Intestine with tumor

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Author: Mikael Häggström [notes 1]

Gross examination

  • Orientation: Determine the proximal (oral) and distal (aboral) parts of the specimen if possible.[1]
  • Measure the length of the entire specimen.[1] Optionally, also measure diameter.
  • Surfaces that appear to overlie a tumor can be inked[notes 2].
  • Initial cutting can be:
  • A longitudinal cut opposite to the tumor if it is relatively demarcated (by sight and/or palpation).
  • Transverse (cross-sectional) slicing, until reacing the tumor, particularly for circumferential tumors.
  • Measure the distances proximal and distal to the tumor.[1]
  • Note any accompanying polyps.[1] See Colorectal polyp
Gross pathology of small intestine with adenocarcinoma, serosal view, showing cancer with infiltrative growth (in this case an adenocarcinoma), causing stenosis.
Luminal view, showing the stenotic infiltrative growth across the entire intestinal wall.
Margins that need to be determined.
  • Describe the serosa, and whether there are any suspected tumor breakthroughs hereof.[1]
  • Evaluate the following either before or after slicing it up:[1]
  • Tumor size
  • The proportion of the circumference involved
  • Any significant stricture of the lumen
  • Slice the tumor, either by transverse or longitudinal slicing.[1]
  • Review each slice and note the depth (in terms of anatomic layer, possibly with rough percentage thereof) and distance to the serosa or transverse resection margin for any tumor invasion and/or infiltration.[1]

Tissue selection

Should include:[1]

  • The tumor slices that show the deepest penetration. The slices should include tumor relation to the serosa or resection margin, as well as adjacent normal mucosa.
  • Proximal and distal resection margin, respectively. Take transverse slices except if the tumor is critically close to the margin, in which case it is advisable to take slices perpendicular to that margin, including both the tumor border and the resection margin.
  • Take slices of any other suspicious findings
  • Take a slice of the normal intestinal wall
  • Take slices from any adherent structures and/or organ parts
  • Carefully go through included mesentery for lymph nodes, and cut each in two parts.

Gross report

Should include:[1]

  • Dimensions of entire sample, as well as for the tumor
  • Distance to proximal and distal resection margins
  • Depth of tumor invasion and/or infiltration, preferably with distance to circumferential margin. It can include a "macroscopic staging" as per the #Staging section below.
11.5 cm long intestinal sample. 23 mm from distal margin is a polypoid irregular brown tumor, measuring 58 x 39 x 28 mm. 18 mm to circumferential margin.
This example is Public Domain, and can be copied without any need for author attribution.
See also: General notes on reporting

Microscopic evaluation of colorectal tumors

Determine tumor type and differentiation.

The vast majority of colorectal cancers are adenocarcinomas.[2]
Relative incidences of colorectal carcinomas.

Intestinal tumors are generally colorectal carcinomas, specifically colorectal adenocarcinoma, so each evaluation can primarily focus on whether such is the case. Other cancer types are displayed in section on small intestinal tumors below

Colorectal adenocarcinoma, not otherwise specified

Microscopy criteria for colorectal adenocarcinoma

  • A lesion at least "high grade intramucosal neoplasia" (high grade dysplasia) has:
  • Severe cytologic atypia[3]
  • Cribriform architecture, consisting of juxtaposed gland lumens without stroma in between, with loss of cell polarity. Rarely, they have foci of squamous differentiation (morules).[3]
  • This should be distinguished from cases where piles of well-differentiated mucin-producing cells appear cribriform. In such piles, nuclei show regular polarity with apical mucin, and their nuclei are not markedly enlarged.[3]
  • Invasive adenocarcinoma commonly displays:[3]
  • Varying degrees of gland formation with tall columnar cells
  • Frequenty desmoplasia
  • Dirty necrosis, consisting of extensive central necrosis with granular eosinophilic karyorrhectic cell detritus.[3][4] It is located within the glandular lumina,[4] or often with a garland of cribriform glands in their vicinity.[3]

Further reading: Colorectal adenocarcinoma

Staging

Determine depth of growth and/or infiltration. In case of cancer, stage by the AJCC or TNM system:

Colorectal cancer staging   edit
AJCC stage[5] TNM stage[5] TNM stage criteria[5]
Stage 0 Tis N0 M0 Tis: Tumor confined to mucosa; cancer-in-situ
Stage I T1 N0 M0 T1: Tumor invades submucosa
T2 N0 M0 T2: Tumor invades muscularis propria
Stage II-A T3 N0 M0 T3: Tumor invades subserosa or beyond (without other organs involved)
Stage II-B T4a N0 M0 T4a: Tumor perforates the visceral peritoneum
Stage II-C T4b N0 M0 T4b: Tumor invades adjacent organs
Stage III-A
  • T1-2 N1 M0 or
  • T1, N2a, M0
  • N1: Tumor cells in 1 to 3 regional lymph nodes. T1 or T2.
  • N2a: Tumor cells in 4 to 6 regional lymph nodes. T1
Stage III-B
  • T3-4a, N1 M0 or
  • T2-3, N2a, M0 or
  • T1-2 N2b M0
  • N1: Tumor cells in 1 to 3 regional lymph nodes. T3 or T4
  • N2a: Tumor cells in 4 to 6 regional lymph nodes. T2 or T3
  • N2b: Tumor cells in 7 or more regional lymph nodes. T1 or 2
Stage III-C
  • T4a N2a M0 or
  • T3-4a N2b M0 or
  • T4b N1-2, M0
  • N2a: Tumor cells in 4 to 6 regional lymph nodes. T4a
  • N2b: Tumor cells in 7 or more regional lymph nodes. T3-4a
  • N1-2: Tumor cells in at least one regional lymph node. T4b
Stage IVa any T, any N, M1a M1a: Metastasis to 1 other part of the body beyond the colon, rectum or regional lymph nodes. Any T, any N.
Stage IVb any T, any N, M1b M1b: Metastasis to more than 1 other part of the body beyond the colon, rectum or regional lymph nodes. Any T, any N.
Stage IVc any T, any N, M1c M1c: Metastasis to the peritoneal surface. Any T, any N.
Further information: Evaluation of tumors

Microscopic evaluation of small intestinal tumors

Relative incidences of small intestinal cancers.[6]

Determine tumor type and differentiation.

Type Characteristics Image
Adenocarcinoma As per colorectal cancer in previous section Light microscopy of small intestinal adenocarcinoma.jpg
Neuroendocrine tumors of the midgut Histopathology of small intestinal well-differentiated grade 1 (G1) carcinoid.jpg
Further information: Evaluation of tumors

Microscopy report

edit
It should include:[7]

  • Tumor type[7]
  • Degree of differentiation[7]
  • Depth of growth and/or infiltration
  • Whether the resection is radical
  • Any breakthrough of the serosa and/or resection margin
  • Number of lymph nodes found
  • Number of them with metastases and/or periglandular growth
  • AJCC or TNM stage if applicable

Example:

Colon sample with 50 mm large tubulovillous adenoma with up to high grade columnar epithelial dysplasia. No infiltration. 18 tumor-free lymph nodes. Radical excision.
This example is Public Domain, and can be copied without any need for author attribution.
See also: General notes on reporting

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. Inking can be done with India ink, and will specify the serosa or resection margin in later histopathologic evaluation.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Unless otherwise specified, reference is: Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
  2. Kang, Hakjung; O’Connell, Jessica B.; Leonardi, Michael J.; Maggard, Melinda A.; McGory, Marcia L.; Ko, Clifford Y. (2006). "Rare tumors of the colon and rectum: a national review ". International Journal of Colorectal Disease 22 (2): 183–189. doi:10.1007/s00384-006-0145-2. ISSN 0179-1958. 
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Robert V Rouse. Adenocarcinoma of the Colon and Rectum. Stanford University School of Medicine. Original posting/updates: 1/31/10, 7/15/11, 11/12/11
  4. 4.0 4.1 Li, Lianhuang; Jiang, Weizhong; Yang, Yinghong; Chen, Zhifen; Feng, Changyin; Li, Hongsheng; Guan, Guoxian; Chen, Jianxin (2014). "Identification of dirty necrosis in colorectal carcinoma based on multiphoton microscopy ". Journal of Biomedical Optics 19 (6): 066008. doi:10.1117/1.JBO.19.6.066008. ISSN 1083-3668. 
  5. 5.0 5.1 5.2 . Colorectal Cancer: Stages. Cancer.net (American Society of Clinical Oncology). Retrieved on 2019-09-26. Approved by the Cancer.Net Editorial Board, 11/2018. In turn citing:
    Amin, Mahul B.; Greene, Frederick L.; Edge, Stephen B.; Compton, Carolyn C.; Gershenwald, Jeffrey E.; Brookland, Robert K.; Meyer, Laura; Gress, Donna M.; et al. (2017). "The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging ". CA: A Cancer Journal for Clinicians 67 (2): 93–99. doi:10.3322/caac.21388. ISSN 00079235. 
  6. Qubaiah, O.; Devesa, S. S.; Platz, C. E.; Huycke, M. M.; Dores, G. M. (2010). "Small Intestinal Cancer: a Population-Based Study of Incidence and Survival Patterns in the United States, 1992 to 2006 ". Cancer Epidemiology Biomarkers & Prevention 19 (8): 1908–1918. doi:10.1158/1055-9965.EPI-10-0328. ISSN 1055-9965. 
  7. 7.0 7.1 7.2 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.