Specimen types and tissue handling
FNAs & Diagnostic Biopsies
- FNAs used to support benign clinical/imaging diagnosis or guide next step if suspicious/malignant
- Core biopsies used in screening and symptomatic clinics - sometimes require different diagnostic approaches
- In Screening and in the symptomatic clinic the FNA is used to guide immediate patient management.
- In the context of benign imaging an adequate benign FNA would probably be
followed by a core biopsy which if benign would allow the reassurance of the patient and discharge back to routine screening.
- A suspicious or malignant FNA will always be followed by a core biopsy.
- A malignant FNA will enable the patient's further management to proceed immediately. She will be told about the diagnosis and
- what will happen next - usually staging. The core biopsy is used to confirm the FNA diagnosis before proceeding to further treatment.
In the symptomatic clinic FNAs are used to support benign imaging/clinical features
to allow the immediate discharge of the patient. Depending on the setting some of these will be backed up
by a core biopsy.
Malignant FNAs have the same role in the symptomatic clinic as in screening.
We use a synoptic report which covers all the main points. See also "Communication" for potential pitfalls in
Synoptic report for FNAs
- For each lesion:
- Palpable (Y/N):
- Radiological abnormality:
- Method (Freehand/Stereo/Ultrasound):
- No of slides:
- Result (C1-5):
- Free text:
- Bottom Line:
Reporting Core Biopsies
- Screening core biopsies for calcs require a different approach to other cores
- In screening, ultrasound guided cores - usually for discrete lesions - cover a similar diagnostic spectrum to those from the symptomatic clinic
- Symptomatic clinic cores tend to be from cancers and straightforward benign lesions
- Core biopsies from cancers usually give enough material to assess grade accurately also ER, PGR and even Her2
- Synoptic reporting helps to convey the information in a readily accessible form and assists data entry
Synoptic report for core biopsies
- For each lesion:
- FNA result & ref:
- Method (Freehand/Stereo/Ultrasound):
- Specimen X ray (Y/N):
- X ray Microcalcs (Y/N):
- No of cores:
- Histol Microcalcs (Y/N) (Specify N, benign, malig,combination):
- Result (B1-5a/b):
- ER (Cat Score):
- Free text:
- Bottom Line:
Operative Specimens - diagnostic and/or therapeutic
Conservation operative specimens
- Unoriented therapeutic and diagnostic open biopsies - usually for anticipated benign conditions
- Oriented diagnostic biopsies - often screening cases without a diagnostic core biopsy where malignancy is a realistic prospect
- Oriented therapeutic biopsies with or without lymph nodes - see below
- Non-conservation specimens - mastectomies
Unoriented diagnostic biopsies
When certain benign lesions have been diagnosed preoperatively they may be managed by simple excision. The commonest lesion
is a fibroadenoma but a spectrum of other benign conditions is possible.
If the lesion is small block the case in its
entirety. If larger take between two and four representative blocks - you can always go back and take more. See also BMS Trimming.
See BMS Trimming for guidance on how to handle oriented breast biopsies on the dissecting bench.
These will fall into two main categories:
- Screening cases, usually for calcs
- Symptomatic cases e.g. duct excisions for nipple discharge
The screening cases can be complex and will have to be handled in close correlation with
the specimen X ray. It is often necessary to X ray specimen slices to localise calcs
precisely to guide block selection. For smaller biopsies (up to 30 grams) it is
often sensible to block the entire specimen.
The symptomatic cases may reveal a macroscopic abnormality when the slices are examined.
If not, then within reason block the entire specimen. In a larger specimen
it is reasonable to take selected blocks and then revisit the specimen having looked at the
initial sections and reviewed the core biopsy (if it exists).
These are usually carried out for the following reasons:
- Tumours too large for conservation therapy
- More than one tumour
- Recent "failed" wide local excision - usually due to positive margins
- Recurrent carcinoma
- Extensive DCIS (usually >40mm)
- Prophylaxis in high risk patients - strong family history or BrCa1 carriers for example
- "Balancing" mastectomies where the patient suffers discomfort because of a previous mastectomy
- Patient choice
The specimen may be accomanied by a specimen X ray which sometimes helps the pathologist to find the lesion.
If there is more than one tumour this should be indicated on the X ray if present and
always on the request form.
If the mastectomy has followed screen-detected DCIS (usually multifocal or extensive calcs with
core biopsy confirmed DCIS) then it is often necessary to X ray the breast slices
to localise the calcs and select blocks appropriately.
Blocks from a mastectomy should concentrate on the lesions rather than macroscopically normal areas. Sample the nearest margin to a
carcinoma, a small number of blocks from "normal" breast and one block from the nipple.
Remember - the core biopsy will have confirmed the diagnosis, the purpose of the mastectomy
is primarily therapeutic - to give the patient the best chance of surviving her cancer, reduce the risk of local recurrence and also to
gather prognostic information - tumour size, grade, lymphatic invasion, receptors and lymph nodes (see below).
The synoptic report will cover all these points:
Synoptic report for wide local excisions and mastectomies for cancer:
- Invasive cancer:
- Size (mm):
- In situ cancer:
- Vasc/lymphatic invasion:
- Lymph nodes (Sample/Clearance):
- Sentinel nodes:
- Apical tissue/nodes:
- ER Category score:
- Her 2 status:
- TNM stage:
The rationale behind the procedures
Lymph node status is the most important prognostic factor in breast cancer. The choice of
type axillary lymph node assessment has to balance the following issues:
- Axillary node sampling is as accurate as node clearance in determining node positive v node negative status
- Axillary node sampling is diagnostic rather than therapeutic - a positive sample may require further treatment
- Axillary node clearance is therapeutic
- Axillary node clearance has its own morbidity - shoulder movement; lymphoedema - but reduces the risk of axillary relapse
- Axillary node sampling carries a much lower morbidity
- A positive axillary node sample carries an increased risk of axillary relapse - radiotherapy or clearance will often be considered
- Sentinel node biopsy is a targeted form of node sampling and carries similar risks/benefits as sampling
Lymph node specimens
- Lymph node samples - usually 4 or 5 separate nodes
- Sentinel nodes - up to 4 nodes, sometimes more
- Axillary node clearances
- Apical nodes
Handling and reporting
One of the guiding principles of lymph node assessment in (breast) cancer is to maximise
the chance of identifying metastases because of their importance in clinical management. Lymph
nodes should be cut to maximise the area visible in the section (multiple thin slices). In some
circumstances levels are cut also - see below.
A second guiding principle is to ensure that on review of a case it is possible
to be able to count accurately the number of nodes examined and the number of nodes
involved. This may seem obvious but when nodes have been sliced and each slide appears to contain
multiple fragments this is not easy unless a strict protocol is adhered to. In this department
we describe lymph nodes as "A" nodes, "B" nodes and "C" nodes with the following definition:
- "A" nodes - These are nodes which contain macroscopic tumour - multiple nodes per cassette - node count as per section
- "B" nodes - Nodes >5mm - sliced (bisected, at least), usually one per cassette; if large distribute over more than one cassette and describe in macro
- "C" nodes - Nodes <5mm - multiple nodes in each cassette - usually between 3 and 6, levels cut, node count as per section
When reporting metastases give the size in mm of the largest deposit and state whether there is extranodal
tumour extension. If nodes are matted together say so in the macro.
Lymph node samples
Treat as "B" nodes, usually one node per cassette unless large.
Treat as "B" nodes, usually one node per cassette. Subsequent sectioning and staining
currently controversial. Currently agreed to cut three levels on each block. Immunohistochemistry
not required unless it is to confirm a suspicious focus seen on the H&E. This general principle about the use of
immunohistochemistry in lymph node assessment applies throughout our breast cancer
Cytokeratin stain used to confirm a small subcapsular lymph node deposit of metastatic carcinoma - in this case the deposit measured marginally >0.2mm on the cytokeratin section and is classified a micrometastasis
Axillary node clearances
Sort into "A", "B" and "C" nodes and block accordingly.
Usually received as a small piece of fatty tissue containing one or more small nodes. If
individual nodes can be dissected then treat as "A", "B" or "C" nodes as appropriate. Otherwise
if specimen small process in entirety and assess node numbers/involvement on sections.