Difference between revisions of "Appendix"

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{{Fixation - standard}}
 
{{Fixation - standard}}
 
{{Fixation - general notes}}
 
{{Fixation - general notes}}
 +
==Main requests==
 +
*[[Appendicitis]]
 +
 +
{{Comprehensiveness}}
 +
 
==Gross processing==
 
==Gross processing==
*Measure the length of the appendix.<ref name=lilla>{{Lilla utskärningen}}</ref>
+
*Measure the '''length''' of the appendix.<ref name=lilla>{{Lilla utskärningen}}</ref>
*Note its shape and thickness<ref name=lilla/>
+
*{{Comprehensive-begin}}Note its '''shape'''.<ref name=lilla/> {{Comprehensive-end}}
*Cut off about 1.5 cm from the tip and split it in half long the lumen. Divide the remainder into about 3-5 mm thick transverse slices.<ref name=lilla/>
+
*Inspect the '''serosa''' (color, congestion, adhesions,  hemorrhage, exudate etc)
 +
*{{Comprehensive-begin}}Describe and measure the '''mesoappendix'''.{{Comprehensive-end}}
 +
*'''Cut''' off about 1.5 cm from the tip and split it in half long the lumen. Divide the remainder into about 3-5 mm thick transverse slices.<ref name=lilla/>
 +
*{{Comprehensive-begin}}Note the wall '''thickness'''<ref name=lilla/>{{Comprehensive-end}}
 
*Look mainly for:<ref name=lilla/>
 
*Look mainly for:<ref name=lilla/>
:*Luminal pus or obstruction, including stones. Carcinoids may hide behind obstructions in the tip.
+
:*Luminal '''pus''' or '''obstruction''', including stones.
:*Wall defects
+
:*Look for any yellow firm areas at the tip, which may be '''carcinoids'''. Carcinoids may hide behind obstructions in the tip. If found grossly, submit entire appendix, and ink the surgical margin and submit separately enface.
:*Exterior coatings. Note if it contains "stones" or fruit kernels.  
+
:*'''Wall defects'''
 +
:*Exterior '''coatings'''. Note if it contains "stones" or fruit kernels.  
 +
*Any '''tumor'''. If found:
 +
:*Measure the greatest '''dimension''' of the tumor
 +
:*Look for foci of carcinoma or lymph nodes in the mesoappendiceal '''fat''', which may be lymphatic or perineural invasion
 +
 
 +
===Tissue selection===
 
*Submit:<ref name=lilla/>
 
*Submit:<ref name=lilla/>
:*At least one half of the tip
+
:*At least one half of the '''tip'''
:*A transverse slice closest to the base, that is, the surgical cut.
+
:*At least one slice from visually inflamed areas.
:*At least one transverse slice from an intermediate part.  
+
:*{{Comprehensive-begin}}A transverse slice closest to the '''base''', that is, the surgical cut.{{Comprehensive-end}}
Particular findings indicating sampling include:<ref name=lilla/>
+
:*{{Comprehensive-begin}}At least one transverse slice from an '''intermediate''' part.{{Comprehensive-end}}
*Wall discoloration
+
 
*External green-gray-yellow coating  
+
Particular findings indicating additional sampling include:<ref name=lilla/>
*Suspected wall defects
+
*Wall '''discoloration'''
 +
*External green-gray-yellow '''coating'''
 +
*Suspected wall '''defects'''
 +
 
 +
Submit the '''entire''' appendix if:
 +
[[File:Gross pathology of mucocele of the appendix.jpg|thumb|Gross pathology of '''mucocele''' of the appendix.]]
 +
*You find a mucocele.
 +
*The surgical report mentions perforation but none is found grossly.
 +
*The surgical report mentions appendicitis but no significant inflammation is found grossly.
 +
 
 +
===Gross report===
 +
Example:
 +
{|class=wikitable
 +
| {{Comprehensive-begin}}Labeled - appendix. The specimen is received in formalin and consists of a resected{{Comprehensive-end}} appendix measuring __ cm in length and __ cm in maximum diameter. The serosa is tan-red {{Finding-begin}}and
 +
*hyperemic?
 +
*smooth / ragged / granular?
 +
*congested?
 +
*with a patchy purulent exudate?
 +
*with adhesions?{{Finding-end}}
 +
The attached mesoappendix measures __ cm and appears {{Finding-begin}}
 +
*unremarkable?
 +
*hyperemic?
 +
*(focally) inflamed?{{Finding-end}}
 +
On cut sections, the lumen {{Finding-begin}}is dilated and contains {{Finding-begin}}
 +
*(brown) (semisolid) fecal material?
 +
*purulent (blood-tinged) exudate?
 +
*a small amount of blood?
 +
*a fecalith?{{Finding-end}}
 +
No perforation is identified. {{Comprehensive-begin}}Representative sections are submitted for microscopic examination in __ cassette(s).{{Comprehensive-end}}
 +
|}
 
{{Gross processing}}
 
{{Gross processing}}
 
[[File:Histopathology of appendicitis.jpg|140px|right]]
 
  
 
==Microscopic evaluation==
 
==Microscopic evaluation==
 +
Always look for inflammation and malignancy.
 
===Inflammation===
 
===Inflammation===
 
[[File:Appendix neoplasms by incidence and prognosis.png|thumb|Appendix neoplasms by incidence and prognosis.]]
 
[[File:Appendix neoplasms by incidence and prognosis.png|thumb|Appendix neoplasms by incidence and prognosis.]]
*Evaluate depth of any inflammation.
+
{{Main|Appendicitis}}
*Look for any perforation of the wall
+
Neutrophilic infiltrates of the wall of the appendix in the correct clinical context confers a diagnosis of '''[[appendicitis]]'''.
  
 
===Malignancy===
 
===Malignancy===
*Look for cancerous cells (also for specimens with clinical appendicitis).
+
*Look for '''cancerous cells''' (also for specimens with clinical appendicitis).
 +
:*Look in particular for carcinoid tumors of the distal tip.
 +
:*In the presence of mucus, look for any mucinous neoplasm.
  
 
<gallery mode=packed heights=190>
 
<gallery mode=packed heights=190>
 
File:Histopathology of appendiceal carcinoid.jpg|Appendiceal '''carcinoid'''. The arrow points out a cluster of neuroendocrine cells. There are also inflammatory cells consistent with acute appendicitis.<ref>{{cite journal|last1=Elkbuli|first1=Adel|last2=Sanchez|first2=Carol|last3=McKenney|first3=Mark|last4=Boneva|first4=Dessy|title=Incidental neuro-endocrine tumor of the appendix: Case report and literature review|journal=Annals of Medicine and Surgery|volume=43|year=2019|pages=44–47|issn=20490801|doi=10.1016/j.amsu.2019.05.015}}</ref>
 
File:Histopathology of appendiceal carcinoid.jpg|Appendiceal '''carcinoid'''. The arrow points out a cluster of neuroendocrine cells. There are also inflammatory cells consistent with acute appendicitis.<ref>{{cite journal|last1=Elkbuli|first1=Adel|last2=Sanchez|first2=Carol|last3=McKenney|first3=Mark|last4=Boneva|first4=Dessy|title=Incidental neuro-endocrine tumor of the appendix: Case report and literature review|journal=Annals of Medicine and Surgery|volume=43|year=2019|pages=44–47|issn=20490801|doi=10.1016/j.amsu.2019.05.015}}</ref>
 
File:Histopathology of low-grade appendiceal mucinous neoplasm.jpg|Low-grade appendiceal '''mucinous neoplasm''': Minimal cytological atypia of the epithelial cells.<ref>{{cite journal|last1=Hajjar|first1=Roy|last2=Dubé|first2=Pierre|last3=Mitchell|first3=Andrew|last4=Sidéris|first4=Lucas|title=Combined Mucinous and Neuroendocrine Tumours of the Appendix Managed with Surgical Cytoreduction and Oxaliplatin-based Hyperthermic Intraperitoneal Chemotherapy|journal=Cureus|year=2019|issn=2168-8184|doi=10.7759/cureus.3894}}</ref>
 
File:Histopathology of low-grade appendiceal mucinous neoplasm.jpg|Low-grade appendiceal '''mucinous neoplasm''': Minimal cytological atypia of the epithelial cells.<ref>{{cite journal|last1=Hajjar|first1=Roy|last2=Dubé|first2=Pierre|last3=Mitchell|first3=Andrew|last4=Sidéris|first4=Lucas|title=Combined Mucinous and Neuroendocrine Tumours of the Appendix Managed with Surgical Cytoreduction and Oxaliplatin-based Hyperthermic Intraperitoneal Chemotherapy|journal=Cureus|year=2019|issn=2168-8184|doi=10.7759/cureus.3894}}</ref>
 +
File:Pie chart of histological types of mucocele of the appendix.jpg|Pie chart of histological types of '''mucocele''' of the appendix, with relative incidences
 
</gallery>
 
</gallery>
 +
 
===Report===
 
===Report===
 
*Description of objective findings.
 
*Description of objective findings.
 
*Presence or absence of malignancy.
 
*Presence or absence of malignancy.
Example, using image at top:
+
Example, using image at right:
 +
[[File:Histopathology of appendicitis.jpg|150px|right]]
 
{|class="wikitable"
 
{|class="wikitable"
 
|
 
|
Mucosa with ulceration. No atypia in residual mucosa. Inflammatory cells in the stroma and all muscle layers, as well as on the serosal surface and adherent adipose tissue. No evidence of malignancy.
+
Mucosa with ulceration. {{Comprehensive-begin}}No atypia in residual mucosa.{{Comprehensive-end}} Inflammatory cells in the stroma and all muscle layers, as well as on the serosal surface and adherent adipose tissue. No evidence of malignancy. {{Comprehensive-begin}}Optionally: No perforation{{Comprehensive-end}}
 
|}
 
|}
 
{{Reporting}}
 
{{Reporting}}
 
{{Bottom}}
 
{{Bottom}}

Revision as of 10:29, 8 April 2021

Author: Mikael Häggström [note 1]

Fixation

Generally 10% neutral buffered formalin.

  See also: General notes on fixation


Main requests

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Gross processing

  • Measure the length of the appendix.[1]
  • ((Note its shape.[1] ))
  • Inspect the serosa (color, congestion, adhesions, hemorrhage, exudate etc)
  • ((Describe and measure the mesoappendix.))
  • Cut off about 1.5 cm from the tip and split it in half long the lumen. Divide the remainder into about 3-5 mm thick transverse slices.[1]
  • ((Note the wall thickness[1]))
  • Look mainly for:[1]
  • Luminal pus or obstruction, including stones.
  • Look for any yellow firm areas at the tip, which may be carcinoids. Carcinoids may hide behind obstructions in the tip. If found grossly, submit entire appendix, and ink the surgical margin and submit separately enface.
  • Wall defects
  • Exterior coatings. Note if it contains "stones" or fruit kernels.
  • Any tumor. If found:
  • Measure the greatest dimension of the tumor
  • Look for foci of carcinoma or lymph nodes in the mesoappendiceal fat, which may be lymphatic or perineural invasion

Tissue selection

  • At least one half of the tip
  • At least one slice from visually inflamed areas.
  • ((A transverse slice closest to the base, that is, the surgical cut.))
  • ((At least one transverse slice from an intermediate part.))

Particular findings indicating additional sampling include:[1]

  • Wall discoloration
  • External green-gray-yellow coating
  • Suspected wall defects

Submit the entire appendix if:

Gross pathology of mucocele of the appendix.
  • You find a mucocele.
  • The surgical report mentions perforation but none is found grossly.
  • The surgical report mentions appendicitis but no significant inflammation is found grossly.

Gross report

Example:

((Labeled - appendix. The specimen is received in formalin and consists of a resected)) appendix measuring __ cm in length and __ cm in maximum diameter. The serosa is tan-red {{and
  • hyperemic?
  • smooth / ragged / granular?
  • congested?
  • with a patchy purulent exudate?
  • with adhesions?}}

The attached mesoappendix measures __ cm and appears {{

  • unremarkable?
  • hyperemic?
  • (focally) inflamed?}}

On cut sections, the lumen {{is dilated and contains {{

  • (brown) (semisolid) fecal material?
  • purulent (blood-tinged) exudate?
  • a small amount of blood?
  • a fecalith?}}

No perforation is identified. ((Representative sections are submitted for microscopic examination in __ cassette(s).))

  See also: General notes on gross processing


Microscopic evaluation

Always look for inflammation and malignancy.

Inflammation

Appendix neoplasms by incidence and prognosis.
Main article: Appendicitis

Neutrophilic infiltrates of the wall of the appendix in the correct clinical context confers a diagnosis of appendicitis.

Malignancy

  • Look for cancerous cells (also for specimens with clinical appendicitis).
  • Look in particular for carcinoid tumors of the distal tip.
  • In the presence of mucus, look for any mucinous neoplasm.

Report

  • Description of objective findings.
  • Presence or absence of malignancy.

Example, using image at right:

Histopathology of appendicitis.jpg

Mucosa with ulceration. ((No atypia in residual mucosa.)) Inflammatory cells in the stroma and all muscle layers, as well as on the serosal surface and adherent adipose tissue. No evidence of malignancy. ((Optionally: No perforation))

  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.

Main page

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg (1997-02-13). Lilla utskärningen.
  2. Elkbuli, Adel; Sanchez, Carol; McKenney, Mark; Boneva, Dessy (2019). "Incidental neuro-endocrine tumor of the appendix: Case report and literature review ". Annals of Medicine and Surgery 43: 44–47. doi:10.1016/j.amsu.2019.05.015. ISSN 20490801. 
  3. Hajjar, Roy; Dubé, Pierre; Mitchell, Andrew; Sidéris, Lucas (2019). "Combined Mucinous and Neuroendocrine Tumours of the Appendix Managed with Surgical Cytoreduction and Oxaliplatin-based Hyperthermic Intraperitoneal Chemotherapy ". Cureus. doi:10.7759/cureus.3894. ISSN 2168-8184. 

Image sources