Wednesday, December 5, 2012

Orienting Hemorrhoids?

Last week I was covering our cytology rotation, which can be very demanding.  There are a lot of diagnostic radiology needles.  We are also responsible for junk surgicals, as we nickname them - gallbladders, tonsils, breast reductions, hemorrhoids.  We call them junk because they are easy to look at and sign out, most being very routine cases with only one or two slides.  Occasionally there is a surprise tough case (gangrenous toe chock full of melanoma, for example) but overall they go quick.

One day I had a tray full of hemorrhoids.  They are usually easy cases, normal sign out being "Dilated submucosal vessels, consistent with hemorrhoids."  You have to check out the overlying epithelium to make sure there is no dysplasia, being ever vigilant.  Some breast reductions have carcinoma in situ.  It happens.  Some hemorrhoids have overlying HPV (Human Papillomavirus) changes.  Whenever I have a surprise like this, I generally contact the clinician.

I usually have a hemorrhoid or two, but a whole tray?  I spoke to a friend.  "Either the surgeons are having a blue light special or there is an epidemic of which I am unaware."  I have written of hemorrhoids in the past.  Gangrenous hemorrhoids, to be exact.  I won't rehash that in this post, but you can read about it here, if you want. I thought that was the most interesting hemorrhoid case I would ever see, but then I came across one that was oriented.

Orientation is necessary in pathology for many cancer cases.  Here's a good example.  In all breast excisional biopsies, the techs will ink the margins according to the surgeon's marks.  Sometimes the surgeons use long and short pieces of thread tied to the tissue.  "Long superior, short lateral."  Since a breast biopsy looks like a technicolor version of a lump of scrambled eggs, this is helpful to us in the gross room.  The tech inks the margins according to the surgeon's notes, and describes it to us in their gross description.  "Black anterior, blue lateral/posterior, green medial/posterior,"  for example.  That way, when we see the slide the next day, if the cancer is plowing into a margin, we can see the green ink and note it in our report (invasive carcinoma transected at the medial/posterior margin) so the surgeon can go back and get a clear margin.

But I was very surprised to see a case of oriented hemorrhoids, my first.  There were three different specimens.  The first two were "left hemorrhoid" and "right hemorrhoid."  Left and right hemorrhoids?  Are you the surgeon looking at the person?  Is the person supine or prone?  Or are you the sitting person?  And the third one was the kicker.  "Left posterior hemorrhoid."  Really, posterior?  Aren't all hemorrhoids posterior?

And why does a hemorrhoid need to be oriented?  If you don't get a clear margin on an invasive cancer, sure, you need to know, because it can recur.  But a hemorrhoid transected?  I imagined a transected hemorrhoid, dangerously spreading and growing out a patient's ears.  Ha ha.  Doesn't happen.

So I'm wondering if any surgeons out there can enlighten me.  Or maybe it was the surgeon's joke on me.  In any instance, I enjoyed wondering why on Earth a hemorrhoid needed to be oriented.


  1. That's funny, and reminds me of the excision I once got for AIN3. The main specimen was labeled "middle earth", and parts B and C were "north margin" and "south margin". I was expecting to find it signed by Gandalf.

  2. 2 possibilities I can think of:
    1. A scared new young surgeon who has had it beat into their head since the beginning of their training the importance of orienting. Everyone has examples of that case of an excision of some benign something that wasn't oriented and turned out to be some cancer that could have been cured by resection IF ONLY it had been oriented.
    2. maybe this person really was concerned that there could be cancer, or maybe AIN or something in which case it would matter
    3. maybe they were just messing with you!

    1. That's a good point about possibility of practicing defense. Makes me wonder about what mistake the surgeon could have possibly made in the past to make him (it was a guy) want to orient a hemorrhoid! What horribly malignant thing was protruding from the anus masquerading as a hemorrhoid?!!??

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  4. I don't know why they would orient the hemorrhoids, that makes no sense to me as a surgeon. But the answer is no, all hemorrhoids are not posterior. There are three hemorrhoidal cushions and they are usually named based on the patients' perspective.


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