Difference between revisions of "Breast biopsy or excision"
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| − | Fresh breast specimens should be put in formalin within one hour.<ref group= | + | Fresh breast specimens should be put in formalin within one hour.<ref group=note name=time>An increased cold ischemia time (time from procurement to time in formalin) negatively effects the utility of immunohistochemistry.<br>- {{cite journal|last1=Khoury|first1=Thaer|title=Delay to Formalin Fixation (Cold Ischemia Time) Effect on Breast Cancer Molecules|journal=American Journal of Clinical Pathology|volume=149|issue=4|year=2018|pages=275–292|issn=0002-9173|doi=10.1093/ajcp/aqx164}}</ref> Breast specimens should be immersed in formalin for 6-72 hours.<ref>{{cite web|url=https://webapps.cap.org/apps/docs/committees/immunohistochemistry/her2_faqs.pdf|title=Recommendations for HER2 Testing in Breast Cancer: ASCO – CAP Clinical Practice Guideline Update|date=2013-10-17|website=College of American Pathologists}}</ref> |
{{Comprehensiveness|otherlegend=yes}} | {{Comprehensiveness|otherlegend=yes}} | ||
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*Determine total specimen '''size'''. {{Comprehensive-begin}}Weight the specimen<ref name=Roychowdhury>{{cite web|url=https://www.pathologyoutlines.com/topic/breastmalignantgrossing.html|title=Grossing (histologic sampling) of breast lesions|author=Monika Roychowdhury|website=Pathologyoutlines.com}} Topic Completed: 1 August 2012. Revised: 19 September 2019</ref>{{Comprehensive-end}} | *Determine total specimen '''size'''. {{Comprehensive-begin}}Weight the specimen<ref name=Roychowdhury>{{cite web|url=https://www.pathologyoutlines.com/topic/breastmalignantgrossing.html|title=Grossing (histologic sampling) of breast lesions|author=Monika Roychowdhury|website=Pathologyoutlines.com}} Topic Completed: 1 August 2012. Revised: 19 September 2019</ref>{{Comprehensive-end}} | ||
*'''[[Ink]]''' margins. If sample orientations are marked, use different colors for different directions.<ref name=Roychowdhury/> | *'''[[Ink]]''' margins. If sample orientations are marked, use different colors for different directions.<ref name=Roychowdhury/> | ||
| − | *'''Palpate''' the specimen for masses. If felt, estimate the greatest dimension.<ref group= | + | *'''Palpate''' the specimen for masses. If felt, estimate the greatest dimension.<ref group=note>A palpated greatest dimension before cutting is still superior to trying to align cut pieces together or mathematically adding the thicknesses of involved slices.</ref> Compare with radiography if available.<ref name=Roychowdhury/> Confirm the presence of any known biopsy clips, either visibly or by post-operative radiography (in order to confirm that the specimen includes the region of interest). |
[[File:Cutting of uneven lumpectomy.jpg|thumb|240px|Cut a lumpectomy in the direction that gives the shortest distance from margin to margin. If a lumpectomy is uneven as shown, cut so that the first and last slice become wedge shaped (because these will later be cut further, perpendicularly to the margin), avoiding a wedge-shape for remaining slices.]] | [[File:Cutting of uneven lumpectomy.jpg|thumb|240px|Cut a lumpectomy in the direction that gives the shortest distance from margin to margin. If a lumpectomy is uneven as shown, cut so that the first and last slice become wedge shaped (because these will later be cut further, perpendicularly to the margin), avoiding a wedge-shape for remaining slices.]] | ||
*'''Serially section''' the specimen. | *'''Serially section''' the specimen. | ||
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:*Consistency<ref name=Roychowdhury/> | :*Consistency<ref name=Roychowdhury/> | ||
*{{Moderate-begin}}Description of sectioning and submissions.{{Moderate-end}} | *{{Moderate-begin}}Description of sectioning and submissions.{{Moderate-end}} | ||
| − | *{{Comprehensive-begin}}Time of procurement and time of placement in formalin.<ref group= | + | *{{Comprehensive-begin}}Time of procurement and time of placement in formalin.<ref group=note name=time/>{{Comprehensive-end}} |
Example: | Example: | ||
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|rowspan=3| '''[[Fibrocystic breast changes]]''' ||rowspan=3| 40% || '''[[Sclerosing adenosis]]''' (pictured), with an increase in glandular elements in addition to stromal proliferation that distorts and compresses glands.<ref>{{cite web|url=https://www.pathologyoutlines.com/topic/breastsclerosingadenosis.html|title=Breast - Fibrocystic changes - Sclerosing adenosis|author=Jaya Ruth Asirvatham, M.B.B.S., Julie M. Jorns, M.D.|website=Pathology Outlines}} Topic Completed: 1 January 2015. Minor changes: 31 December 2020</ref> || [[File:Histopathology of sclerosing adenosis of the breast.jpg|180px]] | |rowspan=3| '''[[Fibrocystic breast changes]]''' ||rowspan=3| 40% || '''[[Sclerosing adenosis]]''' (pictured), with an increase in glandular elements in addition to stromal proliferation that distorts and compresses glands.<ref>{{cite web|url=https://www.pathologyoutlines.com/topic/breastsclerosingadenosis.html|title=Breast - Fibrocystic changes - Sclerosing adenosis|author=Jaya Ruth Asirvatham, M.B.B.S., Julie M. Jorns, M.D.|website=Pathology Outlines}} Topic Completed: 1 January 2015. Minor changes: 31 December 2020</ref> || [[File:Histopathology of sclerosing adenosis of the breast.jpg|180px]] | ||
|- | |- | ||
| − | | '''Radial scar''', seen as a fibroelastic stroma and entrapped glands radiating outward. Measure the size of these.<ref group= | + | | '''Radial scar''', seen as a fibroelastic stroma and entrapped glands radiating outward. Measure the size of these.<ref group=note>Size is a major factor in whether to fully excise radial scars, at an approximate cutoff at around 1 cm.</ref> |
| [[File:Histopathology of a radial scar of the breast.jpg|180px]] | | [[File:Histopathology of a radial scar of the breast.jpg|180px]] | ||
|- | |- | ||
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| No disease || 30% || || | | No disease || 30% || || | ||
|- | |- | ||
| − | | [[Fibroepithelial tumor]] || 7% || Proliferation of both stromal and epithelial components.<ref group= | + | | [[Fibroepithelial tumor]] || 7% || Proliferation of both stromal and epithelial components.<ref group=note>The proliferation of two histological components is called "biplasia", from ''Latin'' bis (“twice”) and -plasia (“formation”), or "biphasic proliferation"</ref> The tumor group mainly includes fibroadenoma and phyllodes tumor. |
| [[File:Micrograph of a fibroadenoma.jpg|180px]] | | [[File:Micrograph of a fibroadenoma.jpg|180px]] | ||
|- | |- | ||
Revision as of 15:41, 19 June 2022
Author:
Mikael Häggström [note 1]
Contents
Fixation
Generally 10% neutral buffered formalin. Fresh breast specimens should be put in formalin within one hour.[note 2] Breast specimens should be immersed in formalin for 6-72 hours.[1]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
- Other legend
<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page
Gross processing
Selection and trimming
For excision (also called lumpectomy):
- Determine total specimen size. ((Weight the specimen[2]))
- Ink margins. If sample orientations are marked, use different colors for different directions.[2]
- Palpate the specimen for masses. If felt, estimate the greatest dimension.[note 3] Compare with radiography if available.[2] Confirm the presence of any known biopsy clips, either visibly or by post-operative radiography (in order to confirm that the specimen includes the region of interest).
Cut a lumpectomy in the direction that gives the shortest distance from margin to margin. If a lumpectomy is uneven as shown, cut so that the first and last slice become wedge shaped (because these will later be cut further, perpendicularly to the margin), avoiding a wedge-shape for remaining slices.
- Serially section the specimen.
- When performing triage of fresh lumpectomies, generally make slices 1.1 to 1.5 cm thick. When laid down and flattened, this is generally thin enough to allow for fixation over at least 6 hours, and thick enough to be further cut into 2 or 3 slices after fixation; Note the direction of up/down on each such thick slice so that the relative orientation of the thinner slices thereof is maintained. Slices with solid tumors are cut somewhat thinner since they won't flatten as much when laid down.
- When selecting tissue for submission after fixation, make 3-4 mm thick slices.[2]
- Inspect for any grossly visible lesions. If found, measure at least the greatest dimension of the lesion on the slice where it appears largest. (Also compare the greatest gross measurement (including any palpated one) with the greatest measurement at previous imaging, and note if it confers a staging discrepancy between imaging and gross dimensions, with cutoffs at 0.1 cm, 0.5 cm, 1.0 cm, 2.0 cm, and 5 cm.)
Invasive ductal carcinomas generally appear grossly as tan-white firm areas, here seen (white arrow) on a slice with inked margins. A radioactive seed (black arrow) was inserted by radiology to locate the tumor.
- Re-excisions
For breast re-excisions, ink the new margin (in this case marked with a suture).
Re-excisions are subsequently serially sectioned perpendicularly to the new margin (to be able to measure distance from any tumor to the new margin). For large specimens, every other section may be submitted.
Tissue selection
Further serially section each of the two end sections into perpendicular sections, so that the distance between the surgical margin and any tumor involvement can be measured. If they are visibly involved as pictured, sections can be selectively taken from there. If end sections are not grossly involved, submit one perpendicular section, (every other perpendicular section), ((or the entire end sections)).
- For lumpectomies, submit:[2]
- Entire specimen if it can fit in 3-5 slices.
- If larger:
- For relatively well demarcated tumors: 1 slice per cm of tumor (minimum of 3 slices of tumor), including both center and periphery of tumor, including closest distance to the surgical margin if possible.
- For diffuse or even invisible tumors such as often is the case for DCIS and ILC, either still submit whole, or use X-ray to guide what tissue to submit.
- Additional suspicious areas, including those indicated by radiography.
- ((Representative sections of margins in each direction.))
Breast specimens where breast cancer is possible should generally not be decalcified even when containing small calcifications, to preserve the ability to perform immunohistochemistry.
See also: General notes on gross processing
Gross report
- Size of original tissue sample, preferably in 3 dimensions.
- Description of inking
- Tumor properties, at least:
- (Description of sectioning and submissions.)
- ((Time of procurement and time of placement in formalin.[note 2]))
Example:
| (The specimen is received fresh and consists of) an irregular fragment of yellow tan fibrofatty tissue measuring 4.0 x 2.8 x 2.0 cm. (The specimen is oriented with two sutures and) the surgical margins are inked as follows: superior-blue, inferior-green, medial-red, lateral-yellow, anterior-orange, and posterior-black. {{A radioactive seed is embedded in the tissue.}} The tissue is serially sectioned {{to reveal a tan-gray, spiculated, indurated mass measuring _cm in greatest dimension. The mass is located _cm from the nearest (<<superior, inferior etc>>) margin. (The specimen is entirely submitted in sequential sections from medial to lateral in 10 cassettes. The medial and lateral margins are submitted as perpendicular sections.) The specimen was procured at _AM/PM on _/_/2020. The specimen was placed in formalin at _AM/PM on _/_/2020. |
Lymph nodes
When lymph nodes are submitted together with a biopsy or excision of a suspected or previously confirmed invasive lobular carcinoma (but not necessarily invasive carcinoma with lobular features), generally put the lymph node specimen through H&E processing at a relative rush. If you don't see any involvement on the H&E stain, order immunostain for CK AE1/AE3 in order to visualize otherwise occult lymph node involvement. The rushing of the lymph node samples allows you to have the immunostained slides by a similar time as the rest of the case.[3]
- Further information: Lymph node
Staining
Usually H&E staining.
Microscopic evaluation
If tumor is found, determine:
- Tumor size
- Malignancy
- Distance from excision margin
Malignancy
The most important is to classify a sample as either of the following:
- Benign
- Carcinoma in situ
- Invasive cancer
Most common types
| Finding | Relative incidence |
Histopathology | Image |
|---|---|---|---|
| Fibrocystic breast changes | 40% | Sclerosing adenosis (pictured), with an increase in glandular elements in addition to stromal proliferation that distorts and compresses glands.[5] | 
|
| Radial scar, seen as a fibroelastic stroma and entrapped glands radiating outward. Measure the size of these.[note 4] | 
| ||
| Usual ductal hyperplasia: Cohesive proliferation with haphazard, jumbled cell arrangement or streaming growth pattern. Cells have mild variation in cellular and nuclear size and shape.[6] | 
| ||
| No disease | 30% | ||
| Fibroepithelial tumor | 7% | Proliferation of both stromal and epithelial components.[note 5] The tumor group mainly includes fibroadenoma and phyllodes tumor. | 
|
| Atypical ductal hyperplasia | 7%[7] | Epithelial proliferations which are not qualitatively or quantitatively abnormal enough to be classified as ductal carcinoma in situ.[7] | 
|
| Other benign mammary dysplasias and neoplasms | 5% | Including:
|
|
| Intraductal papilloma: unremarkable epithelial cells lining fibrovascular cores. | 
| ||
| Pseudoangiomatous stromal hyperplasia (PASH): Complex interanastomosing vessel-like spaces in dense collagenous, keloid-like stroma. | .jpg)
| ||
| Breast cancer (in situ or invasive) | 10% | See next section. |
Breast cancer types
| Cancer type | Histopathology | Image |
|---|---|---|
| Invasive ductal carcinoma (IDC) | Carcinomatous cells are seen below the basement membrane of lactiferous ducts. Otherwise, there are no specific histologic characteristics, essentially making it a diagnosis of exclusion.[10] | 
|
| Ductal carcinoma in situ (DCIS) | Malignant epithelial cells confined to the ductal system of the breast, without invasion through the basement membrane.[11] | 
|
| Invasive lobular carcinoma (ILC) | The "classic" pattern is round or ovoid cells with little cytoplasm in a single-file infiltrating pattern, sometimes concentrically giving a targetoid pattern. | .jpg)
|
| Lobular carcinoma in situ (LCIS) |
Cells have indistinct cell borders, pale cytoplasm, and uniform small nuclei with evenly distributed chromatin and inconspicuous nucleoli.[12] |
|
| Mucinous carcinoma | Extracellular mucin areas around tumor cells. | 
|
| Medullary carcinoma | Seemingly fused tumor cells (syncytial pattern), and a prominent lymphoid infiltrate. | 
|
- Further information: Evaluation of tumors
Previous biopsy site
(For excisions or larger, look up past biopsies, and if in the same area, look for biopsy sites in order to confirm that the previous biopsy represents the same pathologies.)
Biopsy site at 11 days, low magnification, showing involved area consistent with a needle size
High magnification shows granulation tissue (fibroblasts, red blood cells and lymphocytes). Multinucleated giant cells may be present.
One month after biopsy, typically showing fibrosis. Foreign material is also present.
If tumor is not found
Check the imaging indication, and look for abnormalities that may explain the diagnostic findings:
- Dense stromal fibrosis for radiodense areas.
- Calcifications if found on X-ray.
If still not found, note their absence, since it indicates that the biopsy may have missed the target of interest.
Dense stromal fibrosis, in this case with entrapped fat cells and involuted entrapped ducts (arrows). In contrast, normal breast parenchyma has loose collagenous mammary stroma.[13]
Stacking of cells on top of each may mimic microcalcifications, but will be revealed by focusing at different levels.
Microscopy report
A normal biopsy may be reported as follows
| (Fibrofatty tissue with benign ducts and lobules.) Negative for (atypia and) malignancy. |
More detailed reports are given at the disease-related articles.
See also: General notes on reporting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ 2.0 2.1 An increased cold ischemia time (time from procurement to time in formalin) negatively effects the utility of immunohistochemistry.
- Khoury, Thaer (2018). "Delay to Formalin Fixation (Cold Ischemia Time) Effect on Breast Cancer Molecules ". American Journal of Clinical Pathology 149 (4): 275–292. doi:. ISSN 0002-9173. - ↑ A palpated greatest dimension before cutting is still superior to trying to align cut pieces together or mathematically adding the thicknesses of involved slices.
- ↑ Size is a major factor in whether to fully excise radial scars, at an approximate cutoff at around 1 cm.
- ↑ The proliferation of two histological components is called "biplasia", from Latin bis (“twice”) and -plasia (“formation”), or "biphasic proliferation"
Main page
References
- ↑ . Recommendations for HER2 Testing in Breast Cancer: ASCO – CAP Clinical Practice Guideline Update. College of American Pathologists (2013-10-17).
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Monika Roychowdhury. Grossing (histologic sampling) of breast lesions. Pathologyoutlines.com. Topic Completed: 1 August 2012. Revised: 19 September 2019
- ↑ Chandler IP, Oommen R, Lawson CW (2003). "Invasive lobular carcinoma and cytokeratin immunohistochemistry: an audit. ". J Clin Pathol 56 (3): 240. doi:. PMID 12610108. PMC: 1769908. Archived from the original. .
- ↑ Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson (2007). Robbins Basic Pathology (8th ed.). Philadelphia: Saunders. p. 739. ISBN 978-1-4160-2973-1.
- ↑ Jaya Ruth Asirvatham, M.B.B.S., Julie M. Jorns, M.D.. Breast - Fibrocystic changes - Sclerosing adenosis. Pathology Outlines. Topic Completed: 1 January 2015. Minor changes: 31 December 2020
- ↑ Sofia Lérias, M.D., Melinda Lerwill, M.D.. Usual ductal hyperplasia. Pathology Outlines. Last author update: 11 February 2021. Last staff update: 25 April 2022
- ↑ 7.0 7.1 David J. Myers; Andrew L. Walls.. Atypical Breast Hyperplasia. StatPearls, National Center for Biotechnology Information. Last Update: February 15, 2019.
- ↑ Schnitt, Stuart J (2003). "The diagnosis and management of pre-invasive breast disease: Flat epithelial atypia – classification, pathologic features and clinical significance ". Breast Cancer Research 5 (5). doi:. ISSN 1465-542X.
- ↑ Logullo, Angela Flavia; Nimir, Cristiane (2019). "Columnar cell lesions of the breast: a practical review for the pathologist ". Surgical and Experimental Pathology 2 (1). doi:. ISSN 2520-8454.
- ↑ Peter Abdelmessieh. Breast Cancer Histology. Medscape. Retrieved on 2019-10-04. Updated: May 24, 2018
- ↑ Siziopikou, Kalliopi P. (2013). "Ductal Carcinoma In Situ of the Breast: Current Concepts and Future Directions ". Archives of Pathology & Laboratory Medicine 137 (4): 462–466. doi:. ISSN 0003-9985.
- ↑ 12.0 12.1 Sucheta Srivastava. Breast - Noninvasive lobular neoplasia - LCIS classic. Topic Completed: 1 September 2017. Minor changes: 21 June 2020
- ↑ Nassar, Lara; Baassiri, Amro; Salah, Fatima; Barakat, Andrew; Najem, Elie; Boulos, Fouad; Berjawi, Ghina (2019). "Stromal Fibrosis of the Breast: A Spectrum of Benign to Malignant Imaging Appearances ". Radiology Research and Practice 2019: 1–6. doi:. ISSN 2090-1941.
Image sources
