Mastectomy

Auto Text: “Insert Breast Sparing Mastectomy”,”Insert Breast Simple Mastectomy”, or “Insert Breast Modified Radical Mastectomy”

Types of Mastectomies:

  • Simple: Breast with Skin, Nipple, Areola (NO axillary tail)
  • Modified Radical: Simple PLUS axillary tail and pectoralis fascia
  • Radical: Simple PLUS axillary tail and pectoralis muscles
  • Skin-Sparing: Breast with Nipple & Areola only (NOT much skin surrounding areola)
  • Nipple-Sparing: Breast WITHOUT any skin or nipple or areola

Triage

One of the most important aspects of grossing breast specimens is to correlate what you see to what was seen radiographically.  Prior to grossing, always check (1) radiology reports and (2) Epic records.

  1. All breast resections for tumor must be triaged and placed in formalin within an hour of receipt, in order to minimize cold ischemic time and preserve antigenicity for receptor status (per CAP guidelines). Therefore, breasts cannot sit in the OR fridge overnight, and must be triaged even if they arrive late in the day. If a breast case is going late in the OR (i.e. past 7pm), the gross room resident, PAs, and if necessary, LMROC, should discuss timely triage of the specimen.
  2. If you receive a Breast with radioactive seeds, please consult a PA and read procedure UCMC 1145 in MediaLab (Handling Radioactive Specimens in the Gross Pathology Laboratory).
  3. Verify that the orientation and laterality on the requisition matches the container label and the actual specimen.  If there are discrepancies with the orientation or laterality, page and speak to the attending pathologist and/or surgeon before proceeding.
  4. Weigh.
  5. Measure medial to lateral, superior to inferior, anterior to posterior.
  6. If axillary tail is included, measure it separately.
  7. Measure skin ellipse, areola, nipple.
  8. Ink all cases as follows:
    • Deep surface = black
    • Anterior-superior surface = blue (sky!)
    • Anterior-inferior surface = green (grass!)
    • If nipple-sparing: Anterior nipple = red
  9. Dry off excess ink!  Apply vinegar to help ink stick to tissue.
  10. Simple Mastectomy: 
  11. Modified Radical Mastectomy: 
  12. Scan all mastectomies INTACT with the Faxitron. Save image of clip(s) under the accession number. Contact the attending pathologist if the indicated number of clips (according to EPIC records) are not identified!
  13. Serially section the specimen at the DEEP surface from medial to lateral OR lateral to medial (start from the side with the area of interest/lesion), NOT cutting all the way through. Each slice should be between 0.5-1.0 cm thick.
  14. Identify and carefully measure the lesion, designating medial to lateral, superior to inferior, anterior to posterior dimensions. Note in which slices the lesion is located.
  15. If there are multiple lesions, note spatial relation (i.e. lesion #1 is superior to lesion #2), distance between lesions, and total span of lesional tissue.
  16. Measure distance of lesion(s) to nearest margins.
  17. Look for clip(s) and biopsy site change(s). See below for images of various clips. Faxitron the specimen if the clip(s) is not grossly identified. Contact the attending pathologist if the clip(s) identified before sectioning is no longer there!
  18. Do not remove clips from the specimen. Designate the slice number each clip is in. Mark the location of the clip(s) in the specimen with a pin.  If the clip(s) fell out during sectioning, be sure to note that on the triage sheet.
  19. Wrap strips of gauze in between the slices in order to wick formalin between the slices.
  20. Fix in formalin.
  21. Note the time the specimen is placed in formalin.
  22. Ensure that the specimen is in a container in which the volume of formalin is 10-times the volume of the tissue.

modified from Shah AD, et al. Clin Imaging. 2018 Nov-Dec;52:123-136.

Gross

  1. For each case, consult with PA and/or person who triaged the specimen.
  2. Tissue submission:  All cases are unique and this manual is only a guide.  Some general pointers:
    • For lesions <2 cm, submit entirely.
    • For lesions >2 cm, submit 2 representative sections per cm of lesion.
    • For post-treatment tumor beds, submit entirely if <5 cm.  If >5 cm, submit 2 representative sections per cm of tumor bed.
    • All lesions, discrete or ill-defined, should have flanking sections submitted on both sides of the greatest dimension.
    • If there are multiple lesions, submit a section of tissue intervening between the lesions.
    • Submit the closest anterior and posterior margins to the lesion (these sections should have discernable ink).
  3. Take representative section from each of the four quadrants: UOQ, UIQ, LOQ, LIQ, noting which slice.
  4. Take a single representative section of skin, noting which slice.
  5. Take a single representative section of the nipple and areola, noting which slice.  If there are gross findings (such as ulceration or retraction), submit the nipple entirely.
    • If the specimen is a nipple-sparing mastectomy: shave, serially section, and submit the nipple margin entirely.
  6. Dissect for and submit all lymph nodes if axillary tail is present.  Also look for lymph nodes in the lateral slices.
  7. For ALL breast cases, dictate the following: Tissue fixed for at least 6 hours in 10% NBF and no more than 72 hours. (Auto Text: “Insert Breast Fixation”)
  8. All cassettes should be no more than 50% full of tissue and no greater than 3 mm in thickness.

Updates 6-25-19 NAC, 06-05-2021 NAC

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