Surgical Pathology of Wide Local Excision of Breast Venkateswaran K Iyer Assistant Professor Department of Pathology ALL INDIA INSTITUTE OF MEDICAL SCIENCES These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

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 Van Nuys Score Feature 1 2 3 Tumor size (mm) <15 16-40 >40 Margin (mm) >10 1-9 <1 Pathology grade 1 2 3 Necrosis - + +/- Nuclear Grade 1-2 1-2 3

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 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

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

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