Sampling of TURBT specimens?

[acurax]

Is there a limit on how many blocks or what % of tissue needs to be sampled in TURBT cases with regard to noninvasive or lamina propria invasive urothelial carcinomas?

The CAP Genitourinary guideline offer this:

"In TURBT specimens, submit one section per centimeter of tumor diameter (up to 10 cassettes). If the tumor is noninvasive by the initial sampling, additional submission of tissue (including possibly submitting all tissue) is necessary to diagnose or rule out the presence of invasion. If tumor is invasive into lamina propria in the initial sampling, additional sections (including possibly submitting the entire specimen) may be necessary to diagnose or rule out the possibility of muscularis propria invasion."

Which I find to be non-committal. Why not just explicitly state to submit in entirety? Does block count play any role (e.g. do we stop at 25, 50, 75, 100, etc.)? Or just ensure a certain percentage of tissue is sampled?

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[Med Director New England]

The de facto standard of care for TURBT has become to submit the tissue entirely, fairly infrequent for a TURBT to exceed 1o blocks. Some labs examine each block with 2 levels, others only one. I suppose you could submit 1 / cm but you will end up going back to the bucket a lot (in the cases that you dont find muscle invasive disease on initial blocks). I think if you examine TURBT routinely with 2 levels for larger ones, say > 5 blocks, you could reasonable only examine one level.

This specimen is a money loser on the for the TC after about 5 blocks...

 

[CDX-2]

Is there a limit on how many blocks or what % of tissue needs to be sampled in TURBT cases with regard to noninvasive or lamina propria invasive urothelial carcinomas?

The CAP Genitourinary guideline offer this:

"In TURBT specimens, submit one section per centimeter of tumor diameter (up to 10 cassettes). If the tumor is noninvasive by the initial sampling, additional submission of tissue (including possibly submitting all tissue) is necessary to diagnose or rule out the presence of invasion. If tumor is invasive into lamina propria in the initial sampling, additional sections (including possibly submitting the entire specimen) may be necessary to diagnose or rule out the possibility of muscularis propria invasion."

Which I find to be non-committal. Why not just explicitly state to submit in entirety? Does block count play any role (e.g. do we stop at 25, 50, 75, 100, etc.)? Or just ensure a certain percentage of tissue is sampled?

In my current lab, we submit the TURBT all in, and each block gets examined for three levels.

If it's a really large amount of TURBT (>10 blocks), then we initially do 10 blocks but examine each at one level, and then the consultant / attending decides if more tissue needs to be submitted.

 

[deleted314957]

In my current lab, we submit the TURBT all in, and each block gets examined for three levels.

If it's a really large amount of TURBT (>10 blocks), then we initially do 10 blocks but examine each at one level, and then the consultant / attending decides if more tissue needs to be submitted.

10 blocks and punt to staff for grossing direction. And we wonder why residents
can’t hit the ground running after 4 years.

 

[Euchromatin]

We typically submit TURBTs entirely and we do 3 levels up front on bladder biopsies and the TURBTs that are 3 blocks or less. I don't recall seeing one greater than 10 blocks recently, but if we had an unusually large specimen, the PAs would probably call whichever pathologist was supervising the gross room that day to touch base and ask if they wanted just 10-12 to start vs the entire thing.

10 blocks and punt to staff for grossing direction. And we wonder why residents
can’t hit the ground running after 4 years.

Not sure why you are giving CDX-2 a hard time about this. I know he is in Australia, where things may be different, but if I were an attending and I had either a PA or a resident grossing in a TURBT for me that might be greater than 10 blocks, I WOULD appreciate that they call or otherwise touch base with me to ask if I want more up front (and if so, how much).

 

[Euchromatin]

Which I find to be non-committal. Why not just explicitly state to submit in entirety? Does block count play any role (e.g. do we stop at 25, 50, 75, 100, etc.)? Or just ensure a certain percentage of tissue is sampled?

Obviously confirming presence/absence of muscularis propria/detrusor muscle invasion is a major factor in determining whether a patient may go on to cystectomy. So if you don't find any in the initial sampling, it may be necessary to just keep submitting more until all tissue is examined. I would guess the CAP guideline is offering some wiggle room here for cases in which you are able to confirm there is high grade with lamina propria and muscularis propria invasion present in a more limited initial sample. At that point probably there isn't really a need to submit more.

 

[CDX-2]

10 blocks and punt to staff for grossing direction. And we wonder why residents
can’t hit the ground running after 4 years.

Most of the TURBT specimens that we get in our lab can be entirely submitted within 5 blocks.

In the exceptionally large case which I mentioned, I showed the consultant the specimen and they said to initially do 10 blocks at one level / block, and then they'll ask me to put more in depending on the initial slides.

The next day, they were unable to definitively identify muscularis propria / detrussor muscle invasion with the original 10 blocks,
so they told me to put the remainder all in, which was another 20 blocks (ie 30 blocks total).

 

[Alteran]

What kind of TURBT specimens are you all getting (rhetorical question)? The TURBT specimens I routinely get are so minute I actually have to log into the EMR and read the Op note to see if it was meant to be a TURBT or just a simple biopsy. I have never seen one our TURBTs go past 5 blocks with everything submitted, even on the 5 cm or greater tumors. Our urologists just fry the ever loving snot out of these tumors and we just get the heavily cauterized leftovers for histology.

 

[CDX-2]

What kind of TURBT specimens are you all getting (rhetorical question)? The TURBT specimens I routinely get are so minute I actually have to log into the EMR and read the Op note to see if it was meant to be a TURBT or just a simple biopsy. I have never seen one our TURBTs go past 5 blocks with everything submitted, even on the 5 cm or greater tumors. Our urologists just fry the ever loving snot out of these tumors and we just get the heavily cauterized leftovers for histology.

Most of our TURBT specimens are small and are put all into 1 or 2 blocks. There are some that are larger and need up to 5 blocks.

In the case of the really huge one, I initially thought it was prostate chips and was wondering if they made a mistake with the specimen labeling. I told the consultant / attending and they said they were expecting a huge TURBT specimen from one of the urologists that day. It looked like tan / red tissue fragments with some admixed blood clot. I remembered that a lot of the fragments had a papillary appearance.

In our lab, if it was prostate chips, the protocol would be to submit 8 blocks for the first 10 grams, and then 1 extra block for every 10 grams after that.

 

[pathslides]

What kind of TURBT specimens are you all getting (rhetorical question)? The TURBT specimens I routinely get are so minute I actually have to log into the EMR and read the Op note to see if it was meant to be a TURBT or just a simple biopsy. I have never seen one our TURBTs go past 5 blocks with everything submitted, even on the 5 cm or greater tumors. Our urologists just fry the ever loving snot out of these tumors and we just get the heavily cauterized leftovers for histology.

I was wondering the same. I rarely get up to 3 blocks totally submitted.

 

[acurax]

The number of blocks has been extremely variable for me. In residency, usually less than 5 slides. In fellowship, typically less than 10 slides from in-house cases (external reviews wide variation from minute fragments on one slide up to a tray or two. Now in practice, I'm seeing much larger TURBTs with more frequency (I had two last week which were 20+ blocks). I have everything submitted if takes <= 10 blocks. Larger than that, I'll start with 10 up front, with "additional sections (including possibly submitting the entire specimen)" as necessary per the CAP cancer protocol.