Routine tonsillectomy is done for enlarged tonsils—usually benign. These are small specimens without specific orientation.
Radical tonsillectomy is usually done for known carcinoma. These are very different specimens—larger, oriented, and more similar to a composite ENT resection. Portions of tongue or other items may be included.
Biopsies may be done to evaluate enlarging or asymmetric tonsils or cases with imaging abnormalities. Since tonsil is a lymphoid organ, there is often some concern for lymphoma, and the clinicians will occasionally request a "lymphoma workup" or "lymphoma protocol".
Biopsy or Routine TonsillectomyEdit
- If the requisition mentions lymphoma or hematopathology, page the hematopathology to the gross room to see the specimen, take a sample for flow or make smears; or do whatever is standard at your institution for heme cases.
- Fix in formalin.
- Make certain you understand the anatomy of the specimen. These resections are customized to the individual lesion and each one is unique.
- The surgeon should always orient the specimen at frozen bench. Ask for help if you are unsure. These are hard to reconstruct after they are fixed, much less cut.
- You need to know if the specimen has any true margins, which only the surgeon can tell you. The true margins should be well inked. It is useful to use another color to ink additional surfaces that are not true margins, so that you will know when you are seeing the edge of the specimen on the glass slides.
- Fix in formalin, pinned to cork if large or floppy. The surgeon will often pin the specimen out for you.
- If possible to identify mucosa, bisect specimen and submit on edge so that mucosa is seen on the section.
- Submit entirely.
- For young patients (<40 years) with no clinical suspicion for cancer, one representative section is sufficient.
- For older patients with suspicion for cancer, asymmetric tonsils, or imaging abnormalities, submit in toto.
- Check that specimen is inked adequately.
- It is useful to take a gross photograph and label your subsequent sections on a printout of the photo.
- Serially section to demonstrate relation of lesion to closest margins. Lay slices out for further inspection. Consider photographing some of the slices.
- Describe specimen size, shape, texture.
- State what tissue is present in specimen (tonsil, portion of tongue, portion of floor mouth, pterygoids and such).
- Describe lesion
- Size, color, shape, texture.
- Depth of invasion.
- Distances to all surgical margins.
- If less than 15 blocks: Submit in toto. If more than 15: Submit representatively.
- Submit 3-4 sections of tumor; show deepest invasion, relationship tumor to margins, tumor in relationship to precursor if present.
- Submit margins as identified by surgeon. These will usually be perpendicular margins showing the relationship of the lesion to the margin—even if the lesion is far away (in which case lesion will not be present in the section, demonstrating how far it is).
- Submit any other unusual areas, for example to demonstrate presence of bone or muscle.
Review and SignoutEdit
1. Tonsil, right, biopsy:
2. Tonsil, left, tonsillectomy:
- Tonsillar tissue, no specific pathologic change.
- Tonsillar tissue with reactive lymphoid hyperplasia.
- Squamous cell carcinoma, well differentiated, keratinizing, involving tonsil.
- Squamous cell carcinoma, poorly differentiated, non-keratinizing, ___ cm, present at ___ margin.
If tissue was sent for flow cytometry, correlate with the report and mention its results in the note. If lymphoma is suspected from flow or histology, your attending will send the case to heme path as a consult.
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