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Composite Resection

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IntroductionEdit

Composite resections or regional ENT resections are performed for head and neck lesions (often tongue, floor of mouth, nose, mandible or maxilla) when tumor involves multiple adjacent structures. Each resection specimen will be handled differently according to the individual anatomy of the specimen and lesional extent. The surgical approach often involves performing numerous frozen sections to evaluate various margins, then sending a main specimen for permanent section that has no true margins or possibly just one or two margins. Consult the frozen fellow, surgeon, and surgical pathology attending regarding margin evaluation, inking of true margins, suspected tumor extent, etc. if at all in doubt.

These can be difficult specimens to handle, as they often include bone. Fortunately, there is often relatively little that needs to be documented (chiefly margins which are mainly submitted as separate specimens).


Fresh handlingEdit

  • Composite resection cases often start with frozen sections for margins (between one and twenty specimens), then end with a main specimen that may have no true margins of its own. Your most important task when this main specimen comes up is to determine whether it does have true margins. If not indicated on the requisition, call the operating room to ask.
  • Identify the different anatomic parts contained within the composite resection: mandible, alveolar ridge, tongue, etc.
  • Identify and describe: Lesion location, size in three dimensions, relation (distance) to margins, color, shape (flat/polypoid/lobulated/necrotic), texture (soft/firm), extension into soft tissue and bone, gross vascular or nerve invasion (unlikely to see grossly).
  • If tumor is large, consider tumor banking.
  • Search for other lesions besides the primary. Many oral cavity lesions are accompanied by diffuse dysplasia and carcinoma in situ (look for small firm nodules or white patches away from tumor)
  • Ink and maintain orientation as provided by surgeon.
  • If in doubt, ask for help!
  • Fix in formalin. Specimen must be fixed before decalcification.

Grossing inEdit

  • Frozen section remnants:
    • Submit entirely and request only one H&E level. Often these specimens are accessioned as “ENT biopsies”, so three levels will be cut unless you cancel two of them.
  • Main specimen, tumor:
    • 3-4 sections; take more if you need to show tumor heterogeneity.
    • Also show tumor in relation to adjacent structures that may be invaded (e.g., bone; see below).
  • Main specimen, margins:
    • Submit sections perpendicular to all surgical margins, showing tumor in relation to the margin if sufficiently close. **The margins will often be close in these specimens.
    • The specimen may have no true margins. In this case, demonstrating the presence of tumor at specimen margin is not necessary. The final margins are already sampled in the frozen sections.
    • Usually one perpendicular section per margin is sufficient.
    • Bone margins, which are never evaluated by frozen, are shaved and submitted following decalcification. See below.
  • Bone:
    • There will sometimes be one or two bone margins which you can shave and submit.
    • In addition to demonstrating bone margins, you must also take a section of tumor as it approaches or invades bone.
      • Method 1: Use the band saw or Stryker saw to shave off a thin bone margin, or to make two parallel cuts to demonstrate tumor in relation to bone. Fit the tissue into a cassette, then fix and decalcify that cassette.
      • Method 2: After taking the rest of your sections, decalcify the entire specimen until it is soft.
      • Recommendation: 24 hours of fixation followed by 24 hours in rapid decalcifier. Solid bone will require overnight decalcification.
      • You do not need to have these sections ready in time for initial signout.
  • Eye:
    • On very rare occasions, these specimens will include an eye. (The surgeon may use the euphemisms “enucleated globe” or “orbital contents”.) If this applies to your specimen, consult your attending. Ocular pathology may be signed out specifically by a different service. One practice is to do everything but the eye part of the specimen, then forward the specimen to the ocular pathologists to sign out an addendum.

Review and signout:Edit

If any of the frozen sections were called anything other than negative, retrieve those slides for correlation with the frozen controls at signout. Also retrieve the patient’s biopsy, if available.

Glossectomy or radical tonsillectomyEdit

For squamous cell carcinoma involving the tongue or tonsil. In the "microscopic description" add a template for oral cancers.

1. Tongue, right, partial glossectomy:

A. Invasive squamous cell carcinoma, X cm, (well, moderately, poorly) differentiated, (non) keratinizing, invasive to a depth of Y cm, (perineural invasion present), smd(F9).
B. Resection margins free of tumor. (If the margins are separate specimens, you can leave this out).

Mandible or maxillaEdit

Again, usually for squamous cell carcinoma of the oral cavity. In the "microscopic description" add a template for oral cancers. If it's for an ameloblastoma or an odontogenic cyst or something other than squamous carcinoma, you don't have to add the template.

1. Mandible, left, partial mandibulectomy:

A. Invasive squamous cell carcinoma, X cm, (well, moderately, poorly) differentiated, (non) keratinizing, involving the (submucosa, salivary gland, skeletal muscle, bone) to a depth of Y cm, (perineural invasion present), smd(F9).
B. Resection margins free of dysplasia and carcinoma.

Sometimes the only true margin on the main specimen is the bony margin, in which case you should say "Bone resection margins free of involvement."


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