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== | ||
[[File:Gross pathology of surgical margin sampling in lobectomy.jpg|thumb|Surgical margin sampling of a lobectomy for intraoperative consultation.]] | [[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> | 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. | *'''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. | ||
*'''Palpate''' for any tumors. | *'''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. | *[[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 | :*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}} | *{{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. | *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. | *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]]''': | *For any found '''[[lung tumor]]''': | ||
:*Measure '''tumor size''' as a maximum diameter {{Moderate-begin}}or 3 dimensions{{Moderate-end}} | :*Measure '''tumor size''' as a maximum diameter {{Moderate-begin}}or 3 dimensions{{Moderate-end}} | ||
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===Tissue selection=== | ===Tissue selection=== | ||
*1 from bronchial and vascular margins, | [[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 | *1 from nearest parenchymal margin, en face | ||
*Sections of any tumor | *Sections of any tumor | ||
*Any other focal change | *Any other focal change | ||
*1 from | *1 from random non-neoplastic lung tissue | ||
===Gross report=== | ===Gross report=== | ||
{{Report-begin|fresh=yes|intraop=yes}} 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 {{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}} | {{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> | <gallery mode=packed heights=190> | ||
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[[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.]] | [[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> | </gallery> | ||
{{Gross processing}} | |||
==Microscopic evaluation== | ==Microscopic evaluation== | ||