DR. I.M.NAWROZ CONSULTANT PATHOLOGIST FIFE AREA LAB FIFE SCOTLAND HONORARY SENIOR LECTURER St. ANDREWS MEDICAL SCHOOL

Transcription

1 PATHOLOGICAL HANDLING OF SURGICAL BREAST SPECIMENS DR. I.M.NAWROZ CONSULTANT PATHOLOGIST FIFE AREA LAB FIFE SCOTLAND HONORARY SENIOR LECTURER St. ANDREWS MEDICAL SCHOOL

2 PATHOLOGICAL HANDLING OF BREAST SURGICAL SPECIMENS Surgical breast specimens of various type are a common part of routine surgical pathology, usually portray deceptively simple but often macroscopically quite complex especially when dealing with multifocal disease, screen-detected micro calcification and post neo-adjuvant excision specimens. Accurate macroscopic assessment/handling with proper adequate sampling are paramount if we are to convey an accurate pathological set of data. Accurate assessment of the size and excision margin status with appropriate and adequate sampling cannot be overstated. Proper fixation is also essential for morphological preservation, accurate grading, accurate assessment of mitotic activity (under fixation with dampen mitotic activity) and protein preservation for hormonal and HER2 assessments. Impalpable lesions, often screen-detected may require stereotactic or ultrasound localisation while clinically palpable lesions usually need no such localisation unless surrounding further abnormality is detected which need to be localised and excised in the main mass. The guidelines for various malignant breast surgical specimens will be discussed, the complexity of some post neo-adjuvant chemotherapy excisional specimens and the usefulness of pro forma minimum data set will be highlighted.

3 Macroscopically could be deceptively simple,often complex Accurate, adequate macroscopic handling and proper adequate sampling Surgical Beast specimens Common surgical pathology specimen Proper fixation to preserve morphology and protein

4 Breast specimens Needle core biopsy Diagnostic biopsy Excision specimen Mastectomy Free hand, USS, Stereocore WLE POST NEO- ADJUVANT WLE Unguided and Wire Guided Michrodochetomy Primary M. Secondary M. Post neo-adjuvant Prophylactic M. Reduction Mastopexy Male Mastectomy

5 B3 B4 Uncertain malignant potential Suspicious of malignancy Diagnostic Excision Weigh, measure three dimensions and serially slice into 3-5 mm thickness slices. 3 cm or less diagnostic biopsy could all be processed. Larger specimens,size permitting, all could be processed otherwise well marked representative blocks representing the abnormality and surrounding normal tissue should be submitted. Localisation diagnostic specimen for screen-detected abnormality, often for microcalcification, may require specimen slice radiography and selection of most representative abnormal area of microcalcification and surrounding normal tissue. Blocks could be marked from the site of the slice radiography and then drawn on slice photograph. Confirm the diagnosis

6 TYPES OF BREAST SURGICAL SPECIMEMS Needle Core biopsy specimen. Diagnostic specimen. Microdochectomy. Excision specimen. Mastectomy specimen Diagnostic Breast Surgical Specimens These often follow needle core biopsy of B3-uncertain malignant potential or B4- suspicious for malignancy. The purpose is to confirm the diagnosis for further management. Weigh the specimen, measure three dimensions and serially slice into 3-5 mm thickness slices. 3 cm or less diagnostic biopsy could all be processed. Larger specimens and size permitting, all could be processed otherwise well marked representative blocks representing the abnormality and surrounding normal tissue should be submitted. Localisation diagnostic specimen for screen-detected abnormality, often for microcalcification, may require specimen slice radiography and selection of most representative abnormal area of microcalcification and surrounding normal tissue. Blocks could be marked from the site of the slice radiography and then drawn on slice photograph.

7 Nipple Discharge Microdochectomy Weigh, measure in three dimensions, depending on local surgical protocols, often surgical superficial aspect essentially the nipple margin is marked. Circumferential margin of the specimen is painted and specimen serially sectioned from superficial to deep 3-5mm thick slices, serially blocked,non opposing full face and cruciate sample from the deep margin submitted. If Microdochectomy marked as wide local excision, sample margins accordingly.

8 TYPES OF BREAST SURGICAL SPECIMEMS Microdochectomies Weigh, measure in three dimensions, depending on local surgical protocols, often surgical superficial aspect essentially the nipple margin is marked. Circumferential margin of the specimen is painted and specimen serially sectioned from superficial to deep 3-5 mm thick, serially blocked and cruciate sample from the deep margin submitted. If microdochectomy marked as wide local excision, sample margins accordingly.

9 Breast specimens Excision specimen WLE POST NEO-ADJUVANT WLE Unguided and Wire Guided

10 Weight, 3 dimension measurement Margin painted as per local protocol Coronal slicing Sagittal slicing Cruciate slicing WLE Therapeutic to achieve local complete.exc. Oriented and with specimen radiograph Identify main lession, measure in 3 dimensions, note any surrounding abnormality, compare to specimen x-ray, measure minimal 6 radial clearance margins, sample and clearly label the tumour with surrounding tissue especially if x-ray reveals microcal. Beyond tumour and 6 radial margins.

11 TYPES OF BREAST SURGICAL SPECIMEMS Wide Local Excision Therapeutic procedure to achieve local complete excision. Surgical specimen oriented by sutures or metal clips, any uncertainty should be clarified with the surgeon before cutting. Standard surgical procedure, excision includes breast specimen from subcutaneous tissue to pectoralis fascia and as such anterior/posterior margins are of less significance than the radial margin. Any exception to this should be pointed out on the request form by the surgeon. Specimen radiograph is essential, needs to be closely examined by the pathologist before trimming to identify the main lesion and particular attention should be given to any abnormality around the main lesion. The cut surface of the slices need to be closely correlated with the radiological appearance. Specimens need to be weighed and measured in three dimensions. External surface inked as per laboratory procedure using one or more than one colour code and depending on the nature of the specimen. Using more than one colour code it is advised to fix the colour with acetic acid and dry it up before the application of a second colour in order to stop seepage of the colours into each other. When one colour is used only one margin should be coloured per block. The blocks should be clearly marked and easily identified.

12 SECTIONING WLE Coronal Slicing Slice coronally from anterior to posterior perpendicular to anteroposterior axis 3-5 mm thick slices. Has the advantage of assessing four radial margins in one slice. More accurate measurement of tumour size and clearance margin. Depending on tumour dimensions, full face tumour can be submitted in one or more than one block and if so clearly mark and if required edges inked with a sketch highlighting the complimentary nature of the blocks taken.

13 CORONAL SECTIONING GUIDED/UNGUIDED LT.WLE

14 CORONAL TRIMING RT. WLE / NEELE LOCALISATION ANT POST. SUPERIOR ANTERIOR INFERIOR POSTERIOR

15 Weight, 3 dimension measurement Margin painted as per local protocol Coronal slicing Sagittal slicing Cruciate slicing WLE Therapeutic to achieve local complete.exc. Oriented and with specimen radiograph Identify main lession, measure in 3 dimensions, note any surrounding abnormality, compare to specimen x-ray, measure minimal 6 radial clearance margins, sample and clearly label the tumour with surrounding tissue especially if x-ray reveals microcal. Beyond tumour and 6 radial margins.

16 RT.WLE

17 RT.WLE ANT. Sup. POS. Lat.. Med. ANT. Inf. POS.

18 Sup.Lat. RT.WLE Sup. Sup.Med Lat Med Inf.Lat Inf.Med Inf.

19 RT.WLE MEDIAL ANTERIOR INFERIOR

20 RT.WLE ANT SUP LAT MED INF POS

21 RT.WLE ANT SUPERIOLATERAL SUP SUPERIOMEDIAL LAT INFERIOLATERAL INF MED INFERIOMEDIAL POS

22 RT.WLE SUP. SUPERIOLATERAL SUPERIOMEDIAL LAT. MED. INFERIOLATERAL INF. INFERIOMEDIAL

23 SECTIONING WLE Sagittal Slicing Serially slice the specimen in sagittal plane from medial to lateral, parallel to the anteroposterior axis in 3-5 mm thick slices. This is particularly useful for mammographically detected duct carcinoma in situ where there may be no macroscopically detected abnormality. Specimens for duct carcinoma in situ often screen detected, radiological micro calcification. Radiography of the slices will facilitate identification of the micro calcification for sampling and the representative block taken can be marked on the specimen radiograph or slice photograph. Adequate normal tissue from the edge of abnormality should be taken, ie beyond the Radiologically detected micro calcification as some duct carcinoma in situ may not be associated with calcification and may extend beyond the Radiologically identifiable micro calcification. Medial-lateral tumour dimension is estimated by multiplying the number of slices containing the tumour tissue by thickness of the slice. All the four radial margins should be sampled giving particular attention to macroscopically close margin. Cruciate samples from medial and latteral slices also taken. Depending on the size of the tumour, two margins and up to four margins can be identified in one block.

24 SAGITAL GUIDED/UNGUIDED LT. WLE

25 SAGITAL SECTIONING GUIDED/UNGUIDED RT. WLE Superior inferior SUPERIOR LATERAL MED. INFERIOR

26 POST CHEMOTHERAPY WIRE GUIDED WLE RT. BREAST SUP LAT ANT MED INF

27 POST CHEMOTHERAPY WIRE GUIDED WLE RT. BREAST Wing marker Localising needle

28 POST CHEMOTHERAPY WIRE GUIDED WLE RT. BREAST CORONAL SLICING SUP LAT ANT MED INF

29 POST WIRE GUIDED WLE RT. BREAST SAGITAL SLICING

30 POST CHEMOTHERY WIRE GUIDED WLE RT. BREAST

31 POST CHEMOTHERAPY WIRE GUIDED WLE RT. BREAST ANTERIOR SUPERIOR MED LAT INFERIOR SUPERIOR LAT MED POSTERIOR INFERIOR

32 POST CHEMTHERPY WIRE GUIDED RT. WLE Localising needle Med Lat. Ant. Inf.

33 POST CHEMOTHERAPY WIRE GUIDED RT. WLE Sup. ANT Med Lat. Med. Lat. Ant. Inf. Inf. POS.

34 POST CHEMOTHERAPY WIRE GUIDED RT. WLE SUP. LAT MED INF.

35 WIRE GUIDED WLE FOR WIDE SPREAD SCREEN DETECTED CALCIFICATION

36 WIRE GUIDED WLE FOR WIDE SPREAD SCREEN DETECTED CALCIFICATION

37 SECTIONING WLE Cruciate Slicing Two cruciate incisions superio-inferior and lateral-medial, quartering the specimen like an orange. Four radial sections from the centre of the mass and up to eight further shave margins can be submitted. Depending on individual breast unit protocol clearance varies from 1 up to 3 mm. Therapeutic Post Neo - adjuvant Wide Local Excision Can be handled using any of the above methods. When complete clinical response and/or no residual palpable tumour, extensive sampling may be required with clearly identifiable and marked blocks to indicate the way in which the abnormal area has been sampled. Quite often what is left is hypocellular hyalinised scar containing some inflammatory cells including foamy macrophages and sometimes only duct carcinoma in situ left.

38 Cruciate ( Radial ) Slicing Lt.WLE

39 Cavity Shave and Re-excision RE-EXCSION CAVITY WALL LT. RE-EXCISION LATERAL AND INFERIOR VAVITY WALL Lat. Cav. New mar. Inf. Cav.

40 LT. MASTECTOMY WITH LT. AXILLARY CLEARANCE

41 LT. MASTECTOMY WITH LT. AXILLARY CLEARANCE

42 LT. MASTECTOMY WITH LT. AXILLARY CLEARANCE

43 LT. MASTECTOMY WITH LT. AXILLARY CLEARANCE

44 LT. MASTECTOMY WITH LT. AXILLARY CLEARANCE

45

46 RT. MASTECTOMY WITH LT. AXILLARY CLEARANCE POSTERIOR

47 B axillary lymph nodes: levels I C axillary lymph nodes: levels II D axillary lymph nodes: levels III E supraclavicular lymph nodes F internal mammary lymph nodes BREST LYMPHATIC DRAINAGE E F Sentinel node

48 PATHOLOGICAL HANDLING AND REPORTING OF AXILLARY SENTINEL LYMPH NODE BIOPSY Axillary sentinel lymph node biopsy is an established and integral part of staging clinically node negative breast carcinoma. The methods of sentinel lymph node biopsy and role of the axillary lymph node surgery in management of breast cancer will be discussed. The methods of assessment, pathological handling and the clinical significance of sentinel node metastasis will be highlighted. Reference: Sentinel lymph node biopsy: review of literature and guidelines for pathological handling and reporting. C. A. Purdie, current diagnostic pathology Vol.13, issue 2, April 2007, P

49 Standard nodal staging procedure in clinically node ve ca. Significantly less morbidity than ALND Axillary Sentinel Lymph Node Direct lymphatic drainage from tumour, likely Axillary lymph node stage is the single most important predictor of carcinoma specific mortality

50 Potentially up to 60% symptomatic Up to 75% screen detected Over treated with ALND 5% ASN false ve 9% Internal Mammary SN ASLN macro metastasis 50% chance MICROMETASTSIS 20% CHANCE OF ASLN ITCs 9% CHANCE Non-SLN METASTASIS ASLN Symptomatic Ca. 40%, Screen detected 25% chance of sentinel nodal metastasis ASLN ITCs IS Node VE Micro / Macrometastasis indication for further therapy ITCs/ Micrometastais leads to stage migration with potential overtreatment therapy

51 3-4 SNs 1% SN false ve 1 SN 10%SN false -ve 4 SN identify nodal metastasis in 99.6% of cases 5 nodes, combination SN,NS identify metastasis in 100% ALNS 4 nodes from lower axilla including SN. 80% of cases Accurate axillary node staging Less morbidity than ALND. Accurate procedure for axillary node staging with lower morbidity than axillary node dissection.

52 Pathological assessment of SLN Preoperative Intraoperative Postoperative USS with FNA or NC biopsy 40% +VE DETECTION FS 6-24% FALSE VE Labour intensive, Tissue loss Operating time increase Imprint cytology 5-66 false -ve Demanding/tasking Relatively more rapid than FS Serial sectioning <2mm thick Non-opposing full face embedding 1-3 H&E full face sectioning If micromet. Deeper levels at micron. intervals CK Immunohistochemistry and PCR

53 SEN.NODE RT. SEN. NODE

54 RT. NODE SAMPLE NODE SAMPLE

55 Breast Carcinoma Conventional Prognostic Factors Grade Correlate with disease free and post relapse survival Interobserver variation limits its use as strong prognostic factor Nodal stage Single most strong factor 5 year over all survival node ve 92% 1-3 +ve nodes 81% 4 or more 57% Tumour size 2 nd strongest prognostic factor 5 year over all survival 1 cm node ve 99% 1-3 cm node ve 89% 3-5 cm node ve 86% Tumour type 90% NST 5% Lobular Tubular, Papillary and Medullary better prognosis Hormonal status ER,PR status indicative slow growth, predictive of H. therapy response but non altered metastatic potential after 5 years ER+VE prognostically significant in 1 st 5 yeas survival

56 Sup.Lat. RT.WLE Sup. Sup.Med. Lat. Med. Med. Inf.Lat Inf.Med Inf.

57 BREAST CANCER MORPHOLOGY TO MOLECULAR PATHOLOGY ANT. POS.

58 SEN.NODE RT. SEN. NODE

59 RT. NODE SAMPLE NODE SAMPLE

60 ER RT.WLE DIC G3 LVI VEIN

61 MICROMETASTASIS RT. SEN. NODE

62 HANDLING BRAST SPECIMENS INVASIVE CANCER: GRADE: SIZE: MARGINS: MULTI-FOCAL: LVI: IN-SITU CANCER: GRADE: EXTENT: MARGINS: OVERALL DIAMETER: LYMPH NODES: SENTINEL NODES: ER: HER2: TNM: NPI: or Adjuvant! Online, St Gallen Guidlines COMMENT

63 PATHOLOGICAL HANDLING OF BREAST SURGICAL SPECIMENS SUMMARY Adequate fixation, proper, adequate macroscopic examination with proper well labelled sampling are of paramount importance. There is more than one method of handling breast specimens. Individual specimen must be considered in the clinical and radiological setting and different samples may be best handled by different needs. Samples should include all four radial aspects of the carcinoma and all radial margins should be sampled in all wide local excision specimens. Depending on tumour size, at least 4-6 blocks should be taken including either full face section of the carcinoma or two radial tumour blocks which incorporate maximum dimension of the carcinoma and surrounding macroscopically uninvolved tissue.

64 Axillary Sentinel Lymph Node SUMMARY No widely accepted consensus or guidelines on best method of postoperative pathological examination of sentinel lymph nodes. Node should be serially sliced in < 2mm thick slices, processed in entirety, all slices embedded with non-opposing faces are examined completely. Macrometastasis should be identified when present. Single full face H&E from each block would ensure identification of micrometastasis < 2mm in dimension. If micrometastasis < 2mm identified, a micro-interval deeper level examination would aid identifying greater metastasis (macrometastasis). Individual cell tumour metastasis could be highlighted more by Cytokeratin immunohistochemistry. In difficult borderline cases TNM classification rule 4 should apply i.e. if doubt lower category nodal stage should be allocated.

65 BREAST CARCINOMA NEW PROGNOSTIC MARKERS NEW PROGNOSTIC MARKERS HER2-ONCOGEN,15-20% OF BREAST CA. PREDICTIVE HERCEPTIN RESPONSE AND HORMON THERAPY RESISTANCE IRRESPECTIVE OF ER STATUS PROGNOSTIC- UP TO12% RISK OF RECURRANCE IN NODE VE COMPARED TO HER2 VE ANGIOGENESIS MARKERS MICROVASCULAR DNSITY BASIC FIBROBLASTIC FACTOR RESISTANCE TO THERAPY MARKERS ER STATUS Topoisomerase 2a (target for Anthracycline) Protein tau(resistance to Taxanes) Tumour Serum Markers CA15.3, CA27, CA27.29 INVASIVE MARKER CATHEPSIN D P53 TUMOUR SUPRESSOR GENE, RELATIVE RECURRANCE RISK 1.5% AND 2-2.6% DEATH IN NODE -VE

66 THE END