The vermiform appendix almost always arrives in the surgical pathology laboratory as the result of a simple appendectomy, usually in the context of appendicitis. However, appendicitis in an older adult should raise your concern for an underlying tumor. Appendices also accompany right colectomies (if not previously removed), and should be carefully sought after within larger specimens.

Fresh HandlingEdit

  1. Fix in formalin if you receive a simple appendectomy. Follow the steps below for adequate grossing when necessary.

Grossing InEdit

  1. Identify the type of specimen and its accompanying tissues (e.g.: mesoappendix, cecum, small bowel).
  2. Measurements: Length, maximal-minimal diameters (while noting the relative locations), the appendiceal shape, and the dimensions of the mesoappendix. Also note the wall thickness after sectioning.
  3. External surface - Note whether it is shiny and glistening, or dull. Are any of the following present: Pus, hemorrhage, fibrin, hyperemia, or perforation?
  4. What is the appearance of the mesoappendix?
  5. Make a transverse section about 2 cm from the tip (distal end).
  6. Serially section the larger proximal portion transversely at 5 mm intervals and divide the distal fragment into two by a single longitudinal cut. If tumor is suspected, you must ink the proximal and all surgical resection margins with India ink and search for lymph nodes.
  7. Photograph, if indicated.
  8. Wall - Is it thickened? Are there any localized lesions? Where?
  9. Lumen - Does the appendix appear dilated? Is the lumen obliterated? Is there inspissated fecal material (fecaliths) or mucin? If there is mucin, there may be an underlying mucinous neoplasm of the appendix. In this case, the entire specimen will need to be submitted to rule out invasion (i.e. adenocarcinoma).
  10. Is there a mass? Neuroendocrine tumors (carcinoids) are the most common tumor of the appendix, and are frequently found incidentally.
  11. Summary of sections
    1. Routine: Submit one transverse section each from the proximal and middle thirds, as well as half of the bisected distal third (tip), all in one cassette.
    2. In the case of tumor, one should submit several extra sections and in mucinous lesions, the entire appendix may have to be submitted to rule out mural invasion.

Sample DictationEdit

Appendectomy, appendicitis:Edit

The specimen is received in one formalin-filled container labeled with the patient's name and medical record number, designated "appendix", and consists of one pink-tan, intact, vermiform appendix measuring x cm in length and x cm in average diameter. The attached yellow-tan, red, slightly hemorrhagic mesoappendicular fat measures ­ _ x _ x _ cm. The serosal surface of the appendix is pink-tan, glistening and slightly hemorrhagic. The specimen is serially sectioned disclosing a lumen filled with brown-green fecalith material. The mucosal surface is pink-tan, glistening and slightly hemorrhagic. Representative sections are submitted in 1A.

Appendectomy, mucinous neoplasm:Edit

Specimen #_ is designated "appendix" and consists of a vermiform appendix measuring x cm in length and x cm in diameter, with a minimal amount of attached yellow-tan, lobulated, mesoappendicular fat measuring _ x _ x _ cm. The serosal surface is pink-tan, glistening and mildly hemorrhagic. The specimen is serially sectioned disclosing a lumen filled with yellow-green mucoid material. The mucosal surface is pink-tan and glistening. The specimen is submitted entirely as follows:

1A: proximal resection margin.
1B: distal tip
1C-F: cross sections, submitted entirely

Review and SignoutEdit

Essentially, document whether or not there is appendicitis (acute inflammation involving the epithelium) and/or serositis (acute inflammation in the serosal tissue), also called periappendicitis). If there is a tumor, follow the AJCC staging, document lymph nodes and margins of resection.

  1. Appendix, appendectomy:
Acute appendicitis and periappendicitis.
  1. Appendix, appendectomy:
Low-grade mucinous appendiceal neoplasm, 1.5 cm, with abundant dissecting mucin; acellular periappendiceal mucin present; no invasion seen; see note.

Return to Gastrointestinal Grossing

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