GP2-A2 TEMPLATEpathology.ucla.edu/workfiles/Education/Breast_2018.docx · Web viewSP 1.02.02...

Department of Pathology and Laboratory Medicine Procedure# SP 1.02.02Surgical Pathology Effective Date: 8/15/16 Los Angeles, California 90095 Page

BREAST PATHOLOGY GROSSING GUIDELINES

THINGS TO CONSIDER:

A. Please review ALL imaging and previous biopsies PRIOR to grossing any breast case.

a. It may be helpful to draw out your own guide to assist when grossingB. Faxitron your breast to look for clips and calcs. Make sure the clip location(s)

correlates with imaging. a. Place mastectomies into Faxitron with POSTERIOR surface down

C. After sectioning your breast into levels, when evaluating the mass size, make sure the dimensions correlate with clinical findings (do not calculate the mass size based off the presence of a mass in certain levels, as this may give you an incorrect and overestimated size).

D. If you receive a mastectomy with multifocal lesions, measure and document the distance between the lesions in your gross.

E. Be descriptive in your cassette summary as this is useful when reviewing your slides the following day.

a. Document level and location of your sections:i. Level 1- superior OR level 1- upper inner quadrantii. Level 13- parenchyma between lesion #1 and lesion #2iii. Level 4- lesion #1 at closest approach to posterior marginiv. Level 2- lesion #1 in relation to superior margin

FORMALIN FIXATION

Specimen collection time: The OR nurses record the collection time of all breast specimens in Beaker. This time indicates when the breast specimen has been removed from the patient. The OR staff will contact SurgPath personnel to pick up every breast lumpectomy and mastectomy to try and ensure the ischemic time is within the appropriate limits.

Ischemic time: Breast excisions/re-excisions/lumpectomies/partial mastectomies and all mastectomies (including prophylactic ones) are to be immediately (within 1 hour) weighed and placed in 10% neutral buffered formalin (NBF) once received or picked up from the OR. Ideally, this task will be performed by the personnel/technician prior to accessioning the case. The time the specimen was placed in 10% NBF will be written on the specimen container and documented in Case Notes in Beaker. The collection time and the time the specimen has been placed in 10% NBF will be used to calculate ischemic time:

(Time tissue placed in formalin) – (Collection time) = Ischemic TimeSP 1.02.02 Handling Original Blocks and Slides.doc Surgical Pathology SOP Manual


Due to CAP-recommended guidelines for ER, PR, and HER2/neu (including FISH) testing, as much as possible, specimens should be placed in formalin within one hour after surgery. Furthermore, the breast tissue should be in contact with formalin for 6-48 hours, not to exceed 72 hours. Therefore, when a specimen comes in late on Friday, gross the specimen such that you identify the tumor and submit sections of the tumor for the Friday late processor. If the specimen is still very fresh, then please submit the remaining sections (including lymph nodes) during the weekend such that they’ll run on the Sunday processor.

When a specimen comes in on the weekend (occasionally on Saturdays), then please gross the entire specimen and submit sections for the Sunday processor. For such Saturday specimens, waiting until Monday to submit sections for the Monday processor will result in suboptimal testing conditions for breast biomarkers, since this will exceed the recommended 48-hour ideal formalin fixation time frame.

As always, RECORD THE ISCHEMIC TIME AND THE FORMALIN FIXATION TIME

Note: The exception to this is when the requisition states 'Rule out Lymphoma' or a prior core needle biopsy diagnosis was reported as lymphoma. In these cases, call for a lymphoma work-up and DO NOT fix the breast tissue in 10% NBF.

Calculating formalin fixation times (Westwood):Monday – Thursday calculate fixation time until 3amFriday calculate fixation time until 2amSaturday - Sunday calculate fixation time until 8pm on Sunday

Holiday weekends contact histology to ensure cassettes are transferred from formalin and placed into alcohol so as not to exceed the formalin fixation time (6-72 hours). The tissue is in formalin for 2 hours on the processor, so please be mindful of accounting for this when calculating fixation times

Calculating formalin fixation times (Santa Monica):Monday – Thursday 6:30 pm VIP load: calculate fixation time until 8:30pm

Late load: calculate fixation time until 3am

Friday calculate fixation time until 2amSaturday - Sunday calculate fixation time until 8pm on Sunday

SP 1.02.02 Handling Original Blocks and Slides.doc Surgical Pathology SOP Manual


SURGICAL PATHOLOGY SPECIMEN RADIOGRAPHY: FAXITRON

Faxitron image(s) must be obtained and uploaded into Beaker for the following specimen types:1) All excisional biopsy/lumpectomy/partial mastectomy specimens in order to verify microclip(s) and/or microcalcifications 2) All mastectomy specimens 3) Consider Faxitron imaging paraffin blocks of needle core biopsies as needed for microcalcifications (when initial 3 H&E sections do not show calcs and specimen radiography showed calcs)

When an image is taken, an annotation of the patient’s name and surgical case number must be included in each image. Any additional annotations that are relevant to the particular case should also be included, for instance, measurement(s) and relationships of specific anatomic locations to lesion(s), size of tumor, area of calcifications, location of suspicious area(s), summary of sections, etc.

Image(s) should be uploaded into the case in Beaker; this must be noted in the gross description for billing purposes. (i.e., “A Faxitron image was taken of the specimen.”)

A PDF copy of the Faxitron user manual can be downloaded from the Resident’s Corner website:

http://164.67.97.205/residents/manuals/index?folder%5fid=39110


http://164.67.97.205/residents/manuals/index?folder_id=39110


Specimen Type: NEEDLE CORE BIOPSY Procedure:

1. Count number of cores2. Measure lengths or range of lengths and average diameter of cores3. If specimen taken for calcifications, indicate how many cores are received in

mesh bag/cassette and designate which cassette these cores are placed in, as they will most often contain the calcifications

4.Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] are [number of core biopsies/color/size] measuring [aggregate/range]. The specimen is entirely submitted in [number of cassettes].

Total Ischemic Time: [***] minutesTotal Formalin fixation Time: [***] hours

Cassette Submission: All tissue submitted. Dictate as a RUSH case and ensure case has been accessioned with a BREAST PACKAGE (H&E x3 and unstained immune slides x3).

Specimen Type: IMPLANTS/EXPANDERS/PROSTHESIS with and without CAPSULEProcedure:

1. Photograph all implants/expanders and indicate defects with probe2. Weigh, measure3. Document if intact, ruptured (measure size of tear), or deflated

a. If NO defect identified please include “no defects are identified with firm pressure” in gross description

4. Silicone vs saline; surface of implant- textured/smooth5. Describe attached capsule if present (weigh, measure, describe inner lining,

and presence of calcs)6. Dictate any medical inscriptions7. Log into Gross Only log book as specimen may have medico-legal

implications

Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a [***g], [***x***x***cm] [intact/ruptured/deflated] [silicone/saline] implant with the following medical inscription: “__.” The external surface is [textured/smooth/describe adherent tissue]. A gross photograph is taken. The specimen is for gross examination only.



Cassette Submission: Up to two cassette of adherent soft tissue (please remove last sentences in template). If no adherent soft tissue is identified, no sections are submitted (gross only).

Specimen Type: REDUCTION MAMMOPLASTY/ GYNECOMASTIA/ GENDER DYSPHORIAProcedure:

1. Weigh in aggregate if fragmented2. Measure (range and aggregate)3. Document number of portions lined with skin (check for skin lesions/scars)4. Describe cut surfaces (masses, cysts, %fibrous and %fatty tissue)

Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] are [number of portions] ranging from [***-***cm] in maximum dimensions and aggregating to [***x***x***cm]. [number] of portions are surfaced with [pink-tan/unremarkable] skin. Sectioning reveals [describe cut surfaces]. The tissue consists of __% tan-yellow adipose tissue and __% white fibrous tissue. No lesions or masses are identified.

Cassette Submission: 3-5 cassettes (more if gross abnormality identified). Can include two sections of tissue in each cassette. Include skin with at least one section. If specimen is just breast skin you may submit one cassette of three representative cross sections.A1 Fibroadipose tissue and skinA2-A5 Fibroadipose tissue

Specimen Type: MARGIN EXCISION/ RE-EXCISION Procedure:

A. Oriented margin1. Measure 2. Ink new margin black and remaining surface blue3. Section perpendicular to new margin and longest dimension4. Describe cut surface and any grossly identifiable masses

B. Un-oriented margin1. If fragmented- aggregate weight, measurement- embed uninked2. If intact- weigh, measure

a. ink external surfaceb. section perpendicular to longest dimensionc. describe cut surface and grossly identifiable masses



Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is an [oriented/un-oriented] margin (re)excision with a suture indicating [new margin]. The specimen measures [***x***x***cm] in greatest overall dimension. Sectioning reveals [describe cut surfaces]. The specimen is entirely submitted sequentially from one end to the opposite end. Ink Key:Black- new marginBlue- remaining surface

Cassette Submission: All tissue submitted. You can place up to 3 levels into one cassette. If additional margin is very large, consult with attending.

Specimen Type: LUMPECTOMY/ SEGMENTAL MASTECTOMY/ WIRE-LOCALIZED LUMPECTOMY Procedure:

1. Review patient’s pertinent history and imaging in EPIC in order to correlate with gross findings

2. Weigh (fresh weight should be written on specimen container)3. Orient specimen (typically- long-lateral; short-superior)4. Measure (entire specimen, skin ellipse, and nipple if present)5. Faxitron (prior to inking) and look for microclip(s) and calcifications

a. Please state in gross “A Faxitron image is taken to reveal…..calcs, no clips, clips present, etc)

b. You may increase the magnification if the specimen is small enough to do so. Ask for assistance if needed.

6. Ink specimen:

Blue- superior Purple-medialGreen- inferior Yellow- lateralOrange- anterior/superficial Black- posterior/deep

** If un-oriented- ink entire margin black

7. Serially section perpendicular to longest dimension and describe cut surfacea. End margins will be further sectioned perpendicularly

8. Measure lesion and give distance to all margins9. Submit one level per cassette. Bisect levels if needed.




Gross Protocol for Lumpectomy

Weigh and measure in 3-D

Color and cut

Submit tissue

Reconstruct

Slide 1

DCIS size in largest maximum dimension

Level 1 Level 2 Level 3 Level 4

Slide 3

Slide 2

Slide 5

Slide 4

1 2 3 4 5 6 7 8 9


Suggested sections for histology:

- If specimen is ≤ 5cm in greatest dimension- ENTIRELY submit- You may consult with an attending if specimen is > 5cm

IDC/ Re-excision with close prior margins (may have lumpectomy cavity)

Edges of lesionFlanking levels

Lesion in relation to closest marginsEnd margins- perpendicular

Representative uninvolved parenchyma

DCIS/ADH/LCIS/ILCPost neo-adjuvant chemotherapy (NAT)

Papillary lesionNo gross lesion

Levels with biopsy site/tumor bed/papillary lesion*2 sections per 1 cm of tumor bed (NAT)

Flanking levelsEnd marginsCalcifications

Representative uninvolved parenchyma

CalcificationsAll levels with calcifications

Flanking levelsEnd margins

Fibroadenoma 1 section per 1 cm of lesionUninvolved breast if present (1-2 cassettes)

Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a *** gram, [oriented/un-oriented] [lumpectomy/wire-localized lumpectomy] with [indicate provided suture orientation]. The specimen measures ***cm (superior- inferior) x *** cm (medial - lateral) x *** cm (anterior - posterior).

The specimen is serially sectioned from medial to lateral into [number] levels to reveal [describe lesion- size/shape/distance to all margins]. The lesion is located in [note which level(s)]. [Describe site of metallic clip if present]. [Document hemorrhage, necrosis, calcifications within lesion].

The remainder of the uninvolved parenchyma is [tan-yellow, unremarkable] and consists of __% tan-yellow adipose tissue and __% white fibrous tissue. No additional lesions or



masses are identified. A Faxitron image is taken. [The entire specimen/ Representative sections] is/are submitted.


Sample Cassette Submission:

Lump ≤ 5cmA1 Level 1 (medial margin), perpendicularA2 Level 2 with lesion and calcificationA3-A4 Level 3 with lesion and biopsy clip, bisectedA5 Level 4 with lesion (lateral margin), perpendicular

Lump > 5cm with IDC and calcsA1 Level 1 (superior margin), perpendicularA2 Level 2, unremarkable parenchyma superior to lesionA3-A5 Level 3 with full cross section of lesion, trisected A6 Level 4 with lesion, biopsy clip, and calcificationA7 Level 5, lesion in relation to medial marginA8 Level 6, unremarkable parenchyma inferior to lesionA9 Level 7 (inferior margin), perpendicular

Specimen Type: MASTECTOMYProcedure:

1. Review patient’s pertinent history and imaging in EPIC in order to correlate with gross findings

2. Weigh (fresh weight should be written on specimen container)3. Orient specimen (typically- long-lateral; short-superior)

a. Quadrants will be determined based on location of nipple 4. Measure (entire specimen, skin ellipse, nipple, and axillary tail if present)

a. Provide oriented dimensions of breast (ANT-POST; MED-LAT; SUP-INF)

i. Medial-lateral dimension DOES NOT include axillary tail ii. Measure axillary tail separately

5. Check skin for scar, puckering or ulcerations6. Document if nipple is everted, inverted, or retracted7. Faxitron (prior to inking) and look for microclip(s) and calcifications

a. Include “A Faxitron image is taken to reveal…” in your gross


Department of Pathology and Laboratory Medicine Procedure# SP 1.02.02Surgical Pathology Effective Date: 8/15/16 Los Angeles, California 90095 Page 13

b. Place breast with POSTERIOR surface down in the Faxitron

8. Ink specimen:Blue- superior Purple-medialGreen- inferior Yellow- lateralOrange- anterior/superficial Black- posterior/deep

**If nipple sparing- ink sub-areolar disc (use color which hasn’t been used for medial)**If axillary tail present-no need to ink axillary tail tissue. It is helpful to ink mastectomy prior to removing the axillary tail so that you do not ink the lateral cut surface (which is not a true margin). It is fine if yellow ink extends onto the axillary fat

9. If lesion is NOT close to nipple (where a perpendicular section would best demonstrate skin involvement), amputate the nipple. Take a shave of the nipple base and further serially section the amputated nipple

a. This maximizes the surface area of epidermis evaluated microscopically to check for Paget’s and/or other lesions

10.Serially section, from medial to lateral into complete 1cm or thinner cross sections

a. Document number of levelsb. Document in which level the nipple is located

11.Measure lesion(s)a. Indicate location (quadrant and clock face orientation)b. Give distance to all margins, nipplec. If multiple lesions present give the distance between the lesions/biopsy

sites and distance between the farthest ends of the lesion (in case the grossly separate lesions are one large lesion)

12.Palpate and section through axillary tail for lymph nodes (try to find 10-20 LN at minimum)

a. If oriented (typically one suture- level 1; two sutures-level 2) cut into two levels and indicate which LN are in each level in cassette summary

b. Document if there are any biopsy clips present and indicate corresponding LN in cassette summary

c. Even if no axillary tail is present try and palpate the upper outer quadrant for lymph nodes

Suggested sections for histology:Standard Sections

- Nipple – base in one cassette and serial sections in separate cassette- Nipple sparing: sub-areolar disc, perpendicularly sectioned

- Skin overlying lesion/biopsy cavity/to include scarSP 1.02.02 Handling Original Blocks and Slides.doc Surgical Pathology SOP Manual


- 4-6 sections of lesion to include closest margins, if possible- Tissue between multiple lesions, if present - Random tissue from each quadrant, focusing on fibrous tissue

-1 cassette from each quadrant if gross lesion seen-2 cassettes from each quadrant if no gross lesion seen or prophylacticAll lymph nodes

Additional sections to include:

Prophylactic 2 sections per quadrant, focusing on fibrous tissue

DCIS/ADH/LCIS/ILCBRCA or CHEK2 mutations Sections from EVERY level

IDCIDC with DCIS

Sections of every level of lesionFlank levels

1 section per quadrant, focusing on fibrous tissue

Multicentric Lesions Sections between foci

Post neo-adjuvent chemotherapy (NACT)

Sections from EVERY level

2 sections per 1 cm of the tumor bed (entirely embed if tumor bed can fit in 15

cassettes or fewer OR indicate % of tumor bed submitted)

Prior lumpectomy cavity 2 times the largest dimension (e.g. 10 cassettes if cavity is 5 cm)



Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a *** gram, [oriented/un-oriented] [simple/skin- sparing/skin and nipple sparing/modified radical/radical/prophylactic mastectomy] with [indicate provided suture orientation]. The specimen measures *** cm (superior- inferior) x *** cm (medial - lateral) x *** cm (anterior - posterior). The skin ellipse [measure, describe scar/induration/ulceration]. The [everted/retracted/flattened] nipple measures [***x***x***cm]. [If a nipple is not present, note the presence/absence of a suture marking the subareolar disc]. The axillary tail measures ***x***x***cm [indicate orientation if provided].

The specimen is serially sectioned from medial to lateral into [number] levels. The nipple is located in __ level(s). The cut surface is tan-yellow and remarkable for [describe lesion(s) – size/shape/location/distance to all margins]. [Describe texture of lesion]. The lesion is located in [note which levels/quadrant/clock location/distance from nipple]. [Describe site of metallic clip if present]. [If no clip/mass is located – radiograph the specimen and contact pathologist].

[Describe any other gross abnormalities, particularly the ones that can be correlated with imaging findings - Provide individual description for each lesion present. Note which slices/quadrant/direction and distance to the main mass/distance to margins]. The remainder of the uninvolved parenchyma [fatty, unremarkable, consists of __% tan-yellow adipose tissue and __% white fibrous tissue]. The [upper outer quadrant/axillary tail] is palpated and [no lymph nodes/number of LN] are identified ranging from __-__cm in maximum dimension.

All identified lymph nodes in their entirety and representative sections of the remaining specimen are submitted.


Department of Pathology and Laboratory Medicine Procedure# SP 1.02.02Surgical Pathology Effective Date: 8/15/16 Los Angeles, California 90095


Sample Cassette Submission:

Case with biopsy proven invasive carcinoma

A1: Nipple base, shaveA2: Nipple, serially sectionA3: mass/bx cavity (General rule is 2 cassettes/ 1 cm)A4: mass to the closest margin in perpendicular relationshipA5: level x (mass 1)A6: level x (section between mass 1 and 2)A7: level x (mass 2)A8: level x

Specimen Type: AXILLARY LYMPH NODES Procedure:

1. Weigh, measure, and indicate orientation if provided2. If oriented (typically- level 1 and level 2), arbitrarily cut into two levels and

palpate for lymph nodes. To ensure a thorough dissection is performed section the fibroadipose tissue as well.

3. Submit all lymph nodes (ideally between 10-20 LN)

Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a [***x***x***] cm portion of [oriented/unoriented] fibroadipose tissue. [Indicate orientation provided]. [Number] lymph nodes are found from level 1, which range from ***-***cm in maximum dimension. [Number] of lymph nodes are found from level 2, which range from ***-*** cm in maximum dimension. The lymph nodes are sectioned to reveal [describe cut surface, indicate if grossly evident metastatic tumor present and provide maximum dimension]. Representative sections of the grossly positive lymph nodes and all remaining identified lymph nodes are entirely submitted.

Cassette Submission: 10-15 cassettes

- submit all lymph nodes grossly negative for metastasis- submit representative section(s) of grossly positive lymph nodes. Indicate largest dimension of LN in cassette summary



Sample Cassette Submission:A1 Four lymph nodesA2 One grossly positive lymph node (2.1cm in maximum dimension)A3 Two lymph nodes (differentially inked blue and black, both bisected)

Specimen Type: BREAST SENTINEL LYMPH NODES Procedure:

1. Measure fibroadipose tissue2. Count and measure lymph nodes (range or 3D if single node)3. Serially section lymph nodes at 2-3mm intervals if large enough4. Submit all tissue

a. SLN- order protocolb. Remaining fibroadipose tissue- 1 H&E

Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a [***x***x***cm] portion of a [tan-yellow] fibroadipose tissue. Sectioning reveals [number] lymph nodes measuring [range if multiple/ three dimensions if single LN]. The lymph node is serially sectioned to reveal [describe cut surface]. The specimen is entirely submitted.

Cassette Submission:1-3 cassettes (submit all tissue)- Order sentinel lymph node package - If metastatic carcinoma is present on frozen section, there is no need to order

SLN package

Sample Cassette Submission:A1 One lymph node, serially sectionedA2-A3 Remaining fibroadipose tissue


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