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Breast malignant, males, children

Miscellaneous

Grossing (histologic sampling) of breast lesions


Reviewer: Monika Roychowdhury, M.D. (see Reviewers page)
Revised: 18 November 2012, last major update August 2012
Copyright: (c) 2001-2012, PathologyOutlines.com, Inc.

Definition
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● For grossly benign biopsies, focus on fibrous tissue, since unlikely to detect carcinoma or atypia exclusively in unremarkable adipose tissue (Am J Surg Pathol 1989;13:505)
● Clinical outcomes of positive shaved and inked margins may differ (Cancer 1997;79:1568)
● Grossly negative margins may be histologically positive in up to 25% of specimens (Am Surg 2005;71:22)

Grossing the biopsy or excision of a palpable breast mass
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● Measure and (optionally) weigh specimen
● Take radiograph, if indicated
● Blot dry, ink margins and blot dry again
● If multiple orientations obtained, may want to ink in multiple colors to identify tumor proximity to specific margins
Example: superior margin-blue, inferior margin-green, anterior margin-yellow, posterior margin-black, section and submit from medial to lateral
● Palpate specimen for masses and correlate with radiograph
● Section specimen as thin as possible (3-4 mm slices, may need to fix first)
● May want to photograph / make drawing and indicate where sections came from
Describe: tumor (size in three dimensions, color, distance from margins, consistency, necrosis), fibrosis, cysts (number, size, content) and calcifications, if margins are submitted as shaved or perpendicular
● Submit entire specimen, if possible, in 3-5 sections; otherwise, at least 3 sections of tumor or 1 section per cm of tumor diameter (whichever is more), any suspicious areas and surgical margins; include center and periphery of tumor and adjacent tissue, areas of mammographic abnormality; Rosai suggests at least 2/3 of nonadipose breast tissue
Note: resection by surgeon of 4-5 additional tumor cavity margins during breast conserving surgery for early stage invasive breast cancer is recommended (Ann Surg Oncol 2010;17:228)

Grossing re-excision for residual disease
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● Either submit entire specimen or submit 2 blocks per cm if grossly benign, remaining tissue if carcinoma identified (Am J Surg Pathol 1999;23:316)

Grossing a needle localization specimen
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● Review radiograph to confirm that calcified areas have been excised
● Measure and (optional) weigh specimen
● Blot dry, ink margins and blot dry again
● If multiple orientations obtained, may want to ink in multiple colors to identify tumor proximity to specific margins
Example: superior margin-blue, inferior margin-green, anterior margin-yellow, posterior margin-black, section and submit from medial to lateral
● Palpate specimen for masses and correlate with radiograph
● May want to photograph / make drawing and indicate where sections came from
● Section specimen as thin as possible (3-4 mm slices, may need to fix first)
● Some recommend radiographs of sections to confirm that the calcified areas are being submitted
Describe: tumor (size in three dimensions, color, distance from margins, consistency, necrosis), fibrosis, cysts (number, size, content) and calcifications, if margins are submitted as shaved or perpendicular
● Submit entire specimen, if possible, in 3-5 sections; otherwise, at least 3 sections of tumor or 1 section per cm of tumor diameter (whichever is more), any suspicious areas and surgical margins; include center and periphery of tumor and adjacent tissue, areas of mammographic abnormality; Rosai suggests at least 2/3 of nonadipose breast tissue
● Make sure to submit area of specimen containing radiographic microcalcifications; if carcinoma or atypical hyperplasia is found, submit additional sections (Am J Surg Pathol 1990;14:578)

Grossing a mastectomy specimen
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Radical mastectomy: rare procedure currently; removal of entire breast, underlying and adjacent adipose tissue, pectoralis major and minor muscles and axillary contents en bloc
Supraradical mastectomy: not performed today, radical mastectomy, chest wall, various ribs, sternum, internal mammary vessels and nodes, variable pleura
Modified radical mastectomy: common, preserves pectoralis muscles, some skin is preserved (but nipple, areola and surrounding areas are excised), some lymph nodes containing fat from lower axilla
Simple mastectomy: most / all mammary tissue, nipple and variable adjacent skin
Subcutaneous mastectomy: most of mammary tissue, no skin or nipple and variable axillary tail
Quadrantectomy: one of four anatomic breast quadrants, usually with axillary content
Tylectomy / lumpectomy / excisional biopsy: removal of mass and variable amount of adjacent breast tissue
Cavity margin sampling: surgeon biopsies entire wall of residual cavity created by prior procedure; results supercede lumpectomy margins, which are often falsely positive (i.e. positive when cavity margin is negative, Am J Surg Pathol 2005;29:1625)

● Measure and weigh specimen
● Ink margins (deep, superior, inferior, lateral, medial) - can use different colors to establish tumor distance to margins microscopically
● Palpate specimen for masses and correlate with radiograph (if present)
● Orient by using axillary fat as lateral
● If possible, separate axillary nodes into level I (low - inferior to lower border of pectoralis minor muscle in radical mastectomy specimens), level II (middle - between upper and lower borders of pectoralis minor muscle) and level III (high - superior to upper border of pectoralis minor muscle)
● If pectoralis minor muscle not present, separate lymph nodes into upper and lower half
● Should be 20 lymph nodes in usual radical mastectomy
● Recommended to fix overnight with Carnoy’s solution to clear the fat (although this is not often done)
● Section nipple and areola
● Divide breast into quadrants (with marker or mentally)
● Section entire breast into 2 cm thick slices, examine for tumor or suspicious areas
● May want to photograph / make drawing and indicate where sections came from

Describe: specimen, tumor (size in three dimensions, color, distance from margins, consistency, necrosis), fibrosis, cysts (number, size, content), calcifications, gross abnormalities of skin, nipple, scar, biopsy site / cavity and lymph node findings, if margins are submitted as shaved or perpendicular

Sections: nipple (perpendicular cuts to maximize cross sectional area), scar, tumor (at least 3 sections or 1 per cm of diameter, whichever is greater, include center and periphery of tumor and adjacent tissue), other gross lesions, areas of mammographic abnormality, closest tumor margin, other margins, representative sections of nonadipose tissue from each quadrant (upper-outer, lower-outer, upper-inner, lower-inner, Breast J 2003;9:307) and all lymph nodes (separate into upper and lower half or levels (for radical mastectomy), recommended to submit entire node unless grossly involved by tumor, Mod Pathol 1999;12:781)

Grossing a microdochectomy specimen
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Definition: removal of diseased duct system to investigate nipple discharge
● Surgeon marks apex of specimen with suture and leaves probe in affected duct
● Duct may also be wire marked (BMC Cancer 2009;9:151)
● Dissect by making serial slices across duct lumen (or can open duct with fine scissors)
● Should report whether cause for nipple discharge was demonstrated
Additional references: Breast 2008;17:309, BMC Cancer 2006;6:164

Microdochectomy images
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Insertion of ductoscope  Selective lactiferous duct sample

Protocols
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● CAP protocol for excision of DCIS (Arch Pathol Lab Med 2009;133:15)
● CAP protocol for excision of breast cancer (Arch Pathol Lab Med 2000;124:1026)
● CAP protocol: updated regularly - visit http://www.cap.org, then type cancer protocols and checklists into search box
RCPA, Drexel University

Additional references
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Ann Diagn Pathol 2011;15:291

End of Breast malignant, males, children > Miscellaneous > Grossing (histologic sampling) of breast lesions


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