Composite oral resections (including mandible, maxilla, palate, ear, temporal bone) require proper orientation and can be complex. CONSULT an attending and take gross photographs (BOTH intact and after sectioning).
Remember: For any tumor adjacent to / involving bone, if any part of the tumor is SOFT and does not NEED decalcification, please isolate 1-2 sections and submit as non-decalcified tumor. Then proceed with fixation and decalcification as necessary for the remainder of the case. Consider submitting a section in EDTA if the entire tissue requires decalcification (consult an attending).
Types of Maxillectomies
- Medial maxillectomy: the part of the maxilla that is next to the nose is removed, but the eye and the hard palate are preserved.
- Infrastructure maxillectomy: the hard palate and lower portion of the maxilla with teeth are removed. It does not require the removal of the orbital floor.
- Suprastructure maxillectomy: the upper portion of the maxilla and orbital floor are removed, but the hard palate is left intact. The orbit may be removed or left in place.
- Subtotal maxillectomy: removes only part of the maxilla using some variation of the above procedures.
- Total maxillectomy: the entire maxilla as well as the hard palate and orbital floor are removed. When the orbit is removed during this surgery, it is termed total maxillectomy with orbital exenteration.
- Orient specimen, noting laterality, anterior-posterior, superior-inferior, and medial-lateral.
- Photograph fresh specimen (prior to sectioning) in all planes that are helpful for visualization.
- Measure specimen in 3D (A-P, S-I, M-L). If applicable, separately measure bone versus attached large pieces of soft tissue / skin.
- Ink Margins: Think before you ink and discuss with attending!
- Plan out your grossing strategy before inking. You can use different colors if it will help your later prosection (such as medial and lateral sides different colors).
- Ink peripheral soft tissue margins.
- If a bone margin will be taken en face, it does not need to be inked. If a bone margin will be taken radially, ink the cut surface (looks like marrow surrounded by cortex).
- NOTE: The outer surface of thick bony cortex / subperiosteum does not usually need to be be inked, as it often rubs off and can be cumbersome.
- If specimen is small with delicate bone, fix in formalin overnight. If large, you might want to section prior to fixation, to allow better penetration of formalin. DISCUSS WITH ATTENDING!
- Margins to consider include:
- Mucosal (for tumors that originate or spread along mucosa, such as SCC or melanoma).
- Soft tissue.
- Bone (cut surfaces).
- Always discuss your approach to grossing with an attending.
- Specimens can usually be sectioned in one direction (perpendicular to long axis).
- Photograph cut sections prior to decalcification.
- In order to facilitate decalcification, we recommend you cut your sections with a bone saw FIRST, and then decalcify thin sections. You can always thin down your sections after initial decalcification if they are too thick.
- For SMALL, DELICATE specimens, consider complete decalcification followed by sectioning with a long blade. ALWAYS consult an attending FIRST if this is your plan.
- Teeth will decalcify, but fillings or other foreign materials will NOT. If these materials are present, do NOT submit for histology.
- Always dictate which blocks were decalcified (or if entire specimen).
New NAC 06-23-2020