Stomach gastrectomy

Background

Stomach may be partially, or less commonly, totally resected for primary tumours, benign ulcers. It may also be received in conjunction with resections of oesophagus or pancreas. 1-3


Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

Fresh tissue received
  • No
    • Non-routine fixation (not formalin), describe.
  • Yes
    • Special studies required, describe.
    • Ensure samples are taken prior to fixation.
Intraoperative consultation
  • Not performed
  • Performed, describe type and result
    • Frozen section
    • Imprints
    • Other, describe

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

External InspectionBack to top


Orientate and identify the anatomical features of the specimen.

Orientation markers

Record additional orientation or designation provided by operating clinician:

  • Absent
  • Present
    • Method of designation (e.g. suture, incision)
    • Featured denoted

Photograph the intact specimen if required.

Describe the following features of the specimen:

Procedure

Record as stated by the clinician.

Options
  • Total gastrectomy
  • Subtotal gastrectomy
    • Proximal
    • Distal
  • Other, describe

Specimen integrity

  • Intact
  • Opened

Anatomical components included (more than one may apply) and dimensions (mm)

Describe and measure the anatomical components present.
  • Stomach
    • Lesser curve, length
    • Greater curve, length
  • Duodenum, length
  • Oesophagus, length
  • Greater omentum, three dimensions
  • Other, specify

DissectionBack to top


The lumen of specimens should be gently rinsed on arrival in laboratory.

Paint the oesophageal circumferential resection margin with ink (if present). 2

Open longitudinally along the greater curve of the stomach avoiding the tumour.

After opening the specimen may require longer fixation in larger quantity of formalin. The specimen can be pinned out around tumour on a board to promote fixation.2

More detail
Dissect the perioesophageal fat and look for lymph nodes. 1

Internal InspectionBack to top


Describe the internal appearance including the following items:

Tumour

  • Absent
  • Present
    • Number; if more than one tumour, designate and describe each tumour separately
Prophylactic gastrectomies from CDH1 mutation carriers

Specific protocols should be followed for these specimens. The stomachs are macroscopically normal, yet contain multifocal microscopic tumours. 4

Gastrectomies for non-neoplastic conditions

Describe the non-tumour lesion appearance, size and location. 3

Tumour site

Record the site(s) of the tumour. More than one may apply.

Options
  • Gastro-oesophageal junction
  • Cardia 5
  • Fundus
  • Antrum
  • Body
  • Pylorus
  • Greater curve
  • Lesser curve
  • Anterior wall
  • Posterior wall

Macroscopic tumour type 6-10

Early cancer (pT1/pT2)
  • Type 0-I     Protruded
  • Type 0-IIa  Elevated
  • Type 0-IIb  Flat
  • Type 0-III   Excavated
  • Type 0-IIc  Depressed

Advanced cancer (pT3/pT4)

  • Type I        Polypoid
  • Type II       Fungating
  • Type III      Ulcerated
  • Type IV      Infiltrative

Tumour size and distances to surgical margins (mm)

  • Maximum dimension
  • Distance of tumour to nearest proximal or distal margin (cut end)
  • Distance of tumour to the circumferential resection margin (proximal/cardia tumours)

Serosal involvement by tumour

  • Absent
  • Suspicious
  • Involved
More detail

Where the tumour is located close to the gastro-oesophageal margin (proximal cardia), examine the outer surface for tumour penetration. Any abnormalities, nodule or plaques should be described as they may represent serosal involvement by carcinoma. 1

Lymph nodes

Retrieved from resection specimen

  • Describe site(s)
  • Number retrieved

Separately submitted

  • For each container, record specimen number and designation
  • Collective size of tissue in three dimensions (mm)
  • Number of grossly identified lymph nodes submitted
  • Maximum diameter of each (mm)

Regional lymph nodes are the perigastric nodes along the lesser and greater curvatures and the nodes along the left gastric, common hepatic, hepatoduodenal, splenic and celiac arteries. Lymph node groups offer no significant prognostic information, therefore all regional nodes can be reported together. 1

Photograph the dissected specimen.

Note photographs taken, diagrams recorded, ink or marks used for identification.

ProcessingBack to top


Dissect the specimen further and submit sections for processing according to the diagram provided.

Submit representative sections of:

  • Tumour; at least four blocks demonstrating:
    • Greatest depth of invasion
    • Tumour closest to or at the serosa
    • Tumour closest to the circumferential resection margin (if applicable)
  • Any area of perforation (if applicable)
  • Proximal resection margin
  • Distal resection margin
Tumours of the cardia

Submit sections from adjacent proximal and distal mucosa.

Tumours of the antrum and body

Submit sections of non-neoplastic mucosa. If tumour is very close to the margin, perpendicular sections can be valuable.

Neoadjuvant specimens

Neoadjuvant specimens can be difficult to assess macroscopically. Look for central oedematous, fibrous areas that are indicative of the tumour bed of the original tumour. 1,3

Submit at least five sections from the tumour site.

Submit all lymph nodes describing location.

Stomach with non-neoplastic lesion

Submit representative sections of:

  • Lesion (ulcer, abscess, fistula or other), demonstrating relationship with circumferential margin or serosal surface
  • Longitudinal sections proximal and distal to the lesion
  • Non-lesional tissue
  • Adjacent tissues,describe
  • Lymph nodes
Stomach with no lesion apparent

Submit representative sections of the specimen.

Prophylactic gastrectomies

Prophylactic gastrectomies from CDH1 mutation carriers 4

  • Submit representative sections of the margins.
  • Submit entire stomach in 3 x 20 mm sections (100-300 blocks).

Record details of each cassette.

An illustrated block key similar to the one below may be useful.

Block allocation key

Cassette id
Site
No. of pieces
A
Proximal margin
 
B
Distal margin
 
C-F
Tumour
 
G
GOJ
 
H
Stomach, body
 

Acknowledgements

Prof Priyanthi Kumarasinghe for her contribution in reviewing and editing this protocol.

ReferencesBack to top


  1. Kumarasinghe P, Brown I, Charlton A, de Boer B, Eckstein R, Epari K, Gill A, Lauwers G, Ormonde D and Price T. Gastric cancer structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2011. 
  2. Novelli MR. Dataset for the histopathological reporting of gastric carcinoma, 2nd ed. The Royal College of Pathologists, London, 2007. 
  3. Feakins R, Campbell F, Mears L, Moffat C, Scott N and Allen D. Tissue pathways for gastrointestinal and pancreatobiliary pathology, The Royal College of Pathologists, London, 2009. 
  4. Fitzgerald RC, Hardwick R, Huntsman D, Carneiro F, Guilford P, Blair V, Chung DC, Norton J, Ragunath K, van Krieken JH, Dwerryhouse S and Caldas C. Hereditary diffuse gastric cancer: updated consensus guidelines for clinical management and directions for future research. J Med Genet 2010;47(7):436-444.
  5. Huang Q, Shi J, Feng A, Fan X, Zhang L, Mashimo H, Cohen D and Lauwers G. Gastric cardiac carcinomas involving the esophagus are more adequately staged as gastric cancers by the 7th edition of the American Joint Commission on Cancer Staging System. Mod Pathol 2011;24(1):138-146.
  6. Japanese research society for gastric cancer. Group classification of gastric biopsy specimens. In: Japanese Classification of Gastric CarcinomaFirst English ed. Tokyo: Kanehara & Co., Ltd, 1995. 
  7. Japanese Gastric Cancer Association. Japanese Classification of Gastric Carcinoma - 2nd English Edition. Gastric Cancer 1998;1: 10–24.
  8.  Xuan ZX, Ueyama T, Yao T and Tsuneyoshi M. Time trends of early gastric carcinoma. A clinicopathologic analysis of 2846 cases. Cancer 1993;72(10):2889-2894.
  9. Saragoni L, Morgagni P, Gardini A, Marfisi C, Vittimberga G, Garcea D and Scarpi E. Early gastric cancer: diagnosis, staging, and clinical impact. Evaluation of 530 patients. New elements for an updated definition and classification. Gastric Cancer 2013 16(4):549-54.
  10. Murakami T. Pathomorphological diagnosis. Definition and gross classification of early gastric cancer. Gann Monogr Cancer Res 1971;11:53-55.