Difference between revisions of "Appendix"
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− | {{Top | + | <noinclude>{{Top |
|author1=[[User:Mikael Häggström|Mikael Häggström]] | |author1=[[User:Mikael Häggström|Mikael Häggström]] | ||
|author2= | |author2= | ||
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{{Fixation - standard}} | {{Fixation - standard}} | ||
{{Fixation - general notes}} | {{Fixation - general notes}} | ||
+ | ==Main requests== | ||
+ | *[[Appendicitis]] | ||
+ | |||
+ | {{Comprehensiveness}} | ||
+ | </noinclude> | ||
==Gross processing== | ==Gross processing== | ||
+ | *Measure the '''length''' of the appendix.<ref name=lilla>{{Lilla utskärningen}}</ref> | ||
+ | *{{Comprehensive-begin}}Note its '''shape'''.<ref name=lilla/> {{Comprehensive-end}} | ||
+ | *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/> | ||
+ | :*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 {{en face}} | ||
+ | :*'''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/> | ||
+ | :*At least one half of the '''tip''' | ||
+ | :*At least one slice from visually inflamed areas. | ||
+ | :*{{Comprehensive-begin}}A transverse slice closest to the '''base''', that is, the surgical cut.{{Comprehensive-end}} | ||
+ | :*{{Comprehensive-begin}}At least one transverse slice from an '''intermediate''' part.{{Comprehensive-end}} | ||
+ | |||
+ | Particular findings indicating additional sampling include:<ref name=lilla/> | ||
+ | *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|Excessive '''mucus'''.]] | ||
+ | *There is excessive amounts of '''mucus''', {{Moderate-begin}}including a representative section of any free mucus if the eppendix is perforated{{Moderate-end}}. | ||
+ | *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}} | ||
+ | |||
==Microscopic evaluation== | ==Microscopic evaluation== | ||
+ | Always look for inflammation and malignancy. | ||
+ | ===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.]] | ||
− | *Look for cancerous cells (also for specimens with clinical appendicitis). | + | {{Main|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. | ||
− | <gallery> | + | <gallery mode=packed heights=190> |
− | 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 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: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 right: | ||
+ | [[File:Histopathology of appendicitis.jpg|150px|thumb]] | ||
+ | {|class="wikitable" | ||
+ | | | ||
+ | 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}} | ||
+ | |} | ||
+ | {{CAP}} | ||
{{Reporting}} | {{Reporting}} | ||
{{Bottom}} | {{Bottom}} |
Latest revision as of 19:18, 2 December 2022
Author:
Mikael Häggström [note 1]
Contents
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 en face[note 2]
- 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:[1]
- 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:
- There is excessive amounts of mucus, (including a representative section of any free mucus if the eppendix is perforated).
- 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
The attached mesoappendix measures __ cm and appears {{
On cut sections, the lumen {{is dilated and contains {{
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
- 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.
Appendiceal carcinoid. The arrow points out a cluster of neuroendocrine cells. There are also inflammatory cells consistent with acute appendicitis.[2]
Low-grade appendiceal mucinous neoplasm: Minimal cytological atypia of the epithelial cells.[3]
Report
- Description of objective findings.
- Presence or absence of malignancy.
Example, using image at right:
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)) |
For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.
See also: General notes on reporting
Notes
- ↑ 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.
- ↑ En face means that the section is tangential to the region of interest (such as a lesion) of a specimen. Further information: Gross_processing#Cutting
Main page
References
- ↑ 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.
- ↑ 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: . ISSN 20490801.
- ↑ 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: . ISSN 2168-8184.
Image sources