GROSSING OF GROSSING OF BREAST BREAST

SPECIMENSSPECIMENSDr Malini Goswami

ANATOMYANATOMY Lies in the superficial

fascia on the anterior chest wall

Extends from lateral border of the sternum to the midaxillary line and vertically from the 2nd to the 6th rib

Lies on the following muscles: Pectoralis major Serratus anterior Latissmus dorsi

THE BREASTTHE BREAST Divided into 4 quadrants

& a tail.

Breast tissue extending from the upper outer quadrant into the axilla , forms the tail of Spence.

Tail of Spence (Axillary tail) extends along the inferolateral edge of the pectoralis major muscle and enters a Hiatus of Langer in the deep fascia of the medial axillary wall.

LYMPHATIC DRAINAGELYMPHATIC DRAINAGEThe axillary lymph nodes The axillary lymph nodes are divided into are divided into levels 1, 2 & 3

Level I: lateral to the lateral border of the pectoralis minor muscle

Level II: under the pectoralis minor muscle & interpectoral (Rotter’s) nodes

Level III: medial to the medial border of the pectoralis minor muscle

Intramammary nodes : Intramammary nodes : Mostly found in outer Mostly found in outer

quadrantquadrant May rarely be sentinel May rarely be sentinel

lymph nodeslymph nodes Included with axillary Included with axillary

nodes.nodes. Internal mammary Internal mammary

nodes, Supraclavicular nodes, Supraclavicular nodes & nodes & Infraclavicular nodes :Infraclavicular nodes : Rarely removed for Rarely removed for

breast cancer stagingbreast cancer staging

TYPES OF BREAST TYPES OF BREAST SURGERIESSURGERIES

EXCISIONS EXCISIONS : Resecting breast tissue without the : Resecting breast tissue without the intent of removing the entire breast.intent of removing the entire breast.

LUMPECTOMYLUMPECTOMY : R : Removal of a small malignant tumor/discrete mass with variable amount of surrounding breast tissue ; In combination with axillary node dissection. ---Lesion palpable by surgeon ---Lesion palpable by surgeon

QUADRANTECTOMY : excision corresponding to one of the four quadrants(rarely done)

TYPES OF BREAST TYPES OF BREAST SURGERIESSURGERIES

WIRE GUIDED LOCALIZED EXCISIONS : Non palpable tumors (invasive and DCIS) Non palpable tumors (invasive and DCIS) Calcifications for ADH, FEA Calcifications for ADH, FEA Radial scars, papillary lesions Radial scars, papillary lesions

TYPES OF BREAST TYPES OF BREAST SURGERIESSURGERIES

SIMPLE MASTECTOMY : Total mastectomy without axillary dissection.

SKIN SPARING MASTECTOMY. NIPPLE SPARING MASTECTOMY. RADICAL MASTECTOMY involves

removal of - Breast and Axillary lymph

nodes Pectoralis major and minor

muscles and the fascia

TYPES OF BREAST TYPES OF BREAST SURGERIESSURGERIES

MODIFIED RADICAL MASTECTOMY involves – Removal of the breast and axillary lymph

nodes Preserving the pectoralis muscles

INDICATIONS OF MASTECTOMY VERSUS LUMPECTOMY

Patient choice Patient choice Large tumor Large tumor Multifocal tumor Multifocal tumor Recurrence or new primary in a Recurrence or new primary in a

patient previously treated with breast patient previously treated with breast conserving therapy (BCT) conserving therapy (BCT)

Prophylactic Prophylactic Radiation therapy contraindicated in Radiation therapy contraindicated in

pregnancy.pregnancy.

INDICATIONS OF MASTECTOMY

Inflammatory breast cancer.Inflammatory breast cancer. Diffuse suspicious or malignant Diffuse suspicious or malignant

appearing microcalcification.appearing microcalcification. Radical mastectomy is reserved for Radical mastectomy is reserved for

tumors involving pectoralis major tumors involving pectoralis major muscle or recurrent breast cancers muscle or recurrent breast cancers involving chest wall. involving chest wall.

Neoadjuvant Therapy Neoadjuvant Therapy (NAT)(NAT)

Administration of systemic therapy Administration of systemic therapy (chemotherapy or anti-hormonal therapy) (chemotherapy or anti-hormonal therapy) prior to definitive surgical resection prior to definitive surgical resection Inflammatory breast cancer Inflammatory breast cancer Inoperable locally advanced disease Inoperable locally advanced disease Render breast conserving surgery Render breast conserving surgery possiblepossiblePrimary management of aggressive Primary management of aggressive subtypes of diseasesubtypes of disease

Steps to be followed Steps to be followed prior to grossingprior to grossing

Previous biopsy report Previous biopsy report Relevant radiology Relevant radiology Relevant clinical information Relevant clinical information Specimen diagramSpecimen diagram Specimen photographSpecimen photograph

Goals of grossingGoals of grossing Primary goals :Primary goals :(i)identify the specimen, determine its orientation, and (i)identify the specimen, determine its orientation, and dimensionsdimensions(ii) identify the presence, location, and dimensions of (ii) identify the presence, location, and dimensions of lesions (masses, calcifications, etc.)lesions (masses, calcifications, etc.)(iii) estimate the distance of lesions from surgical (iii) estimate the distance of lesions from surgical marginsmargins(iv) take samples for more precise microscopic (iv) take samples for more precise microscopic evaluation. evaluation. Secondary goals :Secondary goals :Taking samples from various other locations depending Taking samples from various other locations depending on the type of specimen (e.g., nipple, all quadrants, and on the type of specimen (e.g., nipple, all quadrants, and lymph nodes associated with mastectomies).lymph nodes associated with mastectomies).

MRM – STEPS FOR MRM – STEPS FOR FIXATIONFIXATION

Use the axillary tail & skin to orient Use the axillary tail & skin to orient the specimen.the specimen.

Ink the deep marginInk the deep margin ““Bread-loaf ” at 1cm intervalsBread-loaf ” at 1cm intervals Submerge in the Submerge in the 10% neutral buffered 10% neutral buffered

formalin (NBF) for a minimum of formalin (NBF) for a minimum of 8 to 8 to 12 hours. 12 hours.

The recommended maximum fixation The recommended maximum fixation time is time is 72 hours.72 hours.

EXAMINATION OF EXAMINATION OF SPECIMENSPECIMEN

Dimensions of specimen & skin Dimensions of specimen & skin ellipseellipse

Localization , dimensions of Localization , dimensions of tumortumor

Margins of tumorMargins of tumor Distance from overlying Distance from overlying

skin ,deep & closest marginskin ,deep & closest margin Surrounding breast, Nipple Surrounding breast, Nipple

areola & Overlying skin.areola & Overlying skin. If previous biopsy site/cavity If previous biopsy site/cavity

present, describe size, present, describe size, appearance, and location. Also appearance, and location. Also note the presence of any note the presence of any residual tumor.residual tumor.

If additional localized lesions are If additional localized lesions are identified describe size, location in identified describe size, location in quadrant. quadrant.

If separate from primary lesion give an If separate from primary lesion give an estimate of its distance from the primary estimate of its distance from the primary lesion. Sample the areas in between the lesion. Sample the areas in between the two tumors.two tumors.

Dissect out the Axillary lymph nodes. Note Dissect out the Axillary lymph nodes. Note the size of grossly positive & /or largest the size of grossly positive & /or largest lymph node.lymph node.

SECTIONS TO BE SECTIONS TO BE SUBMITTEDSUBMITTED

TumorTumor Surrounding breastSurrounding breast Nipple areola & skinNipple areola & skin Skin overlying tumorSkin overlying tumor Deep margin/closest marginDeep margin/closest margin Any suspicious grey white areaAny suspicious grey white area Axillary lymph nodesAxillary lymph nodes Level III lymph nodesLevel III lymph nodes

Post nact Post nact

LUMPECTOMYLUMPECTOMY Arrange the specimen as

per the stated orientation of sutures.

Pat the surface dry before applying the ink.

4-6 ink color approach is useful to orient the margins.

Measure skin ellipse. If wire localized, dictate

where they enter into tissue.

Note the site & size of tumor.

Distances from various margins ( S.I.M.L.A.P.)

LYMPH NODE LYMPH NODE SAMPLINGSAMPLING

Grossly positive nodes :Grossly positive nodes : Measure the size of the node.Measure the size of the node. Cancerous nodules in the axillary fat Cancerous nodules in the axillary fat

adjacent to breast , without evidence of adjacent to breast , without evidence of histologic lymph node tissue : Regional histologic lymph node tissue : Regional lymph node metastasis.lymph node metastasis.

Grossly negative nodes : Grossly negative nodes : Each node should be thinly sliced along Each node should be thinly sliced along

the long axis at 2mm.the long axis at 2mm.

GROSSING OF BREAST GROSSING OF BREAST DCISDCIS