HANDLING AND PROCESSING
MASTECTOMY SPECIMEN.
DRAFT COPY ONLY.
(Procedure 172).
Gladys L. G. Alonsozana, MD.
http://www.netautopsy.org/axsop/axsop172.htm


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United States Government Work, uncopyrighted, public-domain, DRAFT COPY ONLY. This document does not necessarily represent the views or policies of any United States Government agency. This document is provided "as is", without warranty of any kind, express or implied, including but not limited to the warranties of merchantability, fitness for a particular purpose and non-infringement. In no event shall the authors be liable for any claim, damages or other liability, whether in an action of contract, tort or otherwise, arising from, out of, or in connection with the document or the use or other dealings made with the document.



PRINCIPLE OF THE TEST.


A mastectomy is performed for known or suspected cancer, or other clinical indication, and received in surgical pathology for evaluation. The specimen should be oriented, evaluated grossly, surgical margins inked, and any gross abnormalities described thoroughly. The final report should reflect an adequate sampling of tissue, and should include the size and TNM stage of any tumor.



SPECIMEN REQUIRED.


Tissue Specimen and filled-out Tissue Examination Form (USSF515).



REAGENTS, INSTRUMENTATION.


1. Dissection Instruments.



STEP-BY-STEP DESCRIPTION.


BIOPSY FOR MAMMOGRAPHIC ABNORMALITY.


1. A mastectomy is performed for known or suspected cancer, or other clinical indication, and received in surgical pathology for evaluation. The specimen should be oriented, evaluated grossly, surgical margins inked, and any gross abnormalities described thoroughly. The final report should reflect an adequate sampling of tissue, and should include the size and TNM stage of any tumor.

2. Ink the specimen in different colors to demonstrate the main orientation (superior, inferior, medial, lateral). Often a radiographic grid is submitted with the specimen, labeled A,B,C,D,E,... superior-to-inferior; and 1,2,3,4,5,... lateral-to-medial. Make certain that the gross dictation allows the reader to reconstruct the submitted specimen based upon the text alone. While it may be helpful to draw a diagram, these diagrams may become lost, and it is necessary to be able to reconstruct the diagram from text-only.

3. Serially section the specimen into thin slices, 2-3 mm thick.

4. Describe any lesions and distance to the margins.

5. Submit the specimen entirely, even if it involves dozens of tissue-blocks.

6. Be sure to describe which tissue-blocks contain the lesion or the site of the biopsy needle.

LUMPECTOMY.


7. Orient the specimen using attached sutures, and record its dimensions.

8. Use up to six different colors to demonstrate the orientation of specific margins. The best colors in our laboratory are yellow, black, and blue. Red may be confused with hemolyzed blood. Green may be confused with blue.

9. Fix the specimen overnight. Fat fixes very slowly, and unfixed fat is very difficult to cut precisely

10. Serially section the specimen into thin slices, 2-3 mm thick, parallel to the short axis of the specimen.

11. Describe any lesions and distance to the margins.

12. Submit the specimen entirely, in sequential cassettes, even if it involves dozens of tissue-blocks.

13. Oversize lesions should be bisected and submitted in separate cassettes. Cassettes should have tissue no thicker than 3 mm and no wider than 1 cm.

MASTECTOMY.


14. Use the axillary tail to orient the specimen. The axillary tail arises from the upper outer quadrant of the breast.

15. Remove the axillary tail. Dissect out and submit the lymph nodes. Place a pin or other tag into the upper outer quadrant.

16. Turn the breast over so that the posterior aspect faces the prosector, and divide the breast into four quadrants.

17. Note the size, location, and appearance of any tumors.

18. Submit at least five sections of tumor, at least two sections from each quadrant, at least two sections of nipple and skin, and at least two sections from the biopsy site.



FIGURE 172.001.0. Radical mastectomy specimen.
Radical mastectomy specimen.


19. SAMPLE GROSS DICTATION. 
  PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
                 
  1.  SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
  AND "RIGHT BREAST BIOPSY (SHORT SUTURE SUPERIOR, LONG SUTURE
  LATERAL)", AND CONSISTS OF A YELLOW, IRREGULARLY SHAPED PIECE OF
  FIBROADIPOSE TISSUE, MEASURING ... CM SUPERIOR TO INFERIOR, ... CM
  MEDIAL TO LATERAL, AND ... CM ANTERIOR TO POSTERIOR.  A SHORT SUTURE
  DESIGNATES THE SUPERIOR SURFACE AND A LONG SUTURE DESIGNATES THE
  LATERAL SURFACE.  THERE IS A GUIDEWIRE ENTERING THE SUPERIOR-ANTERIOR
  SURFACE, WITH THE TIP ENDING IN THE CENTRAL INFERIOR-POSTERIOR SURFACE.
  IN THE CENTRAL POSTERIOR-INFERIOR SURFACE, THERE IS A BROWN
  CAUTERIZED FIRM AREA, MEASURING ... CM.  THE SPECIMEN
  IS SERIALLY SECTIONED, MEDIAL TO LATERAL, TO REVEAL THAT THE TISSUE
  UNDERLYING THE CAUTERIZED AREA IS WHITE AND FIBROTIC.  THIS FIBROTIC
  AREA MEASURES ... CM SUPERIOR TO INFERIOR, ... CM ANTERIOR TO
  POSTERIOR AND ... CM MEDIAL TO LATERAL.  THIS FIBROTIC AREA ABUTS THE
  POSTERIOR MARGIN AND ABUTS THE ANTERIOR-INFERIOR MARGIN.
  THE MEDIAL-LATERAL ENDS ARE FURTHER SECTIONED SUPERIOR-INFERIOR.
  THE POSTERIOR SURFACE IS INKED BLUE.  THE INFERIOR-ANTERIOR SURFACE
  IS INKED RED, AND THE SUPERIOR-ANTERIOR SURFACE IS INKED YELLOW.
  THE SPECIMEN IS SUBMITTED IN ITS ENTIRETY.
                     
  SUMMARY OF SECTION:
                     
  1-1,  MEDIAL END, INFERIOR PORTION, MULTIPLE PIECES.
                     
  1-2,  MEDIAL END, SUPERIOR PORTION, MULTIPLE PIECES.
                        
  1-3,  LATERAL TO 1-1, AND 1-2,  1 PIECE.
                        
  1-4,  LATERAL TO 1-3, INFERIOR PORTION, 1 PIECE.
                       
  1-5,  LATERAL TO 1-3, SUPERIOR PORTION, 1 PIECE.
                       
  1-6,  LATERAL TO 1-4, INFERIOR PORTION, 1 PIECE.
                       
  1-7,  LATERAL TO 1-5, SUPERIOR PORTION, 1 PIECE.
                          
  1-8,  LATERAL TO 1-6, INFERIOR PORTION, 1 PIECE.
                       
  1-9,  LATERAL TO 1-7, SUPERIOR PORTION, 1 PIECE.
                          
  1-10,  LATERAL END, INFERIOR PORTION, 3 PIECES.
                    
  1-11,  LATERAL END, SUPERIOR PORTION, 3 PIECES.
                    
  1-12,  SUPERIOR HALF, 1 PIECE.
                 
  1-13,  INFERIOR HALF, 1 PIECE.
                     
  1-14,  SUPERIOR HALF, 1 PIECE.
                        
  1-15,  INFERIOR HALF, 1 PIECE.
Assay results for ER/PR (ER/PR Pharm Dx Kit, DAKO Co. ER monoclonal anti-human clone 1D5 PR monoclonal anti-human clone PgR 636) and Her-2-neu (HercepTest X, DAKO Co., monoclonal anti-human clone PN2A) performed on formalin-fixed paraffin-embedded tissue were performed (Quest Diagnostics Nichols Institute, CA) with the following results:

Estrogen receptor:
Progesterone receptor:
Her-2 stain intensity:

Scoring system used:

0: NEGATIVE for overexpression by immunohistochemistry. Reflex testing by FISH is not performed.

1+: NEGATIVE for overexpression by immunohistochemistry. Reflex FISH testing is performed (see below)

2+: WEAKLY POSITIVE for overexpression by immunohistochemistry. Reflex FISH testing is performed (see below).

3+: STRONGLY POSITIVE for overexpression by immunohistochemistry. Reflex FISH testing is not performed.

Reference: CAP Strategic Science I: Her-2/neu testing of Breast Cancer Patients in Clinical Practice. May 4&5, 2002. Rosemont, Illinois.

DNA index/ploidy (PATHVYSION/FISH):
S-phase fraction:

20. TNM STAGING.


TUMOR STAGING:
T0 ... No primary.
T1 ... 2 cm or less.
T1a ... <0.5 cm.
T1b ... 0.5-1 cm.
T1c ... 1-2 cm.
T2 ... 2-5 cm.
T3 ... >5 cm.
T4 ... Any size with:
T4a ... Extension to chest wall.
T4b ... Edema or ulceration of the skin.
T4c ... T4a and T4b.
T4d ... Inflammatory carcinoma.

NODAL STAGING:
N0 ... None.
N1 ... Moveable ipsilateral axillary nodes.
N1a ... All lymph node metastases <0.2 cm.
N1b ... LN metastasis >0.2cm.
N1bi ... 1-3 LNs, all <2cm.
N1bii ... >=4 LNs, all <2 cm.
N1biii ... Beyond LN capsule, <2 cm.
N1biv ... Any lymph node >2 cm.
N2 ... Fixed ipsilateral axillary nodes.
N3 ... Ipsilateral internal mammary nodes positive.

METASTASIS STAGING:
M0 ... No metastases.
M1 ... Distant metastases (includes pelvic lymph nodes).



REFERENCES.


1. Rosai J.
Rosai and Ackerman's Surgical Pathology. Ninth Edition.
St Louis: C.V. Mosby. 2004;:.
ISBN: 0323013422, 3080 pages.

2. Mills SE, Carter D, Greenson JK, Oberman HA, Reuter VE, Stoler MH, eds.
Sternberg's Diagnostic Surgical Pathology. Fourth Edition.
New York: Lippincott Williams & Wilkins. 2004;:.
ISBN: 0781740517, 3089 pages.

3. Westra WH, Hruban RH, Phelps TH, Isacson C.
Surgical Pathology Dissection. An Illustrated Guide. Second Edition. With a Forward by Askin FB.
New York: Springer. 2002;:.
ISBN 0-387-95559-3, 258 pages.

4. Lester SC.
Manual of Surgical Pathology.
New York: Churchill Livingstone. A Harcourt Health Sciences Company. 2001;:.
ISBN 0-443-07918-8, 336 pages.

5. Sinard JH.
Outlines in Pathology.
Philadelphia: W.B.Saunders Company. A Harcourt Health Sciences Company. 1996.
ISBN 0-7216-6341-9, 229 pages.

6. American Joint Committee on Cancer.
AJCC Cancer Staging Manual. Sixth Edition.
New York: Springer. 2002.
ISBN 0-387-95271-3, 421 pages.