PATHOLOGY GROSSING STEPS

1. GROSSING OF
PENECTOMY SPECIMEN
 PRESENTOR-DR.SURUCHI GAIKWAD
 GOVERNMENT CANCER
HOSPITAL,AURANGABAD

2. DISCUSSION-
 ANATOMY
 ORIENTATION OF SPECIMEN
 HISTOLOGY OF PENIS
 GROSSING STEPS
 GROSSING DISCRIPTION
 SECTIONSTO BE SUBMITTED
 STAGING

6. Anatomical structers-
Penis is Suspended from front and sides
of pubic arch, contains majority of
urethra
 There are 3 main parts: proximal
root, middle body (corpus or shaft)
and the distal glans (head)
 Orientation: the upper surface is
termed dorsal, the undersurface is
termed ventral
 Penile shaft / middle body
 Composed of three cylindrical masses
of cavernous erectile tissue
(specialized venous sinuses of variable
diameter and widely interconnected)
bound together by fibrous tunica
albuginea

7. Parts of penis

8. ROOT OF PENIS
 Is Most Proximal Fixed Part
Of Penis
 It Is Located InThe
Superficial Perineal Pouch
OfThe Pelvic Floor
 The Root Contains Three
ErectileTissue [2 Crura And
Bulb Of Penis ] And 2
Muscles Ischiocavernosus
And Bulbospongiosus

9. Shaft/BODY
:
 The Free Part Of Penis Is Located In
Between Root And Glans
 It Is Suspended From Pubic Symphysis
 It is made up of 3 cylindrical erectile
tissue
 Corpora cavernosa:
Two lateral masses of erectile tissue that
form bulk of penis;
 Its posterior portions are called crura and
connect to pubic arch
 Which is covered by tough fibroelastic
coat called tunica albuginea
 On dorsal aspect of corpora cavernosa
deep dorsal vein and paired dorsal
arteries and branches of dorsal nerves are
conttained within deep penile fascia

10.  Corpus spongiosum:
Median mass of
erectile tissue that
contains most of
urethra and is lies
ventrally and is
continues distally to
form bulbous
expansion termed as
glans penis or head of
the penis.

11. Distal penis
 It is conical in shape and is
formed by distal expansion
of corpus spongiosum
 Glans:
 Conical cup covering distal end
of penile shaft
 Portion distal to coronal sulcus
 Layers are squamous
epithelium, lamina propria,
corpus spongiosum, tunica
albuginea and corpora
cavernosa


12. 
Dartos layer:[superfacial fascia]
Smooth discontinuous muscle layer
extending from homologous scrotal
layer
 Extends throughout entire shaft
between dermis and penile fascia
 Penile (Buck) fascia:
 [ deep fascia]
Loose connective tissue located
between dartos layer of the shaft
and tunica albuginea
 Extends from penile root to coronal
sulcus
 Contents are small blood vessels,
penile dorsal veins, nerve bundles
and adipocytes
skin
Superficial fascia
Tunica albugianea
Buck’s fascia

13. 
Tunica albuginea:
Dense fibrous membrane
covering and separating
dorsal corpora cavernosa
and ventral corpus
spongiosum
 Extends from penile root
to tips of corpora
cavernosa
 It consists of outer
longitudinal &inner
circular muscle fibres


14.  Coronal sulcus:
 Narrow and circumferential cul de
sac (in noncircumcised) behind glans
corona;
 Is area of insertion of dartos layer and
Buck fascia
 Glans coronal:
At base of glans, slightly elevated
circumferential rim
 Frenulum:
Fibrous band of tissue attaching
foreskin to ventral glans


15.  Meatus urethralis:
 Urethral opening
 Usually at central ventral glans
penis
 Vertical cleft, related to
frenulum

Fossa navicularis:
 Terminal dilated portion of
penile urethra, contains
stratified, nonkeratinized and
squamous epithelium


16.  Male urethra:
Divided into 3 portions:
 prostatic urethra (proximal, surrounded by
prostate, contains urothelium),
 membranous urethra (from lower pole of
prostate to bulb of corpus spongiosum,
stratified columnar or pseudostratified
columnar epithelium) and
 penile / distal urethra (passes through corpus
spongiosum, lined by stratified columnar or
pseudostratified with stratified squamous
epithelium distally)
 Penile urethra contains plasma cells,T
lymphocytes and macrophages; epithelium
contains IgA secretory component and
dendritic cells; protect against ascending
infections

17.  Foreskin/prepuce:
 Skin folded on itself
covering the glans (clitoris
in females)
 In normal males, long
foreskins cover the meatus
and glans is not visible
 Layers are outer to inner
side –1.skin [epidermis
&dermis ],
 2. dartos layer
 3. lamina propria
 4.squamous epithelium of
the mucosal surface ,

18. Surgical Pathology
Specimens: Clinical Aspects
 Biopsy Specimens
 Specimens are punch biopsies
 For Macules, papules, nodules, and ulcers from the
glans are biopsied to exclude neoplasia or confi m
the diagnosis particularly if these lesions have been
long-standing.
 Circumcision specimens consisting of the foreskin
are removed more often in the context of benign
penile conditions (phimosis paraphimosis).

19.  Occasionally a small cancer is removed in this
fashion, and margins in this case will be
important
 For carcinoma in situ of the glans with or
without adjacent skin involvementWide local
excision with circumcision may be adequate
therapy for control of lesions limited to the
foreskin.


20.  Whether the amputation is partial, total, or
radical will depend on the extent and location
of the neoplasm.
 Radiation therapy with surgical salvage is an
alternative approach.
 There is no standard treatment which is
curative for stage IV penile cancer.
 Therapy is directed at palliation, which may be
achieved either with surgery or radiation
therapy.

21. Glansectomy
 This procedure involves removing the foreskin
and glans
 although is not commonly performed,
 is indicated for localized tumors and carcinoma
in situ of the glans.
 There is a higher risk of incomplete removal
and therefore tumor recurrence.

22. Partial Penectomy
 Successful local control by partial penectomy
depends on division of the penis 2 cm proximal
to the gross tumor extent.

23. Total Penectomy
 If the size/site precludes partial penectomy,
then as part of penile amputation the proximal
urethra is dissected and transposed to the
perineum with an indwelling catheter placed
for an adequate urinary stream.

24. Radical Surgery
 T his is rarely performed but involves
penectomy including removal of the scrotum,
testes, spermatic cords, and ilioinguinal lymph
node dissection.

25. Resection Specimens
 The goal of treatment in invasive penile carcinoma is
complete excision with adequate margins.
 For lesions involving the prepuce, this may be
accomplished with simple circumcision.
 For infiltrating tumors of the glans, with or without
involvement of the adjacent skin, the choice of therapy is
dictated by tumor size, extent of infiltration, and degree
of tumor destruction of normal tissue.The options
include penile amputation (partial or total penectomy)
and irradiation.
 Stage I and II penile cancer is most frequently managed
by penile amputation for local control.

26. GROSS discription
record the dimensions of the entire specimen and the
dimensions of each of its individual components (i.e.,
foreskin, glans, and shaft).
 Tumor Site- (urethral meatus/glans/prepuce/coronal
sulcus/shaft – dorsal, ventral, lateral)
 Single/multifocal
 Appearance -(verrucous/warty/exophytic/ –
sessile/ulcerated)
 Foreskin- Ulcerated/thickened/papule/warty
 Glans -Erythematous/ulcerated/macule/papule/ –
warty
 Others- scars of previous surgery/biopsy

27.  Examine the cut surfaces of the
specimen. Locate and describe the
appearance of the penile urethra
and the four anatomic levels of the
glans.
 [1 ]the epithelium, the flat less than
1 mm layer of epithelium covering
the surface of the glans;
 (2) the lamina propria, the
approximately 2 mm thick layer of
loose connective tissue beneath the
epithelium;
 [3]the corpus spongiosum (grossly
reddish, spongy tissue located
between the lamina propria and the
tunica albuginea) surrounding the
distal urethra; and
 (4)the corpora cavernosa (spongy
reddish brown tissue encased in a
band of firm white tissue, the tunica
albuginea).

28.  Depending on the size of penectomy, make
parallel slices to central slice.[bread loafing]
 Identify clearly the deepest point of invasion of
tumour.
 6. Document the extent of corpus spongiosum
(pT2), corpora cavernosae (pT3) with or
without urethral involvement by tumour.
 7 . Measure the distance of proximal resected
margin from the tumour.(including already
taken cut margin)
 look for any satellite/skip metastasis within
shaft.

29. Surgical Pathology Specimens:
Biopsy Specimens
 Diagnostic punch and incisional
biopsies : Count, measure (mm),
process intact, and cut through three
levels.
 PAS stain for fungi if suspected.
 Elliptical excisions : Measure (mm), ink
the deep and lateral (circumferential)
margins, and cut into multiple
transverse serial slices.

30. Foreskin Foreskins removed from
infants are usually not
submitted to the surgical
pathology laboratory for
examination.
 If you do receive one of these
specimens, measure it,
describe its appearance, and
submit a section for
histologic evaluation.
 Foreskins removed from
older patients are routinely
submitted for evaluation,
because they are more likely
to harbor pathology.

31.  Ink the epithelial margin, and
carefully inspect the surfaces of
the specimen. Record the number,
size, location, and appearance of
any lesions. .
 Ideally pin the four corners of the
specimen with the mucosa
oriented on one side and the skin
on the other.
 Even if no lesions are appreciated
on gross inspection, liberally
sample foreskins removed from
adults to look for early neoplastic
changes.

32.  Use perpendicular
sections so that the
epithelial margin is
included in the sections.
When a neoplasm is
suspected, each quadrant
of the epithelial margin
should be sampled.
 More extensive sampling
may be necessary if a
visible lesion is large or if
the lesion approaches the
margin at several sites

33. GLANCECTOMY
Bread loafing is done
Cut three to six serial
sections, 2–3 mm in
width from each half..
. Respective site
sections are to be
given

34. PARTIAL PENECTOMY
 Size - Distances (cm) from the urethral and
surgical resection margins I
 Identify the shaft and glans.
 If the foreskin is affected by tumor, do not
remove. Ideal sectioning is longitudinal,
centered along the urethra, with additional
parallel sections on both sides.
 Shaft margin: usually a large specimen Divide it
in two, from dorsal to ventral along the central
septum, and submit the cut surface entirely.
 With a probe as a guide, the urethra is opened
along the ventral aspect where it is closest to the
surface and the cut is then continued to bisect
the penis.
 Each half should be labeled left or right. If the
specimen has a long shaft, cut two or three
additional sections distal to the margin.
 Examination of the cut surface of the glans
represents the best approach for surgical
pathology evaluation.

35. PENECTOMY:
 1. Mention the type of specimen (total or
partial).
 2. Measure the length of penectomy
specimen.
 3 . Ink the proximal cut margin completely
.
 Begin the dissection by taking a shave
section from the penile shaft at the
amputation site.This section represents
the only margin.
 If this section is large, divide it into two or
three sections separately cut margin and
spongiosum with urethra and periurethral
tissue cut margin
 With anterior meatus as guide, gently
pass a probe carefully (do not force it) and
cut through the whole specimen into right
and left halves

36.  Bread-loaf the shaft perpendicular to its
long axis.
 Begin at the proximal end of the
specimen, and stop 1 to 2 cm from the
corona.
 Next, serially section the distal penis
parallel to its long axis.
 The first of these parallel longitudinal
sections should bisect the proximal
penis into equal halves midline through
the urethra.
 This is not a difficult section if you first
use scissors toopen the urethra at the 6-
o’clock position (i.e., midventral plane),
 and then insert a knife into the opened
urethra to complete the longitudinal
section.
 Serially section the rest of the glans
parallel to this initial midline cut in the
sagittal plane.

37.  8.Take following sections:
 a.Tumour with glans, coronal sulcus and shaft ,
both on left and right halves
 b.Tumour with the deepest point of invasion
for microscopic confirmation of depth and
compartment of deepest infiltration
 C.Tumour with urethra
 d. Skin, corporal and urethra

38. Blocks for histology
 -Shave section from the shaft margin (including skin, erectile
bodies, and urethra).
 Samples of foreskin to include associated conditions.
 Sample four sections of tumor to demonstrate depth of
invasion and relationships to the adjacent surface epithelium,
corpora cavernosa, corpus spongiosum, and urethra.
 Sample two to three transverse sections through the shaft at
different levels.
 Sample longitudinal sections through the glans to include
the urethra.
 In larger specimens, it is important to submit two to three
additional sections of the more distal urethral cylinder to
ensure adequacy of the resection margin.
 Count and sample all lymph nodes accompanying the
specimen.

39. HISTOLOGY OF PENIS:

40. CORPORA SPONGIOSUM PENILE URETHRA

41. CORPORA CAVERNOSA

42. GLANS:-

43. HISTOLOGY OF GLANS

44. Histopathology report :
 Tumor site (urethra, foreskin, glans, shaft)
 Tumor size and depth (mm)
 Patterns of growth and histological type
 Tumor grade (well, moderately, poorly
differentiated, or verrucous)
 Tumor extension: corpus spongiosum, corpus
cavernosum, urethra, tunica albuginea.
 In situ component (present/absent/extent
multifocal)

45.  Lymphovascular space invasion (present/
absent).
 Perineural space invasion (present/absent).
 Regional lymph nodes-
 These are the superficial and deep inguinal
nodes and the pelvic node

46. TNM Staging [2017 8th edition
 pT0 - No evidence of primary tumor
 PTis - Carcinoma in situ [PeIN]
 pTa- Noninvasive verrucous carcinoma
 pT1- Invades lamina propria
 pT1a -without lymphovascular invasion
and is not poorly differentiated
 pT1b -with lymphovascular invasion and
or perineural invasion is poorly
differentiated
 pT2 Tumor invades corpus spongiosum
ONLY with or without urethra invasion
 pT3 Tumor invades corpora cavernosa
[including tunica albuginea] with or
without urethra invasion
 pT4 Tumor invades other adjacent
structures[scrotum,prostate and bone]

47.  pN0 No regional lymph node metastasis
 pN1 Metastasis in a single inguinal lymph node
pN2 Metastasis in multiple or bilateral inguinal
lymph nodes
 pN3 Extranodal extension of lymph node
metastasis or pelvic lymph node(s) unilateral or
bilateral

48. Important Issues to Address in Your
Surgical Pathology Report on
Penectomies
 •What procedure was performed
 and what structures/organs are present?
 • Is a neoplasm present?
 •Where is the tumor located (e.g., foreskin,
glans, shaft, and/or urethra)?
 • Is the tumor in situ or infiltrating?
 What are the histologic type and grade of the
tumor?

49.  •What is the size of the tumor, and how deeply
(in millimeters) does the tumor infiltrate the
penis?
 • Is vascular invasion identified? •
 What deep structures does the tumor involve
(e.g., lamina propria, corpus spongiosum,
corpora cavernosa, urethra, prostate, adjacent
structures)?
 • Are the resection margins free of tumor? •
 Does the non-neoplastic portion of the penis
show any pathology?