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Macroscopy and cut up

 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
 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 the nipple and clock face orientation.
 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 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 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 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 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.
Breast re-excision specimen dimensions” at:

 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)
 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 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 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

 Slice fixed WLEs at 3mm

 See Video 4 & Video 5. Breast re-excision specimen


dissection at
http://www.rcpa.edu.au/Library/Practising-
Pathology/Macroscopic-Cut-
Up/Specimen/Breast/Breast-tumour-resection
 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.
 See “Video 7. Breast re-excision specimen block allocation” at
http://www.rcpa.edu.au/Library/Practising-Pathology/Macroscopic-
Cut-Up/Specimen/Breast/Breast-tumour-resection
 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 tissue” at
http://www.rcpa.edu.au/Library/Practising-
Pathology/Macroscopic-Cut-
Up/Specimen/Breast/Breast-tumour-resection
 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 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
 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 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 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:
◦ 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
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
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 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.