Lung

Background

Lobectomies and pneumonectomies may be undertaken to remove tumours. Bullectomies are used to treat severe emphysema. Extrapleural pneumonectomies remove the lung, part of the pericardium, part of the diaphragm and part of the parietal pleura for the treatment of mesothelioma. Lungs are also removed prior to patients receiving lung transplants. 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
    • Microbiology
    • Flow cytometry

The potential for an infectious biohazard should always be considered with fresh specimens but particularly with respiratory samples due to the possibility of mycobacterial infections. 3 Ensure strict safe specimen handling and decontamination protocols are in place in the laboratory.

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.

Describe the following features of the specimen:

Procedure

Record as stated by the clinician.

Options
  • Wedge resection
  • Segmentectomy
  • Lobectomy
    • Upper
    • Middle
    • Lower
  • Pneumonectomy
    • With chest wall
    • Without chest wall
  • Other, describe

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

Describe the components present and measure as applicable.

  • Lung, in three dimensions
  • Pleura
  • Extra-pulmonary tissues
  • Hilar soft tissues, in three dimensions
  • Parietal pleura
  • Mediastinal tissue, in three dimensions
  • Pericardium
  • Diaphragm, in three dimensions
  • Other, describe

Weight (g)

  • If applicable record

Specimen laterality

  • Left
  • Right

Specimen integrity

  • Intact
  • Disrupted/opened, describe

DissectionBack to top


Most lung specimens can be inflated with formalin and allowed to fix before dissection. The only exceptions are some non-neoplastic specimens in which inflation can affect histological interpretation. Resection specimens are inflated via cannulation of the bronchus at the medial resection line if possible. Where this is not practical (wedge resections and occluded bronchi) inflation can be achieved by injection of formalin through the visceral pleura. 1

Resection for tumour

After sufficient fixation, carefully remove any clips or staple lines and paint the relevant surgical margin(s) with ink (hilar soft tissue, chest wall or wedge biopsy surgical margin, pleura overlying tumour) and record the colours applied.

Remove and submit any attached hilar lymph nodes.

Take shave sections of any hilar vessels together with a transverse shave of the bronchial margin.

If present, open the main, lobar or segmental bronchi and determine whether the tumour originates in a bronchus. Insert a probe towards the segment containing tumour and section at 4-5mm intervals. 1

Serially section the lung in the transverse plane from superior to inferior (perpendicular to the bronchial resection margin) to demonstrate the distance between the tumour and both the bronchial resection margin and the closest pleural surface.

Resection non-neoplastic

Carefully remove the staple line if present. Serially section the specimen perpendicular to the cut edge (staple line) at 4-5mm intervals, keeping the specimen largely intact.

After opening, the specimen may require longer fixation in larger quantity of formalin.

Internal InspectionBack to top


Describe the internal or cut surface appearance including the following items:

Tumour 1

  • Absent
  • Present
    • Number; if more than one tumour, designate and describe each tumour separately

Tumour site

  • Right lobe
    • Upper
    • Middle
    • Lower
  • Left lobe
    • Upper
    • Lower
  • Main bronchus

Location

  • Central, describe if possible
    • Mainstem bronchus
    • Lobar bronchus
    • Segmental bronchus
  • Peripheral

Tumour size (mm)

  • Maximum dimension
  • Other dimensions

Distance of tumour to margin (mm)

Measure:

  • Distance of tumour to the bronchial resection margin

Extent of spread of tumour

Describe:

  • Pleura overlying a peripheral tumour
    • Normal
    • Puckered
    • Distance between tumour and closest pleural surface
  • Separate tumour nodule(s) 4
    • Number
    • Maximum dimension of each (mm)

Non-neoplastic lung

Describe any abnormalities present:

  • Emphysema
  • Fibrosis
  • Other, describe
  • Location
    • Diffuse
    • Localised
  • Location in lobe, bronchopulmonary segment
  • Relationship to bronchi, vessels and pleura
  • Bronchial mucosa and luminal contents, measure lumen diameter (mm)

Describe the non-lesional tissue appearance:

  • Parenchyma
Lymph nodes

Retrieved from resection specimen

  • Describe site(s)
  • Number retrieved

Separately submitted

  • For each specimen 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)

Photograph the dissected specimen.

Note photographs taken, diagrams recorded and markings used for identification.


ProcessingBack to top


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

Resection for tumour 1,2

Submit representative sections of:

  • Bronchial resection margin
  • Vascular resection margin
  • Tumour demonstrating relationship with adjacent tissue
  • If tumour <20mm in maximum dimension, submit all tumour
  • If tumour is >20mm, all heterogeneous areas of tumour
  • Central scar, if present
  • Visceral pleura overlying tumour, if present
  • Parietal pleura/chest wall overlying tumour, if present
  • Non-neoplastic lung
  • Hilar soft tissues, mediastinal tissue, pericardium, diaphragm if present

Submit all lymph nodes and identify the site of each.

Resection non-neoplastic lung 3

Submit all tissue.

Record details of each cassette.

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

Block allocation key

Lung with tumour
Cassette id
Site
No. of pieces
A
Bronchial and vascular resection margins
 
B
Perihilar lymph nodes
 
C-G
Tumour, all sections (if <20mm) or representative sections including all heterogeneous areas (if >20mm) to visceral pleura and interface with normal lung
 
H
Background lung tissue
 
I+ Hilar soft tissues, mediastinal tissue, pericardium and diaphragm, if applicable  
Non-neoplastic lung
Cassette id
Site
No. of pieces
A+
Lung, all sections
 

Acknowledgements

Dr Jenny Ma Wyatt for her contribution in reviewing and editing this protocol.

ReferencesBack to top


  1. Ma Wyatt J, Ball D, Clarke B, Cooper W, Ellis D, Henderson D, McCaughan B and Millward M. Lung cancer structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2010.
  2. Nicholson AG, Gibbs A, Kerr K and Gosney J. Dataset for lung cancer histopathology reports, The Royal College of Pathologists, London, 2014.
  3. Nicholson AG. Tissue pathway for non-neoplastic thoracic pathology, The Royal College of Pathologists, London, 2013.
  4. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010.