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Surgical Pathology of Wide Local Excision of Breast These Power Point presentations are free to download only for academic purposes, with due acknowledgements.

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Presentation on theme: "Surgical Pathology of Wide Local Excision of Breast These Power Point presentations are free to download only for academic purposes, with due acknowledgements."— Presentation transcript:

1 Surgical Pathology of Wide Local Excision of Breast These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

2 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

3 Key Issues in Grossing  Exact tumor size  Ductal Carcinoma in Situ  Surgical margins

4 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

5 Gross size measurement Microscopic examination is used to revise the basic gross measurement downwards

6 Gross size measurement Microscopic examination is used to revise the basic gross measurement upwards

7 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

8 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

9 Van Nuys Prognostic Index Van Nuys Score Feature Tumor size (mm) 40 Margin (mm) > <1 Pathology grade Necrosis - + +/- Nuclear Grade

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11 Evaluation of Margins  Tumor bed biopsy by surgeon  Specimen scrape cytology  Shaved margins: sampling by pathologist  Shaved margins: total  Inked margins

12 Evaluation of Margins  Tumor bed biopsy by surgeon  Specimen scrape cytology  Shaved margins: sampling by pathologist  Shaved margins: total  Inked margins

13 Evaluation of Margins  Tumor bed biopsy by surgeon  Specimen scrape cytology  Shaved margins: sampling by pathologist  Shaved margins: total  Inked margins

14 Inking the Margins  Paint entire surface of specimen with ink  Nature of ink: Insoluble  Water, formalin  Alcohol  Acetone  Xylene  Paraffin  Cut into the specimen margin for sections.  Ink on margin will be visible on microscopy

15 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

16 Ideal: Sequential Processing The entire specimen is processed Sequential serial sections end to end

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23 Infiltrating duct carcinoma at inked margin Ink washout: tumor close to margin DCIS 5 mm from margin

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29 Surrounding Breast  DCIS or LCIS  Atypical ductal/lobular hyperplasia  Lymphatic permeation  Pagetoid spread along the ducts

30 Future Options  Muc1 RT-PCR of drainage fluid  Specimen scrape cytology  Sentinel Lymph Node imprint cytology

31 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

32 What is an adequate margin  >=1 cm: Adequate  >=5 mm: Not adequate, evaluate  1 -5 mm: Inadequate  <=1mm:Positive margin

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