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Handling the Surgical Specimen

 
 
Method of Specimen Handling
Dr. Yao-Shi Fu
Department of Pathology
Providence Saint Joseph Medical Center
Burbank, California
1. Stereotactic Core Biopsy
 
1. Should use proper sized needle to obtain tissue at least 10 mm in length and 1 mm in diameter to allow for preservation of tissue architecture and to minimize crush artefact.
2. The use of smaller needle results in tissue fragmentation and crush artefact, both impede optimal interpretation and accurate diagnosis.
3. Once the tissue is removed from the needle, it is first placed on a piece of paper, such as index card for the purpose of x-ray study if necessary. If the tissue is placed directly into formalin, the tissue curls due to uneven tissue contraction.
4. Tissue sections should be cut at least three levels to ensure inclusion of diagnostic tissue.
5. If biopsies are performed from more than one site, label and submit each biopsy separately. (Slide 1 and Slide 2)
 
 
2.Excision of mammographically detected lesion
 
1. Excised specimen with J wire is first radiographed to ensure removal of calcified area.
2. Orient the excised specimen for anterior, posterior, superior, inferior, medial, lateral borders by sutures or a diagram. The location of nipple in relation to the specimen is helpful to know. It is assumed that most lesions of DCIS start in the terminal duct and lobular unit, and spread proximally towards the nipple.
3. Once received in the pathology laboratory, the pathologist applies different colored ink for specific margins (Slide 3 and Slide 4).
Once the specimen is cut without proper orientation, it is impossible to reconstruct the sliced tissue fragments for the following parameters:
1. tumor size
2. surgical margin
3. multifocality
4. Pathologist slices the entire specimen at 3-4 mm thickness to identify gross lesions.
The presence of a gross lesion greater than 1 cm justifies the performance of frozen section to determine the nature and the status of surgical margin.
Frozen section diagnosis on a specimen without gross lesion or on a lesion less than 1 cm in size is of questionable value.
5. Describe the gross abnormal findings, including lesion size, shape, borders, consistency, appearance, necrosis, hemorrhage, cysts, and relationship to surgical margins.
6. Most fibrous areas are submitted for histologic examination
Small DCIS may not be apparent grossly.
7. Notice the tissue artefact of prior needle biopsy
 
3. Tissue Artefacts of Prior Needle Biopsy
 
1. Hemorrhage
2. Necrosis
3. Granulation and scar tissue
4. Distorted glands in the stroma and scar tissue of needle tract of DCIS and benign intraductal papilloma can simulatie invasive carcinoma
5. Reactive nuclear atypia
6. Epithelial cells misplaced by needle simulating vascular space invasion.
 
4. Method of reporting surgical margins
 
1. Margin positive: tumor cells are cut through as indicated by their presence on the inked border or crush artefact (Slide 6 and Slide 7)
2. Margin clear but close to tumor cells. Specify the distance from margin within one high power microscopic field, 1 mm, or 2 mm (Slide 8)
3. Margin clear by more than 3 mm or 5 mm (Slide 9)
 
5. Why a clear margin does not necessarily correspond to a true tumor free margin?
 
1. Tumor cells spread in ducts with three dimension, the involved ducts may not appear in a two dimensional tissue sections
2. Lesions may be multifocal, multicentric or skip
3. In case of invasive carcinoma, tumor cells spread by vascular lymphatic spaces
4. Routine histologic sections are not serial sections
5. In a study involving 181 women, whose initial excisional biopsies had a 1 mm or more of clearance for DCIS, 43% had residual disease in mastectomy or reexcision specimens. This is in contrast to 76% of residual disease, when the clearance for DCIS is less than 1 mm (Silverstein et al). Comedo type and tumor size greater than 2.5 cm have high frequency of residual disease.

References:

Photos - Slides


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