1. Stereotactic Core Biopsy
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- 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)
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| 2.Excision
of mammographically detected lesion |
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- 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
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| 3.
Tissue Artefacts of Prior Needle Biopsy |
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- 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.
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| 4.
Method of reporting surgical margins |
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- 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)
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| 5. Why
a clear margin does not necessarily correspond to
a true tumor free margin? |
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- 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.
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