Chapter 11

Surgical Specimen Handling for Conjunctival and Eyelid Tumors

Sheri L. DeMartelaere, Frank W. Scribbick, and Doina Ivan

Abstract Ophthalmologists need to be familiar with surgical specimen handling in order to provide optimal patient care. The cornerstone of proper specimen handling is communication between the ophthalmologist and the pathologist before, during, and after surgery. Conjunctival tissue presents unique surgical specimen handling challenges as the tissue has a propensity to curl up on itself, making it difficult to maintain proper tissue orientation and alignment. For pathologic evaluation of eyelid specimens, specimen orientation is the key. Proper specimen handling and discussion with the pathologist can help alleviate these difficulties.

11.1 Introduction

Proper specimen handling is a critical component of the surgical removal of periocular tumors. Specimen handling is a critical determinant of diagnostic accuracy and the completeness of excision, which in turn influence the patient’s prognosis and recommendations for adjuvant treatment [1].

For several types of periocular tumors, the first excisional biopsy provides the only opportunity to assess tumor thickness. In addition, for malignant periocular tumors for which complete surgical resection is the treatment of choice, correct evaluation of the margins of resection is essential [2]. In both situations, the surgical specimen must be prepared carefully to allow the pathologist to perform an appropriate evaluation and provide the information the surgeon needs.

Every ophthalmologist needs to be familiar with the basics of specimen handling in order to provide optimal patient care.

S.L. DeMartelaere (B)

Ophthalmology Service, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA

e-mail: sheri.l.demartelaere@us.army.mil

Oncology Series 6, DOI 10.1007/978-1-4419-0374-7_11,

C Springer Science+Business Media, LLC 2011

11.2 Communication with the Pathologist

The cornerstone of proper specimen handling is communication between the ophthalmologist and the pathologist before, during, and after surgery. Before surgery, this communication may involve simply filling out the specimen-processing form with the patient’s age, clinical history, clinical diagnosis, and lesion location or may involve speaking with the pathologist to discuss the proper tissue medium so that the appropriate studies can be obtained.

Intraoperatively, the pathologist needs to know what question the surgeon is asking. If fresh tissue is submitted, is the reason that the surgeon wants to know if the margins are clear or that the surgeon wants to determine if sufficient diagnostic tissue has been submitted? Or perhaps the tissue is being sent for special studies such as flow cytometry analysis of a suspected lymphoproliferative lesion. Do special stains need to be done to look for microorganisms? If the ophthalmologist suspects that a patient has sebaceous gland carcinoma, the Oil Red O fat stain can be used to highlight sebocytes.

Tumors in the periocular region present unique challenges for the surgeon and the pathologist. Frequently, one is trying to spare critical tissue such as the canalicular system or limbal stem cells, and thus the surgical specimens are small. If specimen tissue is limited, the pathologist needs to know which clinical diagnoses are most critical to establish or rule out so that the most pertinent diagnostic studies are performed.

Open communication with the pathologist during surgery may be necessary. It is useful to have the pathologist come to the operating room for precise specimen orientation prior to specimen removal. If this is not done, the surgeon should take the specimen to the pathologist and orient the margins of interest. This type of interaction can help the pathologist determine whether to use an en face technique or serial perpendicular sectioning of the specimen to ensure that the critical margins are tumor free [3]. The surgeon needs to consider intraoperative technique to minimize manipulation of the tissue and thereby minimize crush artifact and tissue desiccation.

Postoperatively, the surgeon and the pathologist need to continue to work together. It is not uncommon for a lesion that the surgeon considers to be clinically benign to be revealed to be malignant upon histopathologic examination. For example, what appears to be a common eyelid chalazion can turn out to be a rare tumor such as an angiosarcoma, Merkel cell carcinoma, or sebaceous gland carcinoma [4]. For this reason, it is highly recommended that all chalazion specimens be submitted for histopathologic examination and reviewed by an ocular pathologist— particularly if a chalazion has recurred after incision and curettage [5]. Surgeons need to follow up on all specimen results and keep the pathologist apprised of any supportive clinical or laboratory information that might aid in the diagnosis of a difficult case. Often this ongoing communication is facilitated by a monthly tumor board conference.

The basic steps in proper surgical specimen handling are outlined in Table 11.1.

Table 11.1 Checklist for proper surgical specimen handling

Routine specimens

Preoperative

Complete pathology request form

Patient age, sex, history of present illness, previous biopsy

Location of lesion

Clinical diagnosis

Intraoperative

Generally, use 10% neutral buffered formalin (at least five times the volume of biopsy specimen) as fixative

Place each specimen in separate formalin-filled container

Label container(s) with patient-identifying information and biopsy location Include sketch of biopsy location to facilitate orientation by pathologist Postoperative

Follow-up to find out diagnosis (seemingly benign lesions may turn out to be malignant and seemingly negative margins may turn out to be positive)

Communicate with pathologist about controversial findings

Fresh specimens

Preoperative

Explain to pathologist why fresh tissue is being submitted Complete pathology request form

Patient age, sex, history of present illness, previous biopsy Location of lesion

Clinical diagnosis

Reason for submitting fresh specimen [margin evaluation, diagnosis, determination of adequacy of tissue specimen, special studies (e.g., flow cytometry when a lymphoproliferative lesion is suspected)]

Assure whether correct fixative is available Intraoperative

Lay out specimen on sketch labeled for orientation

Place suture or ink specimen to assist pathologist with orientation

Hand-deliver tissue to pathologist as quickly as possible

Ink margins with pathologist

Await results and submit more fresh tissue if indicated

Postoperative

Follow-up to find out diagnosis

Communicate with pathologist about controversial findings

11.3 Conjunctival Specimens

Conjunctival tissue presents unique specimen handling challenges. First and most important of these challenges is the tissue’s propensity to curl up on itself, making it difficult to maintain proper tissue orientation and alignment. Second, the surgeon often wishes to preserve as much normal tissue as possible, and thus margins of normal tissue surrounding a conjunctival tumor are frequently measured in millimeters. These two factors together can result in small specimens with curled-up edges that make it difficult for the pathologist to orient the specimen, assess the margins, and provide the surgeon with meaningful data.

142 S.L. DeMartelaere et al.

Proper specimen handling can help alleviate these difficulties. Intraoperatively, conjunctival specimens can be flattened out on a piece of nonadherent dressing such as Telfa. It is important not to place conjunctival specimens on sponges, which expand in fixative and distort the specimen. For orientation, surgical sutures are preferred to methylene blue or toluidine blue ink, which tend to spread out into the tissue. Ideally, the surgical site is sketched on the nonadherent dressing, and then the specimen is laid out in the correct orientation on the sketch (Fig. 11.1). This visual guide, a simple supplement to the specimen-processing paperwork, is very effective for specimen orientation.

Laying out the specimen also aids the pathologist in sectioning the specimen perpendicularly and avoiding tangential cuts. This is critical for assessing tumor invasion and tumor thickness [6]. In the specimen shown in Fig. 11.2, tangential cutting made it impossible to determine whether there had been invasion below the basement membrane and thus impossible to differentiate between invasive squamous cell carcinoma and in situ disease. In the specimen shown in Fig. 11.3, tangential sectioning of a melanoma made it impossible to appropriately assess the tumor thickness. In melanoma, tumor thickness is the most important prognostic factor, and its correct assessment is critical for patient care, as sentinel lymph node biopsy may be recommended for tumors with thickness greater than a certain Breslow-equivalent thickness (Fig. 11.4) [7].

After the specimen is received in the pathology department, it is of paramount importance that processing occurs rapidly to minimize tissue drying. The decision whether to use en face technique or serial perpendicular sectioning depends on the size of the specimen and the particulars of the case as discussed with the surgeon, emphasizing the importance of communication between the surgeon and the pathologist.

Frozen section analysis is not recommended for melanocytic conjunctival lesions. As previously mentioned, the pathologist dealing with a conjunctival

Fig. 11.1 Surgical conjunctival specimen, involving both the palpebral and the bulbar conjunctiva, placed on Telfa with a drawing of the area of resection for orientation. Photo courtesy of Dr. Bita Esmaeli

Fig. 11.2 Tangentially sectioned conjunctival biopsy specimen. It was not possible to assess whether the specimen represented carcinoma in situ or invasive squamous cell carcinoma

Fig. 11.3 Tangentially sectioned conjunctival biopsy specimen. It was not possible to assess whether the specimen represented primary acquired melanosis or melanoma

Fig. 11.4 Perpendicularly sectioned conjunctival melanoma specimen, allowing for measurement of tumor thickness

specimen is already challenged by the limited tissue and the difficulty of obliquely sectioning the tissue because of its contractile properties. An even more significant consideration is the difficulty of interpreting melanocytic cells with frozen section technique [8]. Most surgeons and pathologists would agree that permanent section technique is the gold standard for ensuring margin control for conjunctival or eyelid melanomas [9].