Lung wedge resection and lobectomy: Difference between revisions

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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==
==Grossing==
Perform the following:<ref>{{cite web|url=https://www.uclahealth.org/pathology/workfiles/Education/Residency%20Program/Gross%20Manual/Wedge%20Resection.pdf|title=Pulmonary pathology grossing guidelines|accessdate=2021-03-17}}</ref>
[[File:Gross pathology of surgical margin sampling in lobectomy.jpg|thumb|Surgical margin sampling of a lobectomy for intraoperative consultation.]]
Perform the following:<ref>Partially using the following procedure:{{cite web|url=https://www.uclahealth.org/pathology/workfiles/Education/Residency%20Program/Gross%20Manual/Wedge%20Resection.pdf|title=Pulmonary pathology grossing guidelines|accessdate=2021-03-17}}</ref>
*'''Measure''' the specimen in 3 dimensions.
*{{Moderate-begin}}'''Weigh''' lobectomies.{{Moderate-end}}.
*Describe '''pleural surface''', including color, and any presence of granularity, adhesions, retraction, or tumor.
*Describe '''pleural surface''', including color, and any presence of granularity, adhesions, retraction, or tumor.
*Serially '''section''' the specimen. Describe the cut surface, including color and consistency, and any focal lesions. For tumors, see '''[[Lung 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.
*{{Comprehensive-begin}}Sample the entire surgical margin for standard processing.{{Comprehensive-end}}
*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.
{|class=wikitable align=right
|+Initial measurements when<br> triaging fresh lobectomies
|
*Size of lobe in 3 dimenstions
*Size of tumor {{Moderate-begin}}in 3 dimensions{{Moderate-end}}
*{{Moderate-begin}}Weight{{Moderate-end}}
*Distance from tumor to closest<br> parenchymal, bronchial and vascular margins
|}
*For any found '''[[lung tumor]]''':
:*Measure '''tumor size''' as a maximum diameter {{Moderate-begin}}or 3 dimensions{{Moderate-end}}
:*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.
*Describe any '''lymph nodes''', including location, range of sizes and appearance of cut surface.
===Tissue selection===
[[File:Margins of a lobectomy.jpg|thumb|250px|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, {{Comprehensive-begin}}differentially inked{{Comprehensive-end}}
*1 from nearest parenchymal margin, en face
*Sections of any tumor
*Any other focal change
*1 from random non-neoplastic lung tissue
===Gross report===
{{Report-begin|fresh=yes|intraop=yes}} of a right upper lobe of lung which measures __ x __ x __ cm {{Moderate-begin}}and weighs __ g{{Moderate-end}}.  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 {{Finding-begin}}and slightly puckered on the __ aspect{{Finding-end}}. There is a staple line representing the parenchymal margin measuring __ cm in length. The stapled margin is inked black. {{Moderate-begin}}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.{{Moderate-end}} {{Finding-begin}}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.{{Finding-end}} The remaining parenchyma is pink and spongy. {{Moderate-begin}}No lymph nodes are identified in the peribronchial region.{{Moderate-end}}{{Report-end}}
<gallery mode=packed heights=190>
File:Squamous cell carcinoma involving a subsegmental bronchus.jpg|'''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.
[[File:Large cell carcinoma of the lung.jpg|thumb|'''Large cell carcinoma''', with a large multilobulated tumor adjacent to the hilum. A metastatically involved lymph node is present next to the bronchus.]]
</gallery>
{{Gross processing}}


==Microscopic evaluation==
==Microscopic evaluation==
Look mainly for '''carcinoma'''. {{further|Lung tumor|linebreak=no}}
Look mainly for '''carcinoma'''. {{further|Lung tumor}}


===Microscopy report===
===Microscopy report===
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:Histologic type
:Histologic type
:Margins
:Margins
 
{{Reporting}}
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{{Bottom}}
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