HOME PAGE PRACTICE & PROTOCOLS INVESTIGATIONS BENIGN / BORDERLINE MALIGNANT CASE MATERIAL

Specimen types and tissue handling



Page layout:




Pre-operative diagnosis




FNAs





In the symptomatic clinic FNAs are used to support benign imaging/clinical features to allow the immediate discharge of the patient. Depending on the setting some of these will be backed up by a core biopsy.

Malignant FNAs have the same role in the symptomatic clinic as in screening.

Reporting FNAs


We use a synoptic report which covers all the main points. See also "Communication" for potential pitfalls in reporting:

Synoptic report for FNAs

Reporting Core Biopsies





Synoptic report for core biopsies



Operative Specimens - diagnostic and/or therapeutic





Unoriented diagnostic biopsies



When certain benign lesions have been diagnosed preoperatively they may be managed by simple excision. The commonest lesion is a fibroadenoma but a spectrum of
other benign conditions is possible. If the lesion is small block the case in its entirety. If larger take between two and four representative blocks - you can always go back and take more. See also BMS Trimming.


Oriented diagnostic biopsies



See
BMS Trimming for guidance on how to handle oriented breast biopsies on the dissecting bench.
These will fall into two main categories:

  1. Screening cases, usually for calcs
  2. Symptomatic cases e.g. duct excisions for nipple discharge


The screening cases can be complex and will have to be handled in close correlation with the specimen X ray. It is often necessary to X ray specimen slices to localise calcs precisely to guide block selection. For smaller biopsies (up to 30 grams) it is often sensible to block the entire specimen.

The symptomatic cases may reveal a macroscopic abnormality when the slices are examined. If not, then within reason block the entire specimen. In a larger specimen it is reasonable to take selected blocks and then revisit the specimen having looked at the initial sections and reviewed the core biopsy (if it exists).



Mastectomies



These are usually carried out for the following reasons:





The specimen may be accomanied by a specimen X ray which sometimes helps the pathologist to find the lesion. If there is more than one tumour this should be indicated on the X ray if present and always on the request form.

If the mastectomy has followed screen-detected DCIS (usually multifocal or extensive calcs with core biopsy confirmed DCIS) then it is often necessary to X ray the breast slices to localise the calcs and select blocks appropriately.

Blocks from a mastectomy should concentrate on the lesions rather than macroscopically normal areas. Sample the nearest margin to a carcinoma, a small number of blocks from "normal" breast and one block from the nipple.

Remember - the core biopsy will have confirmed the diagnosis, the purpose of the mastectomy is primarily therapeutic - to give the patient the best chance of surviving her cancer, reduce the risk of local recurrence and also to gather prognostic information - tumour size, grade, lymphatic invasion, receptors and lymph nodes (see below). The synoptic report will cover all these points:



Synoptic report for wide local excisions and mastectomies for cancer:



Lymph nodes



The rationale behind the procedures

Lymph node status is the most important prognostic factor in breast cancer. The choice of type axillary lymph node assessment has to balance the following issues:







Handling and reporting

One of the guiding principles of lymph node assessment in (breast) cancer is to maximise the chance of identifying metastases because of their importance in clinical management. Lymph nodes should be cut to maximise the area visible in the section (multiple thin slices). In some circumstances levels are cut also - see below.

A second guiding principle is to ensure that on review of a case it is possible to be able to count accurately the number of nodes examined and the number of nodes involved. This may seem obvious but when nodes have been sliced and each slide appears to contain multiple fragments this is not easy unless a strict protocol is adhered to. In this department we describe lymph nodes as "A" nodes, "B" nodes and "C" nodes with the following definition:





When reporting metastases give the size in mm of the largest deposit and state whether there is extranodal tumour extension. If nodes are matted together say so in the macro.

Lymph node samples

Treat as "B" nodes, usually one node per cassette unless large.

Sentinel nodes

Treat as "B" nodes, usually one node per cassette. Subsequent sectioning and staining currently controversial. Currently agreed to cut three levels on each block. Immunohistochemistry not required unless it is to confirm a suspicious focus seen on the H&E. This general principle about the use of immunohistochemistry in lymph node assessment applies throughout our breast cancer practice.




Cytokeratin stain used to confirm a small subcapsular lymph node deposit of metastatic carcinoma - in this case the deposit measured marginally >0.2mm on the cytokeratin section and is classified a micrometastasis
In this section the small subcapsular metastatic tumour deposit measured 70 microns and would be classified as 'isolated tumour cells which are sometimes discarded as clinically irrelevant. The deposit measures just over 200 microns on the cytokeratin section and therefore qualifies as a micrometastasis - clinically relevant


Axillary node clearances

Sort into "A", "B" and "C" nodes and block accordingly.



Apical nodes


Usually received as a small piece of fatty tissue containing one or more small nodes. If individual nodes can be dissected then treat as "A", "B" or "C" nodes as appropriate. Otherwise if specimen small process in entirety and assess node numbers/involvement on sections.




Return to top of page