Guidelines for Radical Prostatectomy Specimen Handling
Posted May 22 2009 10:40pm
Guideline for Optimization of Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management: CANCER CARE ONTARIO,CANADA GUIDE LINES.
1. What are the recommended procedures for handling the RP specimen in the operating room and for handling and processing the RP specimen (with or without lymph nodes) in the pathology lab? 2. What diagnostic and prognostic elements should be included in the pathology report,what format should be used, and what reporting elements should be included?
(1)Handling of the Radical Prostatectomy Specimen in the Operating Room
• Frozen section analysis of the radical prostatectomy specimen (RPS) for margin status is not recommended. • For routine handling, the RPS should be fixed in 10% neutral buffered formalin or other appropriate fixative. The specimen should be put in an appropriately sized container with a minimum formalin/tissue ratio of 10:1 (i.e., 500 cc formalin for a 50 cc prostate).
Pathology Requisition Information • The surgical specimen should be accompanied by an appropriate pathology requisition that includes demographic and other identifying information, relevant clinical data (e.g.,serum PSA, DRE findings [T1c versus T2], Gleason score on biopsy), and the history of neoadjuvant therapy (e.g., hormones )
Pathology Report • The surgical pathology report should include the relevant diagnostic and prognostic information as outlined in the CAP Cancer Protocol for Carcinomas of the Prostate Gland (2) CCO has recommended as a minimum standard that all mandatory elements on the CAP checklist (Section 2: Appendix 2) be included in the RPS pathology report. • It is recommended that the diagnostic and prognostic factors be presented as a synopsis as opposed to a narrative or paragraph form. Data from CCO indicates that synopses are more likely to be complete.
Technical Considerations for Handling and Processing the Radical Prostatectomy Specimen in the Pathology Laboratory • In the Pathology Laboratory, the RPS (with or without lymph nodes) is accessioned in the usual fashion. • The RPS should be fixed in neutral buffered formalin (minimum 10:1 ratio) for a minimum of 18-24 hours prior to sectioning. A microwave-assisted technique may be used to reduce fixation time. • The prostate gland should be weighed and measured in three dimensions; seminal vesicles should be measured; accompanying lymph node specimens should also be measured and a record made of the number and size of grossly identified nodes. • The outer aspects of the RPS should be carefully inked to identify the surgical margins,prior to tissue banking. • After appropriate fixation and inking, the distal apical segment is transected and then serially sectioned, perpendicular to the inked surface. An en face (shave) technique is to be discouraged at the apex, as this approach can result in false-positive margin interpretation. • The basal (bladder neck) aspect is commonly doughnut shaped and irregular. It is transected from the main specimen and should also be submitted in a perpendicular fashion to minimize the possibility of a false-positive margin at this location. • The intervening transverse sections can be either totally or subtotally submitted using regular-sized blocks. The submission protocol should be documented with an appropriate diagramatic or written block legend. • For subtotal submissions, a systematic approach to include the posterolateral peripheral zone should be used. • All lymph nodes accompanying the RPS should be submitted for histological analysis. It is not necessary to submit all perinodal fat, although it is often difficult to distinguish between adipose tissue and fatty lymph nodes. • The full CAP checklist and protocol for RP are available at http://www.cap.org/apps/docs/cancer_protocols/2006/prostate06_pw.pdf