Use Of Digital Maps and Sampling of Radical Prostatectomy Specimens

To the Editor.—The use of digital technology is replacing the traditional methods of prostatectomy handling in the pathology laboratory. We have recently started using digital maps for radical prostatectomy specimens in our centralized urologic pathology service. In our gross room we have installed the MacroPATH system (Milestone Medical, Bergamo, Italy), which can be mounted on (or next to) the grossing station. The system has a digital camera and a touch screen monitor and allows capture and saving of macroscopic images of gross specimens. The completely sectioned prostatectomy specimen is laid out and a digital image is captured using a foot control system that also has a zoom in/out control. The image of the specimen is labeled with the surgical number of the case, which is the only step of the procedure that requires use of a keyboard. The system also allows for automatic specimen measurement from the image, labeling of the image for specimen orientation (eg, apex/base, left/right), and enumeration of the sampled blocks (Figure 1). This is done on a screen monitor using a plastic pen tool. Our pathology technologists spend on average 15 minutes to complete this procedure. The system requires an introductory in-service training of 1 hour and it is simple to use. The signing pathologist can access the digital images of the specimen through the information system, or alternatively the images can be e-mailed to the pathologist. A hard copy map of the specimen can be printed (in color or black and white) and used during case sign-out for block orientation and recording of the prostatectomy findings. The images can be stored permanently and retrieved using the system software and they can be incorporated into digital and hard copy pathology reports. We also routinely capture a digital image of the accompanying requisition of the specimen for quality assurance (eg, to avoid mismatch errors if multiple prostatectomies are grossed the same day). Prostatectomy specimen handling using either digital or photocopy maps essentially obviates the need for whole mount (or whole organ) prostatectomy processing. Whole mount prostatectomy processing has several technical and cost issues associated with it, such as use of large blocks and glass slides that require separate fixation, processing, storage, and use of separate microtomes for block cutting by personnel with special technical expertise.In our practice, digital prostatectomy maps have replaced the photocopy prostatectomy maps that we have used for many years and that were generated by laying out prostatectomy slices on a transparent Plexiglas plastic board.1 The transparent board was labeled for apex/ base and left/right orientation; the slices were then covered with another transparent board. This allowed for easier specimen handling to obtain a photocopy and to generate a prostatectomy working map for the pathologist (Figure 2). Proper orientation of the specimen required attention because the map represented a mirror image of the grossed specimen. To avoid the removal of the specimen from the gross room and contamination of the office space and copier, we had a dedicated copier for this purpose in the grossing room.We process yearly 300 to 350 radical prostatectomies and we fix all specimens en bloc in 10% neutral buffered formalin for at least 24 hours. The specimens are submitted in toto using a standard grossing protocol. Complete submission is optimal and we find it justified because the majority of the patients present currently with nonpalpable disease (stage T1c) and show lower tumor volumes. Although the survey conducted in the United States in 1994 indicated that only in 12% of the laboratories radical prostatectomies had been submitted in toto, this number has likely increased; unfortunately there are no data of the current sampling practices.2 However, a systematic partial prostatectomy sampling may reduce the number of sampled blocks and still may allow for adequate specimen sampling.13 In our practice, the specimens are painted over the surface with black (left) and blue (right) dye, and the anterior is painted green. The seminal vesicles are amputated at the prostate junction and a complete longitudinal section is obtained from each vesicle; the junction area on both sides is painted yellow. The prostatectomy specimen is serially sectioned, resulting in prostate slices of 3 to 4 mm thickness, representing transverse planes parallel to the initial apical and basal sections. The apical and basal margins (also 3–4 mm thick) are sectioned perpendicularly to assess the resection margin status. Each slice of the prostate is processed, depending on its size, into complete, halved, or quartered sections to fit the standard size cassettes and 1 hematoxylin-eosin slide is sectioned per block.

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