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Surgical pathology
Surgical pathology
Surgical pathology
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Malignant melanoma of the skin. This is as it would appear on the patient.
Malignant melanoma of the skin. This is a section of tissue, stained with hematoxylin & eosin, and viewed on a microscope slide.

Surgical pathology is the most significant and time-consuming area of practice for most anatomical pathologists. Surgical pathology involves gross and microscopic examination of surgical specimens, as well as biopsies submitted by surgeons and non-surgeons such as general internists, medical subspecialists, dermatologists, and interventional radiologists.

The practice of surgical pathology allows for definitive diagnosis of disease (or lack thereof) in any case where tissue is surgically removed from a patient. This is usually performed by a combination of gross (i.e., macroscopic) and histologic (i.e., microscopic) examination of the tissue, and may involve evaluations of molecular properties of the tissue by immunohistochemistry or other laboratory tests.

Specimens

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There are two major types of specimens submitted for surgical pathology analysis: biopsies and surgical resections.[1]

A biopsy is a small piece of tissue removed primarily for the purposes of surgical pathology analysis, most often in order to render a definitive diagnosis. Types of biopsies include core biopsies, which are obtained through the use of large-bore needles, sometimes under the guidance of radiological techniques such as ultrasound, CT scan, or magnetic resonance imaging. Core biopsies, which preserve tissue architecture, should not be confused with fine-needle aspiration specimens, which are analyzed using cytopathology techniques. Incisional biopsies are obtained through diagnostic surgical procedures that remove part of a suspicious lesion, whereas excisional biopsies remove the entire lesion and are similar to therapeutic surgical resections. Excisional biopsies of skin lesions and gastrointestinal polyps are very common. The pathologist's interpretation of a biopsy is critical to establishing the diagnosis of a benign or malignant tumor, and can differentiate between different types and grades of cancer, as well as determining the activity of specific molecular pathways in the tumor. This information is important for estimating the patient's prognosis and for choosing the best treatment to administer. Biopsies are also used to diagnose diseases other than cancer, including inflammatory, infectious, or idiopathic diseases of the skin and gastrointestinal tract, to name only a few.

Surgical resection specimens are obtained by the therapeutic surgical removal of an entire diseased area or organ (and occasionally multiple organs). These procedures are often intended as definitive surgical treatment of a disease in which the diagnosis is already known or strongly suspected. However, pathological analysis of these specimens is critically important in confirming the previous diagnosis, staging the extent of malignant disease, establishing whether or not the entire diseased area was removed (a process called "determination of the surgical margin", often using frozen section), identifying the presence of unsuspected concurrent diseases, and providing information for postoperative treatment, such as adjuvant chemotherapy in the case of cancer.

In the determination of surgical margin of a surgical resection, one can use the bread loafing technique, or CCPDMA. A special type of CCPDMA is named after a general surgeon, or the Mohs surgery method.

Workflow

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Subspecialties

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Histologic slide demonstrating viral myocarditis, an infection of the heart muscle

Many pathologists seek fellowship-level training, or otherwise pursue expertise in a focused area of surgical pathology. Subspecialization is particularly prevalent in the academic setting, where pathologists may specialise in an area of diagnostic surgical pathology that is relevant to their research, but is becoming increasingly prevalent in private practice as well. Subspecialization has a number of benefits, such as allowing for increased experience and skill at interpreting challenging cases, as well as development of a closer working relationship between the pathologist and clinicians within a subspecialty area. Commonly recognized subspecialties of surgical pathology include the following:

See also

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Notes and references

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Bibliography

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Revisions and contributorsEdit on WikipediaRead on Wikipedia

Surgical pathology

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Surgical pathology is a of anatomic that involves the gross (macroscopic) and microscopic examination of tissue specimens removed from patients during surgical procedures, biopsies, or other invasive interventions to diseases, determine their extent, and guide treatment decisions. This discipline is essential for identifying pathological changes in tissues, such as tumors, infections, or inflammatory conditions, and plays a pivotal role in by characterizing malignancies to inform and therapeutic strategies. The practice of surgical pathology requires pathologists to possess broad expertise across various organ systems and processes, handling a diverse array of specimens from specialties like , gynecology, and orthopedics. Key procedures include preparing tissue sections for histological , performing intraoperative frozen sections for real-time surgical guidance, and employing ancillary techniques such as special stains, , and molecular testing to enhance diagnostic accuracy. Pathologists typically review 30 to 80 cases per day in high-volume settings, contributing to the generation of reports that directly influence patient care and multidisciplinary team discussions. Historically, surgical pathology emerged in the late alongside advances in antisepsis, , and , evolving from autopsy-based studies to a focused discipline aiding living patients. Milestones include William Henry Welch's first frozen section in 1891 at and Louis B. Wilson's refinements in 1905 at the , which standardized intraoperative consultations. Influential figures such as James Ewing, who advanced tumor classification, and Arthur Purdy , a pioneer in soft tissue pathology training, shaped its development into a cornerstone of modern medicine. Today, it integrates cutting-edge technologies like and to support precision medicine, particularly in cancer diagnostics.

Overview

Definition and Scope

Surgical pathology is a of anatomic dedicated to the macroscopic and microscopic examination of tissues removed from living patients during surgical procedures to diagnose a wide range of diseases, with a primary focus on neoplasms, infections, and inflammatory conditions. This discipline relies on the analysis of surgical specimens, such as biopsies and resections, to provide precise characterizations of pathological processes that inform clinical management. Unlike autopsy pathology, which involves post-mortem examination of organs and tissues to investigate causes of death, surgical pathology centers exclusively on specimens from living individuals to support immediate therapeutic decisions. In contrast to , which encompasses laboratory-based testing of body fluids, , and for evaluation, surgical pathology emphasizes direct tissue evaluation to establish definitive diagnoses. These distinctions highlight surgical pathology's pivotal role in bridging surgical intervention with histopathological insights for patient care. The scope of surgical pathology includes providing intraoperative consultations, notably through frozen section analysis, where tissue is rapidly processed and examined to offer real-time guidance to surgeons on margins, lesion nature, or unexpected findings during operations. Beyond these urgent assessments, it extends to comprehensive evaluations of permanent specimens for definitive diagnoses, often integrating gross morphology, , and to classify diseases accurately. Surgical pathologists routinely collaborate with surgeons and oncologists, correlating pathological results with clinical to refine treatment strategies and predict outcomes. Key concepts in surgical pathology revolve around tissue-based , where morphological features are meticulously correlated with patient history to ensure diagnostic accuracy and relevance. This approach profoundly influences patient care, particularly in , by enabling according to the TNM system, which assesses tumor size (T), nodal involvement (N), and (M) to guide prognosis and therapy selection. Such evaluations underscore the discipline's essential contribution to , directly impacting decisions on , , and .

Historical Development

Surgical pathology emerged in the as a discipline rooted in advancements in and cellular theory, pioneered by , who in 1858 published Cellular Pathology, establishing the foundational principle that diseases arise from abnormalities in cells and tissues, thereby shifting pathology from gross anatomy to microscopic tissue diagnosis. 's work at the Hospital in emphasized systematic examination of surgical specimens to correlate microscopic findings with clinical outcomes, laying the groundwork for tissue-based diagnostics. His student, Julius Cohnheim, further advanced the field in the 1860s and 1870s through studies on and tumor growth, introducing techniques like the freezing of fresh tissues for rapid microscopic analysis and demonstrating cellular migration in , which enhanced the precision of intraoperative assessments. A pivotal milestone occurred in 1891 when William Henry Welch performed the first frozen section at . In 1905, Louis B. Wilson at the refined and standardized the frozen section technique, enabling pathologists to provide rapid intraoperative diagnoses by freezing and sectioning fresh surgical specimens within minutes, a method that revolutionized surgical decision-making and reduced operative risks. Influential figures like James Ewing, who advanced tumor classification, and Arthur Purdy Stout, a pioneer in soft tissue pathology training, further shaped the discipline. Following , standardization efforts accelerated with the founding of the (CAP) in 1947, which promoted uniform laboratory practices, quality assurance, and accreditation for pathology services, including surgical specimen handling. Concurrently, the (WHO) began developing its tumor classification system in the 1950s, with initial handbooks published in the 1960s, providing internationally accepted criteria for tumor diagnosis that integrated histological features and facilitated consistent reporting in surgical pathology. Immunohistochemistry (IHC), first introduced in the 1940s with techniques and advanced in the 1960s with enzyme-based methods, marked a transformation in the by using antibody-based to detect specific proteins in tissue sections, which transformed diagnostic accuracy by allowing differentiation of tumors based on molecular markers beyond routine . By the 1990s, technologies, including whole-slide scanners and telepathology systems, enabled the capture and remote sharing of high-resolution tissue images, improving consultation efficiency and paving the way for computational analysis in surgical pathology workflows. In the 2020s, (AI) has integrated into diagnostics, with tools like AI-assisted image analysis achieving FDA approvals for tasks such as tumor detection and quantification, enhancing speed and reproducibility while supporting multimodal data integration from , genetics, and clinical records. This evolution has shifted surgical pathology from primarily descriptive to a comprehensive, precision-oriented discipline that informs personalized patient care.

Specimen Acquisition and Preparation

Types of Specimens

Surgical pathology specimens are broadly categorized into biopsies, resections, and cytological samples obtained during surgical procedures, each serving distinct diagnostic, therapeutic, or staging purposes. Biopsies involve the removal of small tissue samples to evaluate suspicious lesions, while resections encompass larger excisions for treatment and comprehensive assessment. Cytological specimens, though primarily cellular rather than tissue-based, are integral in intraoperative contexts for rapid evaluation. These specimens originate from diverse anatomical sites, including skin, organs, and lymph nodes, and are indicated for confirming malignancies, assessing margins, or determining disease extent. Biopsy specimens represent the most common type submitted for initial diagnostic evaluation of potential abnormalities. Core needle biopsies are acquired via a large-bore needle, often under imaging guidance such as or CT, to obtain cylindrical tissue cores from internal structures like the or liver, indicated for diagnosing masses without full excision. Incisional biopsies remove only a portion of a using a , suitable for large tumors where complete removal is impractical, allowing assessment of tissue architecture in conditions like soft tissue sarcomas. Excisional biopsies entail the full removal of the suspected along with a margin of surrounding tissue, commonly performed for smaller tumors such as suspected melanomas to both diagnose and treat. In , punch biopsies employ a circular tool to extract deeper samples, ideal for evaluating inflammatory or neoplastic dermatoses. These biopsy types are primarily diagnostic, targeting suspicious masses to guide further management. Resection specimens involve the surgical removal of larger tissue volumes, often entire organs or significant portions, for therapeutic intent with integrated pathological analysis. Partial resections, such as lumpectomies in , excise the tumor and adjacent tissue to achieve clear margins while preserving organ function. Complete resections, exemplified by for advanced breast carcinoma, remove the entire affected organ, enabling thorough staging and margin evaluation. In gastrointestinal pathology, specimens from colorectal tumor resections provide material for assessing tumor invasion depth and involvement. These specimens support both therapeutic goals, like margin assessment to prevent recurrence, and staging to inform . Cytological specimens in surgical pathology contexts primarily consist of fine-needle aspirations (FNAs) performed intraoperatively or periprocedurally to sample cellular material from masses or fluids. FNAs use a thin needle and to extract cells from palpable lesions, such as nodules or breast lumps, often under guidance, providing rapid cytological to influence surgical decisions. These are indicated for initial evaluation of suspicious masses or to confirm in accessible sites. Specialized specimens include sentinel lymph nodes, which are the first nodes in the lymphatic drainage pathway from a , biopsied to stage malignancies like or by detecting early . In , sentinel node biopsy identifies nodal involvement without full axillary dissection, guiding treatment escalation. Similarly, endoscopic biopsies from the yield multiple small mucosal samples during procedures like , indicated for diagnosing or colorectal polyps. These targeted specimens enhance precision in staging and therapeutic planning for specific cancers.

Handling, Fixation, and Processing

Upon receipt from the operating room, surgical pathology specimens must be handled promptly to minimize autolysis and degradation. Specimens should be transported fresh to the as soon as possible in a leak-proof , without fixative, to allow for gross examination and appropriate fixation thereafter. The standard fixative is 10% neutral buffered formalin, applied at a volume ratio of at least 10:1 (fixative to tissue), ensuring the specimen is fully submerged to facilitate uniform penetration. Cold ischemia time—the interval from excision to fixation—should be limited to less than 60 minutes to preserve tissue integrity for accurate diagnosis, as recommended by ASCO/ guidelines. Fixation involves chemical preservation through cross-linking of proteins by , forming methylene bridges that stabilize cellular structures and prevent postmortem decay. The process begins rapidly upon immersion in 10% neutral buffered formalin (equivalent to 4% ), with initial cross-linking completing within 24 hours for specimens up to 20 mm thick at . Duration varies by specimen size: small biopsies require 6-24 hours, while larger resections need 24-48 hours for adequate penetration, though prolonged fixation beyond 72 hours can reduce antigenicity for ancillary tests like . Under-fixation risks artifactual distortion, whereas over-fixation may harden tissues, complicating sectioning. Following fixation, tissue processing prepares specimens for microscopic evaluation through a series of automated or manual steps. Dehydration removes water by sequential immersion in graded ethanol solutions (70% to 100%), typically over 2-4 hours, to render the tissue compatible with non-aqueous agents. Clearing then replaces ethanol with a solvent like xylene, which matches the refractive index of dehydrated tissue and facilitates paraffin infiltration, lasting 1-3 hours depending on tissue volume. Infiltration embeds the cleared tissue in molten paraffin wax at 55-63°C, followed by cooling to form solid blocks. Finally, blocks are sectioned using a microtome to produce ribbons of 4-5 μm thickness, which are floated on water baths and mounted on slides for staining. For intraoperative consultations, frozen sections bypass routine fixation to enable rapid analysis; fresh tissue is snap-frozen in medium and sectioned at 4-7 μm thickness using a maintained at -20 to -15°C. This method, while prone to artifacts like formation, provides diagnoses within 20-30 minutes to guide surgical decisions. Specimen orientation is critical for margin assessment, achieved by surgeons marking surfaces with sutures, clips, or dyes (e.g., short suture for superior, long for lateral) prior to submission, allowing pathologists to align tissues accurately during embedding and sectioning. All handling adheres to biohazard safety protocols under OSHA standards for bloodborne pathogens, requiring specimens to be placed in leak-proof, labeled containers with biohazard symbols to prevent exposure during transport and processing. Personnel must use , including gloves and gowns, and decontaminate surfaces and wastes via autoclaving or to mitigate risks from infectious materials. Formalin exposure is monitored annually, with ventilation ensuring levels below permissible limits.

Diagnostic Workflow

Gross Examination

Gross examination in surgical pathology involves the macroscopic evaluation of resected specimens to document visible features, guide tissue sampling for microscopic , and provide preliminary diagnostic insights. This step occurs after initial fixation and , allowing pathologists or trained assistants to assess the specimen's gross characteristics under adequate lighting and . The process ensures that representative portions of the tissue are selected for further study, facilitating accurate , staging, and margin assessment in oncologic cases. The procedure begins with systematic , where the specimen is oriented, measured in three dimensions, and weighed to record its physical attributes. Key features evaluated include tumor size, the presence of , gross invasion depth, and the condition of surgical margins, which are often stained with colored inks (e.g., black for deep margins, blue for lateral, green for superficial) immediately upon receipt to distinguish and preserve orientation. Photographic is routinely performed using standardized to capture overall appearance, cross-sections, and notable abnormalities, aiding in report illustration and potential correlation with . For complex specimens like mastectomies or colectomies, follows protocols that prioritize areas of interest, such as tumor-normal tissue interfaces. Sampling strategies emphasize representative selection to avoid under- or over-sampling. Sections are typically taken from the tumor periphery to include interfaces with normal tissue, ensuring evaluation of and margins; for heterogeneous tumors, multiple areas differing in color, texture, or consistency are sampled. Lymph nodes are meticulously dissected from surrounding fat using techniques like manual or fat , with all nodes smaller than 0.5 cm submitted entirely in a single cassette, while larger nodes (>5 mm) are serially sectioned at 2-3 mm intervals for comprehensive examination. These approaches align with guidelines to maximize detection of metastases without compromising efficiency. Intraoperative gross examination provides rapid feedback during surgery, often preceding or supplementing frozen sections. Specimens are expeditiously transported to pathology for immediate by the pathologist, focusing on critical elements like resectability, margin status, and gross tumor extent to inform surgical decisions in real time. This assessment, performed under time constraints, relies on gross morphology without fixation and is documented succinctly to support intraoperative consultations. Documentation follows standardized synoptic reporting per () protocols, which structure the gross description to include specimen identifiers, measurements, sampled sections (e.g., "A1: tumor-normal interface"), and preliminary findings. This format ensures completeness for cancer datasets, such as tumor dimensions and node counts, and facilitates by integrating with electronic reporting systems. Adherence to these protocols enhances and supports multidisciplinary care.

Microscopic Examination

Microscopic examination is a cornerstone of surgical pathology, involving the detailed analysis of tissue sections under a light microscope to identify pathological changes at the cellular and tissue level. This process allows pathologists to diagnose diseases, particularly neoplasms, infections, and inflammatory conditions, by evaluating morphological features that correlate with clinical outcomes. The examination builds upon gross findings by providing high-resolution insights into tissue architecture and cellular details, enabling precise classification and grading of lesions. The standard staining method in microscopic examination is hematoxylin and eosin (H&E), where hematoxylin stains nuclei blue to highlight patterns and nuclear atypia, while stains and pink to delineate cellular boundaries and stromal components. This routine stain is sufficient for most diagnoses, revealing key features such as nuclear pleomorphism, hyperchromasia, and mitotic figures in malignant cells. For suspected infectious agents, special stains are employed; for instance, periodic acid-Schiff (PAS) highlights fungal elements like those in Candida species by staining and mucopolysaccharides magenta, aiding in the identification of pathogens that may not be visible on H&E. Other special stains, such as Gram for or Ziehl-Neelsen for acid-fast bacilli, are selected based on clinical suspicion to confirm microbial presence. The diagnostic process relies on recognizing architectural patterns and cellular atypia to differentiate benign from malignant processes. Architectural disarray, such as irregular glandular formation in adenocarcinomas of the colon, contrasts with organized structures in benign polyps, while cellular atypia—including enlarged, irregular nuclei and prominent nucleoli—signals dysplasia or malignancy. Grading systems quantify these features for prognostic purposes; the Gleason score, for example, assesses prostate adenocarcinoma by summing the dominant and secondary glandular patterns (ranging from 1 for well-formed glands to 5 for anaplastic sheets), with scores of 6 or less indicating low-grade disease and higher scores correlating with aggressive behavior. Pathologists systematically scan slides at low power for overall patterns before focusing on high-power fields for cytologic details, often quantifying elements like mitotic rate—typically reported as mitoses per 10 high-power fields—to predict tumor behavior in sarcomas or melanomas. Intraoperative frozen sections provide rapid microscopic evaluation during , typically completed in 15-20 minutes by freezing, sectioning, and tissue samples to guide immediate decisions like margin status or resectability. This technique uses cryostat-sectioned tissue stained with H&E, but it is limited by freeze artifacts such as distortion, which can obscure fine nuclear details and lead to diagnostic accuracy rates of about 90-95% compared to permanent sections. Despite these challenges, frozen sections are invaluable for time-sensitive procedures, such as assessing involvement in . Reporting from microscopic examination employs standardized descriptive terminology to ensure clarity and reproducibility, detailing the lesion's location, type, grade, and margins while listing differential diagnoses such as versus . Prognostic features, including or perineural spread, are highlighted to inform treatment; for example, a high mitotic rate in gastrointestinal stromal tumors (>5 mitoses per 50 high-power fields) indicates higher risk of . Pathologists integrate these findings with gross descriptions and clinical —such as age, symptoms, and —to render a final , often correlating microscopic with macroscopic tumor size for staging purposes. This holistic approach ensures the report serves as a comprehensive guide for oncologists and surgeons.

Ancillary Techniques

Ancillary techniques in surgical pathology encompass a range of supplementary methods employed to enhance diagnostic accuracy beyond standard histological examination, particularly for identifying specific cellular or molecular features that inform tumor , , and selection. These tools are selectively applied when routine morphology is inconclusive, allowing pathologists to detect protein expression, genetic alterations, or ultrastructural details that refine differential diagnoses. Immunohistochemistry (IHC) stands as the most widely utilized ancillary technique, leveraging antigen-antibody reactions to visualize protein expression in tissue sections. In breast cancer pathology, IHC detects (ER) and (PR) status, guiding hormonal therapy decisions, with positive staining indicating responsiveness to endocrine treatments. For determining tumor origin in metastatic cases, IHC panels such as 7 (CK7) and 20 (CK20) are routinely employed; for instance, CK7-positive/CK20-negative profiles suggest upper gastrointestinal or primaries, while the reverse favors colorectal origins. Molecular techniques provide critical genetic insights, often through (PCR) or (FISH). PCR-based assays detect mutations like BRAF V600E in , present in approximately 40-50% of cases, enabling targeted therapy with BRAF inhibitors such as . FISH, meanwhile, quantifies gene copy numbers, as in assessing HER2 amplification in , where a HER2/CEP17 ratio greater than 2.0 signals eligibility for therapy. Electron microscopy, though less common due to its labor-intensive nature, offers ultrastructural resolution for select diagnoses, particularly in renal pathology. It reveals subepithelial deposits or foot process effacement in glomerular diseases like membranous nephropathy or , aiding differentiation from light microscopy alone. Flow cytometry serves as a key adjunct for lymphoid specimens, analyzing cell surface markers to assess clonality in . By detecting aberrant immunophenotypes, such as light chain restriction in B-cell populations, it distinguishes reactive from neoplastic processes in lymph nodes or extranodal sites. Despite their value, ancillary techniques face limitations including high costs, variable turnaround times, and the need for rigorous validation. IHC typically yields results in 1-2 days, while next-generation sequencing (NGS) for broader molecular profiling may require 1-2 weeks, potentially delaying patient care. Expenses arise from reagents, equipment, and technical expertise, with NGS panels costing several thousand dollars per case. Laboratories must adhere to () guidelines for validation, ensuring assays demonstrate analytical sensitivity, specificity, and through testing on at least 10 positive and 10 negative specimens for non-predictive markers.

Subspecialties

Anatomic Subspecialties

Anatomic subspecialties in surgical pathology represent specialized divisions focused on organ- or system-specific diseases, allowing pathologists to develop expertise in the unique morphological and clinical features of tissues from particular body regions. These subspecialties emphasize the interpretation of surgical resections, biopsies, and excisions, often integrating gross, microscopic, and ancillary findings to guide treatment decisions such as surgical margins or staging. Pathologists in these areas address diagnostic challenges like distinguishing benign from malignant lesions, assessing tumor invasion, and correlating pathology with clinical or data. Dermatopathology involves the diagnosis of skin and mucosal diseases, including inflammatory conditions, benign neoplasms, and malignancies such as , , and . A key challenge is evaluating excision margins in skin cancers to ensure complete tumor removal, particularly in procedures like Mohs micrographic surgery where immediate frozen section analysis is critical for tissue-sparing outcomes. Dermatopathologists must differentiate subtle histologic patterns, such as atypical melanocytic proliferations, which can mimic and require careful correlation with clinical features. Gastrointestinal pathology encompasses disorders of the , , intestines, liver, , and , with common entities including (e.g., and ) and premalignant conditions like . Diagnostic challenges include assessing in endoscopic biopsies and distinguishing chronic inflammation from neoplasia in resection specimens, often requiring correlation with endoscopic findings to evaluate extent and severity. Pathologists focus on features like architectural distortion, crypt abscesses, and to inform management, such as intervals or surgical interventions. Gynecologic pathology covers the female reproductive tract, including the , , ovaries, and fallopian tubes, with emphasis on carcinomas such as and cervical squamous cell carcinoma often linked to human papillomavirus (HPV) infection. Challenges arise in classifying HPV-related lesions, like distinguishing low-grade squamous intraepithelial lesions from high-grade, and evaluating staging in specimens for myometrial . Pathologists assess features like glandular architecture, nuclear atypia, and viral cytopathic effects to determine prognosis and guide therapies like or . Breast pathology specializes in mammary gland diseases, focusing on distinguishing (DCIS) from invasive ductal through assessment of integrity and stromal . A critical aspect is performing hormone receptor testing ( and progesterone receptors) and HER2 evaluation on invasive tumors to predict response to targeted therapies like endocrine treatment or . Pathologists navigate challenges in grading lesions using systems like and interpreting microcalcifications in core biopsies to support decisions on versus . Genitourinary pathology focuses on diseases of the urinary tract and , including , , , and testis, with common malignancies such as prostate adenocarcinoma, urothelial carcinoma of the , and . Key challenges involve Gleason grading and assessing in biopsies, evaluating muscularis propria invasion in transurethral resections of tumors, and subclassifying renal tumors using morphologic and immunohistochemical features to guide targeted therapies. Pathologists integrate clinical data like PSA levels and imaging to inform staging and management decisions. Thoracic pathology addresses , pleura, and mediastinal diseases, emphasizing non-small cell lung carcinomas (e.g., and ) and lung cancer, as well as and thymic tumors. Diagnostic difficulties include subclassifying lung s for molecular testing eligibility and distinguishing reactive mesothelial cells from in pleural biopsies. Pathologists evaluate features like lepidic growth patterns, , and to determine and support precision oncology approaches. Bone and soft tissue pathology deals with musculoskeletal tumors and non-neoplastic conditions, including sarcomas like , , and soft tissue sarcomas such as and . Challenges lie in the rarity and diversity of these entities, requiring expertise in recognizing specific histologic patterns, immunohistochemical profiles, and molecular alterations (e.g., EWSR1 rearrangements in ) to differentiate from mimics and guide or surgical planning. Pathologists often collaborate with orthopedic surgeons for margin assessment in limb-sparing resections. Head and neck pathology addresses tumors and inflammatory conditions of the upper aerodigestive tract, sinonasal region, , and s, with squamous cell carcinomas being the most common , often arising from mucosal sites like the oral cavity or . tumors, such as or , present diagnostic difficulties due to their cytologic diversity and overlap with metastatic lesions. Pathologists evaluate , lymphovascular spread, and margins in complex resection specimens to stage disease and inform multidisciplinary care, including radiation planning. Training in anatomic subspecialties typically follows completion of a 3-4 year residency in anatomic and involves 1-year accredited fellowships offered by institutions listed in the American Society for Clinical (ASCP) directory. These fellowships provide hands-on experience in sign-out, frozen sections, and multidisciplinary conferences specific to the subspecialty. Board in subspecialties like , (overlapping with some anatomic areas), or molecular genetic is administered by the American Board of (ABPath), requiring successful completion of primary and fellowship .

Integration with Molecular Pathology

Surgical pathology has increasingly integrated to enhance diagnostic accuracy and guide precision medicine, particularly through the incorporation of genomic profiling alongside traditional histologic examination. This convergence allows pathologists to correlate morphological features with genetic alterations, enabling more refined tumor classifications and personalized therapeutic strategies. For instance, next-generation sequencing (NGS) panels are routinely used to detect actionable mutations such as EGFR in non-small cell specimens, where histologic subtypes like are combined with molecular results to inform targeted therapies like EGFR inhibitors. In subspecialties, this integration manifests in specific molecular augmentations that refine diagnoses. In , IDH1/IDH2 mutation testing via PCR or NGS is essential for classifying gliomas, distinguishing IDH-mutant astrocytomas from wild-type counterparts based on integrated histologic and genetic criteria, which directly impacts and treatment. Similarly, in hematolymphoid pathology, molecular techniques such as NGS for gene rearrangements (e.g., BCR-ABL1 in chronic myeloid leukemia) complement and morphology to confirm clonal neoplasms and identify therapy-relevant variants. These overlaps underscore the evolving role of surgical pathologists in interpreting multifaceted data sets. Professional guidelines standardize this integration to ensure consistent biomarker testing. The (CAP) and (ASCO) recommend universal mismatch repair (MMR) protein or (MSI) testing on colorectal resections, with reflex to NGS if deficient, to identify patients eligible for immune checkpoint inhibitors. Such protocols emphasize the need for pathologists to allocate tissue judiciously, balancing histologic diagnosis with molecular requirements. Despite these advances, challenges persist in implementation. Limited tissue availability often necessitates prioritization, as molecular assays like NGS require sufficient tumor cellularity (typically >20%), potentially compromising material for slides or blocks, leading to repeat biopsies in up to 15-20% of cases. Reimbursement hurdles further complicate adoption, with payers variably covering multiplexed panels due to evolving coding (e.g., CPT codes for tier 1/2 molecular pathology) and concerns over cost-effectiveness, resulting in denials for non-FDA-approved tests. Looking forward, surgical pathology is shifting toward genotype-phenotype , where reports synthesize morphologic, immunophenotypic, and genomic data into unified diagnostic statements, as advocated by expert consensus for solid tumors. This holistic approach, facilitated by standardized templates and bioinformatics, promises to streamline clinical decision-making and support emerging therapies like those targeting co-occurring mutations.

Advances and Challenges

Digital and Computational Pathology

Digital and computational pathology represents a transformative shift in surgical pathology, leveraging whole-slide imaging (WSI) to digitize glass slides for virtual microscopy and analysis. WSI systems scan entire slides at high resolution, enabling pathologists to view and navigate digital images remotely without physical slides. The U.S. (FDA) first approved the IntelliSite Pathology Solution in 2017 for primary diagnostic use in surgical pathology, marking a pivotal milestone for clinical adoption. Subsequent expansions in the 2020s included FDA clearance for the Leica Aperio AT2 DX in 2019 and the VENTANA DP 600 slide scanner in 2024, broadening WSI applications to high-volume scanning and routine diagnostics. Artificial intelligence (AI) applications have advanced computational by automating tasks such as tumor detection and quantification. Convolutional neural networks (CNNs), a cornerstone of in this field, excel in identifying , which are critical for grading breast carcinomas. Studies demonstrate AI achieving over 90% accuracy in identification, with one validation reporting 92% across cohorts, enhancing diagnostic precision and reducing inter-observer variability. These algorithms support tumor detection by analyzing histopathological patterns, streamlining workflows in cases. Telepathology facilitates remote consultations through digital platforms, gaining significant traction post-COVID-19 due to the need for and workforce shortages. Dynamic image streaming and static WSI enable real-time or asynchronous reviews, with applications in frozen sections showing sensitivity of 0.92 and specificity of 0.99 compared to traditional . Post-pandemic adoption has accelerated, allowing second opinions across institutions without slide transport and supporting rapid on-site evaluations in cytology. Key benefits of digital and computational pathology include improved , with reduced turnaround times reported by 91% of users, and enhanced for second opinions via secure sharing. However, limitations persist, such as scan artifacts like out-of-focus regions or tissue folding, which can affect 5-10% of cases and necessitate fallback to glass slides, alongside challenges in requiring substantial . As of 2025, integrations with electronic health records (EHRs) and are advancing outcomes by combining histopathological data with clinical profiles for risk stratification and treatment forecasting. For instance, AI models incorporating EHRs and WSI predict immunotherapy responses with hazard ratios up to 5.46 in non-small cell lung cancer, while biomarker tools stratify recurrence risks in colon cancer. These developments underscore AI's role in precision medicine, though ethical and technical hurdles in data integration remain.

Quality Assurance and Reporting Standards

Quality assurance in surgical pathology encompasses systematic protocols to ensure the accuracy, timeliness, and completeness of diagnostic reports, thereby minimizing errors and enhancing . Central to these efforts are daily measures, such as routine checks on procedures to verify consistency and reliability of histological preparations, which help detect technical issues before they impact diagnoses. Proficiency testing programs, administered by organizations like the (), provide external quality assessment through simulated case evaluations, allowing laboratories to benchmark performance against peers and identify areas for improvement. Diagnostic error rates in surgical pathology are generally low, with studies reporting uncorrected discordant rates around 1.8% for median-performing institutions, though targeted quality initiatives aim to keep major discrepancies below 1% to support reliable clinical decision-making. Reporting standards in surgical pathology emphasize structured formats to standardize communication and include essential diagnostic elements. For cancer cases, synoptic reporting using CAP protocols is widely adopted, requiring the documentation of core data elements such as tumor type, grade, margins, and to facilitate treatment planning and ensure completeness. These templates also incorporate prognostic factors, like tumor stage and biomarker status, which are critical for guiding therapy and predicting outcomes. Accreditation bodies, such as the Commission on Cancer, mandate that at least 90% of eligible pathology reports for surgical resections adhere to these synoptic formats to promote uniformity across institutions. Turnaround times (TAT) are key performance metrics in surgical pathology, balancing diagnostic urgency with thoroughness. Routine cases typically achieve a TAT of 1-2 days from specimen receipt to final report, as recommended by checklists to meet clinical needs without compromising accuracy. For intraoperative frozen sections, TAT is expedited to under 20 minutes for 90% of cases, enabling real-time guidance during . Delays in TAT for complex specimens can extend to 2.7 days on average, influenced by institutional factors like volume and staffing. Challenges in quality assurance include interobserver variability, where pathologists may differ in interpreting subtle morphological features, potentially affecting diagnostic consistency. Consensus guidelines, such as the 2022 (WHO) classifications of tumors, address this by providing updated, standardized criteria that reduce variability through refined definitions and reproducibility-focused categories, as seen in updates for and tumors. Regulatory frameworks underpin these standards, with (CLIA) certification requiring laboratories to maintain proficiency in testing and reporting to ensure reliable results. Voluntary accreditations from bodies like or the build on CLIA by enforcing rigorous inspections and quality metrics, fostering continuous improvement. Non-compliance with these regulations can lead to operational penalties and legal liabilities, as pathology reports serve as critical medico-legal documents in patient care and litigation, underscoring the need for defensible, accurate documentation.

References

  1. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/surgical-pathology
  2. https://stanfordlab.com/content/stanfordlab/en/anatomic-pathology/surgical-pathology.html/
  3. https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis/pathology-reports-fact-sheet
  4. https://health.ucdavis.edu/pathology/services/clinical/anatomic_pathology/surgical_pathology/
  5. https://www.pathology.northwestern.edu/medical-specialties/general-surgical.html
  6. https://pmc.ncbi.nlm.nih.gov/articles/PMC7358476/
  7. https://www.urmc.rochester.edu/encyclopedia/content?contenttypeid=85&contentid=P00967
  8. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/surgical-pathology
  9. https://www.bcm.edu/healthcare/specialties/pathology/for-patients
  10. https://documents.cap.org/documents/overview-anatomic-clinical-pathology-medical-students.pdf
  11. https://www.mayoclinic.org/departments-centers/mayo-clinic-surgery/frozen-section-pathology-lab/gnc-20556813
  12. https://www.ncbi.nlm.nih.gov/books/NBK13237/
  13. https://www.brighamandwomens.org/pathology/anatomic-pathology/surgical-pathology
  14. https://www.cancer.gov/about-cancer/diagnosis-staging/staging
  15. https://academic.oup.com/labmed/article/41/5/311/2504975
  16. https://www.researchgate.net/publication/10892294_Rudolf_Virchow_1821-1902
  17. https://pmc.ncbi.nlm.nih.gov/articles/PMC2895866/
  18. https://pubmed.ncbi.nlm.nih.gov/16329725/
  19. https://www.cap.org/about-the-cap/historical-timeline
  20. https://whobluebooks.iarc.who.int/about/objective-and-historical-perspective/
  21. https://pubmed.ncbi.nlm.nih.gov/34859396/
  22. https://pmc.ncbi.nlm.nih.gov/articles/PMC6369631/
  23. https://pmc.ncbi.nlm.nih.gov/articles/PMC12468387/
  24. https://surgexppathol.biomedcentral.com/articles/10.1186/s42047-025-00197-1
  25. https://www.yalemedicine.org/departments/anatomic-pathology
  26. https://www.creighton.edu/medicine/departments/pathology/pathology-sub-specialties/surgery-pathology
  27. https://www.cancer.org/cancer/diagnosis-staging/tests/biopsy-and-cytology-tests/testing-biopsy-and-cytology-samples-for-cancer/how-samples-are-processed.html
  28. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=P00950
  29. https://training.seer.cancer.gov/treatment/surgery/all_about_biopsy_accessible.pdf
  30. https://pmc.ncbi.nlm.nih.gov/articles/PMC2840913/
  31. https://cap.objects.frb.io/documents/practical-guide-specimen-handling.pdf
  32. https://www.ncbi.nlm.nih.gov/books/NBK557486/
  33. https://pmc.ncbi.nlm.nih.gov/articles/PMC6699370/
  34. https://pmc.ncbi.nlm.nih.gov/articles/PMC5580003/
  35. https://documents.cap.org/documents/Practical_Guide_to_Specimen_Handling_in_Surgical_Pathology_2025.pdf
  36. https://pmc.ncbi.nlm.nih.gov/articles/PMC3267913/
  37. https://pubmed.ncbi.nlm.nih.gov/39442372/
  38. https://vetmed.tamu.edu/gilab/wp-content/uploads/sites/12/2024/10/AAPIA-General-Tissue-Handling-Guidelines-infographic.pdf
  39. https://pmc.ncbi.nlm.nih.gov/articles/PMC3519217/
  40. https://meridian.allenpress.com/aplm/article/132/12/1929/63731/Tissue-Handling-and-Specimen-Preparation-in
  41. https://www.leicabiosystems.com/us/knowledge-pathway/an-introduction-to-specimen-processing/
  42. https://www.pathologyoutlines.com/topic/cytopathologyfrozen.html
  43. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030
  44. https://www.cap.org/protocols-and-guidelines/cancer-reporting-tools/cancer-protocol-templates
  45. https://kecraven.com/wp-content/uploads/2019/01/SPDissection-1-General-Approach.pdf
  46. https://pmc.ncbi.nlm.nih.gov/articles/PMC2903959/
  47. https://pmc.ncbi.nlm.nih.gov/articles/PMC4807883/
  48. https://pubmed.ncbi.nlm.nih.gov/25015143/
  49. https://pubmed.ncbi.nlm.nih.gov/20126585/
  50. https://pmc.ncbi.nlm.nih.gov/articles/PMC5758899/
  51. https://pubmed.ncbi.nlm.nih.gov/31043248/
  52. https://pmc.ncbi.nlm.nih.gov/articles/PMC11126192/
  53. https://pubmed.ncbi.nlm.nih.gov/10821487/
  54. https://pmc.ncbi.nlm.nih.gov/articles/PMC11585344/
  55. https://www.cap.org/protocols-and-guidelines/cap-guidelines/current-cap-guidelines/principles-of-analytic-validation-of-immunohistochemical-assays
  56. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties
  57. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/dermatopathology
  58. https://pmc.ncbi.nlm.nih.gov/articles/PMC8790591/
  59. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/gastrointestinal-liver-pathology
  60. https://pmc.ncbi.nlm.nih.gov/articles/PMC7121816/
  61. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/gynecologic-pathology
  62. https://pubmed.ncbi.nlm.nih.gov/3414609/
  63. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/breast-pathology
  64. https://pmc.ncbi.nlm.nih.gov/articles/PMC5980866/
  65. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/genitourinary-pathology
  66. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/pulmonary-pathology
  67. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/bone-soft-tissue-pathology
  68. https://www.cap.org/member-resources/pathology-careers/pathology-subspecialties/head-neck-pathology
  69. https://pubmed.ncbi.nlm.nih.gov/37285683/
  70. https://www.ascp.org/apps/fellowship/
  71. https://abpath.org/requirements/
  72. https://abpath.org/wp-content/uploads/2025/02/ABP_BOI.pdf
  73. https://www.sciencedirect.com/science/article/pii/S0893395223000315
  74. https://ascopubs.org/doi/10.1200/JCO.2023.41.16_suppl.8539
  75. https://pmc.ncbi.nlm.nih.gov/articles/PMC10948579/
  76. https://meridian.allenpress.com/aplm/article/141/3/355/65888/Genomic-Analysis-in-the-Practice-of-Surgical
  77. https://meridian.allenpress.com/aplm/article/141/3/341/65717/Multimodality-Technologies-in-the-Assessment-of
  78. https://documents.cap.org/documents/cap-18-mmr-msi-for-crc-2019.pdf
  79. https://ascopubs.org/doi/10.1200/JCO.22.02462
  80. https://academic.oup.com/ajcp/article/155/6/781/6134812
  81. https://www.sciencedirect.com/science/article/pii/S0169500222005797
  82. https://pmc.ncbi.nlm.nih.gov/articles/PMC7267794/
  83. https://onlinelibrary.wiley.com/doi/10.1111/1468-0009.12587
  84. https://pmc.ncbi.nlm.nih.gov/articles/PMC5243883/
  85. https://pmc.ncbi.nlm.nih.gov/articles/PMC7922586/
  86. https://www.fda.gov/news-events/press-announcements/fda-allows-marketing-first-whole-slide-imaging-system-digital-pathology
  87. https://pmc.ncbi.nlm.nih.gov/articles/PMC10584409/
  88. https://diagnostics.roche.com/global/en/news-listing/2024/roches-momentum-in-digital-pathology-continues-with-fda-clearance-on-its-high-volume-slide-scanner.html
  89. https://www.modernpathology.org/article/S0893-3952(23)00321-6/fulltext
  90. https://pmc.ncbi.nlm.nih.gov/articles/PMC7698715/
  91. https://pmc.ncbi.nlm.nih.gov/articles/PMC12427515/
  92. https://proscia.com/digital-pathology-and-ai-highlights-from-asco-2025/
  93. https://www.sciencedirect.com/science/article/abs/pii/S1756231713001746
  94. https://meridian.allenpress.com/aplm/article/138/9/1156/204742/Q-Probes-Studies-in-Anatomic-Pathology-Quality
  95. https://www.cap.org/protocols-and-guidelines/cancer-reporting-tools/cancer-protocols
  96. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2021/12/synoptic-reporting-for-cancer-surgery-current-requirements-and-future-state/
  97. https://www.sciencedirect.com/science/article/abs/pii/S0046817711004801
  98. https://pubmed.ncbi.nlm.nih.gov/9199619/
  99. https://meridian.allenpress.com/aplm/article/139/2/171/193706/Turnaround-Time-for-Large-or-Complex-Specimens-in
  100. https://pmc.ncbi.nlm.nih.gov/articles/PMC10342216/
  101. https://erc.bioscientifica.com/view/journals/erc/30/2/ERC-22-0293.xml
  102. https://www.europeanurology.com/article/S0302-2838%2822%2902477-0/fulltext
  103. https://www.fda.gov/medical-devices/ivd-regulatory-assistance/clinical-laboratory-improvement-amendments-clia
  104. https://www.jointcommission.org/en-us/accreditation/laboratory-services
  105. https://www.mybiosource.com/learn/understanding-the-importance-of-clia-compliance-in-clinical-laboratories/
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