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GASTROINTESTINAL PATHOLOGY GROSSING GUIDELINES

Placing Cytogenetic/Molecular Orders on an Existing Case (Page 52-61)

Outreach (or Student Health) Cases (Page 54)

PowerPath Cases, or Cases where Collection Date is OVER 16 days old (Page 55-57)

Cases where the Collection Date is NOT OVER 16 days old (Page 58-61)

EMR or ESR (Page 2-3)

STOMA

End Stoma (Page 4)

Loop Stoma (Page 5)

Anastomic Ring or Donut (Page 6)

ESOPHAGUS

Esophagectomy (Page 7-8)

Esophagogastrectomy (Page 9-11)

STOMACH

Sleeve Gastrectomy (2)

Gastrectomy (Page 13-15)

SMALL BOWEL

Small Bowel for Tumor (Page 16-17)

Hemorrhoidectomy (Page 43)

APPENDIX

Appendix- benign (Page 40)

Appendix for Tumor (Page 41-42)

COLON & RECTUM

Diverticular Disease (Page 18)

Chron's Disease (Page 19-20)

Ulcerative Colitis (Page 21-22)

Familial Adenomatous Polyposis (Page 23-24)

Trauma (i.e. gunshot) (Page 25)

Ischemic Bowel (Page 26)

Volvulus or Obstruction (Page 27)

Segmental Resection for Tumor (Page 28-30)

Right Hemicolectomy (Page 31-33)

Low Anterior Resection (LAR) (Page 34-36)

Abdominoperineal Resection (APR) (Page 37-39)

PANCREAS

Whipple (Page 44-47)

Distal Pancreatectomy (Page 48-49)

Central Pancreatectomy (Page 50-51)

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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:

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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 in [describe cassette submission]. Cassette Submission: 5-10 cassettes

- Submit levels sequentially into cassetteso End margins are in separate cassettes and perpendicularly

sectioned (see diagram)- Multiple levels can be placed into the same cassette- The cassette key should clearly indicate what is submitted (ie, A1: level

one, perpendicularly, A2: next 3 serial slices, A3: Next 2 serial slices, A4: last slice, perpendicularly sectioned)

Sample Cassette Submission:A1 One end, perpendicularA2- A4 Central sections (lesion: A3 - A4)A5 Opposite end, perpendicular

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Specimen Type: END STOMAProcedure:

1. Measure the length and diameter 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 *** cm in 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 (measuring *** cm in width, if present). 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

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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 (measuring *** cm in width if present). 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

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Specimen Type: ANASTOMOTIC RING/DONUTProcedure:

1. Measure the length and diameter.a. The donut may come on an EEA (end to end anastomosis) device. There is

no need to comment on or photograph the device.2. Describe the serosa and mucosa.3. Serially section bowel and describe the thickness and cut surface of the wall.

Gross Template:Labeled with the 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. No need to entirely submit.

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Specimen 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. Ink adventitial surface of the esophagus at the lesional site.3. Describe external surface noting areas of retraction, induration, extension of tumor,

perforation, presence of enlarged lymph nodes.4. 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.

5. 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.

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

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

8. 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 adventitial surface of the esophagus 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 to have a [describe cut surface of lesion] and a *** cm maximum thickness. The lesion measures *** cm from the proximal margin [or *** cm from the GE junction], *** cm from the distal 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.

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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, OR if

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

Show nearest approach of tumor to esophageal adventitial margin

o 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 nodeso No number of lymph nodes is recommended. Usually the entire

adventitial soft tissue is submitted for lymph nodes.- Note: If no gross tumor is present, block out ulcerated/fibrotic area

and entirely submit

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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, its diameter or circumference at the distal gastric margin, and wall thickness.

3. Ink adventitial 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 esophagogastrectomy on a board and fix in 10% formalin. 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 adventitial surface of the esophagus 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 to have 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 omental margin at the greater curvature (if applicable), and *** cm from the omental margin at the lesser curvature (if applicable).

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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 esophageal resection margin, shave

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

o Submit perpendicular section if lesion is close to margino If lesion is a grossly recognizable mass, shave or perpendicular

sections from nearest margin area are adequateo If lesion is diffuse type cancer (such as signet-ring cell carcinoma),

the entire margin should be submitted - One cassette per 1 cm of lesion (OR at least 5 sections of tumor OR if


Show nearest approach of tumor to esophageal adventitial margin or gastric serosal surface

o 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.)- Omental margin (greater or lesser curvature), shave, if tumor is mainly

located in the stomach- Submit all lymph nodes identified and adventitial soft tissue

o Separate gastric and esophageal lymph nodeso No number is recommended for esophageal cancer. Usually the

entire adventitial soft tissue is submitted for lymph nodes.o At least 16 regional lymph nodes are suggested for gastric

carcinoma.- Note: If no gross tumor is present, block out ulcerated/fibrotic area

and entirely submit

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http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCM3Pz_ih9cgCFZGiiAodjgoF0w&url=http://www.rcpa.edu.au/Library/Practising-Pathology/Macroscopic-Cut-Up/Specimen/Gastrointestinal/Oesophagus-and-stomach/Oesophaegus-and-gastro-oesophageal-junction&psig=AFQjCNGfvRlYBmCaE2mxwjGu9BIAtaeA5w&ust=1446674818811903

Specimen Type: SLEEVE GASTRECTOMYProcedure:

1. Measure the length, range of diameter or circumference, and wall thickness 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 *** cm in length, *** to *** cm in diameter or circumference, and *** cm in wall thickness. 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]. No lesions are grossly identified. [Describe lesions- if present.] Representative sections are submitted.

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

- Submit two representative sections of stomach wall in one cassetteo Include area of congestion or any other abnormal findings

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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 at 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 the 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 the wall.

8. Ink the 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, and *** cm [in maximum or average open circumference OR ranging from *** cm to *** cm in circumference] [include open circumference of pylorus if present]. The wall thickness ranges from *** cm in the [location] to *** cm in the [location]. The 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] to have 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 serosal surface, *** cm from proximal or distal resection margin, and *** cm from the nearest [greater or lesser] omental resection margin [if applicable].

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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 overlying the tumor or ulcer[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, shave

o Submit perpendicular section if lesion close to margino If lesion is a grossly recognizable mass, shave or perpendicular


the entire margin should be submitted- Distal resection margin, shave

o Submit perpendicular section if lesion close to margino If lesion is a grossly recognizable mass, shave or perpendicular


the entire margin should be submitted- Omental margin- One cassette per 1 cm of lesion (OR at least 5 sections of tumor OR if


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

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

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If lesion is a large ulcer – submit representative sections with relationship to adjacent mucosa

o Show relationship to unremarkable mucosa- Uninvolved body and antrum proximal and distal to tumor

o 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 (at least 16 nodes are suggested for

gastric carcinoma)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.

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Specimen 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 surface overlying 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 surface 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] to have 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 serosal surface [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.

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


o Submit perpendicular section if in relationship to lesion- Distal resection margin, shave

o Submit perpendicular section if in relationship to lesion- Mesenteric resection margin nearest to tumor, shave- One cassette per 1 cm of lesion (OR at least 5 sections of tumor OR if

small enough, entirely submit)o Show maximum depth of invasiono Show nearest approach to serosao Show relationship to unremarkable mucosao Show relationship to any contiguous or adherent organso 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 separately

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

- Submit all lymph nodes identified (no number is recommended)- Note: When a lymphoma is suspected (frequently intramural), submit

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

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Specimen Type: COLON RESECTION (Diverticular Disease)Procedure:

1. Measure length, range of diameter or circumference, and wall thickness.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 along the anti-mesenteric border, 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 (estimate), location and appearance of diverticula, as well as distance to the closest margin.

a. Note if there are any sites of hemorrhage, abscess formation or perforation. The diverticula should be probed to determine if there is perforation and/or fistula tracts, if grossly apparent.

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

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 ***cm in length x *** to ***cm in open circumference with two stapled ends. Fibroadipose tissue extends ***from the bowel wall.

The serosal surface is remarkable for [describe adhesions, plaques, full-thickness defects (perforations or enterotomies)]. There are [#/>10/multiple] diverticula, which measure *** cm from the [proximal/distal/closest] resection 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]. Sectioning reveals [no gross evidence of perforation or abscess formation/ perforation and/or abscess formation (describe location, size, and distance to nearest margin)].

The remainder of the serosa is [tan, smooth, glistening, and unremarkable]. 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. Representative sections of the specimen are submitted.

Cassette Submission: 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

- 1 cassette of normal mucosa- No lymph nodes are needed

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Specimen Type: INFLAMMATORY BOWEL DISEASE- Chron’s DiseaseProcedure:

1. Measure the length and range of diameter or circumference.2. Measure the terminal ileum and right colon separately for right hemicolectomy

specimens. 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 the serosal 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 bowel 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.

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] ileocectomy with two stapled ends. The ileum measures *** cm in length x ***cm in open circumference and is in continuation with a *** cm in length x *** cm in open circumference segment of colon. The appendix measures ***cm in length x ***cm in diameter. Fibroadipose tissue extends ***from the bowel wall. Mesoappendiceal tissue extends up to ***cm away from the appendiceal wall.

The serosal surface is remarkable for [describe presence of fat wrapping, fistulas, or perforations]. [Describe presence of strictures- length, location, luminal circumference, mucosa in this region, and distance to nearest margin]. The mucosal surface [describe presence and location of cobblestoning, ulcerations, pseudopolyps(give range in size), lesions, etc.]. Sectioning reveals [no gross evidence of perforation or abscess formation/ a perforation and/or abscess formation (describe location, size, and distance to nearest margin)]. There is a ***cm ileal wall thickness and a ***cm average bowel wall thickness.

The remaining ileal and colonic mucosal surface, including the resection margins, is grossly unremarkable. [No stricture/fistula/lesions are identified]. The appendiceal serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions/perforations]. The appendiceal mucosa is [tan, glistening, folded, and unremarkable or describe any additional

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lesions]. The appendix has a ***cm luminal diameter and a ***cm wall thickness. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension. Representative sections are submitted.

Cassette Submission: 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(s)- 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.- Standard sections of the appendix in one cassette, if present- Representative section(s) of the terminal ileum in one cassette if it is long

enough (such as that in a right hemicolectomy specimen); otherwise, a shave of the proximal (ileal) margin will be adequate. However, if the resection is for Crohn’s disease in the terminal ileum, sections should be taken for diseased areas as described above

- Representative lymph nodeso 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.

o No more than 5 lymph nodes need to be submitted, if there is no cancer.

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Specimen Type: INFLAMMATORY BOWEL DISEASE- Ulcerative ColitisProcedure:

1. Measure the length and range of diameter or circumference.2. Measure the terminal ileum and right colon separately for right hemicolectomy

specimens. 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 the serosal 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 bowel 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


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] ileocectomy with two stapled ends. The ileum measures *** cm in length x ***cm in open circumference and is in continuation with a *** cm in length x *** cm in open circumference segment of colon. The appendix measures ***cm in length x ***cm in diameter. Fibroadipose tissue extends ***from the bowel wall. Mesoappendiceal tissue extends up to ***cm away from the appendiceal wall.

The serosal surface is remarkable for [describe presence of fat wrapping, fistulas, or perforations]. [Describe presence of strictures- length, location, luminal circumference, mucosa in this region, and distance to nearest margin]. The mucosal surface is [tan, red, granular, shows flattened folds] that involves [the entire colon/ the distal __cm, which extends to the distal margin]. Sectioning reveals [no gross evidence of perforation or abscess formation/ a perforation and/or abscess formation (describe location, size, and distance to nearest margin)]. There is a ***cm ileal wall thickness and a ***cm average bowel wall thickness.

The remaining ileal and colonic mucosal surface, including the resection margins, is grossly unremarkable. [No stricture/fistula/lesions are identified]. The appendiceal

Page | 21

serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions/perforations]. The appendiceal mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions]. The appendix has a ***cm luminal diameter and a ***cm wall thickness. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension. Representative sections are submitted.

Cassette Submission: 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(s)- 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.- Standard sections of the appendix in one cassette, if present- Representative section(s) of the terminal ileum in one cassette if it is long

enough (such as that in a right hemicolectomy specimen); otherwise, a shave of the proximal (ileal) margin will be adequate. However, if the resection is for Crohn’s disease in the terminal ileum, sections should be taken for diseased areas as described above

- Representative lymph nodeso 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.

o No more than 5 lymph nodes need to be submitted, if there is no cancer.

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Specimen Type: FAMILIAL ADENOMATOUS POLYPOSISProcedure:

1. Measure the length, range of diameter or circumference, and wall thickness.2. Describe serosal 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


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 with two stapled ends. The ileum measures *** cm in length x ***cm in open circumference [if present] and is in continuation with a *** cm in length x *** cm in open circumference segment of colon. The appendix measures ***cm in length x ***cm in diameter. Fibroadipose tissue extends ***from the bowel wall. Mesoappendiceal tissue extends up to ***cm away from the appendiceal wall.

The serosal surface is remarkable for [describe presence of fat wrapping, fistulas, or perforations]. [Describe presence of strictures- length, location, luminal circumference, mucosa in this region, and distance to nearest margin]. The mucosal surface is remarkable for [give average number, size, shape, color and location of polyps (if larger in one portion of bowel, specify location), and distance to margins]. Sectioning reveals [the polyps are grossly superficial or describe any evident areas of invasion]. There is a ***cm ileal wall thickness and a ***cm average bowel wall thickness.

[Describe uninvolved mucosa of ileum and colon, if present]. The appendiceal serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions/perforations]. The appendiceal mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions]. The appendix has a ***cm luminal diameter and a ***cm wall thickness. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension. Representative sections are submitted.

Cassette Submission: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.

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- 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.

- Submit proximal and distal shave margins- Two cassettes containing representative sections of large mesenteric

blood vessels.- No lymph nodes are needed

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Specimen Type: TRAUMA (i.e. gunshot wounds)Procedure:

1. Measure the length, diameter or circumference and wall thickness 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. 5. Photograph the specimen and probe defects.

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 ***cm in length x *** to ***cm in open circumference with two stapled ends. [Mesenteric/Pericolic] fibroadipose tissue extends ***from the bowel wall.

The serosal surface is remarkable for [describe adhesions, plaques, absence of serosa, full-thickness defects (perforations or enterotomies)]. The mucosal surface is remarkable for a [describe areas of ischemia/discoloration- size and distance to margins]. Sectioning reveals [no gross evidence of perforation/ a perforation and/or abscess formation (describe location, size, and distance to nearest margin)].

The remainder of the bowel [describe any additional lesions]. Sectioning reveals a [white, hemorrhagic, etc] bowel wall with a thickness ranging from *** - *** cm. Representative sections of the specimen are submitted.

Cassette Submission: 2-3 cassettes- Proximal and distal shave margins in one cassette- 1-2 sections to include perforation or damaged area- No lymph nodes are needed

Page | 25

Specimen Type: ISCHEMIC BOWELProcedure:

1. 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.


The serosal surface is remarkable for [describe adhesions, plaques, full-thickness defects (perforations or enterotomies)]. The mucosal surface is remarkable for a [describe areas of ischemia/discoloration- size and distance to margins, or presence of pseudomembranes]. Sectioning reveals [no gross evidence of perforation/ a perforation and/or abscess formation (describe location, size, and distance to nearest margin)].

The remainder of the bowel [describe any additional lesions]. Sectioning reveals a [white, hemorrhagic, etc] bowel wall with a thickness ranging from *** - *** cm. [Describe presence of thrombi in mesenteric vessels, if grossly evident]. Representative sections of the specimen are submitted.

Cassette Submission: 3-5 cassettes- Proximal and distal shave margins.

o Both margin shaves can be submitted in one cassette if the specimen is un-oriented.

o 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.

- No lymph nodes are needed

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Specimen Type: VOLVULUS or BOWEL OBSTRUCTIONProcedure:

1. 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.


[Describe presence of twisted and/or intussuscepted bowel]. The serosal surface is remarkable for [describe adhesions, plaques, full-thickness defects (perforations or enterotomies)]. The mucosal surface is remarkable for a [describe areas of ischemia/discoloration- size and distance to margins, or presence of pseudomembranes]. Sectioning reveals [no gross evidence of perforation/ a perforation and/or abscess formation (describe location, size, and distance to nearest margin)].

The remainder of the bowel [describe any additional lesions]. Sectioning reveals a [white, hemorrhagic, etc] bowel wall with a thickness ranging from *** - *** cm. [Describe presence of thrombi in mesenteric vessels, if grossly evident]. Representative sections of the specimen are submitted.

Cassette Submission: 2-7 cassettes- Proximal resection margin, shave- Distal resection margin, shave- 2-3 cassettes of abnormal area/mucosa

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

- 1 cassette of normal mucosa- 2 cassettes of large mesenteric blood vessels for ischemic bowel (one

cassette can include multiple cross sections of large vessels)- No lymph nodes are needed

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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/puckering, 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 the 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 (location, length, diameter or circumference, wall thickness), noting relation to tumor.

6. Describe tumor, noting size, shape, color, consistency, appearance of cut surface, % of 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 location of the tumor must also be oriented: anterior, posterior, right lateral, left lateral.

b. If a rectal tumor is close to distal margin, the distance of tumor to the distal 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 shave margin, if tumor is far from the radial margin; and perpendicular sections showing the relationship of the tumor to the inked radial 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 perpendicular 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.

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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 serosal surface 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] to have 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 serosal surface [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.


Ink key:Black – mesenteric OR radial margin overlying lesion

* Be sure you indicate the appropriate marginBlue – serosa overlying lesion [Additional inking description if proximal/distal margins taken perpendicularly]

Page | 29


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

o Perpendicular if close to tumor- Mesenteric resection margin (transverse and sigmoid colon)

o A representative shave sectiono Or a perpendicular section with nearest approach to tumor

- Radial/circumferential margin (for segments without mesentery: cecum, ascending colon, descending colon, rectum)

o A representative shave sectiono OR a perpendicular section with nearest approach to tumor

- One cassette per 1 cm of tumor (OR at least 5 sections of tumor OR if small enough, entirely submit)

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

- If the resection is for a large adenomatous polyp with no gross invasion - entirely submit

- Sampling of any additional pathology in the gross description (ulcers, polyps, tattoo ink, etc.)

- Representative sections of unremarkable colon in one cassette- Submit all lymph nodes identified (at least 12 lymph nodes are suggested

for colorectal carcinoma)- 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.

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Specimen Type: RIGHT HEMICOLECTOMY (for tumor)Procedure:

1. Measure length and range of diameter or circumference of terminal ileum and colon.

2. Measure length and diameter of appendix. Measure width of mesoappendix.3. Describe external surface, noting color, granularity, adhesions, fistula,

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

4. Open the bowel longitudinally along the tenia coli, while trying to avoid cutting through the tumor.


6. Describe tumor, noting size, shape, color, consistency, appearance of cut surface, % of 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 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 perpendicular sections must be taken to show the relationship of the tumor to the inked serosal surface).

b. Evaluate the mesenteric root margin (vascular supply) and measure the distance of tumor to the margin.




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. The 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] to have a [describe color, consistency] cut surface. The [lesion/mass] [is grossly superficial, extends into the bowel wall, extends through the bowel wall into the

Page | 31

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 margin, and *** cm from the mesenteric margin. [please ask for margin determination if needed], and *** cm from the serosal surface [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]. The unremarkable bowel wall measures ***cm in thickness [can describe varying thickness of wall, provide location where wall is thicker]. The appendiceal serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions/perforations]. The appendiceal mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions]. The appendix has a ***cm luminal diameter and a ***cm wall 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 –radial margin overlying lesion Blue – serosa overlying lesion [Additional inking description if proximal/distal margins taken perpendicularly]

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

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

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

o Perpendicular section with nearest approach to tumor o OR a shave if tumor is far away

- One cassette per 1 cm of tumor (OR at least 5 sections of tumor OR if small enough, entirely submit)

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

- If the resection is for a large adenomatous polyp with no gross invasion - entirely submit- Sampling any additional pathology in the gross description (ulcers,

polyps, etc.)- Representative sections of unremarkable colon in one cassette- Representative sections of unremarkable ileum in one cassette- Appendix- 2 cross sections and longitudinally bisected tip in 1-2 cassettes

Page | 32

- Submit all lymph nodes identified (at least 12 lymph nodes are suggested for colorectal carcinoma)

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

Page | 33

Specimen Type: LAR (LOW ANTERIOR RESECTION)Procedure:

1. Measure length and range of diameter or circumference. Measure the bowel and anus separately.

2. Describe external surface, noting color, granularity, adhesions, fistula, discontinuous tumor deposits, areas of retraction/puckering, induration, stricture, or perforation.

3. Note any enlarged lymph nodes and thrombosed vessels or other vascular abnormalities.

4. Open the bowel longitudinally along the anterior surface, while trying to avoid cutting through the tumor.




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


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




Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is a low anterior resection. [Indicate orientation if provided]. The colon measures *** cm in length and ranges from *** to *** cm in open circumference. Attached fibroadipose tissue extends up to *** cm from the bowel wall.

Page | 34

The serosal surface is remarkable for [describe, if applicable]. The mucosa of the [describe location-sigmoid, rectosigmoid junction, rectum] 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.] The lesion is located *** cm [proximal/distal] to the rectosigmoid junction. 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 ulceration).] 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 serosal surface [if located above the level of peritoneal reflection].

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


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

Cassette Submission: 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), or a shave if tumor is far away- One cassette per 1 cm of tumor (OR at least 5 sections of tumor OR if

small enough, entirely submit)o Show maximum depth of invasiono Show nearest approach to serosal surfaceo Show relationship to unremarkable mucosao Show relationship to any contiguous or adherent organs

- If the resection is for a large adenomatous polyp with no gross invasion - entirely submit- Sampling any additional pathology in the gross description (ulcers,

polyps, etc.)- Representative sections of unremarkable colon/rectum in one cassette

Page | 35

- Submit all lymph nodes identified (at least 12 lymph nodes are suggested for colorectal carcinoma)

- 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.

Anatomic Subsites of the Colon and RectumSite Relationship to Peritoneum Dimensions (approximate)Cecum Entirely covered by peritoneum 6 x 9 cm

Ascending colon Retroperitoneal; posterior surface lacks peritoneal covering; lateral and anterior surfaces covered by visceral peritoneum (serosa)

15-20 cm long

Transverse colon Intraperitoneal; has mesentery Variable

Descending colon Retroperitoneal; posterior surface lacks peritoneal covering; lateral and anterior surfaces covered by visceral peritoneum (serosa)

10-15 cm long

Sigmoid colon Intraperitoneal; has mesentery Variable

Rectum Upper third covered by peritoneum on anterior and lateral surfaces; middle third covered by peritoneum only on anterior surface; lower third has no peritoneal covering

12 cm long

Page | 36

Specimen Type: APR (ABDOMINO-PERINEAL RESECTION)Procedure:

1. Measure length and range of diameter or circumference. Measure the bowel and anus separately.

2. Describe external surface, noting color, granularity, adhesions, fistula, discontinuous tumor deposits, areas of retraction/puckering, induration, stricture, or perforation.

3. Note any enlarged lymph nodes and thrombosed vessels or other vascular abnormalities.

4. Open the bowel longitudinally along the anterior surface, while trying to avoid cutting through the tumor.




b. If a rectal tumor is close to distal margin, the distance of tumor to the distal margin should be measured when specimen is stretched. This is usually done during intraoperative gross consultation when specimen is fresh. Describe the relation/distance of tumor to dentate line.


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




Gross Template: Labeled with the patient’s name (***), medical record number (***), designated ***, and received [fresh/in formalin] is an abdominoperineal resection. [Indicate orientation if provided]. The colon measures *** cm in length from proximal margin to dentate line x *** cm in average open

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cirucumference and *** cm in open cirucumference at the dentate line. The distance from the dentate line to the margin of resection of perianal skin measures *** cm (or ranges from *** to *** cm) x *** in open circumference. Pericolic/perirectal fat extends up to *** cm from the bowel wall. The anterior peritoneal reflection is located *** cm from the resection margin of the perianal skin (or from the proximal resection margin). The mesorectal envelope is [complete, nearly complete, incomplete- describe defects if necessary- see classification below].

The serosal surface 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 (or *** cm from the dentate line or involves the dentate line), *** cm from the [circumferential radial/mesenteric] margin [please ask for margin determination if needed], and *** cm from the serosal surface [if located above the level of peritoneal reflection].

The remainder of the bowel serosa is [tan, smooth, glistening, and unremarkable or describe any additional lesions]. The remainder of the bowel mucosa is [tan, glistening, folded, and unremarkable or describe any additional lesions]. The bowel wall thickness ranges from *** to *** cm. The anal skin ranges from*** to *** cm in thickness.The unremarkable bowel wall measures ***cm in thickness [can describe varying thickness of wall, provide location where wall is thicker]. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension.


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

Cassette Submission: 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), or a shave if tumor is far away- One cassette per 1 cm of tumor (OR at least 5 sections of tumor OR if

small enough, entirely submit)o Show maximum depth of invasiono Show nearest approach to serosal surfaceo Show relationship to unremarkable mucosa

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o Show relationship to any contiguous or adherent organs- If the resection is for a large adenomatous polyp with no gross invasion - entirely submit- Sampling any additional pathology in the gross description (ulcers,

polyps, etc.)- Representative sections of unremarkable colon/rectum in one cassette- Submit all lymph nodes identified (at least 12 lymph nodes are suggested

for colorectal carcinoma)

- 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.

Assessment of Mesorectal Envelope

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Specimen 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, masses or other lesions 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.

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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 (mucin, 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 and mucin]. The lumen ranges from *** to *** cm in diameter and contains [mucin, 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 appendectomy margin and *** cm from the serosal surface.

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].

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https://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCOLGyc6u9cgCFQnMYwodl7YOEw&url=https://www.pathology.med.umich.edu/cutting-manual/appendix&psig=AFQjCNFVectYNP0YEu2GjTD6-zoeZL30lA&ust=1446678255752775

Ink key:Blue –mesoappendix overlying lesion


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

- Longitudinally bisected tip- Remaining cross sections, entirely 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.

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Specimen 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

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Specimen 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 surface) 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 (usually the distal portion)

13. Describe the size, location, color and consistency of the tumor. Note its relationship to the bile duct, pancreatic duct, 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 partially obstructed (usually at the proximal portion), measure

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the length and diameter or circumference of the distal unobstructed portion from the pancreatic neck resection margin; if not obstructed do NOT measure the length of the duct, just measure the diameter or circumference]. The common bile duct measures *** cm in length x *** cm in average diameter or circumference [describe dilated areas and give range in diameter]. . The duodenum measures *** cm in length x *** cm in open circumference. The stomach (if present) measures *** cm in length x *** cm in open circumference at the proximal resection margin. [If attached gallbladder is present, mention and measure.]

Sectioning the specimen 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, length of the stricture, relationship to bile duct margin, wall thickness, luminal diameter or circumference, and mucosal surface of the stricture.]

The lesion is located *** cm from the distal 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, length of the stricture, relationship to distal pancreatic margin, wall thickness, luminal diameter or circumference, 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 serosa of the duodenum and stomach (if present) is [tan, smooth, glistening, and unremarkable or describe any additional lesions]. 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 gastric mucosa (if present) is

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[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.

- Proximal gastric resection margin, shave- Proximal duodenal resection margin, shave- Common bile duct resection margin, shave- Uncinate margin – shave off the entire uncinate margin of specimen and

then perpendicularly section. Submit entirely in 2-5 cassettes (one cassette can contain multiple pieces of perpendicularly sectioned tissue).

- If a solid tumor: one cassette per 1 cm of lesion (OR at least five sections of mass OR if small enough, entirely submit)

o Show relationship to peripancreatic soft tissue o Show relationship to pancreatic resection margin, if ableo Show relationship to common bile ducto Show relationship to pancreatic ducto Show relationship to ampulla of Vater and/or adjacent duodenum

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o Show relationship to vascular groove- If a cystic lesion: entirely embed the lesion (if the lesion is too large -

consult with attending pathologist)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 pancreatic and/or common bile ducts

Include relationship to serosal surface of duodenum (particularly the posterior surface) in a few sections

- One section of ampulla in relation to tumor (if 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 (at least 12 lymph nodes are

suggested)o Submit all peripancreatic soft tissue for lymph nodes if necessary

(i.e. resection is for cancer)o Most lymph nodes are buried in the posterior peripancreatic

tissue, which may not be easy to strip off. Shave off the entire posterior pancreatic tissue may be helpful to find an adequate number of lymph nodes

- Note: If the tumor in the pancreas is ill defined and the tumor size cannot be accurately measured grossly, or a definitive mass lesion cannot be identified (such as post neoadjuvant therapy), both halves of the pancreas should be carefully breadloafed at 0.5 cm intervals (after bivalved along the pancreatic and common bile ducts). 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).

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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 *** 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.

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, and *** cm from the splenic hilum. The main pancreatic duct [is/is not] patent with a [describe mucosal surface (e.g. smooth, roughened, granular, hemorrhagic)], and a luminal diameter [or circumference] 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, length of the stricture, relationship to proximal pancreatic margin, 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.


Ink key:Blue – anterior surface

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Green – 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 (OR at least five

sections of mass OR if small enough, entirely submit) - If a cystic lesion: entirely embed the lesion (if the lesion is too large,


- Any additional lesions in the gross description- One cassette of unremarkable pancreatic parenchyma- One cassette of unremarkable spleen - Submit all lymph nodes identified (at least 12 lymph nodes are suggested,

but this may be difficult for distal pancreatectomy specimen)o Submit all peripancreatic soft tissue for lymph nodes if necessary



- Note: If the tumor in the pancreas is ill defined and the tumor size cannot be accurately measured grossly, or a definitive mass lesion cannot be identified (such as post neoadjuvant therapy), both halves of the pancreas should be carefully breadloafed at 0.5 cm intervals (after bivalved along the pancreatic duct). Take one cross section every 1 cm sequentially along the length of pancreas from proximal margin towards the splenic hilum 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).

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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, length of stricture, 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]. *** of lymph nodes are identified, ranging from *** to *** cm in greatest dimension.


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

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

of mass OR if small enough, entirely submit)- If a cystic lesion: entirely embed the lesion (if the lesion is too large,


- Representative sections of all additional lesions in the gross description- One cassette of unremarkable pancreatic parenchyma- Submit all lymph nodes identified (at least 12 lymph nodes are suggested,

but this may be difficult for central pancreatectomy specimen)o Submit all peripancreatic soft tissue for lymph nodes if necessary



- Note: If the tumor in the pancreas is ill defined and the tumor size cannot be accurately measured grossly, or a definitive mass lesion cannot be identified (such as post neoadjuvant therapy), both halves of the pancreas should be carefully breadloafed at 0.5 cm intervals (after bivalved along the pancreatic duct). Take one cross section every 1 cm sequentially along the length of pancreas from proximal margin towards the splenic hilum 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).

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IntroductionAt times ancillary testing needs to be performed on Paraffin Embedded Tissue from existing case. The following Job Aid describes various scenarios for placing such add-on orders.

There are three scenarios to consider:1. Outreach (or Student Health) cases

a. Includes cases requiring the use of Requisition Entry2. PowerPath Cases, or Cases where the Collection Date is OVER 16 Days Old3. Cases where the Collection Date is NOT OVER 16 Days Old

Scenario Page(s) SummaryScenario 1: Pg. 3 Outreach (or Student Health) cases, you will primarily be documenting via

email what your needs are for testing.Scenario 2: Pg. 4-5 PowerPath Cases, or Cases where the Collection Date is OVER 16 Days Old,

you will be going through an additional step of creating an encounter, and then placing an order on the case.

The additional step is required as after 16 days, the original encounter has been closed due to billing considerations.

If you do not feel comfortable with the process outlined for scenario 2 please contact the resident SuperUsers, or seek assistance from the surgical pathology HLTs (Tim’s staff)

Scenario 3: Pg. 6-8 Cases where the Collection Date is NOT OVER 16 Days Old, you will be pulling up a case, and using order entry to place an order.

IMPORTANT: Do not select a UCLA pathologist as either the Ordering or Authorizing Provider. Doing so creates compliance and billing issues

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Scenario 1: Outreach (or Student Health) cases

1) E-mail Pathology Outreach Client Services ([email protected]) with clear instructions on which orders to place.

2) For the order to be processed correctly, the minimum following details must be included in the communication:a) Indicate if this is Cytogenetics or Molecular testing. b) Specify the case and block #.c) List probes (for cytogenetics testing) or genes (for molecular testing). d) Give a clear indication whether a new H&E slide is needed to be marked, and to which user it

needs to go. i) For FISH orders , the cytogenetics lab needs an H&E with the area of tumor circled in order

to complete testing. If you already have a suitable H&E for this, circle the tumor and send directly to the cytogenetics/FISH lab and indicate in the e-mail that this was done. If you need a recut H&E for this, indicate it in the e-mail and Outreach will order it and have it sent to you (or other designated pathologist/resident for circling). This slide is then sent to the cytogenetics/FISH lab.

ii) For molecular orders, the molecular lab needs an H&E, however, circling tumor is not necessary. If you have a suitable H&E, indicate that you will send it to the molecular lab. If you don’t, request a recut to be sent to the molecular lab.

e) MISSING ANY OF THIS INFORMATION MAY RESULT IN DELAYED PROCESSING OF RESULTS.3) The Outreach staff will handle the ordering of the test(s), as well as any tasks needed to process this

order.

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Scenario 2: PowerPath Cases, or Cases where the Collection Date is OVER 16 Days Old

When a case to which you need to add an order originated in PowerPath, or is over 16 days old, a new encounter needs to be generated in order to accommodate both ordering and billing. The following will guide you through the steps of creating a one-click encounter so that you can add the order.

1. Open Patient Station for your patient.

2. Click One Click button on the Patient Station toolbar.

3. Select the first available time slot.

4. Click on Encounter Info folder of the registration.

a. Information is required for billing must be filled out on the encounter

5. Fill out Accident related? (either yes/no)

6. Fill out Attending Provider name

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7. Click on Referring Provider folder,

8. In Referral Source and type “=”, this will set referral source as the same Attending provider

9. Click Continue Check In on the bottom of the page.

10. On the next screen, click Accept to finalize the One Click workflow.

11. You are back in the Patient Station for the previously selected patient.

a. BE CAREFUL TO SELECT THE CORRECT APPOINTMENT

b. Double-click the newly scheduled appointment.

12. Click Order Entry activity tab on the left

13. Follow standard order entry workflow (continue on to page 7, Step 6)

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Scenario 3: Cases where the Collection Date is NOT OVER 16 Days Old

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1. Open Case Results from the User toolbar, or from Outstanding List.

2. If opening from User toolbar, scan case label to bring up case, or enter Case ID in Cases search

field3. Click Accept. Case Results activity opens

4. Verify that the correct case is open5. Click the Actions button in the top right corner of the activity; select Order Entry.*

*Note:a. The way the case was originally accessioned will determine

how the add-on order will be placed. b. If the case originated in CareConnect through an ambulatory,

inpatient, emergency, or surgery encounter, Order Entry button will be available.

c. If the case was accessioned via Requisition Entry, Requisition Entry will be available to place additional orders.

d. There can never be an instance when both Order Entry and Requisition Entry buttons are active.

If the Requisition Entry button is active… FOLLOW OUTREACH SCENERIO

The case originated from Requisition Entry, most likely this is an Outreach case, and should be handled by the

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Outreach department.6. Click Order Entry. 7. Find the order you want to place on case in the New Order field. Refer to table below for order-specific

descriptions and codes.

Cytogenetics Orders

Order Name Order Code Order Description

FISH Only (Paraffin Embedded Tissue)

LAB9206 THIS IS THE MAIN ORDER TO USE FOR FISH ORDERS ON PARAFFIN EMBEDDED TISSUE.

FISH (FISH ONLY) LAB9138RThis order is to be used for Outreach orders with a source of NON-Paraffin Embedded Tissue

FISH Only LAB9138This order is to be used on orders with a source of NON-Paraffin Embedded Tissue

FISH Only (HER2 Paraffin Embedded Tissue)

LAB9206To be used for ordering HER2 testing with a source of Paraffin Embedded Tissue. Selecting this order will default HER2 as the probe for testing.

Urovysion FISH (ONLY) LAB9203 To be used for ordering Urovysion FISH testing.

8. Indicate on which block test should be performed. Otherwise, specify case and block # in the Comments field.

9. Specify whether a new H&E slide is needed. a. Selecting Yes will prompt the receiving lab to order a recut H&E slide

i. H&E slide will be sent directly to molecular lab for molecular orders ii. H&E slide will be sent to you for circling and then sending on to the

cytogenetics/FISH lab). o For FISH orders a circled H&E is required.

b. Selecting No means the receiving lab will expect you to send the H&E slide i. Send to molecular lab for molecular orders

ii. Send to cytogenetics/FISH lab (WITH TUMOR CIRCLED) for FISH orders.

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10. Select the appropriate answers to all additional questions, and add the clinical indications in the Comments field.

a. For example, to order ALK/ROS1, select Solid Tumor Probes option in the FISH Probe Category, then choose ALK and ROS1 options.

11. Click Accept when complete

12. Once all the order details are filled out, click Sign Orders button on the activity toolbar.

13. Select an Order Mode of Standard*14. Verify the correct Authorizing Provider

a. Do not select a UCLA pathologist as either the Ordering or Authorizing Provider.15. Click Accept.

a. When the order is signed, an InBasket message will be sent to Cytogenetics/MDL, notifying them that a new order has been placed for them on this patient.

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*Note: If the add-on testing was requested by a different provider than the provider who placed the original Tissue Exam order via e-mail, telephone, or fax, you should change the name of the provider to reflect the name of the provider who is actually is requesting the add-on testing. In such case, the order mode should be changed to Verbal with Readback.

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