Spleen
Three
elements are essential for the thorough dissection of the spleen: (1) Be
familiar with the patient’s clinical history. The dissection of a spleen
removed for trauma is very different from the dissection of a spleen removed
for a hemato-poietic malignancy. (2) Remember that fresh tis-sue for
immunophenotypic and genetic studies may be necessary to classify hematopoietic
neo-plasms involving the spleen. (3) Sections of the spleen for histology need
to be very thinly sliced and well fixed.
Once
resected, the spleen should immediately be brought fresh to the surgical
pathology labora-tory. The spleen should then be weighed and measured. Next,
examine the appearance of the splenic capsule. This step is particularly
im-portant in cases of trauma. In particular, docu-ment whether the capsule is
intact or lacerated, and if it is tense or wrinkled. Next, examine splenic
hilum for lymph nodes. If any are found, they should be removed and a
representative section of each submitted for histology.
Section
the spleen in whichever plane you want, just make sure to section it thinly.
Use a long sharp blade to cut the spleen into 2- to 3-mm slices. Examine both
sides of each slice for any lesions. Carefully document both the white and red
pulp. Expansion of the white pulp gives the cut surface the appearance of white
nodules on a red background, while expansion of the red pulp gives the cut
surface of the spleen a diffuse red appearance. This step is important because
some diseases, such as non-Hodgkin’s lym-phoma, preferentially involve the
white pulp,while others, such as Gaucher’s disease, myelo-proliferative
disorders, and hairy cell leukemia, preferentially involve the red pulp. If
nodules are present, count the number of discrete nodules. If the spleen was
removed for trauma and if no nodules are found, submit two to four sections of
the splenic parenchyma, including a section to demonstrate any parenchymal
hemorrhage.
If
nodules are present, or if the spleen was removed for a hematopoietic
malignancy, then the rest of the approach to the spleen should now follow the
approach taken for lymph nodes with suspected hematopoietic malignancies.
First, prepare touch imprints. Take touch imprints from any discrete nodules.
Before preparing these imprints, remove excess blood by blotting the surface of
the spleen with a towel. Prepare at least five air-dried and two 95%
alcohol-fixed slides.
Next,
submit fresh tissue for immunopheno-typing. Although the exact techniques vary
among laboratories, in general, a representative section should be snap-frozen
in optimal controlled temperature embedding medium for frozen tis-sue specimens
(OCT) for immunohistochemical studies, and a separate 0.5- to 0.7-cm cube
should be submitted fresh for flow cytometry. Fresh tissue should also be sent
for genetic studies such as gene rearrangements and karyotyping; and if
clinically indicated, fresh sterile tissue should be submitted for
microbiologic studies. If multiple dramatically distinct nodules are pre-sent,
each type should be separately submitted for these ancillary studies.
Next,
tissue should be submitted for light mi-croscopy. Submit thin sections so that
they can fix well, and submit at least one section representing each type of
lesion seen and one section that in-cludes the splenic capsule. It is not
necessary, and in fact not desired, for sections to fill the tissue cassette
completely. If multiple small nodules are present, submit two to four representative
sections. If both large and small nodules are seen, each must be represented in
sampling. If the spleen is enlarged but no lesions are noted, three to four
sections are sufficient. As was true for lymph nodes, at least one section
should be fixed in B-5 or an equivalent fixative. (If you do submit a section
in B-5, remember to notify your tissue processing laboratory because these
sections re-quire special processing.) If a storage disease is suspected,
tissue should also be fixed in glutaral-dehyde for possible electron
microscopy.
• What procedure was performed, and what
structures/organs are present?
• What is the weight of the spleen?
• Is the white pulp architecture normal,
more prominent than usual, or obscured (as by a diffuse red pulp infiltrate)?
• In the case of splenic trauma, is the
capsule torn, and how much intraparenchymal hemorrhage is present?
• In the case of hematopoietic neoplasm,
what type and grade of neoplasm is present, and how many discrete neoplastic
nodules are pres-ent? Does the neoplasm involve the lymph nodes in the splenic
hilum?
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