Fundamentals of SURGICAL PATHOLOGY
Fundamentals of SURGICAL PATHOLOGY
Second Edition
Shameem Shariff MBBS MD (Pathology) PhD (Pathology)
Formerly Professor and Head Department of Pathology St John's Medical College and Hospital and MVJ Medical College and Research Hospital Bengaluru, Karnataka, India
Foreword
Harsh Mohan
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Fundamentals of Surgical Pathology
First Edition: 2010
Second Edition: 2019
9789388958967
Printed at
My Parents
Husband, Dr MH Shariff
and my Children, Raheel and Mariam Zeba.
I am pleased and honored to have been asked by Professor Shameem Shariff, the author of Fundamentals of Surgical Pathology, to write Foreword for the second edition of her book.
While we are all aware of a few well-known and voluminous reference books in Surgical Pathology which trainees and pathologists consult frequently during sign-outs in surgical pathology, here is a pleasing book on basics of surgical pathology assimilating sufficient ‘must know’ material which may be best summed up as ‘Mini-Surgical Pathology’.
As you open the preliminary pages of the book, you will come across five subheadings under which the author has addressed major aspects of surgical pathology of each system/topic: Grossing Techniques, Gross Pearls, Microscopy and Aids in Diagnosis, Immunochemistry, and Synoptic Reporting and Minimum Datasets. Each of these aspects has been covered adequately, and in a user-friendly manner. Presentation of the text is in simple language, having short sentences or phrases, with bulleted or numerical points and various levels of headings and subheadings, making it easy-to-read and understand quickly, and also helps the user for a rapid review later. The text is beautifully supported by numerous nicely drawn and well-annotated line diagrams, especially on gross anatomical pathology, and photomicrographs of important and common lesions. Wherever required, tables for classification and comparative listing of closely-related conditions have been efficiently used by the author and added recent WHO classification schemes in the revised edition. The format of description of grossing, first detailed, and then short of it (‘Grossing Pearls’), is to let the reader understand the basic concepts first, followed by ‘cherry-picking’ when you concentrate only on the most important facts in each topic. She has accomplished a herculean task of picking-up ‘pearls’ from the ocean of microscopic pathology, listing important microscopic features of the lesions, in a highly user-friendly manner, and supported the same with photomicrographs. These features make the book as a complete and excellent mini-Surgical Pathology. We know that contemporary practice of surgical pathology requires a comprehensive and clinically relevant report, but not necessarily detailed narration; she has achieved this objective by including an edited version of synoptic reports or minimum datasets by checklist format of most of the tumors as recommended by the Royal College of Pathologists or the Directors of Pathology, USA. I feel this is just appropriate for the needs of users in the developing countries and will sensitize young trainees in pathology as well as practitioners in surgical pathology to adopt the abridged checklist format of surgical pathology reports in their sign-outs.
Overall, the content of the book and the style of writing by Shameem Shariff reflect her deep knowledge of the subject, which enabled her to present the matter in such a concise, yet adequate manner. Her writing also shows her clarity of thinking and quality as an exceptionally talented and committed teacher in Pathology; I compliment her on achieving this excellent outcome.
I am sure, users of this book will enjoy reading, learning and practicing basics of surgical pathology and adapted synoptic reporting, as much as I did when I went through it before sitting down to write this foreword.
Harsh Mohan
MD FAMS FICPath FUICC
Former Professor and Head
Department of Pathology
Former Medical Superintendent
Former Professor In-Charge, Academics
Government Medical College and Hospital, Chandigarh, India
President, IAPM, 2008
Editor-in-Chief, IJPM, 2003-2007
Preface to the Second Edition
The second edition of Fundamentals of Surgical Pathology is a fruition of the last few years of untiring effort. I hope this update of first edition, serves to enhance the knowledge of the surgical pathologists, in the current classifications, recent advances and better understanding of the concepts of surgical pathology reporting.
The style of the book has been retained, with sections on how best to deal with specimens while grossing, appearances on gross pathology, microscopic pearls and synoptic reporting with minimum data sets. I have tried to weave a pleasing pattern of inter-relationship between normal anatomy, gross pathology, microscopy, immunohistochemistry and genetic profile of pathologic lesions.
Additional chapters have been added and the result I hope will stimulate all surgical pathologists towards better clarity while dealing surgical specimens and a better reporting format in fulfilling their duty towards patients and clinicians.
The section on microscopy gives features of all surgical lesions commonly encountered in a tertiary care hospital. It gives salient points of differentiation between two entities with similar microscopic morphology, outlined crisply in tabular forms. Data in its entirety is out of scope of this book and is in no way complete, but offers useful hints based on the author's experience in countering problems in routine practice. Photomicrographs of several lesions have been added in this edition and give a lucid picture of the disease entities.
A complete chapter on Immunohistochemistry has been introduced considering its usage in modern practices. This gives details on all antigens with regard to their origin, use on tissues, their positivity in various tumors and the differentiating features of their staining patterns. Immunohistochemistry is a double-edged sword and can do more harm than good if taken out of context of the clinical and morphological setting. The importance of this fact has been outlined.
I shall conclude by saying that investment in knowledge pays the best dividends and hope this small contribution helps surgical pathologists to walk the bridge of uncertainty towards a better knowledge and greater achievements.
Shameem Shariff
Preface to the First Edition
Surgical Pathology is a vital aspect of pathology, which determines patient treatment and well-being. The pathologist's contribution to patient welfare cannot be more aptly emphasized than by the responsibility of giving accurate, precise and comprehensive reports. By comprehensive is not meant voluminous reports but reports, which contain precise data which aid patient management. We are presently in an era of molecular pathology with giant strides being made towards genomic typing of tumors; yet treatment in most hospitals, including tertiary care hospitals is decided on the conventional histopathology reporting and this will I believe prevail for the next couple of decades.
It becomes mandatory that specimen handling, grossing, and microscopic reporting of slides be as standardized as possible in order to send out precise and accurate reports from any histopathology laboratory.
The section on grossing outlines step-by-step how a specimen is to be handled in the laboratory. With several diagrams, it helps the pathologist to systematically examine, cut through the specimen along the optimal planes and take representative bits for section.
Gross Pathology and descriptions are mainly to aid the pathologist in correlating the naked eye appearances of specimens with varied pathological appearances as against their normal morphology. Gross Pearls will be of immense help to the postgraduates.
Microscopy: What the mind does not know the eyes cannot see holds very true for histologic reporting. A thorough knowledge of the microscopic findings in various pathologic lesions goes a long way in the correct interpretation of disease. A pathologist should aim at identifying each and every normal and abnormal cellular detail in every case; and when the report is made, it should appear as a completely solved jigsaw puzzle with clinical features, gross and microscopic blending one with the other to form a complete wholesome. This can be only achieved when one gets acquainted with all cells in the human body—both friends (normal cells) and foes (abnormal and neoplastic cells) alike! Therefore, it is important to keep in touch on a daily basis!
Microscopy: Aids in Diagnosis gives the salient features and points of differentiation between lesions with similar microscopic morphology. It is in no way complete, but offers useful hints based on the authors’ experience with the common lesions encountered routinely in day-to-day practice.
Delivering goods: The ultimate beneficiary of all our efforts is the patient and to convey meaningful histopathology reports, it becomes mandatory to lay down criteria in histopathologic reporting. Core information for proper treatment and management should be conveyed to the treating physician. A uniformity of reporting pattern goes a long way in maintaining standards in histopathology reports. A complete checklist of information to be given should be at hand. This is more meaningful and helps much more than giving descriptive reports in flowery language! The last section Synoptic Histopathology Reporting and Minimum Data Sets outlines the responsibilities of a reporting pathologist in conveying to the clinician all relevant data for patient management. In this regard minimum data sets have been provided for the reporting of all organ systems based on the Royal College of Pathologists criteria as well as The Directors of Anatomic Pathology, America with minor modifications.
Last but not the least, all cannot be excellent pathologists but, what we can strive to achieve is to give correct and sensible information towards health care and avoid grave mistakes which would jeopardize patient welfare.
I hope that this small endeavor helps surgical pathologists, both seniors and juniors in their task of reporting.
Shameem Shariff
Acknowledgments
I would like to thank the faculty members of the Department of Pathology at MVJ Medical College, for their help and support in updating certain sections of this edition—Dr Raja Parthiban, Professor and Head; Dr Shruthi NS, Dr Purvi Mathur, Dr Indrani K, Dr Rashmi, Assistant Professors, and my trainees, Dr Pritha Aggarwal, Dr Hasrath Mohamadi, Dr Sneha Burela, Dr Shobhitha, Dr Hema Priya, Dr Roma Jawane, Dr Najmunnisa, and Dr Sumayya.
I thank Dr Harsh Mohan, formerly Professor and Head, Department of Pathology and Professor In-Charge, Academics; Government Medical College and Hospital, Chandigarh, India, President IAPM 2008, and Editor-in-Chief, IJPM (2003-2007), for having written the Foreword for this edition of the book.
I wish to acknowledge the encouragement, guidance and support of my husband, Dr MH Shariff. His immense patience in bearing with my long hours spent in the writing of this book, and his contribution to oncologic pathology dealt with in the book is deeply appreciated.
I wish to record that the Institutions where I have worked—St John's Medical College and Hospital, Bengaluru, Karnataka, India; Salmaniya Medical Complex and Arabian Gulf University, Bahrain; Royal Hospital (Ministry of Health), Muscat, Oman; MVJ Medical College and Research Hospital, Bengaluru, have been the portals of entry to the vast experience in the field; the knowledge gained has enabled me to fulfill this venture for the benefit of others.
Lastly, I would like to thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Ms Chetna Malhotra Vohra (Associate Director—Content Strategy), Mr Ashwani Kumar (Proofreader), Mohd Iqbal (Typesetter), Mr Manoj Pahuja (Graphic Designer) and all the staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their untiring support during these two years.
Introduction
Surgical Pathology is a dynamic and challenging science. The art of being a complete surgical pathologist lies in the realization of a chain of events-receipt of specimen, grossing, microscopic study of the gross bits taken, analysis of clinical data in combination with gross and microscopic findings and the “final diagnosis” which is to be signed out in black and white by the reporting pathologist. Ancillary techniques have always helped but the pressure of adhering to the turn around time to match the clinician's curiosity and patient anxiety have a toll on the surgical pathologist. A meticulous methodology carries a long way in achieving the desired accuracy in diagnosis and the following chapters of this book unfold means of doing the same.
GROSSING
Grossing of specimens is a vital area in pathology. It is as important as microscopic interpretation and representative sampling is extremely essential. Surgical pathologists examine specimens routinely and decide what representative areas are to be taken for study under the microscope.
Grossing is an art and the importance of it should be ingrained into a postgraduate student from ‘day one’ of his training course. A knowledge of what needs to be grossed is crucial to the final diagnosis. Tissue appearances both normal and abnormal need to form a mental picture in the pathologist's mind enabling him to read the specimen. Specimens should be easily accessible, and should be examined and re-examined in problematic cases.
Prerequisites for ‘Grossing’
- Specimens may be grossed in the fresh state on the day of the operation. This may initially prove difficult but it is only a matter of practice in getting used to handling of fresh specimens. Only those specimens which need a longer time for fixation like the eyeball, etc. may be pended for the next day's grossing. Allocate a standard time for grossing daily preferably at 2 pm when most surgeries are over with dispatch of specimens to the laboratory. The specimens may then be grossed directly. This enables the tissue processor to be started at around 4 or 4.30 pm and keeps tissue ready for embedding the next morning. With this schedule, slides may be ready for viewing the following day.
- If there is a problem in the grossing of any specimen the surgeon should always be called upon.
- Before receipt of specimens in the lab, check whether the requisition form is adequately filled with the patient's name, age, hospital number, clinical details, provisional diagnosis and a request for histopathological examination. The origin of the tissue should be mentioned along with the type of surgery performed.
- Check the specimen bottle/container which should also possess the patient's name, age, hospital number/nursing home name, ward and bed number.
- Check whether the specimen has been immersed in a fixative.
- Give a laboratory accession number to the specimen. The histopathology report will go by this number.
- Take photographs wherever necessary.
- Record the weight and dimensions of the specimen.
- Remove sutures, clips and bone fragments.
- Describe the specimen in such a way that a person who has not seen it will get a clear mental picture of it by reading the description.
- A line diagram at the time of grossing with areas clearly marked out on it where bits for microscopic study have been taken, should accompany every request form at the time of reporting.
- As far as possible, cut bits into flat surfaces and straight edges. Bits taken for histology should not be too thick; ideally the thickness should be 2-3 mm and the size of the bit should measure 1 × 1.5 cm.
- Do not compromise on the number of blocks.
- Mark all surgical margins taken for study with India ink so as to enable its visualization on the slide (it appears as a black line on the tissue section).
- Any tissue taken as frozen section bits should each be given as a separate paraffin block.
- All lymph nodes in malignancy should be studied histologically. Mark all half lymph nodes left in the specimen (particularly in malignancies) by eosin to indicate that they have been sampled.
- Embedding surfaces other than those of surgical margins may also be marked with eosin.
- The knives and the board are to be cleaned after taking sections (especially from tumors) to prevent carryover of tumor tissue to subsequent blocks.
- Specimens are not be kept intact without sectioning if due to various reasons they are to be grossed after a day or two. Either open them out as in the case of hollow viscera or section through them and immerse in formalin till such time as grossing is done.
Methods of Studying Surgical Margins
In case of esophagus, stomach and intestine sections may be taken in two ways:
- Enface, with the long axis of the bit running parallel to the cut margin or
- Longitudinally, i.e. perpendicular to the margin.
- If sections are taken horizontally or enface, microscopic viewing can be done in two ways:
- The embedding outer surface is marked with eosin and not India ink, in which case this will not be visualized on the slide. Study the cut surface which has been marked with eosin and embedded, for presence of tumor. Since some of the tissues would have been shaved off while trimming the block, this in truth may not be the actual surgical margin, but may be read as such for practical purposes.
- An alternative method is to eosin and embed the cut margin which is apposition to the intestine and study the surface sequentially. If tumor is detected on the first section, further sectioning will ensure whether the tumor is extending up to the actual surgical margin.The above method may also be used to study the cut margins of the vaginal cuff in hysterectomy specimens.
- If vertical (longitudinal) sections are taken mark the surgical margin with India ink for viewing on the slide.
MICROSCOPY
An in-depth knowledge with regard to normal organ histology and its variation is essential in order to appreciate the abnormal. The reporting surgical pathologist should be clear with regard to the gross-naked eye appearance of the representative section under study. In case of any doubt he should call for the specimen and re-examine it in the light of microscopic findings.
All sections should be arranged in serial order of bits taken. Each section should be first examined in low power as this gives a good hint towards the diagnosis, e.g. cystic hyperplasia endometrium, polyps, etc. Only after this, should a detailed high power examination be done. Spend enough time examining each section. Problem sections should be re-examined first thing in the morning when eye fatigue has not set in.
HISTOCHEMISTRY AND IMMUNOHISTOCHEMISTRY
Histochemistry and immunohistochemistry (IHC) should be resorted to wherever facility is available and certain reports (as in lymphomas and breast carcinomas) are never complete unless accompanied by IHC results. Every laboratory should have a panel of markers outlined—the first set and the subsequent one if the first set does not help in arriving at a diagnosis. This entails an economical approach, e.g. in a small round cell tumor the first panel could be just an CLA (leukocyte common antigen) and CK (cytokeratin) markers. If this does not yield results then 2nd set could consist of CD99, myogenin/myoD1, chromogranin, etc. IHC should always be interpreted in combination with morphology and never by itself. The importance of histochemistry will only be realized with practise and usage and those who jump the line and resort only to IHC will fail to know what they miss!
SYNOPTIC REPORTING
A synoptic report and checklist ensures that the clinician has been communicated on all aspects of a lesion or neoplasm that enables him to give the best possible treatment. The end of every chapter of this book gives a complete checklist and synoptic reporting format for most lesions. Turn around time as per international norms should be adhered to. Copies of reports should always be archived for future retrieval. Digital archiving should always be supplemented by back up. Policies with regard to this and time of maintaining records should be decided by individual institutions and departments.