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Macroscopy and cut up

 Breast resections are performed for: ◦ malignancy (most commonly carcinomas) ◦ Pre-malignant in situ disease
  • Breast resections are performed for: malignancy (most commonly carcinomas) Pre-malignant in situ disease Some benign masses (e.g. fibroadenomas, intraductal papillomas)

  • The majority of resections are performed for malignancy/pre-malignant disease so margins

are very important.

  • Excision specimens may also re-excise a cavity when previous carcinoma was reported to have close or involved margins.

 Wide local excision  Mastectomy ◦ Post neoadjuvant therapy ◦ Completion mastectomy ◦ Prophylactic mastectomy
  • Wide local excision

  • Mastectomy

Post neoadjuvant therapy

Completion mastectomy

Prophylactic mastectomy

  • Breast reduction surgery

  • Others:

Partial mastectomy Quadrantectomy Segmentectomy Re-excision Duct dissection Nipple wedge excision

It is customary to specify the position of a breast lesion in terms of distance from
It is customary to specify the position of a breast lesion in terms of distance from

It is customary to specify the position of a breast lesion in

terms of distance from the nipple and clock face orientation.

 Familiarise yourself with the results of any previous breast histopathology or cytology from the patient,
  • Familiarise yourself with the results of any

previous breast histopathology or cytology from the patient, and results of specimen radiography, which should be listed on the clinical request

form.

  • Read the clinical notes carefully and be clear as to the type of specimen being considered. In the case of a mastectomy, look for any attached axillary tissue (axillary tail).

  • It is particularly important to ensure that the laterality of the specimen (left or right) is clearly determined and dictated accurately.

 “Pushing through” poorly fixed specimens is strongly discouraged, as this will only make sections difficult
  • “Pushing through” poorly fixed specimens is strongly discouraged, as this will only make sections difficult to cut the next day, usually resulting in poor quality histological material

with suboptimal demonstration of margins.

  • Never take blocks which exceed 3mm in

thickness and which exceed the area of the

holes in the processing cassette: this will lead to processing difficulties and poor quality

sections.

 DCIS /LCIS  Ductal carcinoma in situ / lobular carcinoma in situ – pre- malignant
  • DCIS /LCIS

  • Ductal carcinoma in situ / lobular carcinoma in situ pre- malignant lesions

  • Neoadjuvant therapy

  • Some patients with known breast cancer will have chemotherapy before surgery in order to shrink the tumour it is important to accurately identify and sample the tumour bed in these cases as the presence of any residual tumour has important prognostic implications. For now, leave these cases for the registrar to cut.

  • BRCA 1 or BRCA 2

  • An inherited genetic mutation that predisposes to breast cancer and some other gynaecological cancers. These women may be having prophylactic mastectomies or may already have developed tumours

 Breast specimens are often received fresh. Fresh mastectomy specimens require serial slicing to permit adequate
  • Breast specimens are often received fresh. Fresh mastectomy specimens require serial slicing to permit adequate fixation (WLEs are usually not sliced when fresh).

  • Ink the margins of the mastectomy before serial partial slicing from the posterior aspect

at 1cm intervals in the sagittal plane

  • Insert formalin-soaked paper towelling between slices and place in a container of suitable size with adequate formalin.

 Fixation of breast tissue is a critical factor for accurate biomarker testing. A minimum of
  • Fixation of breast tissue is a critical factor for

accurate biomarker testing. A minimum of 8 hours to a maximum of 72 hours is considered essential.

  • For mastectomy specimens containing a tumour

visible during initial slicing, expose the cut surface of the lesion and remove a thin block of tumour trimmed of fat for immediate fixation.

This block will be used for hormone receptor IHC

and other tests.

  • If there are multiple tumours, blocks can be differentially inked or differentially shaped and placed in the same cassette.

 Watch the RCPA videos, “Video 2. Breast re - excision specimen orientation” and “Video 3.http://www.rcpa.edu.au/Library/Practising- Pathology/Macroscopic-Cut- Up/Specimen/Breast/Breast-tumour-resection  (note that we do not usually weigh breast resections taken for malignancy, only breast reductions) " id="pdf-obj-9-2" src="pdf-obj-9-2.jpg">
 The macroscopic template BREASTCA is to be used for mastectomies for DCIS or cancer. 
  • The macroscopic template BREASTCA is to be used for

mastectomies for DCIS or cancer.

  • A breast macroscopic description diagram form FOR- APHI-005, is available in the cut up room.

  • After fixation, dictate a comprehensive macroscopic

description which states:

the nature of the specimen the anatomical components of the tissue including any skin/nipple/axillary tail, the orientation, presence and position of an orientating wire, the appearance of any accompanying radiographs, the orientation of inking, how the specimen was sliced (orientation and number designation of slices), and whether a fresh block was taken for hormone receptors.

 Always seek the assistance of the supervising pathologist in situations where the position of a
  • Always seek the assistance of the supervising

pathologist in situations where the position of a known

lesion is difficult to find.

  • Describe the appearance of the cut surface of the lesion:

Size Consistency Growth pattern or outline (circumscribed, stellate, invasive)

Distance from margins (specify macroscopic clearance in mm from each of medial, lateral, superior, inferior, superficial and deep margins)

Distance from nipple

Appearance of surrounding tissues, i.e. whether pale/fibrous or mainly fatty

Presence of previous biopsy tract

 For multiple lesions, also describe distance of lesions from each other, including outermost dimensions of
  • For multiple lesions, also describe distance of lesions from each other, including outermost dimensions of the lesions, along with distance from the nipple and margins for each lesion.

  • The presence, and dimensions of skin in the specimen must be recorded. The presence of abnormalities must be recorded (Ulceration,

Paget’s, satellite nodules, other).

  • The presence of muscle must be recorded.

  • Differentially ink in at least three colours.

Deep or posterior surface black Anterior or subcutaneous surface red

Superior surface blue, inferior surface green if specimen is sliced parasagitally from medial to lateral

Medial surface blue, lateral surface green in cases sliced horizontally

  • Use the breast macroscopic description form. FOR-APHI-005 to indicate numbering and orientation of slices and the position of block selection

  • Sample tumours up to 4 blocks, obtaining a full face of maximum dimension of tumour; composite blocks may be required for large tumours. If composite blocks are used, try to indicate on the block where these join up, with small nicks on adjoining edges or inking adjoining edges with the same colour.

  • For all margins less than 10mm from the lesion, take blocks to show tumour with adjacent margins

  • For more distant margins, take a representative section which does not need to contain tumour.

  • Take blocks to show tumour with adjacent firm, pale or fibrous breast tissue, not fat.

  • The end pieces of the WLE should be sectioned perpendicularly to best demonstrate these margins.

  • For WLEs not completely embedded (this will be most of them) it is important to store the slices in such a way as to allow orientation by a pathologist reviewing the macroscopic specimen.

  • See: “Video 8. Breast re-excision specimen residual tissueat

 Specimen designated “right breast WLE”. The specimen comprises an ovoid mass of fatty tissue with
  • Specimen designated “right breast WLE”. The specimen comprises an ovoid mass of fatty tissue with attached orientating sutures (long lateral, short superior, medium medial). The specimen is accompanied by an Austin supplementary information for pathologist form. The dimensions of the specimen are 60mm superoinferiorly, 70 mm mediolaterally, and 40mm from superficial to deep. The surfaces and edges are inked as follows: (insert details). The specimen is sliced sagitally (superior to inferior) and rendered into 10 slices (slice 1 = medial margin, slice 10 = lateral margin). The cut surfaces are predominantly fatty. In slices 6, 7 and 8 there is a white tumour with a stellate form, 15x10x8mm. The tumour is situated --- from the superior margin, --- from the inferior margin, --- from the superficial surface, --- from the deep surface, --- from medial margin and --- from lateral margin. A breast macroscopic description diagram has been completed. Block selection:

 For re-excision (cavity) specimens the original and new margins must be inked in different colours
  • For re-excision (cavity) specimens the

original and new margins must be inked in different colours before cutting (original

margin blue, new margin green). Usually the

cavity surface will be concave, and marked with a suture.

 Ink margins with one colour  The anterior end is usually orientated with a suture
  • Ink margins with one colour

  • The anterior end is usually orientated with a suture

  • Slice perpendicular to long axis of specimen at 3mm intervals.

  • A lesion may or may not be identified macroscopically

  • As these specimens are usually small, they are to be blocked entirely if up to 12 cassettes, in order from superficial) nipple end to deep, with superficial en face end-slice alone in first cassette, and deep en face end-

slice alone in last cassette, although for intervening tissue, up to 2 slices may be placed in a cassette if size allows.

  • For larger specimens of this type, block all lesions, and every second tissue slice (with unblocked tissue stored to allow orientation).

 Differentially ink with two colours the deep surface (usually black or blue) and the anterior/subcutaneous
  • Differentially ink with two colours the deep

surface (usually black or blue) and the anterior/subcutaneous tissue (usually red or

yellow)

  • Slice mastectomies at 1 cm intervals with sub-slicing at 3mm intervals as appropriate.

 Take up to 4 blocks or 5 blocks (at least 1 or 2) from obvious
  • Take up to 4 blocks or 5 blocks (at least 1 or 2) from obvious or suspected tumours, demonstrating relationship to deep margin, skin and nearest radial margin if possible.

  • Take composite blocks of an entire face of the lesional area. Ensure you designate the orientation of each block (e.g. most superior to most inferior, etc)

  • In a large lesion, the overall lesional size may be a combination of carcinoma and DCIS, and a full-face composite section is required to accurately determine the size of carcinoma and DCIS components.

  • If the tumour is multifocal, sample each focus plus all the intervening macroscopically normal breast tissue so that it can be ascertained as to whether the tumours are multifocal or in continuity.

  • For cavities, sample macroscopic tumour or suspicious areas, otherwise 1 section from each wall and include any close margins; take additional sections if likely site of residual tumour is known from the previous pathology report.

  • In cases of DCIS, thoroughly sample pale or grossly abnormal areas guided by clinical information, including adjacent areas of close margin.

  • For sampling of skin, take 1 section from any scar or lesion, more if there is a clinical history of inflammatory carcinoma. In cases of inflammatory carcinoma, areas of cutaneous abnormality and sections from 3, 6, 9 and 12 o’clock skin margins should be sampled.

  • For sampling of nipple, take 2 sections (perpendicular and deep en face).

  • Deep margin, take 1 section at the closest point to the tumour or directly beneath a cavity; always take the section in a perpendicular fashion.

  • Sample other margins if the tumour is very close.

  • One section from each quadrant should be taken, from firm, white or fibrous areas of breast NOT adipose tissue.

 Any identified lesions must be blocked.  In the absence of any gross abnormality, sample:
  • Any identified lesions must be blocked.

  • In the absence of any gross abnormality, sample: 2 blocks of fibrous tissue areas from each of the four quadrants 2 block from the nipple-areolar area.

 Discuss these cases with the supervising Pathologist. The extent of disease is not always macroscopically
  • Discuss these cases with the supervising Pathologist.

The extent of disease is not always macroscopically

apparent.

  • In WLE performed for microcalcification/DCIS, the entire specimen may need to be blocked, especially if

there is no accompanying x-ray.

  • For mastectomies take blocks widely, at measured intervals (measured from a fixed location, ideally nipple) so that overall lesional size can be determined. It is crucial to sample beyond the edges of macroscopically involved areas, to prove outermost lesional extent.

 Each separate lymph node identified in any attached axilla (or separate axillary dissection) must be

Each separate lymph node identified in any attached axilla (or separate axillary dissection) must be completely embedded

Nodes less than 5mm in size can be submitted whole.

Nodes larger than this must be serially sliced at 2-

3mm intervals and completely embedded.

Dissect and embed lymph nodes from apical to mid

and lower axillary levels, placing the apical nodes in a

separate block. You may place multiple slices from multiple nodes in one block, but ink the nodes in

different colours before slicing.

 If a frozen section has been performed, make sure you dictate everything written on the
  • If a frozen section has been performed, make sure you dictate everything written on the FS form, including the pathologist and

time reported.

  • Describe if blue, submit each node entirely, whole or sliced, in separate blocks if >1 node

  • If the node is more than 5mm, it should be sliced at 2mm intervals and all submitted.

  • If more than 1 node is submitted as a sentinel node, each node should be submitted in separate blocks.

  • Try to minimise the number of blocks.

  • In pencil write “SN” on the label of the cassette so that the person embedding the next morning can quickly identify the sentinel nodes.

  • The antibody AE1/AE3 is automatically requested at the time of cut-up on each separate block using the email IHC requesting

system.