Cervix
General
Grossing

Deputy Editor-in-Chief: Jennifer A. Bennett, M.D.
Carlos Parra-Herran, M.D.

Minor changes: 15 April 2021

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PubMed search: Gross cervix specimens

Carlos Parra-Herran, M.D.
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Cite this page: Parra-Herran C. Grossing. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/cervixgrossing.html. Accessed April 19th, 2021.
Definition / general
  • Information provided herein is based on the recommendations from the International Society of Gynecological Pathologists (ISGyP) as part of the ISGyP Endocervical Adenocarcinoma Project, authored by C Parra-Herran, A Malpica, E Oliva, GF Zannoni, PT Ramirez and JT Rabban (Int J Gynecol Pathol 2021;40:S24)
  • Guidelines were based on current evidence, as well as existing institutional grossing protocols and guidelines from the International Collaboration on Cancer Reporting (ICCR) and the College of American Pathologists (CAP)
  • While the guidelines were conceived in the framework of the Endocervical Adenocarcinoma Project, its recommendations are applicable to other types of carcinoma of the cervix
Essential features
  • Surgical specimens originating from or including the uterine cervix must ideally be examined and processed in their fresh state
    • Examination should include measurement of specimen size, as well as size of any tumor or lesion
  • Overnight fixation, if feasible, can facilitate tissue handing and sectioning
  • Trachelectomy specimens usually require intraoperative consultation for frozen section examination of the endocervical margin
Terminology
  • LEEP: loop electrosurgical excision procedure
  • LETZ: large loop excision of the transformation zone
  • Cold knife cone
  • Trachelectomy, simple or radical
  • Hysterectomy, simple or radical
  • Pelvic exenteration, anterior, posterior or total
LEEP / LETZ and cone specimens
  • 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 specimens
  • 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
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

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
Hysterectomy specimens
  • 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
Pelvic exenteration specimens
  • Pelvic exenteration is indicated in patients with recurrent cervical or vaginal cancer in which adjuvant radiation therapy fails to control disease and in those with advanced stage cancer that are suitable for extensive surgical resection (Int J Gynecol Cancer 2013;23:755, Gynecol Oncol 2006;103:1023)
  • Specimen is complex but in most cases can be oriented by identifying organs and tissue landmarks
    • Small organs, such as ureters and urethra, may need to be labeled by the surgical team
  • All organs removed (as per requisition and operative note) should be identified and measured; taking gross photographs is strongly recommended
  • Measurements of all organs should be taken in the fresh state
    • For the uterus and bladder, 3 dimensions should be obtained
    • For the rectum, vagina and ureters, report the length and the range of their diameter
  • Lateral (right and left) soft tissue margins should be inked
  • Any tumor or abnormality should be described in terms of appearance, size and location with respect to all organs present, including whether an organ is involved or the gross distance between the lesion and the organ
  • Recommendations for tumor description and sampling are the same as those made for trachelectomy and hysterectomy specimens
  • Urethral and ureteral margins, as well as proximal and distal rectal margins, should be obtained en face
    • Soft tissue margins, including pararectal, parametrial and paracervical soft tissues, should be sampled, preferably perpendicularly in relationship to the tumor
Procedure
  • LEEP / LETZ:
    • Loop electrosurgical excision procedure / large loop excision of the transformation zone
    • In this procedure, an electrical loop shaped cutting device is used, which cauterizes tissue as it cuts through it
    • Thus, cautery effect can be used to identify the tissue margins
  • Cone:
    • Conservative excision of the cervix, including the transformation zone and surrounding tissue
    • Excision usually results in an intact cone or cylinder shaped specimen
    • It is removed using a cold knife, which does not produce cautery artifact on the tissue edges
    • Sometimes, a second portion of the endocervix is removed (so called top hat)
  • Trachelectomy:
    • Consists of the entire cervix (ectocervix, transformation zone and endocervical canal), with or without upper vagina (cuff of 1 - 2 cm)
    • Radical trachelectomy includes parametrial tissues, whereas simple trachelectomy does not
  • Hysterectomy:
    • Consists of the entire cervix and uterine corpus, with or without upper vagina (cuff of 1 - 2 cm)
    • Radical hysterectomy includes parametrial tissues, whereas simple hysterectomy does not
  • Pelvic exenteration:
    • En bloc resection of pelvic organs, along with the uterus and vagina
    • Anterior exenteration includes bladder, urethra or ureters
    • Posterior exenteration includes rectum
    • Total exenteration includes both anterior and posterior organs (Obstet Gynecol 1989;73:1027)
Gross images

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Grossing diagrams

Sample gross description report
  • Fragmented LEEP:
    • Labeled with patient's name and medical record number, specimen labeled __ consists of (number, multiple) fragments of tissue ranging in size from __ cm to __ cm (__ cm in aggregate). Specimen is submitted in toto in blocks __ (1 - 2 tissue sections per block).
  • Intact LEEP / cone:
    • Labeled with patient's name and medical record number, specimen labeled __ consists of a donut / C shaped fragment of tissue, received (fresh / in fixative). The specimen is (not oriented / oriented with a suture in the __ o'clock position as per requisition). It measures __ cm in length and __ cm in diameter; wall thickness is __ cm on average. The ectocervical margin is inked blue, endocervical margin is inked black. The specimen is opened and radially sectioned in a clockwise fashion. It is submitted entirely (in __ blocks / as follows):
      • Block __-__: 12 to 3 o'clock
      • Block __-__: 3 to 6 o'clock
      • Block __-__: 6 to 9 o'clock
      • Block __-__: 9 to 12 o'clock
  • Trachelectomy:
    • Labeled with patient's name and medical record number, specimen labeled __ consists of a (simple / radical) trachelectomy. The specimen is (not oriented / oriented with a suture in the __ o'clock position as per requisition). Endocervical margin is inked black, paracervical / parametrial margin is inked green, distal vaginal margin is inked blue.
      • Cervix: length __ cm, diameter __ cm, wall thickness __ cm on average
      • Tumor: present / absent
        • Measurement: length __ cm, diameter __ cm, thickness __ cm, depth __ cm
        • Location: __ o'clock position
        • Appearance: fungating / ulcerated / flat; soft / friable / indurated
        • Margins: distal (vaginal): __ cm; endocervical: __ cm; radial __ cm
      • Vaginal cuff: ranging from __ to __ cm; it is (unremarkable versus __)
      • Right parametrium: length __ cm, width __ cm (unremarkable versus __)
      • Left parametrium: length __ cm, width __ cm (unremarkable versus __)
    • Specimen is sampled (entirely / representatively) as follows:
      • Frozen sections, resubmitted
    • If no tumor identified or less than 2 cm in size, specimen is submitted entirely:
      • Cervix and vaginal cuff, 12 - 3 o'clock
      • Cervix and vaginal cuff, 3 - 6 o'clock
      • Cervix and vaginal cuff, 6 - 9 o'clock
      • Cervix and vaginal cuff, 9 - 12 o'clock
      • Right parametrium, in toto
      • Left parametrium, in toto
    • If tumor is 2 cm or more in size, specimen is representatively sampled:
      • Cervical tumor (specify which section has the deepest point of invasion and which has the closest vaginal, endocervical and deep margins)
      • Uninvolved cervix, at __ o'clock
      • Right parametrium, in toto
      • Left parametrium, in toto
      • Anterior lower uterine segment
      • Posterior lower uterine segment
      • Anterior endomyometrium, full thickness
      • Posterior endomyometrium, full thickness
      • Right ovary
      • Right fallopian tube (modified SEE-FIM)
      • Left ovary
      • Left fallopian tube (modified SEE-FIM)
  • Hysterectomy:
    • Labeled with patient's name and medical record number, specimen labeled __ consists of a (simple / radical) hysterectomy. The paracervical / parametrial margin is inked green, distal vaginal margin is inked blue.
      • Uterus: __ grams, __ x __ x __ cm
      • Cervix: length __ cm, diameter __ cm, wall thickness __ cm on average
      • Tumor: present / absent
        • Measurement: length __ cm, diameter __ cm, thickness __ cm, depth __ cm
        • Location: __ o'clock position
        • Appearance: fungating / ulcerated / flat; soft / friable / indurated
        • Margins: distal (vaginal): __ cm; endocervical: __ cm; radial __ cm
      • Vaginal cuff: ranging from __ to __ cm; it is (unremarkable versus __)
      • Right parametrium: length __ cm, width __ cm (unremarkable versus __)
      • Left parametrium: length __ cm, width __ cm (unremarkable versus __)
      • Endometrial cavity: __ x __ cm (length x cornu to cornu)
      • Endometrium: thickness __ cm (unremarkable versus __)
      • Myometrium: thickness __ cm (unremarkable versus __)
      • Ovaries: right __ x __ cm (unremarkable versus __); left __ x __ cm (unremarkable versus __)
      • Fallopian tubes: right __ x __ cm (unremarkable versus __); left __ x __ cm (unremarkable versus __)
    • Specimen is sampled (entirely / representatively) as follows:
      • Frozen sections, resubmitted
    • If no tumor identified or less than 2 cm in size, specimen is submitted entirely:
      • Cervix and vaginal cuff, 12 - 3 o'clock
      • Cervix and vaginal cuff, 3 - 6 o'clock
      • Cervix and vaginal cuff, 6 - 9 o'clock
      • Cervix and vaginal cuff, 9 - 12 o'clock
      • Right parametrium, in toto
      • Left parametrium, in toto
      • Anterior lower uterine segment
      • Posterior lower uterine segment
      • Anterior endomyometrium, full thickness
      • Posterior endomyometrium, full thickness
      • Right ovary (representative section / in toto)
      • Right fallopian tube, fimbriated in __ (modified SEE-FIM)
      • Left ovary (representative section / in toto)
      • Left fallopian tube, fimbriated in __ (modified SEE-FIM)
    • If tumor is 2 cm or more in size, specimen is representatively sampled:
      • Cervical tumor (specify which section has the deepest point of invasion and which has the closest vaginal, endocervical and deep margins)
      • Uninvolved cervix, at __ o'clock
      • Right parametrium, in toto
      • Left parametrium, in toto
      • Anterior lower uterine segment
      • Posterior lower uterine segment
      • Anterior endomyometrium, full thickness
      • Posterior endomyometrium, full thickness
      • Right ovary (representative section / in toto)
      • Right fallopian tube, fimbriated in __ (modified SEE-FIM)
      • Left ovary (representative section / in toto)
      • Left fallopian tube, fimbriated in __ (modified SEE-FIM)
Diagrams / tables

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Hysterectomy specimen

Board review style question #1
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
Board review style answer #1
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.

Comment Here

Reference: Cervix - Grossing
Board review style question #2
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
Board review style answer #2
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
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