Transcript Surgical Patholology - SGPGI-Breast Health Programme

Surgical Pathology of
Wide Local Excision of Breast
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The Specimen
Oval of overlying skin, including any scar
Suture tags : 3 (2 with skin)
 Superior margin with one silk suture
 Lateral margin with two silk sutures
The specimen should not be cut by the
surgeon
 This interferes with gross identification
and inking of margins
Key Issues in Grossing
Exact tumor size
Ductal Carcinoma in Situ
Surgical margins
Tumor Size Measurement
 Gross size of tumor measured with a scale
 Two cross sections with maximum diameter
 Process cross section of entire tumor
 Within one slide if < 1 cm
 Measure size of tumor on microscope stage
 Stage vernier
 Compare gross and microscopic size
 Tumor shows 10-20% shrinkage on slide
Gross size
measurement
Microscopic examination is used to
revise the basic gross measurement
downwards
Gross size
measurement
Microscopic examination is used to
revise the basic gross measurement
upwards
When is this Important?
When tumor size is 0.5 – 2 cm on gross
TNM: T 1 is < 2 cm
 T 1a : < 0.5 cm
Van Nuys (DCIS)
 T 1b : 0.5 – 1.0 cm
1.5 cm
 T 1c : 1.0 – 2.0 cm
Tumor size < 1cm have 10-15% nodal
metastasis and 90% ten year survival
DCIS
Present alone (mammographic detection)
Present adjacent to a carcinoma
Size measurement is important
Evaluation of margins is very important
 Only DCIS: Prognostic relevance
 Adjacent to Ca: Complicates the proper
evaluation of margins
Van Nuys Prognostic Index
Feature
Van Nuys Score
1
2
3
Tumor size (mm)
<15
16-40
>40
Margin (mm)
>10
1-9
<1
1
2
3
-
+
+/-
1-2
1-2
3
Pathology grade
Necrosis
Nuclear Grade
Evaluation of Margins
Tumor bed biopsy by surgeon
Specimen scrape cytology
Shaved margins: sampling by pathologist
Shaved margins: total
Inked margins
Evaluation of Margins
Tumor bed biopsy by surgeon
Specimen scrape cytology
Shaved margins: sampling by pathologist
Shaved margins: total
Inked margins
Evaluation of Margins
Tumor bed biopsy by surgeon
Specimen scrape cytology
Shaved margins: sampling by pathologist
Shaved margins: total
Inked margins
Inking the Margins
Paint entire surface of specimen with ink
Nature of ink: Insoluble
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
Water, formalin
Alcohol
Acetone
Xylene
Paraffin
Cut into the specimen margin for sections.
Ink on margin will be visible on microscopy
Inking Alternatives
India Ink
Mercurochrome
Alcian Blue with Picric Acid fixation
Method:
Fix uncut specimen for 30 mins in formalin, blot
Paint the surface of specimen with the ink
Wait for 15 mins to dry
Keep in formalin for another 15 mins to wash
away excess ink and to fix the ink
 Serial section the specimen and overnight fix
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Ideal: Sequential Processing
•The entire specimen is processed
•Sequential serial sections end to end
Infiltrating duct carcinoma at inked margin
Ink washout: tumor close to margin
DCIS 5 mm from margin
Surrounding Breast
DCIS or LCIS
Atypical ductal/lobular hyperplasia
Lymphatic permeation
Pagetoid spread along the ducts
Future Options
Muc1 RT-PCR of drainage fluid
Specimen scrape cytology
Sentinel Lymph Node imprint cytology
Summary:
Must Do’s of Pathology
Accurate tumor size measurement
Assessment of margins in wide local
excision
 Tumor bed sampling by surgeon
 Shave sampling by pathologist
 Inking of small excision samples
Proper evaluation of DCIS component and
its relation to margin
What is an adequate margin
>=1 cm:
Adequate
>=5 mm:
Not adequate, evaluate
1 -5 mm:
Inadequate
<=1mm:
Positive margin