Grossing Madness

Specimen complexity increases with each round

Case 7

Case 6

Case 5

Case 4

Case 3

Case 2

Case 1

Semifinal

First Round

Second Round

Sweet 16

Elite 8

Final 4

Championship

Case 1

The specimen is labeled " uterine mass." Received fresh and transferred to formalin is a 68 g 8.2 x 6.4 x 3.4 cm aggregate of firm white-tan tissue. Sectioning reveals whorled white-tan cut surfaces with focal intermixed areas of yellow adipose tissue, ranging up to 1.1 cm in greatest dimension. These areas occupy approximately 10% of the specimen. Representative sections to include the areas of possible adipose tissue are submitted in cassettes C1-C4.

C. Uterine, uterine mass: Fragments of leiomyoma(s) and lipo leiomyoma(s).

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Case 2

Case 2

A. The specimen is labeled " pelvic mass with portion of ureter." Received fresh and transferred to formalin is a 134.5g, 7.1 x 5.2 x 4.6 cm tan-brown, firm nodular lesion with a 5.2 x 2.3 x 0.3 cm attached portion of ureter open at one end. A 3.1 x 2.4 cm area of tan-white mucosa is present a portion of the firm lesion. The undesignated the ureter surface adjacent to the margin is inked blue and the rest of the specimen excluding the mucosa is inked black. The specimen is serially sectioned perpendicular to the mucosal and the ureter. The cut surface reveals tan-white fibrosis with multifocal areas of hemorrhagic specks. The lesion is seen abutting the ureter margin and the mucosal surface. Representative sections are submitted as follows. Cassette designation: A1:Ureter margin en face A2-A3: Lesion abutting ureter A4-A5: Lesion abutting mucosal surface A6-A8: Representative lesion A9: Representative ureter

A. Soft Tissue, Pelvic mass with portion of ureter: - Extensive, polypoid endometriosis involving subepithelial (urothelial and squamous mucosa) with focal squamous ulceration, within the lamina propria / subepithelial stroma, muscularis propria, and submucosal fibroconnective tissue. - Endometriosis involves the inked surgical margin of the excision. - Urothelial and squamous mucosa is otherwise unremarkable. - Ureter margin negative for endometriosis, dysplasia, and / or malignancy.

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Case 3

Case 3

Review of Staging

The specimen is labeled " left renal mass." Received fresh and transferred to formalin is a 45.3 g, 6.0 x 5.5 x 3.0 cm partial nephrectomy and adrenal gland. The capsule is smooth tan-pink. The parenchymal resection margin is marked with black ink, and the capsular surface is marked with blue ink. The specimen is serially sectioned to reveal a 5.3 x 3.2 x 2.7 cm multiloculated, partially thinly encapsulated, opaque yellow-orange to red-brown mass with foci of hemorrhage and necrosis. The mass approximates the resection margin and infiltrates through the renal capsule into the perinephric adipose tissue and abuts the adrenal gland. The uninvolved renal parenchyma is tan-pink with a well-defined corticomedullary junction. The remainder of the adrenal gland shows a well-demarcated orange cortex and red-gray medulla, 0.1 and 0.2 cm in maximum thickness, respectively. A gross photograph is taken. Representative sections are submitted as follows: Cassette Designation: A1-A3: Mass abutting resection margin A4: Mass to adjacent perinephric fat A5-A7: Mass abutting the adrenal gland, including foci of hemorrhage and necrosis A8: Additional mass A9: Uninvolved kidney parenchyma (PAS ordered) A10: Uninvolved adrenal gland

Left renal mass; partial nephrectomy and adrenalectomy:- Clear cell renal cell carcinoma (5.3 cm), WHO/ISUP Grade 2 (of 4), pT3a - The tumor extends into the perinephric adipose tissue. - The tumor abuts but does not invade into the adrenal gland (adrenal gland is negative for carcinoma).

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Case 4

Relevant Anatomy

Review of Staging

The specimen is labeled "right testicle." Received fresh and transferred to formalin is a 42 g testis and attached segment of spermatic cord. The testis is 5.1 x 3.4 x 3.2 cm, and the attached segment of spermatic cord is 10.5 cm long x 1.0 cm in diameter. The specimen is marked with black ink, and the spermatic cord margin is removed in shave fashion. The specimen is sectioned, and the tunica vaginalis is opened to reveal a well-demarcated, rubbery solid fibrous and multicystic white cut surface (2.9 x 2.6 x 2.3 cm) which grossly abuts the rete testes, comes to within 0.2 cm to the epididymis, and is grossly distant from the spermatic cord margin. The mass is confined to the testicular parenchyma and the tunica vaginalis is not grossly involved. The multicystic areas (cysts 0.2 to 1.0 cm in greatest dimension), contains partially gelatinous translucent and soft gray-yellow material. The tunica albuginea is smooth, glistening white. Also identified is an additional rubbery to firm, well-demarcated white fibrous nodule (0.6 x 0.5 x 0.5 cm) located at the inferior pole of the testicle, 0.1 cm from the mass, less than 0.1 cm from the tunica albuginea. The uninvolved testicular parenchyma is soft, homogenous, spongiform pale pink with tubules which string with ease. Sections of the spermatic cord reveal a soft, fibrofatty cut surface containing testicular vessels and vas deferens with no focal lesions. Photographs are taken. Representative sections are submitted as follows: Cassette Designation: E1: Spermatic cord margin, shaved E2-E4: Testicular mass, representative sections (E2 - relationship to rete testes and epididymis, two sections; E3-relationship to tunica albuginea E4 - relationship to additional nodule): E5: remaining sections of additional nodule, submitted entirely E6 : uninvolved normal testis, random section E7:Paratesticular spermatic cord section E8: Mid spermatic cord section

A. Retroperitoneal, resection:- Predominantly necrosis / therapy-related changes with focal (0.1 cm) teratoma, see Comment. - Comment: There is a rind of fibrous tissue around the near-completely necrotic tumor, with focal lymphocytic infiltrate, suggestive of involvement of a lymph node or matted lymph nodes (at least 1/1). B. Interaortocaval lymph nodes, excision: - POSITIVE for teratoma in one of three lymph nodes (1/3), 0.4 cm. - The involved lymph node and one negative lymph node have therapy-related changes. C. Paraaortic lymph nodes, excision: - Three lymph nodes, NEGATIVE for malignancy (0/3). D. Iliac lymph node, excision - One lymph node, NEGATIVE for malignancy (0/1). E. Right testicle, radical orchiectomy: - Residual teratoma, grossly 2.9 x 2.6 x 2.3 cm, and therapy-related changes. - Margins are NEGATIVE. - Pathologic Stage (AJCC 8th ed.): ypT1a N1.

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Case 5

Yellow-pubis, green-prostatic, blue-deep pelvic tissue

Case 5

Relevant Anatomy

Review of Staging

Received fresh and transferred to formalin is a total penectomy specimen, consisting of the penile shaft taken from the grossly distal tip that is 13.5 cm in length with a central shaft diameter of 3.0 cm. At the penile base is an additional 4.9 x 3.2 x 2.5 cm rectangular portion of additional pelvic soft tissue. The pelvic soft tissue is received inked with the following designations: Yellow-pubis, green-prostatic, blue-deep pelvic tissue. The soft tissue margins are reinforced with additional ink. The penile tip is surfaced by a 5.5 x 5.5 cm portion of tan-pink wrinkled skin. The penis submitted peripherally is circumcised, with the foreskin completely retracted. The urethral opening is patent, 0.3 cm in diameter. No discrete skin lesions or masses are gross identified. Gross photographs are taken. The ventral soft tissue margin is inked black, and the dorsal soft tissue margin is inked orange. The specimen is bisected longitudinally through the urethra to reveal a 7.0 x 3.7 x 2.8 cm fairly well-circumscribed gray-white multinodular myxoid primary mass located within the penile shaft in the right and left corpus cavernosa. No frank necrosis is gross identified. The mass extends into the corpora spongiosum and abuts the urethra without definitive gross involvement. The mass is well removed from the skin. The mass abuts and possibly involves the buck's fascia but grossly does not extend beyond. Additionally, within the pelvic soft tissue approximately 1.6 cm from the primary mass is a 2.4 x 2.3 x 1.9 cm well-circumscribed soft gray myxoid to mucinous secondary mass. Intervening between the primary and secondary masses is a 3.0 x 2.1 x 1.6 cm area of dense white-pink fibrosis within the pelvic soft tissue and penile base. Combined the primary mass, intervening area of fibrosis, and secondary mass involve a 9.5 x 4.1 x 3.7 cm area. The masses comes to within 0.4 cm of the deep pelvic tissue soft tissue margin, 0.1 cm of the ventral soft tissue margin, 0.9 cm of the dorsal soft tissue margin, 3.0 cm of the closest skin margin (6 o'clock aspect), and abut the pubis soft tissue margin and prostatic soft tissue margin. Gross photographs are taken of the cut surfaces. The uninvolved corpus cavernosum and spongiosum is red-pink soft and congested. The urethral mucosa is white-pink and smooth with a focal area of red granularity near the site of mass abutment.

E1: Skin margin closest to mass, perpendicularE2-E14: Secondary mass and fibrosis with all deep pelvic, prostatic, and pubic soft tissue margins, perpendicular E15-E21: Central composite cross-section of masses displaying greatest dimension and including ventral soft tissue margin, submitted continuously from proximal to distal (secondary mass in E15-E17, area of fibrosis in E16-E18, primary mass in E18-E21) E22: Primary mass with closest dorsal soft tissue margin E23: Primary mass with urethra E24: Primary mass with involvement of corpora spongiosum E25: Primary mass with additional close ventral soft tissue margin

A. Soft Tissue, nodule in buck's fascia:- Benign fibroconnective tissue, negative for malignancy. B. Penis, right base of penis: - Negative for malignancy. C. Soft Tissue, Urethral Margin: - Negative for malignancy. D. Soft Tissue, Margin at tip of Right Corporal Body from Pelvis: - Negative for malignancy. E. Penis, Penectomy with Recurrent Chrondrosarcoma en bloc with Prepubic Mass: - Recurrent chondrosarcoma, grade 2, multifocal, involving the corpus cavernosum and spongiosum of the penis, 2.4 and 7.0 cm in greatest dimensions. - All margins negative for chondrosarcoma (closest prostatic margin is 0.1 cm). F. Soft Tissue, Right lateral groin nodule: - Positive for chondrosarcoma, grade 2. G. Soft Tissue, Right peri-inguinal nodule: - Benign fibrous connective tissue with remnants of prior procedure-related foreign material and associated reactive changes. H. Urethral, Prostatic Urethral Biopsy: - Benign, polypoid urothelial hyperplasia.

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Case 6

Relevant Anatomy

Review of Staging

Review of Staging

Case 6

The specimen is labeled "esophagogastrectomy." Received fresh and transferred to formalin is a 5.6 cm long segment of esophagus, contiguous with a 10.3 cm portion of stomach. A 2.9 cm long segment of tan-white tubing is stapled to the proximal end of the specimen. The distal end is closed with a stapled line. A moderate amount of adherent yellow adipose tissue is present. The adventitial surface of the esophagus is tan-purple. The small amount of exposed serosa on the stomach is tan-purple. The radial margin is marked with black ink. The stapled margins are removed, and the specimen is opened longitudinally to reveal a 6.8 x 4.6 x 2.4 cm ulcerated mass. The mass involves the esophagus extending into this stomach. The center of the mass is straddling the gastroesophageal junction. The mass is 4.4 cm from the proximal resection margin, and 3.6 cm from the distal surgical margin. Sectioning the mass into 16 levels reveals an irregular homogenous tan-white mass with focal hemorrhagic areas from levels 4 through 15. The depth of invasion is 1.8 cm. The mass is abutting the radial margin and extending into the periesophageal adipose tissue in levels 7,8,9,14 and 15. The uninvolved esophageal mucosa is tan-pink white, intact, and the circumference of the esophagus is 6.4 cm. The uninvolved gastric mucosa is tan-pink white rugated mucosa. The specimen is examined for lymph nodes and six possible lymph nodes identified.

Representative sections are submitted as follows: Cassette Designation: B1: Proximal surgical margin B2-B4: Representative distal surgical margin B5-B6: Mass level 5 bisected B7-B8: Mass level 6 bisected B9-B11: Mass level 7 (trisected) with adjacent uninvolved esophagus and gastric mucosa and closest radial margin with periesophageal adipose tissue invasion. B12-B13: Mass level 8 bisected B14-B16: Mass level 9 trisected, (radial margin and peri esophageal adipose tissue invasion) B17: Mass level 11 B18: Level 13 bisected B19-B20: Level 15 bisected (periesophageal adipose tissue invasion) B21: Five possible lymph nodes B22: One lymph node serially section(possible positive) B23-B30: Remaining fibroadipose tissue

A. Bone, xiphoid process, excision: - Fragment of bone with surrounding soft tissue. - For gross examination only, see gross description below. B. Esophagus and proximal stomach, esophagogastrectomy: - Residual undifferentiated carcinoma, 6.8 cm, invading into the adventitia - All resection margins are negative for carcinoma, closest radial margin is 0.3 mm - Negative for lymphovascular or perineural invasion - One lymph node positive for metastatic carcinoma (1/11) - Pathological stage (AJCC 8th edition): ypT3 pN1 - Background Barrett's esophagus is noted C. Soft tissue, epigastric fat, resection: - Fibroadipose tissue without significant abnormality - Negative for carcinoma D. Esophagus, margin, resection: - Portion of esophagus without significant abnormality - Negative for carcinoma or dysplasia

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Case 7

Review of Staging

Relevant Anatomy

Case 7

The specimen is labeled " left hepatectomy." Received fresh and transferred to formalin is a 684.4 g, 24.0 x 12.8 x 6.3 cm left hepatic lobectomy. The specimen has been previously incised twice. There is a focal area of indurated subcapsular bulging within one of the areas of incision having overlying adherent fibroadipose and fibromembranous tissue that is continuous with a portion of the falciform ligament, and this area is inked blue. The remaining capsule is intact, pink-purple and smooth. A 5.4 x 2.8 x 1.8 cm portion of hilar soft tissue is present, having multiple undesignated stapled and sutured luminal margins, all of which are removed and a shave fashion. Palpation of the hilar soft tissue reveals no grossly identifiable lymph nodes. The parenchymal resection margin is diffusely roughened with multiple embedded staple lines, and has a focal area of thinly encapsulated white indurated bulging. The resection margin is inked black, and the specimen is serially sectioned. Sectioning reveals seven independent nodules. Gross photographs are taken of the nodules. Nodule #1, 8.6 x 7.0 x 4.9 cm, has a firm tan multilobulated well-circumscribed cut surface with intermittent central areas of white-pink gray fibrotic to vaguely myxoid discoloration (areas of possible necrosis accounting for approximately 15% of the overall nodule). The nodule abuts the capsule and adherent fibroadipose tissue at the area of incision, abuts the parenchymal margin at the area of bulging, and focally abuts the hilar soft tissue without gross involvement. The mass is well removed from the hilar luminal margins. Nodule #2, 0.5 x 0.5 x 0.4 cm, has a tan-white firm well-circumscribed appearance without gross necrosis. Nodule #2 is 0.3 cm from nodule #1, abuts the capsular surface, is well removed from the hilum, and comes to within 5.8 cm of the parenchymal margin.

Nodule #3, 0.5 x 0.4 x 0.4 cm, has a tan-white firm well-circumscribed appearance without gross necrosis. Nodule #3 is 0.4 cm from nodule #1 and 0.1 cm from nodule #2, being well removed from the hilum, coming to within 0.5 cm of the capsular surface, and 6.0 cm of the parenchymal margin. Nodule #4, 0.4 x 0.3 x 0.3 cm, has a yellow-white soft well-circumscribed appearance without gross necrosis. Nodule #4 is 0.5 cm from nodule #1, is well removed from the hilum and all remaining nodules, and comes to within 0.8 cm of the capsular surface and 0.8 cm of the parenchymal margin. Nodule #5, 0.6 x 0.5 x 0.4 cm, has a tan-white firm well-circumscribed appearance without gross necrosis. Nodule #5 is 1.4 cm from nodule #1, is well removed from the hilum and all remaining nodules, centimeters of the capsular surface and 7.4 cm of the parenchymal margin. The two remaining nodules #6 and #7 are both 0.2 cm in greatest dimension and have a grossly similar appearance to the previously described nodules #2-#5. The nodules are well removed from the surfaces and margins.The uninvolved hepatic parenchyma is red-brown and congested with tan speckling. No additional discrete lesions or masses are grossly identified.

Cassette designation: B1: Hilar luminal margins, en face B2-B7: All hilar soft tissue B8-B9: Nodule #1 with capsular surface and adherent adipose tissue B10-B11: Nodule #1 with parenchymal margin B12-B13: Nodule #1 with hilar soft tissue B14: Nodule #1 Central sections B15-B16: Nodule #1 with entire adjacent nodules #2 and #3 B17-B18: Nodule #1 with entire adjacent nodule #4 B19: Entire nodule #5 with surrounding uninvolved tissue intervening between nodule #1 B20: Entire nodules #6 and #7 B21: Uninvolved hepatic parenchyma well removed from nodules

B. Liver, left hepatectomy:- Hepatocellular carcinoma, steatohepatitic type, 8.6 cm, associated with multiple (6) satellite nodules - Negative for lymphovascular or perineural invasion - Resection margins are negative for carcinoma (see part D) - One lymph node negative for carcinoma (0/1) - Pathological stage (AJCC eighth edition): pT3 pN0 - Background liver with moderate macrovesicular steatosis, steatohepatitis, and sinusoidal fibrosis

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