area.

- Relation of the tumor to the margin

VULVASpecimen Type: PARTIAL/ TOTAL VULVECTOMY (for tumor) Gross Template: Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a [partial/total/simple/radical/subcutaneous] vulvectomy measuring *** x *** cm, and is excised to a depth of *** cm. [Provide orientation].

The epidermis is remarkable for [Describe any lesions – including size, type, borders, color, shape, distance to all margins]. The specimen is sectioned to reveal [describe cut surface and depth of invasion and distance of mass to deep margin].

[Describe remaining cut surface and presence of satellite lesion(s)]. The specimen is entirely submitted/Representative sections are submitted [describe cassette submission]. A gross photograph is taken.

Cassette Submission: 15-20 cassettes

- At least 3 sections of tumor, including sections showing deepest area of invasion and relationship to closest margin of resection.

- Sections of entire lateral margin of resection.- Section of entire vaginal margin of resection.- Sections of any skin surface with altered coloration and texture.- Sections of uninvolved skin from right and left labia majora and

minora, and clitoris.- Sections of lymph nodes, separately labeled.- Take gross photograph

PRODUCTS OF CONCEPTIONSpecimen Type: POC (curettings, vaginal/uterine contents) Procedure:

1. Consider cytogenetic studies and check the clinical history2. Weigh and describe.

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “[ ]”, and received [fresh/in formalin] is a __gram, [___x___x___cm] aggregate of pink-red soft tissue fragments [admixed with blood clot]. Chorionic villi [are/ are not- if present, check for hydropic vesicles] identified. There [are/ are no] fetal or embryonic parts identified. Representative sections are submitted [describe cassette submission].

Cassette Submission: 1-5 cassettes

- If chorionic villi or fetal parts are identified, submit one cassette.- If NO chorionic villi or fetal parts are identified, submit several (3-5)

cassettes.- If hydropic villous changes are present and a molar pregnancy is

suspected, but not definitive, store fresh tissue in RPMI for possible cytogenetic studies.

FETUSSpecimen Type: FETUSProcedure:

1. Weigh and determine phenotypic gender

a. If fetus weighs more than 500 grams or is older than 20 weeks gestational age or 22 last menstrual weeks’ gestation- case should be processed as fetopsy and needs to be sent to autopsy. Do NOT accession as surgical case.

2. If en caul delivery (fetus attached to placenta in amniotic sac)- photograph intact specimen then rupture the membranse and detach fetus (leaving only a short umbilical stump with the fetus). Weigh the fetus and determine if this a is fetopsy or surgical specimen.

3. Photograph if there are any obvious abnormalities present or if fetal demise was unexpected.

(a) If fetus is fragmented and admixed with placental fragments, separate fetal from placental tissues and weight each portion separately. If terminated for anomalies, try to identify tissues suspected of being abnormal to weigh (and possibly photograph) separately. Radiograph skeletal fragments in cases of suspected skeletal dysplasias. (b) Weigh (with cord and membranes removed) and gross placenta as described in placenta gross examination.

4. For a pregnancy termination or fetal demise less than 19 6/7 weeks:A. In all cases, a gross examination should be performed.

Photograph and radiograph fetus if received intact. Determine phenotypic gender (ask for assistance if needed).

B. If fetus received intact and there is no clinical suspicion of fetal abnormality, and if the gross exam is normal an external examination only will be performed.

C. If fetus is received intact and there is clinical suspicion of fetal abnormality, regardless if the patient has signed paperwork asking for fetal remains to be sent to a funeral home for burial, contact Dr. Goldstein and/or the attending on service to see if an internal examination should be performed in addition to a routine external examination.

5. Although not legally required, preferably, an autopsy consent should be obtained for any internal dissection and microscopic examination of an intact fetus less than 20 weeks gestational age. In these instances, the fetus should be accessioned as an autopsy and a complete fetopsy performed. Measure crown-rump, crown-heel length, and estimate fetal age accordingly. Also measure foot length, biparietal diameter, chest circumference, abdominal circumference. If measurements cannot be taken due to fragmented nature of specimen, report this.

Measurements of embryos: A. crown-rump length; B. crown-heel length; C. greatest length.

Gross Template:

Fragmented fetus with placental tissue

Labeled with the patient’s name (last name, first name), medical record number (#), designated “[ ]”, and received [fresh/in formalin] is a __gram, [___x___x___cm] aggregate of pink-red soft tissue fragments [admixed with blood clot]. Additionally received within the specimen container is a(n) __gram, [___x___x___cm]

[intact/fragmented] fetus. Identifiable fetal parts include [describe fetal parts]. The foot length measures __cm. Representative sections are submitted [describe cassette submission].

Intact fetus <19 6/7 gestational age (unwanted, undesired pregnancy)

Labeled with the patient’s name (last name, first name), medical record number (#), designated “[ ]”, and received [fresh/in formalin] is a __gram, [___x___x___cm] intact fetus. Phenotypic gender is [male/female]. The fetus measures __ cm from crown to heel and __cm from crown to rump. The foot length measures __ cm. The head circumference measures __cm; the thoracic circumference measures __cm; and the abdominal circumference measures __ cm. There [is/is no] attached umbilical cord. The eyes are [open/fused]. The ears are [patent/not patent]. The lip/palate is [intact/not fuesd]. The anus is [patent/not patent]. There is [minimal, moderate/extensive] skin slippage. The fetus is for gross examination only. A gross photograph is taken.

Cassette Submission:

-1 cassette- Small embryos - one half or entire embryo or depending on its/their size.- Fragmented fetuses - representative sections, including lung, kidney, liver, and gonads (if identified)(sections of any abnormalities) and placental tissue- Intact fetuses- gross examination only if < 19 6/7 weeks gestational age

PLACENTACOMMENT: PLEASE TAKE GROSS PHOTOS OF INTACT PLACENTAS WITH SIGNIFICANT GROSS FINDINGS; IF UNSURE, TAKE A PHOTO!

SINGLETON 1. Weigh and measure (after umbilical cord and membranes are removal). Note

disc shape and measure any succinturiate lobes, length and appearance of intramembranous vessels.

2. Measure length and diameter of umbilical cord.3. Describe insertion of cord (central, marginal, velamentous; record distance to

nearest edge if < 3 cm). Note presence of knots, strictures, thinning of Wharton’s jelly, thrombi, and other deformities, and number of vessels seen on cross section. Estimate number of coils per 10 cm of cord, coil direction (handedness), and note deep coil grooves, if present.

4. Describe membranes (insertion (Percentage involved by circumvallation or circumargination, if extrachorial), color, opaque or translucent, intact?). Measure distance of point of rupture to placental margin.

5. Describe fetal surface. Note exudate, hemorrhage, cysts, tumors, meconium staining, thrombi, condition of vessels.

6. Describe maternal surface, noting infarcts, adherent blood clots. Measure volume of clot. State whether placenta is complete or incomplete.

7. Serially section the placenta at 0.5 – 1.0 cm intervals. Describe cut surface, measure disc thickness, note areas of depression, note and describe infarcts, clots, intervillous thrombin, and other abnormalities and include location (peripheral vs. central, maternal vs. fetal side vs. intervillous space) and age (recent or old?). If multiple infarcts or lesions are present, report the number of lesions and measure the largest one. INCLUDE PERCENTAGE OF PLACENTAL DISC VOLUME OCCUPIED BY INFARCT(S).

8. Make a roll of the membranes including edge representing point of rupture and if possible a small portion of peripheral disc, wrapping them around a wooden stick and fixing in formalin or Bouin’s solution. Ensure both amnion and chorion are included in roll.

9. Submit sections as follows:a) Cross sections of umbilical cord, near fetal end and approximately 5 cm from

insertion site, and membrane roll.b) Full thickness sections of placenta near umbilical cord insertion site toinclude

chorionic vessels.c) Two full thickness sections from the central 2/3 of the disc (May be split into 2

cassettes each – maternal and fetal halves – if placenta is too thick for a single cassette)

d) One full thickness section of placenta from margin (optional).e) Sections of any lesion(s) or succenturiate lobes.

TWIN1. Indicate whether the placentas are separate or fused. If separate, examine each

placenta as described above. Weigh and measure.2. If fused, note the presence of a dividing membrane and its appearance. Indicate

if no dividing membrane is present.3. If two amniotic cavities are found, indicate if they are of equal or unequal size.4. Describe any surface vessel anastomoses between twins [artery-artery, vein-

vein, artery-vein], or segments perfused by an artery from one twin and venous return to the other (deep anastomoses).

5. Make a roll of the dividing membrane and free membranes from each placenta.6. Examine each half of the placenta(s) as described under "single placenta".7. Submit sections as follows:a) Two cross sections of both umbilical cords, as above.b) Sections of both free membrane rolls to include origin of membranes, if possible.c) Cross section of the roll of the dividing membrane and “T-zone” of the septal

insertion.d) Placental tissue as described under single placenta.

Gross Template:

Labeled with the patient’s name (***), medical record number (***), designated “***”, and received [fresh/in formalin] is a singleton placenta with an attached tan-white, [eccentrically, centrally, marginally, velamentously] located trivascular umbilical cord (*** cm in length x *** cm in average diameter), which inserts *** cm from the margin. There [are/are no] cord knots, thromboses, or focal lesions present. There are [#] [right, left] handed coils per 10 cm.  The fetal surface is [pink-purple and smooth]. There is [scant, moderate, extensive-quantify if extensive] subchorionic fibrin present. There [is/is no] squamous metaplasia, amnion nodosum, or gross meconium. Surface vessels are [normal/congested/focally thrombosed]. The [pink-tan, thin and translucent, green, thickened, opaque] membranes insert [marginally, circumarginate, circumvallate over #% of the disc circumference]. The nearest point of rupture measures *** cm from the margin. There [is/is no] accessory lobe present.  The [ovoid, discoid, bi-lobed, etc.] placental disc (devoid of cord and membranes) weighs *** grams and measures *** x *** x *** cm. The cotyledons are [all present and intact or disrupted or incomplete]. There [is no/is- if present give size and location)] retroplacental hemorrhage. Sectioning reveals [a red-brown cut surface, describe lesions-intervillous hematomas and infarcts (color, consistency, location)-provide % of placental disc involved)]. The remaining parenchyma is [dark red-purple or light pink-red] and soft with [normal, increased] calcifications. No additional lesions or masses are grossly identified. Representative sections are submitted.

Cassette Submission:Singleton

A1 Umbilical cord cross sections and membranesA2Central placenta near cord insertionA3-A4 Central 2/3 of placentaA5-.. Submit any intervillous hematomas and/or infarcts (include

interface between lesion and unremarkable parenchyma)

Week post conceptio

n

Week post last

menstruation

Crown-rump (mm)

Fetal weight (gm)

Placental diameter

(mm)

Placental weight (gm)

Placental thickness

(mm)

Umbilical cord length

(mm)12

1 32 43 5 2.54 6 5 55 7 96 8 14 1.1 67 9 20 28 10 26 5 149 11 33 1110 12 40 17 2611 13 48 23 50 - 75 160 - 18012 14 56 30 42 1013 15 65 4014 16 75 60 65 1215 17 88 90 75 - 100 220 - 30016 18 99 130 9017 19 112 18018 20 125 250 115 1519 21 137 320 100 - 125 330 - 35020 22 150 400 15021 23 163 48022 24 176 560 185 1823 25 188 650 125 - 150 370 - 40024 26 200 750 21025 27 213 87026 28 226 1000 250 2027 29 236 1130 150 - 170 420 - 45028 30 250 1260 28529 31 263 140030 32 276 1550 315 2231 33 289 1700 170 - 200 460 - 49032 34 302 1900 35533 35 315 210034 36 328 2300 390 2435 37 341 2500 200 - 220 500 - 52036 38 354 2750 42537 39 367 300038 40 380 3400 470 25Data taken from table in "Pathology of the Human Placenta", 2nd ed., Benirschke, Kurt, 1990, pg 343. [Data compiled from Boyd & Hamilton (1970), O'Rahilly (1973), Johannigmann et al. (1972), and Winchel (1893)]