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Thymus and mediastinal masses

Background

Thymectomy may be undertaken for the removal of benign and malignant tumours or for the treatment of myasthenia gravis.^1-5

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.

International Thymic Malignancy Interest Group recommendations

The International Thymic Malignancy Interest Group (ITMIG) recommends detailed operative notes that include:⁴

Extent of resection performed (e.g. complete thymectomy)
Presence and location of any residual tumour in the patient
Presence and locations of any adhesions that were not suspicious for involvement
Any additional structures and/or organs removed (e.g. mediastinal pleura, pericardium, phrenic nerve, innominate vein and/or lung)
Any sites of intraoperative concern; method of marking in specimen and in the patient
Lymph nodes explored and extent of assessment (e.g. sampling or complete dissection)
Whether pleural and pericardial spaces were able to be assessed for metastases

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 Inspection

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

Anterior, posterior, and right and left aspects should be identified by the surgeon.²

ITMIG recommendations⁴

A standard approach to surgical orientation and marking is recommended by the International Thymic Malignancy Interest Group.

Indicate with sutures (through loose tissue and into substantial deeper tissue to prevent disruption):

Any margin(s) of concern
Surface adjacent to the pericardium and innominate vein (or the structures if resected)
Surface adjacent to the vena cava (larger tumours, if nearby)
Right and left pleural surfaces (larger tumours if resected)

The specimen should be orientated by the surgeon and orientation communicated clearly to the Pathologist. The ITMIG recommends the following methods:⁴

Mounting the unfurled specimen on a board
A diagram of the specimen with adjacent structures and marking sutures
A digital photograph of the mounted specimen

Photograph the intact specimen.

Describe the following features of the specimen:

Procedure

Record as stated by the clinician.

Options

Biopsy, refer to instructions for respiratory small biopsies
Thymectomy
Partial thymectomy
Mediastinal mass resection (other than thymus)
Other, describe

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

Record the components present and measure as applicable.

Total specimen, in three dimensions^2,3
Thymus
Other, describe
Separate nodules, specify²
- Number
- Sites
- Size of each in three dimensions

Weight (g)

Record the weight of the total specimen.^3,5

Specimen integrity³

Intact
Disrupted, describe surface and area involved
Fragmented

Dissection

Paint the specimen with coloured inks indicating any orientated margins or specific landmarks (it may not be necessary to paint the entire specimen).

Serially section the specimen from superior to inferior at 3-4mm intervals.²

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

Internal Inspection

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

Tumour

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

If only one tumour nodule is identified, it is assumed to represent the primary tumour. If >1 separate tumour nodules are identified, the primary tumour should be separately designated from other tumour nodules 2, 3, 4 etc.

Tumour size (mm)²

Maximum dimension
Other dimensions

Tumour location²

Thymic
Ectopic, specify site if known

Extrathymic tumour spread (if applicable)

Macroscopic extension of tumour into mediastinal fat²
Pulmonary parenchyma, specify lobe(s)
Pleura, specify location
Pericardium
Diaphragm
Other, describe

Distance of tumour to margins (mm)

Distance of tumour to closest surgical margin(s)³
Specify margin

Distance between tumour nodules (mm) -if applicable

If more than one tumour nodule, record:

Distance of other tumour nodules from the primary (largest nodule)

Non-lesional tissue appearance⁵

Fatty
Biopsy related changes
Cystic
Thymic hyperplasia

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)

Processing

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

Small tumours (<20mm)

Submit all sections in sequential order.²

Large tumours (>20mm)

Submit representative sections, at least one block per 10mm of tumour² or lesion demonstrating:

Surgical margins
Relationship with thymic capsule and extrathymic tissue
Cyst walls, if applicable
At least one block of non-lesional thymus

Submit all lymph nodes and identify the site of each.

Record details of each cassette.

An illustrated block key similar to those provided below may be useful.

Block allocation keys

Small tumours

Cassette id	Site	No. of pieces
A+	All sections

Large tumours

Cassette id	Site	No. of pieces
A	Surgical margins
B-D	Tumour demonstrating relationship with thymic capsule and extrathymic tissue
E	Cyst walls, if applicable
F	Non-lesional tissue
G+	Lymph nodes if applicable

Acknowledgements

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

References

Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
Nicholson AG, Kerr K, Gosney J and Cane P. Dataset for the histological reporting of thymic epithelial tumours, The Royal College of Pathologists, London, 2013.
College of American Pathologists. Cancer Protocols. (Accessed 21 Jun 2013).
Detterbeck FC, Moran C, Huang J, Suster S, Walsh G, Kaiser L, et al. Which Way is Up? Policies and Procedures for Surgeons and Pathologists Regarding Resection Specimens of Thymic Malignancy. Journal of Thoracic Oncology. 2011;6(7):S1730-S8.
Nicholson AG. Tissue pathway for non-neoplastic thoracic pathology. London: The Royal College of Pathologists, 2013.

Dictation Template