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GROSS, SPECIAL TECHNIQUES AND AUTOPSY [Rhoderick M. Cruz, MD, DPSP] BIOPSY TYPES A.

Incisional biopsy Takes only a portion of the lesion Use: to diagnose whether lesion is benign or malignant, to determine the type, and to consequently plan the therapy and management of the case {Eg. lymphoma) B. Excisional biopsy Takes the whole organ and margin GENERAL RULES A. The larger the lesion, the more the numerous the biopsies that should be taken from it To enable representative sampling B. In ulcerated tumors, biopsy of the central ulcerated area may show only necrosis and inflammation Must be at the transition between normal and ulcer C. The biopsy should be deep enough that the relationship between tumor and stroma can be properly assessed D. Deep seated lesions are sometimes accompanied by a prominent peripheral tissue reaction Eg. fibrosis, calcifications E. When several fragments of tissue are obtained, they should all be sent to the pathology department F. Crushing or squeezing of the tissue with forceps should be avoided During the operation or processing May cause tissue destruction G. Once the biopsy is obtained, it should be placed immediately into a container with an adequate volume of fixative H. Depending on the presumed or known nature of lesion, consideration should be given to the possible need for special studies 1. Frozen Section 3 legitimate purposes: a. To establish the presence and nature of the lesion b. To determine the adequacy of surgical margins (Eg. for basal cell Ca) c. To establish whether the tissue obtained contains diagnosable or whether additional sampling is indicated For immediate tissue processing Specimen should not be put in formalin GROSS TECHNIQUES IN SURGICAL PATHOLOGY RECEIVING SPECIMENS Current: Manual labeling of accession number and data entry using logbook Automation: Bar coding and laboratory information system Procedure for submitting routine surgical pathology specimen 1. Specimens should be transported observing universal precautions. 2. Tissue samples obtained at the operating room, clinics and referral from other institutions should be submitted in containers of 10% buffered neutral formalin, labeled with the name of the patient and tissue identification.

Each specimen jar should be accompanied by a requisition form containing the same information inscribed on the container, a short clinical history, and ordering physicians name. Large specimens originating from the operating room should be sent to the Surgical Pathology Laboratory unfixed. Do not mutilate or attempt to dissect such a specimen. Do not leave fresh, unfixed tissues at room temperature o To prevent decomposition or autolysis Unacceptable routine surgical pathology specimen criteria 1. Unlabeled specimen cannot be accepted 2. Mislabeled or misidentified specimens cannot be accepted 3. Unidentified specimens (cases in which the specimen is labeled with the patients name but contains no identification of specimen type or source) 4. Other conditions for non- acceptance a. Insufficient quantity b. Empty container c. Improper storage FIXATION Most commonly used: 10% buffered neutral formalin o 1 part conc. Formalin: 9 parts water Current: traditional formalin fixation Automation: accelerated GROSSING Current: traditional grossing 1. Dimensions and weight 2. Color and consistency Automation: specially designed cutting tools, bar coding of tissue cassettes and speech recognition PROCESSING EMBEDDING Medium: paraffin SECTIONING Microtome STAINING Terminologies A. Acidophilia: Reaction of cationic groups (protein amino grps.) with an acidic dye; Proteins are acidophilic B. Basophilia: Reaction of anionic groups (phosphate, sulfate) with a basic dye; Only Heterochromatin, Nucleoli, Ergastoplasm (RNA), and Extracellular Sulfate Sugar Moieties (GAGs) are highly basophilic May be manual or automated Types A. H and E o Hematoxylin (basic) stains acidic groups (nucleus: heterochromatin and GAGSs) blue Nuclei are basophilic o Eosin (acidic) dye stains proteins red Proteins are acidophilic B. Special Stains o Periodic Acid Schiff It stains glycogen, mucin, mucoprotein, glycoprotein, as well as fungi.

PAS is useful for outlining tissue structures--basement membranes, capsules, blood vessels, PAS Reaction: Periodic Acid cleaves sugars into aldehyde groups. Aldehydes react with Schiff ReagentRED o Silver Stain Stains Reticular Fibers and Basement Membrane Black C. Immunohistochemical staining o Use of enzyme-linked antibodies that detect specific antigens o Enzyme-linked antibodies o Targets specific proteins associated with disease o Useful for diagnosis o Example: oral tumor (condyloma) biopsy tests positive for Human Papilloma Virus MOUNTING INTERPRETATION Current: Conventional: Microscopic examination Automation: Telepathology AUTOPSY ('Auto' = Self, 'Opis' = View) "to see for oneself" Autopsy is the Examination of Dead Body. Autopsy has been a key tool of discovery o Early autopsy pathologists were the first to classify the internal systems of the body (circulatory, digestive, respiratory, etc.). o Through the study of tissue sections under the microscope, pathologists learned to recognize normal from abnormal anatomy at the cellular level. o Medical autopsies have also enhanced the field of Epidemiology (the study of the spread of disease). o The original autopsy procedures spun off an unimagined application in the legal community. Forensic (medicolegal) autopsies now supply medical confirmation for the apparent circumstances of violent or unexpected death. o Benefits of research from todays autopsies include the obtaining of new medical information on diseases. o Organ donation, which can potentially save the lives of other patients, can be another benefit of some autopsies

7. Any other next-of-kin, i.e., cousins, etc. (preferably the one that assumes custody of the body for burial). 8. A friend or person charged by law with the responsibility for burial. AUTOPSY: AIDING THE LIVING BY UNDERSTANDING DEATH How families benefit from autopsy o Discovering inherited or familial diseases may help families through early diagnosis and treatment and in family planning. o Uncovering evidence of work-related disease may lead to compensation for the family. o Providing crucial evidence for the settling of insurance claims or death benefits may result in benefits for the family. o Finding a specific cause of death may simply ease the stress of the unknown. o Finding that diagnosis and treatment was appropriate may be comforting to the family. o Knowledge that the death of a loved one has helped someone to live longer may ease the profound sense of loss experienced by families. CLINICAL AUTOPSY Performed in hospital pathology labs or in the hospital morgue and is done to determine the cause of death and possibly for educational or research purposes. They are performed to gain more insight into pathological processes and determine what factors contributed to a patient's death. More importantly, autopsies are performed to ensure the standard of care at hospitals. Autopsies can yield insight into how patient deaths can be prevented in the future. FORENSIC AUTOPSY performed by a qualified medical examiner/pathologist who is specially-trained to perform legal autopsies to determine the cause of death in someone who has no clear-cut reason for being dead. AUTOPSY PROCESS Review of Preliminary Information o The initial stage of an autopsy involves the review of medical records, witness statements and/or circumstantial information and reports surrounding the death. Preliminary Tests o Photography. o These may include: the collection of samples including trace evidence from the surface of the body, removal of clothing and personal possessions for secure storage or examination. o Non invasive procedures such as radiographs or x-rays. o Specialized imaging procedures including CT scans or MRI scans of the body. External Examination o Detailed external examination of the body, which is very similar to the external examination of a living patient. o The eyes, ears, nose and mouth are checked together with the surface of the skin. o Scars and artificial marks such as tattoos are described, and these can assist with confirmation of identity.

AUTHORIZATION FOR AUTOPSY Obtaining authorization from the right person Priority Category 1. Spouse 2. Son or Daughter (preferably the one who assumes custody of the body for burial) 3. Either parent or guardian (both parents or guardians are desirable where possible). 4. A brother or sister (preferably the one who assumes custody of the body for burial). 5. Grandparent, grandchildren, uncle or aunt, nieces or nephews (preferably the one who assumes custody of the body for burial) 6. Great grandparent, great uncle or great aunt (preferably the one who assumes custody of the body for burial).

Many internal diseases in the body are associated with changes that can appear in the skin, so that a detailed external examination of the body can be of considerable importance in focusing the subsequent internal examination. Internal Examination o The internal examination of the body is carried out as an extended surgical technique. o The examination takes place in a mortuary environment using instruments that are the same as, or derived from, normal surgical instruments. o Occupational health and safety procedures need to be very carefully observed, as the pathologist and forensic scientific and technical staff may in some cases be exposed to considerable infectious hazards. Specimen collection o Body fluids and tissues may be collected for special chemical or toxicological analysis, to indicate the presence or absence of particular drugs, poisons or chemicals. This analysis may be very significant in reconstructing how the death occurred, and in many cases, may reveal the cause of death. TYPES OF EVISCERATION TECHNIQUES TECHNIQUE EN MASSE (LE TULLE) PRINCIPLE o Organs are removed as a single bulky aggregate.

o Tissue is also collected for histological analysis to help determine the nature and extent of disease or injury that may be relevant to the cause of death. The Autopsy Report o On completion of all of the scientific and medical tests an autopsy report is completed which contains the results of the autopsy findings together with the results of any specialist tests that may have been undertaken. REASONS WHY AUTOPSIES ARE NO LONGER ROUTINE Grieving families rarely think to request them Doctors sometimes avoid asking for fear of malpractice claims The belief that due to the high technology of imaging and diagnostic testing there are no significant questions left unanswered at death. Pathology personnel also fear potential biohazard risks.

EN BLOC (GHON/ZENKER)

o Maintain all connections between physiologically related organs: o thoracic pluck, coeliac pluck, urogenital pluck o All organs examined systematically. o Brain spinal cord abdominal cavity thoracic cavity organs individually removed and sectioned outside the body. o Basic principle: Disturb the connections between organs as little as possible Dissection occurs in situ with little actual evisceration. o If abnormality is found, regions removed intact combination of en bloc and in situ

ADVANTAGES o Complete preservation of relationships among organs o Speed o Organs removed and stored for later dissection o Preserve impt anatomic relations without unwieldy mass of organs

DISADVANTAGES o Difficult to handle; require assistant

VIRCHOWS

o systematic approach and simplicity for beginning prosectors

o Multiple organ system involvement complicates the procedure o Skill necessary to remove each block from the body intact o destruction of anatomic relationships.

ROKITANSKY (IN SITU)

o Practical for single examiner o Capability of preserving abnormal anatomic relationships

o Expertise necessary to recognize abnormalities

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