Bowel tumors are most often adenocarcinomas; however, resections are also performed for large villous adenomas and other categories of neoplasia.
While the specimen is in the unfixed state, orient it as to proximal and distal (if possible). Attempt to identify the location of tumor by palpation and observation of serosal puckering/adherent fat. Apply ink to the serosa and fat in the area of tumor (i.e. radial or deep margin). Remove the fat in all other areas and dissect the lymph nodes, keeping them divided as to general location (proximal to tumor, distal to tumor, close to tumor). Describe the serosal surface (color, adhesions, puckering, tumor extension).
Ink the proximal and distal margins. Open the specimen from one end to the other along the side opposite the area of tumor attachment, if possible. Gently evacuate the lumen of any fecal matter, and take photographs.
Measure the length of the specimen and the average circumference, noting dilatation proximal to the tumor and the degree of luminal obstruction due to tumor. If you can identify different regions of bowel (e.g. terminal ileum, cecum), measure these segments individually
Measure (2 surface dimensions) the tumor and measure its distance from the proximal and distal margins and from the ileocecal valve, if applicable. Describe the external surface of the tumor (color, shape/configuration, ulceration). Describe the mucosal surface of the remainder of the bowel (color, polyps, diverticulosis, perforation). Measure lesions and their distances to the resection margins. Measure the wall thickness in normal and abnormal areas.
Pin to a board mucosal side up and submerge in formalin for a few hours or overnight. If the tumor is large, make a few cuts in it (in the same plane which you plan to section it) to allow formalin penetration.
After fixation, section the tumor and measure its depth. Note whether it invades the bowel wall and whether it infiltrates the fat. Describe the cut surface of the tumor. After you have submitted tumor sections, examine the peritumoral fat for additional lymph nodes.
Note the presence or absence of the appendix and whether it is involved by tumor. If uninvolved, process as in Appendectomy.
Tumor: minimum of five transmural sections with adipose tissue (if tumor is very thick, you may need to divide a section into two cassettes – superficial and deep). Include adjacent uninvolved mucosa in some sections. Villous adenomas may require extensive sampling to rule out invasion.
Proximal and distal: en face (representatively submitted) if more than 2 cm from tumor; perpendicular (representatively submitted) if 2 cm or less from tumor.
Radial/deep margin: include with tumor sections if possible; otherwise, two sections closest to deep portion of tumor.
Uninvolved colonic wall: two sections from different areas, taken perpendicular to the folds. Additional sections of lesions.
Polyps: entirely submit, cut in half longitudinally so that each half includes both polyp and stalk with colonic wall. Continue to serially section at 3 mm intervals in the same plane of sectioning, if necessary.
Appendix: tip and two cross sections in one block, if present.
Lymph nodes: entirely submit, designated as to location with regard to tumor.
Received without fixative/in formalin, labeled _____ and "_____", is a ileocolectomy specimen including __ cm of terminal ileum, __ cm of cecum and ascending colon, __ x __ cm appendix, and __ x __ x __ cm portion of mesenteric fat. The margin circumferences are __ cm proximally and __ cm distally. The serosa is _____ (color, smooth, adhesion-covered, focally puckered/indurated __ cm from the _____ margin). There is a _____ (color, exophytic, ulcerated, polypoid, necrotic) mass measuring __ x __ cm in surface area and __ cm in height, located __ cm from the proximal/distal margin and __ cm from the ileocecal valve. It is __ cm from the ileocecal valve and __ cm from the nearest (proximal/distal) margin. It involves __% of the circumference, and there is/is not dilatation of the adjacent proximal bowel. It invades into/through the bowel wall and is/is not present in the pericolonic fat/inked external surface. In addition, there is a __ x __ x __ cm sessile/pedunculated _____ (color) polyp located __ cm proximal/distal to the mass. The uninvolved mucosa is _____. The appendix, which is uninvolved by the mass, has a _____ serosal surface and a patent lumen. Multiple _____ (color, consistency) lymph nodes are identified in the pericolonic fat, ranging from __ to __ cm in maximal dimension, and all located within 10 cm of the mass.
#___ = proximal resection margin (cross section).
# ___ = distal resection margin (cross section).
#___ and #___ = mass with serosal margin and adjacent mucosa in (full-thickness sections).
#___ and #___ = mass with adjacent structure (e.g. with ileocecal valve or with adjacent uninvolved mucosa)
#___ and #___ = mass with inked _____ margin.
#___ and #___ = ____ polyps (entirely submitted).
#___ = ileocecal valve
#___ = uninvolved ileal and colonic mucosa .
#___ - #___ = appendix
#___- # ___ = ___ lymph nodes within 5 cm proximal from the mass (uncut lymph nodes in #____), (one bisected node in #___ ).
#___- # ___ = ___ lymph nodes within 5 cm distal from the mass (uncut lymph nodes in #____), (one bisected node in #___ ).
___ lymph nodes within 5 cm distal from the mass in #____ (__ lymph nodes), #___ (one bisected node); #___ - ___ (__ node per cassette).