Gynae specimen Flashcards
- How would you treat a salpingectomy specimen?
a. Confirm patient identification by checking that the identification on the container matches that on the request form
b. Document the type of specimen present and orient using the fimbriated ends.
c. Measure the length and diameter of the fallopian tube
d. Serially section the tube and examine it, identify the lesions and comment on appearance and size of lesion.
e. Take sections from the isthmus, ampulla and infundibulum and several sections of the fimbriae as ovarian cancers tend to arise from here.
- What is a colposcopy and how does acetic acid and iodine help in diagnosis?
A colposcopy is when an optical instrument is inserted through the vagina to examine the vulva and cervix after a pap stain is positive for abnormal cells such as HPV-induced changes or pre-malignant cells were observed. A biopsy can also be obtained through the colposcope.
Acetic acid and iodine are often used during the procedure to determine whether the lesions could be malignant or benign. Acetic acid induces a white colour if glycogen stores are decreased or absent, thus indicating that cells could be malignant while iodine is taken up by healthy normal cells with glycogen content and these appear yellow. Therefore, an aceto-white non-iodine staining lesion should be sampled for further diagnosis.
- A 59-year-old female was referred to a gynaecologist in view of postmenopausal bleeding. Dilatation and curettage was performed and the material obtained was sent to the laboratory for analysis. The patient was found to have complex endometrial hyperplasia with atypia. In view of this result a total abdominal hysterectomy with bilateral salpingo-oophrectomy was carried out and the specimen was again submitted for assessment. Microscopic examination of the resection specimen showed no invasive malignancy.
a. What material is obtained through dilatation and curettage? (1 mark) What is the scope of such procedure? (2 marks)
A dilation and curettage is done to obtain samples from the endometrium, this is used to investigate any abnormalities such as abnormal heavy bleeding, bleeding after miscarriage, abnormal cells detected using liquid based cytology and investigation of infertility. Therefore, it is used for diagnosis of both benign and malignant conditions.
b. What is complex endometrial hyperplasia with atypia? (2 marks) What is its significance? (1 mark)
Complex endometrial hyperplasia is when on histology there is increased proliferation of glandular cells with disturbed pattern of the formation of glands and scant stroma. The cells are also atypical meaning that they are irregular, such as enlarge nuclei, pleomorphism and loss of polarity. This type of observations is correlated with increased risk of developing endometrial carcinoma.
c. Describe what is resected in a total abdominal hysterectomy with bilateral salpingooophorectomy. (5 marks)
The uterus, both fallopian tubes and both ovaries
d. How would you treat such a specimen in the gross laboratory? What important sections would you take? (10 marks)
i. the patients demographics on the request form are check that they match the details on the request form. The patients history is checked to see what is to be looked for.
ii. Identify the different structures present such as the uterus, ovaries and follopian tube and document the type of specimen received.
iii. Weight the specimen and orient it using the round ligaments (anterior) and ovaries (posterior).
iv. Measure the different types of structures and record them on the request form including the uterus, cervix, endometrial cavity, left and right ovaries and fallopian tubes. The diameter of the tubes are also measured.
v. Ink the paracervical and parametrial soft tissue margins and section the uterus through the longitudinal plan from the transformation zone to the lower uterine segment.
vi. Leave to fix if necessary overnight. Once it is fixed identify and lesions present and redcord the size, colour, texture and location. If any macroscopic invasion into important structures such as ovaries, fallopian tubes or resection margins can be observed this is documented as well.
vii. Submit sections of the following:
1. Anterior and posterior cervix
2. Anterior and posterior lower uterine wall
3. from cornua
4. Extensive sampling of neoplastic and normal endometrium
5. the left and right ovaries
6. the left and right fallopian tubes – important to include fimbriated sections
7. shavings of the paracervical and parametrial soft tissue margins
e. Given the result of the material from the dilatation and curettage where would you concentrate your sections on and why? (4 marks)
Important to section the area were the lesions is present and the relation with the margins and leiomyoma to investigate for malignancy and depth of invasion if necessary.
a. What is the clinical significance of human papillomaviruses (HPV) 16 and 18? (5 marks)
These are both high-risk HPV subtypes that increase the chance of developing squamous cervical carcinoma and even adenocarcinoma of the cervix. In fact, HPV 16 is more commonly associated with squamous cell carcinoma while HPV-18 is more commonly associated with adenocarcinoma. E6 and E7 genes that have oncogenic potential and can become integrated with the host nucleus causing uncontrollable proliferation of cells which lead to pre-malignant lesions and possible malignancy.
b. How would you treat a large loop excision of transformation zone (LLETZ) in the laboratory? (5 marks)
i. Confirm patient identification on the container matches that on the request form
ii. Examine and record the type of specimen present, the size, texture and colour.
iii. Ink the endocervical and ectocervical margins in different colours.
iv. Section longitudinally or radially depending on the shape of specimen and embed all the specimen into cassettes.
c. How would you orientate a hysterectomy specimen in the laboratory? (5 marks)
If the fallopian tubes and ovaries are present the fallopian tube is anterior while the ovaries are posterior. If these are not present the higher and rounder surface is the anterior surface while the posterior extends inferiorly and has more of a cone shape.
e. Explain the importance of microscopic examination of tissue from alleged ‘products of conception’. (5 marks)
An embryo may or may not be present, thus, gestation can only be confirmed by microscopic means. Confirmation of products of conception is made by the presence of chorionic villi which are villi lined by trophoblastic cells, the presence of decidualised endometrium alone is not enough to confirm gestation.
d. What is the clinical significance of a diagnosis of ‘complex endometrial hyperplasia with atypia’ on endometrial biopsy? (5 marks)
Complex endometrial hyperplasia is when on histology there is increased proliferation of glandular cells with disturbed pattern of the formation of glands and scant stroma. The cells are also atypical meaning that they are irregular, such as enlarge nuclei, pleomorphism and loss of polarity. This type of observations is correlated with increased risk of developing endometrial carcinoma.
- What sections from a vulvectomy specimen should be submitted?
- Ink the cutaneous and soft margins in one colour and vaginal margin with a separate colour.
- Dissect the inguinal wings for lymph nodes but maintain the right and left orientation.
- Submit sections of
- tumour to demonstrate thickness nearest margins, other abnormalities
- all lymph nodes found in the inguinal wings, normal skin
- sections of the clitoris and anterior vaginal margin
- posterior fourchette and perineal margin
- Tumour nearest cutaneous margin
- Tumour and nearest deep and vaginal margins
