Lung wedge resection and lobectomy

Author: Mikael Häggström

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Intraoperative consultation

Perform:

• Tumor microscopy on frozen sectioning if there is intermediate risk of cancer (if frozen section does not show cancer, the surgeon may not need to perform lymph node dissection)
• Margin assessment: A gross distance from tumor to the parenchymal is generally sufficient, unless a suspected malignancy is close enough to confer a significant risk of extension to the margin, in which case the closest parenchymal margin should be frozen en face. For lobectomies, generally perform frozen section on the bronchial and vascular margin en face.

Grossing

File:Gross pathology of surgical margin sampling in lobectomy.jpg

Surgical margin sampling of a lobectomy for intraoperative consultation.

Perform the following:

• Measure the specimen in 3 dimensions.
• (Weigh lobectomies.).
• Describe pleural surface, including color, and any presence of granularity, adhesions, retraction, or tumor.
• Palpate for any tumors.
• Ink the surgical margin and cut it away just below any sutures or staples. If the margin is substantially stapled (and their removal would be either too tissue-damaging or otherwise inconvenient), ink and use another section of the tissue underneath it for frozen sectioning.

• In intraoperative consultations use a section that is presumably closest to a tumor for frozen sectioning, with the tissue en face, for radicality. This is generally enough to report intraoperatively to the surgeon, unless otherwise requested.

• ((Sample the entire surgical margin for standard processing.))
• Cut open the bronchi of the specimen with a pair of scissors, as far as they can fit within the lumina. Attempt to cut so as to be able to take a section that includes both any tumor and nearest bronchus. Palpate for tumors intermittently. Describe the cut surface, including color and consistency, and any focal lesions.
• Turn the specimen to the side with least cuts so far, and serially section it. Palpate for tumors intermittently.

Initial measurements when
triaging fresh lobectomies

Size of lobe in 3 dimenstions Size of tumor (in 3 dimensions) (Weight) Distance from tumor to closest parenchymal, bronchial and vascular margins

• For any found lung tumor:

• Measure tumor size as a maximum diameter (or 3 dimensions)
• Determine location: Which lobe if applicable, and if it is peripheral, central or hilar.
• Margin length to pleura and hilum/surgical margin.
• Any involvement of major bronchi or blood vessels.

• Describe any lymph nodes, including location, range of sizes and appearance of cut surface.

Tissue selection

Vascular (inked yellow), bronchial (inked blue) and parenchymal (inked black) margins of a lobectomy, showing staple line of bronchial margin being removed with scissors to allow for tissue selection.

• 1 from bronchial and vascular margins, en face, if present, ((differentially inked))
• 1 from nearest parenchymal margin, en face
• Sections of any tumor
• Any other focal change
• 1 from random non-neoplastic lung tissue

Gross report

((A. Labeled - ___. The specimen is received fresh for intraoperative consultation and consists of)) of a right upper lobe of lung which measures __ x __ x __ cm (and weighs __ g). The specimen includes a bronchial stump measuring __ cm in length and __ cm in diameter, which grossly appears unremarkable. The pleural surface is mottled tan-pink {{and slightly puckered on the __ aspect}}. There is a staple line representing the parenchymal margin measuring __ cm in length. The stapled margin is inked black. (On opening the bronchial tree, the mucosa is tan and smooth and the lumens are patent. The blood vessels are opened to reveal no blood clot or tumor.) {{Cut section show an irregular, gray-tan, rubbery firm mass measuring __ x __ x __ cm. The tumor is located __ cm from the bronchial and vascular margin and __ cm from the nearest surgical margin. The tumor abuts smaller bronchi and vessels.}} The remaining parenchyma is pink and spongy. (No lymph nodes are identified in the peribronchial region.) (Representative sections are submitted for microscopic examination in __ cassettes.)

• Squamous cell carcinoma involving a subsegmental bronchus with distal chronic obstructive pneumonia. The tumor is seen as a rounded nodule, approximately 2 cm in diameter, proximal to a more irregular focus of chronic obstructive pneumonia with fibrosis.

  See also: General notes on gross processing

Microscopic evaluation

Look mainly for carcinoma. Further information: Lung tumor

Microscopy report

Lung synoptic reports contain information (number and station) on all lymph nodes received per accession. For example, if Parts A-D are mediastinal nodes (8 in total) and Part E is a lobectomy containing 2 additional peribronchial nodes, the synoptic report for Part E should document all 10 nodes, for example:

A. Lymph node, station 1:
Negative for carcinoma. (0/1, 2 etc)

B. Lymph node, station 2:
Negative for carcinoma. (0/1, 2 etc)

C. Lobectomy, RLL: Adenocarcinoma

Size:

Histologic type

Margins

  See also: General notes on reporting

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