Breast tumour resection

Background

A variety of procedures can be undertaken for the investigation and excision of breast lesions.

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Specimens received in the laboratory may be diagnostic open biopsies, wide local excisions (partial mastectomies, quadrantectomies or segmentectomies, pre or post neoadjuvant therapy), re-excisions, mastectomies (pre or post neoadjuvant therapy) with or without lymph nodes. Lymph node specimens can be sentinel or non-sentinel nodes, axillary sampling or axillary clearance. 1

Duct dissections can be undertaken to investigate a nipple discharge without a palpable mass (commonly finding a large duct papilloma, but sometimes papillary carcinoma in situ or other in situ breast carcinoma). A nipple wedge excision, which includes skin, is performed occasionally to treat a recurrent subareolar abscess.

Breast tissue may also be received after breast reduction surgery or prophylactic mastectomy. Male breast tissue for gynaecomastia and carcinoma is also resected.

Mammographically detected biopsies may contain borderline malignancy lesions, which can be more difficult to distinguish morphologically from benign lesions. 1-4

Methods for the handling and reporting of breast tissue specimens have been widely published. 1-14

See also the protocol for benign breast specimens.

Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles..

Fresh tissue received
  • No
    • Non-routine fixation (not formalin), describe
  • Yes
    • Special studies required, describe
    • Ensure samples are taken prior to fixation.

Note that cold ischaemic time should not be prolonged >1 hour post disruption of blood supply.

Specimen handling more detail

The specimen should be sent immediately to the pathology laboratory, ideally in the fresh state and transferred to fixative as soon as possible on receipt. 5,6 If this is not possible, it should be immediately placed in an appropriately sized container with a sufficient amount of formalin. In some institutions (by arrangement with the Pathologist) the surgeon makes a controlled single or cruciate pair of incisions into the lesion, thus preserving the integrity of key margins while allowing immediate penetration of fixation. 1

Serial slicing into the specimen is required to permit fixation. Inking of margins of mastectomy specimens, the use of mordants and slicing into the tissue prior to placement in formalin facilitates margin assessment in these cases.

Fixation of breast tissue is a critical factor in the accurate testing of tissue biomarkers (e.g. immunohistochemistry for ER, PR and HER2). A minimum of 8 hours to a maximum of 72 hours is considered essential for breast cancer specimens.5-8

See fixation for further information.

Intraoperative consultation
  • Not performed
  • Performed, describe type and result
    • Sentinel node biopsy
    • Frozen section
    • Imprints
    • Other, describe

Note that frozen sections are not routinely performed during breast cancer resection surgery particularly where tumour is <10mm and/or screen-detected. 

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

External InspectionBack to top


Orientate and identify the anatomical features of the specimen.

Orientation markers

Record additional orientation or designation provided by operating clinician:

  • Absent
  • Present
    • Method of designation (e.g. suture, incision)
    • Featured denoted

Photograph the intact specimen if required.

Describe the following features of the specimen: 1

Specimen laterality

  • Right
  • Left
  • Unoriented

Procedure (specimen type)

Record as described by the clinician.

Options
  • Diagnostic open biopsy
  • Wide  local excision (lumpectomy)
  • Partial mastectomy
  • Quadrantectomy
  • Segmentectomy
  • Re-excision
  • Duct dissection
  • Nipple wedge excision
  • Mastectomy
    • Post neoadjuvant therapy
    • Completion mastectomy
    • Prophylactic mastectomy
  • Breast reduction surgery
  • Other, describe

Lymph nodes

  • Sentinel lymph node
  • Axillary lymph node sampling
  • Axillary lymph node clearance
  • Other, describe
See Haematolymphoid, Sentinel and regional lymph nodes -breast protocol for further detail.

Method of localisation method (if described)

  • Palpable
  • Hookwire
  • Carbon
  • Other, describe

Specimen integrity

  • Intact
  • Opened or disrupted, describe

Specimen orientation

  • Not oriented
  • Oriented
    • Method of designation
    • Margin/feature(s) denoted

Evidence of previous biopsy or surgery

  • None
  • Present
    • Needle track
    • Scar
    • Sutures

Anatomical components (more than one may apply) and dimensions (mm)

Describe and measure the anatomical components present.

Total specimen

  • Weight (g)
  • Size in three dimensions
    • If orientated designate:
    • Medial-lateral
    • Superior-inferior
    • Superficial-deep

Skin

  • Absent
  • Present
    • Measure in two dimensions
    • Describe any abnormalities and their dimensions (e.g. nodules)

Nipple

  • Absent
  • Present
    • Normal
    • Ulceration
    • Paget’s disease
    • Satellite nodules of tumour
    • Peau d’orange

Muscle

  • Absent
  • Present
    • Measure in three dimensions

Axillary tissue

Other

  • Describe

DissectionBack to top


After the external description, specimens usually require further fixation before dissection. Partial incisions into the specimen at this stage will facilitate penetration of the fixative.

Mordants such as acid alcohol will assist in fixing ink used to demonstrate surgical margins.

Mordant method

One suggested method is to remove surface fat by immersing the specimen in alcohol and allowing the surface to dry before painting with Alcian blue, Indian ink and/or dyed gelatine solutions. After using Indian ink, 10% acetic acid can be applied to fix the dye. 3

Dissect the specimen according to the specimen type.

Wide local excisions (WLE)

Wide local excisions are usually fixed overnight (8-24 hours) prior to dissection. These specimens are often received in an inadequate amount of formalin. On receipt, ensure they are placed into a sufficient volume of fixative (10:1 formalin to specimen volume) 9 to facilitate adequate fixation.

Orientation by the surgeon is usually present as specific numbers of clips or differing lengths of suture accompanied by an explanation (key or diagram) on the request form or specimen container. If no skin is present to indicate the superficial aspect, three margins need identification by the surgeon to adequately orientate the specimen.

Once fixed, paint the specimen with ink to differentiate the surgical margins. Dissection and inking protocols vary between institutions and individual Pathologists so check with the Pathologist responsible for the specimen.

A common method is to serially section the specimen perpendicularly to the medial–lateral plane.

The number of blocks taken for a specimen will depend on the size of the specimen and the size of the abnormality. If the specimen is not too large, it is often simplest to block and examine all of the tissue. 

For large specimens, sampling should include the extremes of the mammographic abnormality and adjacent tissue in order to avoid underestimation of the size of a lesion. This is particularly important as it is recognised that mammographic size may be an underestimate of true lesion size. 3

Microcalcifications/impalpable lesions

The above dissection method is also commonly used for examination of impalpable lesions, such as microcalcification, as it enables specimen slice radiographic mapping of the specimen and provides a high level of confidence that the lesion has been accurately and adequately sampled. The specimen can be sliced either before fixation or after fixation and marking of the excision margins. The specimen is sliced at intervals of approximately 3–5 mm, usually perpendicular to the medial–lateral axis in the anterior–posterior plane.3

Where microcalcification is the principal feature for which the lesion was removed, unless the entire specimen is submitted, slicing and radiographing the specimen slices will enable blocks to be taken most accurately from the areas corresponding to the mammographic abnormality as well as from any other suspicious areas identified. The sites of sampling can be marked on the specimen radiograph for radiological–pathological discussion in difficult cases. If the excision has been undertaken for calcification or for known DCIS, blocks should be taken to include areas of fibrous breast tissue proximal and distal to the calcification. DCIS, especially the low grade type, may be much more extensive than the radiologically apparent calcification. When no lesion is found despite embedding the entire specimen imaging of the blocks taken can be helpful in directing further levels.3

Other methods such as radial block examination should be considered and more information on this method and others are present in the literature. 3

Mastectomy

Mastectomy specimens should be received orientated by the surgeon. A system should be established to allow immediate incision of the tumour to promote optimal fixation.

Paint any relevant surgical margins. Slice at 5mm intervals perpendicularly to the deep aspect of the specimen to, but not through, the skin surface. Formalin-soaked paper towels can be inserted between the slices to improve formalin penetration. At this point a block of the tumour is sometimes taken for separate fixation and processing for hormone receptor status evaluation.

See internal inspection and processing sections below for information on completion mastectomy specimens.

Allow remaining tissue to fix sufficiently prior to processing.

Neoadjuvant specimens

Pathological evaluation of the excised tumour bed is the gold standard and essential to assess patient response to neoadjuvant chemotherapy. The extent of response is one of the most important prognostic factors in this patient population.1,12

In most cases the pretreatment specimen will be a needle core biopsy which may be useful for comparison with any post-treatment tumour.

The usual post-treatment specimen is a mastectomy but breast-conserving surgery may also be undertaken.

Several methods are available for evaluating pathological response to treatment. 10-12

One example is the residual cancer burden (RCB) system developed at MD Anderson Cancer Center (The University of Texas). 11

Serially section the mastectomy or therapeutic WLE as for a non-neoadjuvant tumour specimen and identify the tumour bed (area of original tumour). 

Identification of the tumour bed can be facilitated by placement of a clip or carbon during the initial needle core biopsy. The tumour bed may have rubbery or fibrous appearance.

Residual tumour within the tumour bed may be seen as fleshy nodules within the tumour bed.

  • Measure the tumour bed in two dimensions and describe the tumour bed, giving the dimensions of any suspicious lesions within this area. This is required for calculating the residual cancer burden index even if there is little or no tumour remaining.
  • Record the distance of the tumour bed to the closest surgical margin.
  • Record the distance of any lesions suspicious of tumour to the closest surgical margin.

A photograph and block key of the tumour bed may be useful.

Although no consensus has been reached on how much of the tumour bed should be sampled, thorough microscopic examination is required before complete pathological response can be declared.

For initial sampling of at least one block per 10mm of pre-treatment tumour size has been postulated.12

If no tumour is found at this point, it is not known how much more tissue should be sampled. However if the tumour bed is small (≤50mm) consideration should be given to embedding the entire tumour bed.  If it is >50mm consideration to blocking the largest cross-sectional area should be considered.

MD Anderson offers an online RCB calculator and has additional information on macroscopic and microscopic reporting. 11

Lay the slices out sequentially and number with an orientation key and patient identification. The extent of the lesion, particularly in the medial and lateral axis, should be well-documented. 

Photograph the slices, print and use as a block key.

Internal InspectionBack to top


Describe the cut surface appearance including the following items:

Tumour/tumour bed

  • Absent
  • Present
    • Number; if more than one tumour, designate and describe each tumour separately
When no tumour is evident -more detail
  • Look for scars and areas of haemorrhage in the specimen.
  • Refer to previous radiology, cytology, histology and clinical history to identify the expected location.
  • Palpate the slices, finely section further and carefully exam for lesions.
  • Consultation between the supervising Pathologist and Surgeon may be required to clarify the location of the tumour.
  • Where tumour is still elusive, the serial slices of the mastectomy specimen may be laid out sequentially from medial to lateral aspects and a radiograph of the specimen undertaken.
  • Radiographic imaging of blocks may also be useful in locating microcalcifications in biopsy or wide local excision specimens 3

Tumour location

  • Slice numbers involved (correlate with specimen block key)
  • Quadrant(s)
  • Correlation with radiographs

Tumour size (mm)

  • In three dimensions 1-3
  • Neoadjuvant specimens -tumour bed in two dimensions 11,12

Distance to nearest tumour foci (mm)

  • Specify distance(s) to other tumours present 1

Distance to surgical margins (mm)

  • Distance of tumour to all surgical margins <5mm 1-3, 13
  • Specify margin(s)

Tumour appearance

  • Border
  • Consistency
  • Colour
Completion mastectomy
  • Inspect the breast slices for a cavity or scar from the previous operation
  • Describe the cavity or scar in the similar way to that of a tumour recording location within the breast, thighs of tumour and its distance to relevant surgical margins
  • If no cavity or scar is present look for evidence of a previous operation in such as haemorrhage and fat necrosis

Other abnormalities

  • Abscess
  • Location
  • Sub-areolar
  • Other
  • Fibrosis
  • Cysts
    • Number
    • Maximum size in mm
    • Contents
  • Calcification
  • Other, describe

Lymph nodes 1-3,14

Sentinel nodes and/or axillary clearance specimens may be received. See Haematolymphoid, Sentinel and regional lymph nodes -breast protocol for further detail.

Sentinel lymph node(s)

  • Site
  • Radioactive count
  • Total number of lymph nodes
  • Uptake of dye (blue)
    • Yes
    • No
  • Measure each lymph node in three dimensions (mm)

Non-sentinel lymph nodes

  • Site
  • Total number of lymph nodes
  • Range of maximum sizes (mm)
  • Description. The description of non-sentinel lymph nodes should include the location of nodes (as described by the clinician) according to the standard code:1
  • Axilla level
    • I
    • II
    • II
  • Internal mammary chain, specify interspace if provided.
Axillary clearance specimens-more detail

Axillary contents received with mastectomy or biopsy specimens should be examined carefully to maximise lymph node yield. This is usually achieved by manual dissection of fixed axillary tissue with careful examination by inspection and palpation.

The axillary contents can be divided into three levels if the surgeon has marked the specimen appropriately. The apical lymph node should be separately identified, if identified surgically.

Every lymph node identified should be examined histologically.

Matted lymph nodes or extension of tumour to edges in axillary clearance specimens is rare but should be reported if present to assist with radiation therapy planning. 12

See Haematolymphoid, Sentinel and regional lymph nodes -breast protocol for further detail.

Photograph the dissected specimen.

Note photographs taken, diagrams recorded & markings used for identification.

ProcessingBack to top


Dissect the specimen further and submit sections for processing according to the diagrams provided.

Several methods for block selection of tumour specimens, including radial and shave sections, are described in the UK guidelines. 3

Wide local excision

For each discernible tumour, submit at least the following representative sections of the specimen:

  • The entire tumour if <20mm
  • One entire slice of tumour (one tumour cross-section) using composite blocks, >4 blocks of tumour
  • Tumour to all margins <5mm
  • Macroscopically normal tissue either side of tumour to confirm tumour extent
  • If >1 tumour, one block of intervening tissue (to confirm macroscopic impression that it is normal tissue)
  • Any other suspicious areas
  • Background breast tissue

In practice, submission of the entire wide local excision may be simpler and more accurate as grossly visible areas of tumour can underestimate the extent of the lesion. 3 If the entire specimen is not submitted, ensure fibrous rather than fatty tissue is sampled. 2

Consideration should be given submitting the entire specimen when:

  • No tumour is apparent macroscopically
  • Lobular carcinoma has been reported on previous biopsy
  • Post neoadjuvant therapy has occurred (gross abnormalities tend to underestimate lesion size)

If removed for suspicious microcalcifications, a specimen radiograph should be considered once sliced to guide block taking. 3

Mastectomy

Submit at least the following representative sections of the specimen:

  • All sections of entire tumour if <20mm
  • Three or more representative sections from the tumour(s) if >20mm
  • Closest margins <5mm
  • Any suspicious areas
  • Non-tumour lesions
  • Non-lesional tissue from each quadrant
  • Sections from the nipple and any abnormal skin lesions

When no tumour or lesion is obviously apparent, ensure representative sections are taken from throughout the specimen, sampling fibrous rather than fatty tissue.

Completion mastectomy

Submit the following representative sections of the specimen:

  • The entire cavity/scar if <20 mm
  • Representative sections from each aspect of a cavity (superior, inferior, anterior, posterior, lateral, medial) or scar (if possible)
  • If the previous pathology report is available sections focused on the previously reported cavity margins involved can be undertaken
  • Sections from the edge of the cavity to the closest margin(s) <5mm
  • Sections from the nipple and any abnormal skin lesions/scars
  • Non-lesional tissue from each quadrant of the breast
Neoadjuvant specimens

Submit representative sections of:

  • Tumour bed >50mm submit the largest cross-sectional area 12
  • Entire tumour bed if <50mm 11
  • Tumour bed, one block per 10mm of pre-treatment tumour size 11
  • Surgical margin closest to the tumour bed 10
  • Sample the remaining specimen as per the mastectomy protocol
Lymph nodes

Submit all lymph nodes.

  • If <5mm, may be submitted whole
  • If >5mm, serially section at 2-3mm intervals and submit all
  • If macroscopically involved the entire lymph node should be submitted unless impractical, when a representative section will suffice. Sections to demonstrate extracapsular spread or surgical margin should be submitted. 
See Haematolymphoid, Sentinel and regional lymph nodes -breast protocol for further detail.

Block allocation keys

Wide local excision
Cassette id
Site
No. of pieces
A-D
Tumour cross-section, composite blocks if necessary
 
E-F
Tumour including margins<5mm
 
G-H
Tissue adjacent to tumour
 
I-J
Intervening tissue between tumours (if >1 tumour) and/or other suspicious areas of tissue
 
L
Background breast tissue
 
M
Sentinel lymph node, if applicable
 
N+
Lymph nodes
 
Mastectomy
Cassette id
Site
No. of pieces
A-D
Tumour, all or representative sections
 
E-F
Tumour including margins <5mm
 
G-I
Intervening tissue between tumours (if >1 tumour) and/or other suspicious areas of tissue
 
J
Non-tumour lesions
 
K-N
Non-lesional tissue from each quadrant
 
O-P
Nipple, one section and abnormal skin lesions
 
Q
Sentinel lymph node
 
R+
Lymph nodes
 
Completion mastectomy
Cassette id
Site
No. of pieces
A-H
Sections from cavity/scar (entire area if <20mm or representative sections from superior, inferior, anterior, posterior, lateral, medial and scar if larger)
 
I
Sections from the edge of the cavity to the closest margin(s) <5mm
 
J
Non-tumour lesions
 
K-N
Non-lesional tissue from each quadrant
 
O-P
Nipple, one section and abnormal skin lesions
 
Neoadjuvant specimens
Cassette id
Site
No. of pieces
A
Surgical margin closest to the tumour bed
 
B-F
Tumour bed, one block per 10mm pre-treatment tumour size or all if <50mm (see above)
 
G-I
Intervening tissue between tumours (if >1 tumour) and/or other suspicious areas of tissue
 
J
Non-tumour lesions
 
K-N
Non-lesional tissue from each quadrant
 
O-P
Nipple, one section and abnormal skin lesions
 
Q
Sentinel lymph node
 
R+
Lymph nodes
 

Acknowledgements

A/Prof Gelareh Farshid for her contribution in reviewing and editing this protocol.

ReferencesBack to top


  1. Farshid G, Ahern V, Chirgwin J, Lakhani S, Pike C, Provenzano E, et al. Invasive breast cancer structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2012. 
  2. Ellis IO, Pinder SE, Bobrow L, Buley ID, Coyne J, Going JJ, et al. Pathology Reporting of Breast Disease, The Royal College of Pathologists, London, 2005. 
  3. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010. 
  4. Hammond ME, Hayes DF, Dowsett M, Allred DC, Hagerty KL, Badve S, et al. American Society of Clinical Oncology/College Of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol. 2010;28(16):2784-95.
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  8. Bancroft JD and Gamble M. Theory and practice of histological techniques. Churchill Livingstone Elsevier, Philadelphia, PA, 2008.
  9. Lester SC, Bose S, Chen YY, Connolly JL, de Baca ME, Fitzgibbons PL, et al. Protocol for the examination of specimens from patients with invasive carcinoma of the breast. Arch Pathol Lab Med. 2009;133(10):1515-38
  10. Residual Cancer Burden Calculator: MD Anderson Cancer Center, The University of Texas; 2014. Available from: MD Anderson
  11. Sahoo S, Lester SC. Pathology of Breast Carcinomas After Neoadjuvant Chemotherapy: An Overview With Recommendations on Specimen Processing and Reporting. Archives of Pathology & Laboratory Medicine. 2009;133(4):633-42.
  12. Behm EC, Beckmann KR, Dahlstrom JE, Zhang Y, Cho C, Stuart-Harris R, Craft P, Rezo A and Buckingham JM. Surgical margins and risk of locoregional recurrence in invasive breast cancer: An analysis of 10-year data from the Breast Cancer Treatment Quality Assurance Project. Breast. 2013;9776(13):51-59.
  13. Huo L. A practical approach to grossing breast specimens. Ann Diagn Pathol. 2011;15(4):291-301.