Cervix

• Intact LEEP and cold knife cones are cylindrical or conical in shape
• Sometimes, removal of the transformation zone requires 2 or more passes or the specimen from the initial pass is too thin and breaks; these result in a fragmented LEEP / LETZ specimen

Specimen orientation

• Specimen has a mucosal surface on 1 side and cauterized connective tissue on the opposite side (the deep margin)
• Intact specimens may be oriented by the surgeon, usually with a suture marking an o'clock position; the ectocervical and endocervical ends are usually easy to recognize
• Ectocervical mucosa is shiny, smooth and white, whereas the endocervical mucosa is finely granular with adherent mucus
• In fragmented LEEP / LETZ, orientation in terms of anatomic position (o'clock position or quadrants) is neither possible nor required
  • In LEEP / LETZ specimens, the resection margins are identified by the thermal artifact on the tissue edges; therefore, inking is not required
• Resection margins or a cold knife cone should always be inked
  • It is recommended to use different colors to distinguish the endocervical end versus the ectocervical end of the specimen

Specimen and tumor measurements

• Whenever possible, measurements should be obtained in the fresh specimen (before fixation and handling)
• For fragmented LEEP / LETZ, document the number of tissue fragments and size range (minimum to maximum)
• For intact LEEP or cones, document the length (dimension parallel to the endocervical canal), width (perpendicular to the length, going from right to left) and wall thickness of the specimen
• Any grossly visible lesion also should be recorded, in terms of length, width and thickness
  • If orientation was provided by the surgeon, document the location of the lesion, e.g. o'clock position or quadrant(s)
• Document the distance between lesion and margins

Specimen processing and tissue sampling

• If an intact LEEP / cone is received fresh and the lab's workflow allows for it, open the specimen along the cervical canal and pin it
  • This allows the mucosa to be properly exposed to the fixative and facilitates obtaining sections that are of even thickness
  • Sectioning will occur after fixation, at 2 - 3 mm intervals, in a manner that consecutive sections, parallel to the canal, are obtained (each going from endocervical to ectocervical, with mucosa on 1 edge and the deep margin on the opposite end)
• If the intact LEEP / cone is received in fixative, it can still be opened along the canal and serially sectioned, with the caveat that the resulting sections may be of uneven thickness and may require trimming
• Fragmented LEEP / LETZ do not require orientation or pinning and can be immediately placed in formalin
  • Each fragment of tissue should be sliced at 2 - 3 mm intervals, cutting parallel to the longitudinal aspect of the cervical mucosa (from ectocervical to endocervical when possible)
• Tissue should be submitted entirely for histologic examination (including trimmed tissue from serially sectioned slices)
• Place at most 1 - 2 tissue fragments in each block; placing more fragments may interfere with proper embedding and tissue orientation potentially resulting in incomplete representation of the mucosa in all sections within the block
• In principle, 1 initial H&E section per block is sufficient for accurate diagnosis; deeper sections can be useful in certain instances, such as missing mucosa in initial H&E, absence of squamous intraepithelial lesion, foci suspicious for stromal invasion, discordance with clinical, colposcopic or cytologic findings (J Clin Pathol 2001;54:650)

• Trachelectomy is a fertility sparing approach for patients with selected stage I cervical cancers (stage IA1 with lymphovascular space invasion, stage IA2 or stage IB1 centered in the distal cervix)
• Trachelectomy specimens are usually received intact and fresh
  • They typically require intraoperative evaluation of the endocervical margin
  • Therefore, specimen orientation, inking and measurement usually occur prior to fixation

Specimen orientation and inking

• Anatomic orientation in the axial (coronal) plane typically requires marking by the surgeon (a suture at the 12 o'clock position will suffice)
• Margins to ink are the endocervical margin, the vaginal margin, the right and left parametrial margins and the nonperitonealized surfaces at the anterior and posterior aspects of the cervix
  • The latter are not considered true margins from the surgical perspective
  • However, they should be inked and reporting is required if tumor involves those surfaces, as it may have implications for adjuvant treatment (J Clin Oncol 2000;18:1606, CAP: Protocol for the Examination of Resection Specimens from Patients with Primary Carcinoma of the Uterine Cervix [Accessed 23 December 2020])

Specimen and tumor measurements

• Specimen and tumor dimensions should be obtained in the fresh specimen, before stretching, pinning, fixation and serial sectioning
• Similar to cone specimens, trachelectomies should be measured in terms of length (parallel to the canal, from proximal to distal), width (dimension perpendicular to the length, going from right to left) and thickness of the wall
  • Vaginal cuff should be measured in terms of average and range of width (from the junction with the cervix to the resection edge)
  • Parametrial tissues should be measured in terms of length (from superior to inferior) and lateral dimension (from uterine wall to most lateral edge)
• Any grossly visible lesion should be documented in terms of appearance, size and location
  • Location should be established using o'clock positions
  • Size should be documented in terms of length, width and thickness
  • In addition, the macroscopic depth of invasion can be included; this dimension can be different from the tumor thickness, which includes the exophytic portion of the tumor
  • Depth, on the other hand, only includes the portion of the cervical wall involved by tumor (thus, it excludes any exophytic component)
  • Distance of the tumor to all margins should also be documented
• Documentation of macroscopic tumor dimensions is essential, as these data are eventually needed to determine the final tumor dimensions after review of the microscopic findings
  • As per the latest FIGO staging system, pathologic variables, including tumor size, supercede clinical and radiologic variables for staging purposes (Int J Gynaecol Obstet 2019;147:279, Int J Gynaecol Obstet 2019;145:129)

Specimen processing and tissue sampling

• Trachelectomy specimen should be opened along the endocervical canal
  • If possible, opening should be performed in an area free of gross tumor
  • Opening will reveal the cervical mucosa, facilitating the macroscopic evaluation of the tumor (including dimensions)
  • The then opened cylinder can now be pinned for fixation
  • It is prudent to also pin the vaginal cuff (while attached to the cervix) to prevent retraction
  • Alternatively, the cervix can be sectioned fresh
• Trachelectomy specimen should be serially sliced at 2 - 3 mm intervals parallel to the endocervical canal
  • Each slice should have mucosa along 1 edge (from the vaginal cuff margin to the endocervical margin) and the radial paracervical connective margin on the opposite edge
  • If the slices are too large to fit in a single block, they can be divided and submitted as a composite section in multiple blocks
• Any grossly visible tumor should always be sampled
  • If the lesion is 2 cm or less in size, it is recommended that it is submitted entirely
  • If the lesion is larger than 2 cm, partial sampling is sufficient
  • Sampling should include tumor in relation to all the margins and tumor at the point of deepest invasion into the cervical wall
• In the absence of any grossly visible lesion, the entire specimens should be submitted for histologic examination
• It is recommended that the vaginal cuff and its respective margin are left attached to the cervix and serially sampled along with it
  • Alternatively, if the cuff is too wide, the margin can be shaved and submitted en face
• Parametrial tissues should be sliced and entirely submitted
  • To this effect, the parametrial tissues can be separated from the cervix; however, if the tumor appears to invade the parametria or is close to it, it is advisable to leave the parametrial tissue attached to the cervix and submit it with a portion of the outer cervix attached to it

• Ovaries or fallopian tubes may be included with hysterectomies

Specimen orientation, margins and inking

• Hysterectomy specimens can usually be oriented following anatomic landmarks:
  • Peritoneal reflections, with the anterior reflection being shorter than the posterior reflection (which goes more distally)
  • On a sagittal plane, the curvature of the uterus is, in most cases, concave on the anterior surface and convex on the posterior surface
  • Fallopian tubes are typically anterior to the ovaries
• Margins to ink are the ectocervical or vaginal margin, the right and left parametrial margins and the nonperitonealized surfaces at the anterior and posterior aspects of the cervix (see Trachelectomy section)
  • Multiple ink colors can be used to separate sides (right versus left, anterior versus posterior)

Specimen and tumor measurements

• Uterus should be weighed
• For measurements of cervix, parametria and vaginal cuff, follow recommendations for Trachelectomy specimens
• Likewise, any visible tumor tumor should be measured as indicated in the Trachelectomy section
• Uterus and each ovary should have 3 dimensions
• Fallopian tubes should be measured in terms of length and average / range diameter

Specimen processing and tissue sampling

• Hysterectomy specimens should be opened and prepared for fixation as soon as possible
  • Delayed fixation usually results in poor preservation of the tissue, which may preclude optimal microscopic evaluation
• Opening the uterus can be achieved in several ways:
  • One is to first amputate the cervix from the corpus; then the cervix is opened, pinned and sectioned as described for Cone or Trachelectomy
  • Alternatively, the cervix is left attached with the corpus; the uterus is then opened along the lateral walls resulting in anterior and posterior halves (bivalve approach)
    • Opening can be done using scissors or by inserting forceps into the uterine cavity, then inserting the knife in between the forceps arms to guide the cutting
• Independent from the method used to open the uterus, the cervix needs to be cut from the corpus and serially sectioned; opening and pinning to optimized fixation is again recommended
• If the tumor is seen grossly involving the uterine corpus or lower uterine segment, then it is advisable to sample the tumor in relationship with the corpus and amputating the cervix may not be necessary
• Uterine corpus should be serially thinly sliced (3 - 5 mm) parallel to the axial plane, from the endometrial surface to the serosa
• Parametrial tissues should be removed from the uterus after margin inking and before opening, unless there is suspicion that the tumor is extending into the parametria, in which case the parametrial tissues should be left attached and sectioned along with the outer cervical wall (in order to properly document a possible extension of the tumor into the parametria)
• Any grossly visible tumor should be described in terms of appearance, size, location and distance to margins following recommendations stated in the Cone and Trachelectomy sections
• Sections of the cervix, should also follow recommendations included in the Trachelectomy section
  • In short, cervix with no lesions or with tumor 2 cm in size or less should be serially sectioned at 2 - 3 mm intervals and submitted entirely
  • If the tumor is larger than 2 cm, representative sections are allowed (to include relationship with margins, vaginal cuff, parametria and lower uterine segment as appropriate)
  • Composite sections should be considered if the canal is too long to fit in a single block
• Representative sections of the uterine corpus and lower uterine segment should be full thickness (from endometrium to serosa) and representative of both the anterior and posterior halves
• If fallopian tubes are present, it is recommended that at least the fimbria are submitted entirely, serially sectioned, along with representative cross sections of the ampullary portion
• If ovaries are present, at least 1 representative section of each should be submitted

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Regarding the assessment and sampling of cervix resection specimens in patients with cervical cancer, which of the following is correct?

1. Tumor should be measured after specimen was been opened, pinned and fixed in formalin
2. Cervix should be cut along the axial plane from superior to inferior aspects
3. Representative sampling of the cervix is indicated if no grossly visible lesion is identified
4. Tumor measurements to include in the report are the length (parallel to the endocervical canal), width (axial plane perpendicular to length, from right to left), thickness and depth

D. The dimensions of any grossly visible cervical mass are the length, width, thickness and depth (if different from thickness). These dimensions should be estimated before fixation and pinning, as processing distorts the tumor size and may result in overestimation. The cervix is sectioned parallel to the endocervical canal plane, not along the axial plane. If no obvious mass is identified, the cervix should be submitted entirely for histologic examination.

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Reference: Cervix - Grossing

Regarding the different specimens encountered in patients with cervical cancer, which of the following is correct?

1. LEEP specimens have a cautery artifact in the tissue edges, introduced by the electrosurgical effect of the loop
2. Simple trachelectomy includes right and left parametrial tissues
3. Anterior pelvic exenteration includes the rectum
4. Radical hysterectomy includes the lower third of the vagina

A. LEEP specimens are obtained by an electrically charged loop device that cauterizes tissue as it cuts through it. Simple trachelectomy / hysterectomy does not have parametria. Anterior pelvic exenteration includes bladder, urethra or ureters along with the uterus, cervix or vagina. Radical hysterectomy usually includes the upper aspect of the vagina, not the lower.

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Reference: Cervix - Grossing