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Gastrectomy, Tumor

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IntroductionEdit

Remember you can have basically two types of gastric adenocarcinoma: a focal, fungating, polypoid or ulcerated mass (intestinal type) or a permeating neoplasm involving the entire gastric wall diffusely (linitis plastica).

The questions to be addressed are:

  • What is the diagnosis?
  • Is the tumor primary or metastatic?
  • What is the depth of invasion?
  • Are the margins free of tumor?
  • Is there underlying mucosal pathology?

Fresh HandlingEdit

  1. Measure - length of greater curvature, lesser curvature, esophageal and duodenal cuffs (if present), staple lines, surrounding fat.
  2. Ink proximal and distal resection margins and deep serosal margin. Allow to dry.
  3. Open on side away from tumor (usually along greater curvature).
  4. Photograph specimen after it is opened. Note that sometimes a photograph of a cross-section of the lesion will better demonstrate pathology.
  5. Pin on corkboard, mucosa side up, and serial section the tumor to allow for optimal fixation. Fix overnight.
  6. In some cases you will receive separate specimens for the different lymph node “stations”. Treat these as any other lymph node dissection.

Grossing InEdit

  1. Describe the type of resection (total or subtotal) and state the measurements.
  2. Describe the tumor characteristics:
    1. location
    2. size (including thickness)
    3. shape (fungating, spreading, ulcerated)
    4. depth of invasion (in cm and also layer involvement)
    5. presence of serosal involvement
    6. extension into duodenum
    7. distance from both lines of resection.
  3. Describe the non-neoplastic mucosa:
    1. rugal abnormalities
    2. presence of ulcer(s)
    3. presence of polyps
    4. abnormal wall thickening
  4. Lymph Nodes – Do they appear grossly involved by tumor? If so, how many? You should find at least 10 lymph nodes. This can be difficult in small specimens, where it may difficult to find any. After you have done a thorough examination and you have less than 10, be sure to dictate that in your report, and submit the fat surrounding the specimen. For enlarged lymph nodes which are obviously involved, a representative section is enough.
  5. See sample dictation for sectioning guidelines.

Sample DictationEdit

Specimen number ___ is received (fresh, in formalin), labeled with the patient’s name and medical record number, designated (subtotal gastrectomy, total gastrectomy). It consists of a portion of (stomach, stomach and distal esophagus and/or proximal duodenum). The stomach measures ___x___x___ cm overall, with the greater curvature measuring ___ cm and the lesser curvature measuring ___ cm. The attached portion of esophagus measures ___x___x___ cm and the attached portion of duodenum measures ___x___x___ cm. The proximal and distal resection margins and deep margin are inked and the specimen is opened along the greater (or lesser) curvature to reveal a mass/lesion present (at the lesser curvature, greater curvature, anterior portion, or posterior portion) of the stomach that measures ___x___, that is ___ cm from the proximal margin and ___ cm from the distal margin. The mass/lesion is (describe shape [fungating, spreading, ulcerated], color, texture). On cut section, the mass measures ___ cm in thickness and grossly appears to invade (depth of invasion: up to, into, through) the muscularis propria, but is ___ cm from the deep inked serosal margin (or describe serosal involvement or extension of tumor into duodenum or adjacent structures, if present). The uninvolved gastric mucosa is (describe normal or other lesions: normal is velvety tan-pink with rugal folds; lesions may include polyps, ulcers, rugal abnormalities, wall thickening) and the wall thickness measures ___ cm. The pylorus appears (normal, stenotic, ulcerated). The uninvolved duodenal mucosa is (describe normal or other lesion: normal is velvety tan-pink). The uninvolved esophageal mucosa is (describe normal or other lesion: normal is glistening, smooth, and white). The attached portion of peri-gastric adipose tissue measures ___x___x___ cm and is dissected to reveal ___ potential lymph nodes (comment if the nodes are grossly positive/negative). A portion of omentum (is/ is not) present and measures ___x___x___ cm and is grossly (involved/ not involved) by tumor.

SECTION KEY:

  • Representative sections of the tumor are submitted as ___.
    • Four sections of the tumor should be submitted: one in association with adjacent proximal gastric mucosa; one in association with adjacent distal gastric mucosa; and two full thickness sections including inked deep resection margin. Remember, one section of tumor can sometimes show both the association with normal and level of invasion.
  • Proximal gastric resection margins submitted as ___.
    • Shave if distant, or take a perpendicular section to demonstrate closest approach.
    • If tumor is focal, one or two sections will suffice; if diffuse, submit entire margin.
    • If esophagus is present, submit shaved esophageal margin as proximal resection margin.
  • Distal gastric resection margin is submitted as ___.
    • Similar to sampling of proximal margin.
    • If duodenum is present, submit shaved duodenal margin as distal resection margin.
  • Uninvolved proximal and distal gastric mucosa submitted as ___ and ___, respectively.
    • One representative section of each.
  • Representative gastroesophageal junction and pylorus are submitted as ___ and ___, respectively.
    • One representative section of each, if present.
  • Representative spleen and pancreas are submitted as ___ and ___, respectively.
    • One representative section of each, if present.
  • Potential lymph nodes submitted as ___.
    • At least ten lymph nodes should be submitted.
  • Other mucosal abnormalities, away from the tumor, submitted as ___.

Review and SignoutEdit

Histologic description should include:

  • Tumor type - intestinal (gland forming), signet ring cell, diffuse.
  • Degree of differentiation.
  • Growth pattern - pushing or diffusely infiltrating.
  • Depth of invasion.
  • Lymphatic or vascular permeation.
  • Margins of resection.
  • Histology of mucosa away from the tumor, i.e., presence or absence of chronic gastritis, intestinal metaplasia, polyps, etc.
  • Lymph Node number and number involved, site.
  • Extension of tumor to other organs (i.e., liver, pancreas, omentum, etc., if present.

Sample diagnostic linesEdit

Stomach, (partial, total, subtotal) gastrectomy:

-Adenocarcinoma, (intestinal type, diffuse type, signet ring type), ___ cm, (well, moderately, poorly) differentiated, invasive into the (lamina propria, muscularis propria, adventitia, adjacent structures), no lymphovascular or perineural invasion identified.
-Proximal (squamous lined, gastric oxyntic, gastric cardiac) and distal (gastric antral, duodenal) resection margins free of tumor.
-X lymph nodes, no tumor seen (0/___). Or Metastatic adenocarcinoma in ___ of ___ lymph nodes (___/___).
-Uninvolved stomach with no specific pathologic change.

Stomach, (partial, total, subtotal) gastrectomy:

-Adenocarcinoma, (intestinal type, diffuse type, signet ring type), ___ cm, (well, moderately, poorly) differentiated, invasive into the (lamina propria, muscularis propria, adventitia, adjacent structures), arising in association with chronic gastritis (intestinal metaplasia, high grade dysplasia), no lymphovascular or perineural invasion identified.
-Proximal (squamous lined, gastric oxyntic, gastric cardiac) and distal (gastric antral, duodenal) resection margins free of tumor.
-X lymph nodes, no tumor seen (0/___). Or Metastatic adenocarcinoma in ___ of ___ lymph nodes (___/___).
-Uninvolved stomach with (chronic gastritis, intestinal metaplasia, atrophic gastritis).

Stomach, (partial, total, subtotal) gastrectomy:

-Gastrointestinal stromal tumor (GIST), ___ cm, confined to stomach (or extending into ___.
-Proximal (squamous lined, gastric oxyntic, gastric cardiac) and distal (gastric antral, duodenal) resection margins free of tumor.

Return to Gastrointestinal Grossing

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