GROSSING BOOTCAMP:

The Breast Lumpectomy

Click on the arrows below to learn the step-by-step process of grossing a breast lumpectomy specimen.

Sample Dictation: 

PLEASE NOTE: The example listed below is the format commonly used/encountered at my institution. Please check with your institution to see if a recommended format is preferred.

Gross Examination:

This case is received [FRESH, IN FORMALIN] in [NUMBER] separate containers, each labeled with the patient's name, medical record number and site designation.

PART A: " [CONTAINER LABEL- EXAMPLE: RIGHT NEEDLE LOCALIZED LUMPECTOMY]"

The specimen consists of a _ g fragment of yellow, lobulated, fibrofatty soft tissue (_ cm anterior-posterior; _ cm medial-lateral and _ cm superior-inferior) [WITH/ WITHOUT] an attached [COLOR, UNREMARKABLE (OR DESCRIBE LESION)] skin ellipse (_ x _ x _ cm). The specimen is oriented by surgical sutures (see below) and contains a needle wire in-situ coursing from the _ to the _ aspect. The specimen radiograph is reviewed showing [LIST RADIOLOGY FINDINGS; microcalcifications; densities; intact needle localization wire etc]. 

 

The specimen is inked and then serially sectioned to reveal _ (CHOOSE FROM BELOW AS APPROPRIATE).

a [CENTRAL/ ECCENTRIC] _ x _ x _ cm [SOLID/ CYSTIC/ HEMORRHAGIC/ FIBROTIC] lesion corresponding to the radiographically-identified area. The lesion has a [STELLATE/ INFILTRATE/ ROUNDED] margin and comes within _ cm of the the nearest (ORIENTATION; COLOR-inked) margin;  _ cm of the (ORIENTATION; COLOR-inked margin(s) (LIST THE DISTANCE OF ANY MARGIN LOCATED WITHIN 2 CM OF THE LESION) ; it is greater than 2 cm from all other margins.

 

A second, separate [SOLID/ CYSTIC/ HEMORRHAGIC/ FIBROTIC]  lesion (_ x _ x _ cm) with a  [STELLATE/ INFILTRATE/ ROUNDED] margin is identified in the [DIRECTION] aspect of the specimen, _ cm from the first lesion and _ cm from the closest [ORIENTATION, COLOR]-inked margin.

DESCRIBE ANY ADDITIONAL FINDINGS.

 

The remaining cut surface is yellow and fatty with no additional lesions grossly identified. [REPRESENTATIVE SECTIONS ARE/ THE SPECIMEN IS ENTIRELY] submitted for histological evaluation as per block summary.

 

ORIENTATION (per requisition sheet) & INK CODE:

Black = Posterior/deep (2 Sutures)

Blue = Medial 

Green = Inferior

Red = Anterior 

Orange = Superior (1 Short suture)

Yellow = Lateral (1 Long suture)

PART B. "[CONTAINER LABEL]"

Gross description

NOTE: The surgeon will oftentimes send the "true surgical margins" separately from the lumpectomy specimen. These margins often contain a surgical clip on one aspect of the fatty, cauterized tissue representing the true surgical margin; (usually, this is the more curved edge). This aspect should be inked  (trying not to get ink on the opposing aspect). The specimen should then be serially (perpendicularly) sectioned and entirely submitted.

 

Basically, we want to be able to tell the surgeon how far a lesion, if present, is located from the true margin. See an example dictation below

PART C. "Right breast needle localized lumpectomy, final anterior margin, clip marks true margin"

The specimen consists of a fragment of yellow lobulated fibrofatty tissue (_ x _ x _ cm) containing a single surgical clip along a more convex-shaped, cauterized surface; the corresponding tissue is inked black. Serial sectioning reveals homogeneous, yellow, lobulated, fibrofatty, glandular breast parenchyma. The specimen is entirely submitted per block summary.

 

etc etc etc

 

Block Summary:

A: [CONTAINER LABEL- EX: Right breast needle localized lumpectomy]

Typically, you should submit the ENTIRE SPECIMEN if it is a small lumpectomy specimen, no lesion is grossly seen or the prior biopsy showed only DCIS or ADH (must rule out cancer). When in doubt, just submit the entire lumpectomy specimen to avoid going back to the bucket!

The specimen is entirely and sequentially submitted from the [LIST] to [LIST] direction

  1. Tissue at [LIST] margin (slice #1), perpendicularly sectioned; _ piece(s)

  2. Slice #2; _ piece(s)

  3. Slice #3; _ piece(s)

  4. Slice #4; _ piece(s)

  5. Slice #_ etc. etc. etc

  6. Tissue at [LIST] margin (final slice #_), perpendicularly sectioned; _ piece(s)

For LARGE lumpectomies with a CLEARLY DEFINED LESION you may choose to submit only REPRESENTATIVE SECTIONS. If you choose this method, make sure you sample every margin. Ideally, you want a perpendicular section of the lesion to the nearest inked margin. If the lesion is widely free of a margin (>2 cm away), then you can submit a representative shave of the margin nearest the lesion (put the inked side FACE DOWN in the cassette)

  1.  Lesion to nearest anterior margin, perpendicularly sectioned

  2. Lesion to nearest posterior margin, perpendicularly sectioned

  3. Lesion to nearest medial margin, perpendicularly sectioned

  4. Lesion to nearest lateral margin, perpendicularly sectioned

  5. Lesion to nearest superior margin, perpendicularly sectioned

  6. Lesion to nearest inferior margin, perpendicularly sectioned

  7. Remaining lesional tissue (If possible, try to submit the entire lesion)

  8. Normal, representative section

B1. Right breast, final superior margin

C1-2. Right breast, final anterior margin

etc etc etc.

Breast Lumpectomy Summary: 
  1. Orient the specimen if sutures or clips are present.

    • If any questions, consult with your PA, pathologist or surgeon.

  2. Measure the overall specimen dimensions and note the general shape of the specimen (ovoid, spherical, etc)

  3. Record & Measure the presence of skin, fascia, and/or skeletal muscle

  4. Ink the specimen per INK CODE used at your institution

  5. Bread-loaf (serially section) the specimen at 2-3 mm intervals (perpendicular to the needle wire, when possible)

  6. Describe any nodules or masses (location, size, shape, well circumscribed/ill-defined/infiltrative edges, consistency, presence of necrosis)

  7. Measure the distance of the lesion to the excision margins (specify which is nearest and give the distances to all margins

    • (Note: It varies from institution, but a general rule of thumb is that in order to call a margin "widely free", it has to be >5 mm. Some use a measurement of 2 cm to make this statement. Check with your institution.)

  8. Search for satellite nodules or additional lesions; describe​ & measure (location; greatest dimensions, distance from primary lesion; distance to nearest margin(s).

  9. Decide whether to submit the entire specimen or just representative sections. Either way, make sure you submit sections that demonstrate the lesion to each of the nearest surgical margins (perpendicular sections preferred).

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BREAST PATHOLOGY

INDEX

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These posts contain high yield information collected from various educational resources including textbooks, journal articles, educational websites and more. They are intended for educational use only and should NOT be taken as medical advice. I strongly believe the spreading of knowledge and depth of learned information should be encouraged in today's society rather than coveted. Membership is required to view these posts  and should be used solely for educational purposes only. 

Step 1: Orientation