1. Surgical Pathology of Wide Local Excision of Breast
Venkateswaran K Iyer
Assistant Professor
Department of Pathology
ALL INDIA INSTITUTE OF MEDICAL SCIENCES
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2. The Specimen Oval of overlying skin, including any scar
Suture tags : 3 (2 with skin)
Superior margin with one silk suture
Lateral margin with two silk sutures
The specimen should not be cut by the surgeon
This interferes with gross identification and inking of margins

3. Key Issues in Grossing Exact tumor size Ductal Carcinoma in Situ
Surgical margins

4. Tumor Size Measurement
Gross size of tumor measured with a scale
Two cross sections with maximum diameter
Process cross section of entire tumor
Within one slide if < 1 cm
Measure size of tumor on microscope stage
Stage vernier
Compare gross and microscopic size
Tumor shows 10-20% shrinkage on slide

5. Gross size measurement
Microscopic examination is used to revise the basic gross measurement downwards

6. Gross size measurement
Microscopic examination is used to revise the basic gross measurement upwards

7. When is this Important? When tumor size is 0.5 – 2 cm on gross
TNM: T 1 is < 2 cm
T 1a : < 0.5 cm Van Nuys (DCIS)
T 1b : 0.5 – 1.0 cm 1.5 cm
T 1c : 1.0 – 2.0 cm
Tumor size < 1cm have 10-15% nodal metastasis and 90% ten year survival

8. DCIS Present alone (mammographic detection)
Present adjacent to a carcinoma
Size measurement is important
Evaluation of margins is very important
Only DCIS: Prognostic relevance
Adjacent to Ca: Complicates the proper evaluation of margins

9. Van Nuys Prognostic Index
Van Nuys Score
Feature
Tumor size (mm) < >40
Margin (mm) > <1
Pathology grade
Necrosis /-
Nuclear Grade

11. Evaluation of Margins Tumor bed biopsy by surgeon
Specimen scrape cytology
Shaved margins: sampling by pathologist
Shaved margins: total
Inked margins

12. Evaluation of Margins Tumor bed biopsy by surgeon
Specimen scrape cytology
Shaved margins: sampling by pathologist
Shaved margins: total
Inked margins

13. Evaluation of Margins Tumor bed biopsy by surgeon
Specimen scrape cytology
Shaved margins: sampling by pathologist
Shaved margins: total
Inked margins

14. Inking the Margins Paint entire surface of specimen with ink
Nature of ink: Insoluble
Water, formalin
Alcohol
Acetone
Xylene
Paraffin
Cut into the specimen margin for sections.
Ink on margin will be visible on microscopy

15. Inking Alternatives India Ink Mercurochrome
Alcian Blue with Picric Acid fixation
Method:
Fix uncut specimen for 30 mins in formalin, blot
Paint the surface of specimen with the ink
Wait for 15 mins to dry
Keep in formalin for another 15 mins to wash away excess ink and to fix the ink
Serial section the specimen and overnight fix

16. Ideal: Sequential Processing
The entire specimen is processed
Sequential serial sections end to end

23. Infiltrating duct carcinoma at inked margin
Ink washout: tumor close to margin
DCIS 5 mm from margin

29. Surrounding Breast DCIS or LCIS Atypical ductal/lobular hyperplasia
Lymphatic permeation
Pagetoid spread along the ducts

30. Future Options Muc1 RT-PCR of drainage fluid Specimen scrape cytology
Sentinel Lymph Node imprint cytology

31. Summary: Must Do’s of Pathology
Accurate tumor size measurement
Assessment of margins in wide local excision
Tumor bed sampling by surgeon
Shave sampling by pathologist
Inking of small excision samples
Proper evaluation of DCIS component and its relation to margin

32. What is an adequate margin
>=1 cm: Adequate
>=5 mm: Not adequate, evaluate
1 -5 mm: Inadequate
<=1mm: Positive margin

33. Thank You