This document provides information on grossing of breast specimens. It discusses the anatomy of the breast and lymphatic drainage. It describes different types of breast specimens including excisions, lumpectomies, quadrantectomies, mastectomies, and microdochectomies. Key steps for grossing include examining the specimen, measuring tumor size and margins, slicing and sectioning the tumor and breast tissue, evaluating lymph nodes, and describing other findings. Special considerations for grossing lumpectomy, mastectomy, and mammocalization specimens are also outlined. The goal of gross examination is to accurately stage the tumor and assess margins, lymph nodes, and other important pathological features.

1. GROSSING OF BREAST
SPECIMEN
PRESENTED BY-DR. ANKITA SHARMA
MODERATOR-DR. ALPANA JAIN

2. ANATOMY
• Lies in the superficial fascia on the
anterior chest wall
• Extends from lateral border of the
sternum to the midaxillary line and
vertically from the 2nd to the 6th rib
• Lies on the following muscles:
Pectoralis major
Serratus anterior
Latissimus dorsi

3. • Divided into 4 quadrants & axillary tail.
• Breast tissue extends from the upper outer
quadrant into the axilla, forms the tail of Spence.
• Tail of Spence (Axillary tail) extends along the
inferolateral edge of the pectoralis major muscle and
enters a Hiatus of Langer in the deep fascia of the
medial axillary wall.

4. LYMPHATIC DRAINAGE
• The axillary lymph nodes are
divided into levels 1,2 and 3
• LEVEL I- lateral to the lateral border
of the pectoralis minor muscle
• LEVEL II- under the pectoralis minor
muscle & interpectoral (Rotter’s
nodes)
• LEVEL III- medial to the medial border
of the pectoralis minor muscle

5. • Intra mammary nodes:
• Mostly found in outer quadrant
• May rarely be sentinel lymph nodes
• Internal mammary, supraclavicular
and infraclavicular lymph nodes

6. Lymphatic drainage

7. TYPES OF BREAST SPECIMENS
• EXCISIONS:- Resecting the breast tissue without the intent of
removing the entire breast.
• LUMPECTOMY:- Removal of a small malignant tumour/discrete mass
with variable amount of surrounding breast tissue ; In combination
with axillary node dissection.
--Lesion palpable by surgeon
• QUADRANTECTOMY:- Excision corresponding to one of the four
quadrants (rarely done)

8. • Breast conserving surgery:-
• More difficult and time consuming to gross than mastectomy
• Often requires more sections
• Margin assessment crucial
• Most patients have radiation post surgery

9. • SIMPLE MASTECTOMY:- Total mastectomy without axillary dissection.
• SKIN SPARING MASTECTOMY
• NIPPLE SPARING MASTECTOMY
• RADICAL MASTECTOMY:- involves removal of
• Breast and axillary lymph nodes
• Pectoralis major and minor muscles and the fascia
• MODIFIED RADICAL MASTECTOMY:- involves-
• Removal of the breast and axillary lymph nodes
• Preserving the pectoralis muscles.

11. • MAMMOLOCALISATION EXCISION
• Lumpectomy for lesions which are radiologically detected, under radiologic
guidance
• MICRODOCHECTOMY
• Excision of nipple ducts with a cuff of surrounding breast parenchyma
• Usually done for intraductal papillomas and for ductal carcinoma in situ (DCIS)
involving the lactiferous ducts

12. INDICATIONS OF MASTECTOMY
• Patient choice
• Large tumours
• Multifocal tumours
• Recurrence or new primary in a patient previously treated with breast
conserving therapy (BCT)
• Prophylactic
• Radiation therapy contraindicated in pregnancy
• Inflammatory breast cancers
• Diffuse suspicious or malignant appearing microcalcification
• Radical mastectomy is reserved for tumours involving pectoralis major
muscle or recurrent breast cancers involving chest wall.

13. NEOADJUVANT THERAPY (NAT)
• Administration of systemic therapy (chemotherapy or anti hormonal
therapy) prior to definitive surgical resection
• Inflammatory breast cancer
• Inoperable locally advanced disease
• Render breast conserving surgery possible
• Primary management of aggressive subtypes of disease

14. Steps to be followed prior to grossing
• Previous biopsy report
• Relevant radiology
• Relevant clinical information
• Specimen diagram
• Specimen photograph

15. • GROSSING is the first basic step in surgical pathology.
• An adequately and correctly grossed mastectomy specimen :
1) Helps to stage the tumour
2) Provides information on prognosis
3) Helps in deciding most appropriate treatment
4) Helps to assess response to therapy

16. IDENTIFICATION OF SPECIMENS AND
REJECTION
• Confirm patient identification information on the requisition
form and specimen container .
• Pathology number generated should be affixed on the requisition
form and the container.
• Note the condition in which specimen is received: fresh and
unfixed, fixed adequately or inadequate formalin, or autolysed.
• If there is incorrect or no identification number, mismatch in
number of specimens mentioned and received then specimens
are returned with details including reason for rejection.

17. FIXATION
• Neutral buffered formalin is must for fixation.
• pH to be maintained at 7.2-7.4
• Breast tissue specimens must be fixed in 10% neutral buffered
formalin (NBF) for no less than 6 hrs and no more than 72 hrs before
processing.
• Under fixation of breast tissue may lead to false negative ER results
and over fixation may lead to false positive HER2 results.

18. EXAMINATION OF SPECIMEN
• Dimensions of specimen & skin ellipse
• Localization , dimensions of tumor
• Margins of tumor
• Distance from overlying skin ,deep & closest margin
• Surrounding breast, Nipple areola & Overlying skin.
• If previous biopsy site/cavity present, describe size,
appearance, and location. Also note the
presence of any residual tumor.

19. • If additional localized lesions are identified describe
size, location in quadrant.
• If separate from primary lesion give an estimate of its
distance from the primary lesion. Sample the areas in
between the two tumors.
• Dissect out the Axillary lymph nodes. Note the size of
grossly positive & /or largest lymph node.

20. Grossing a lumpectomy specimen
1) Measurements : record the size of specimen and confirm
the orientation.
2) Inking external surface: the use of different colour inks on
an individual section can assist microscopic identification
of specific margins.
Colour code used is :
Superior – blue
Inferior – green
Medial – brown /orange/purple
Lateral – yellow
Superficial – red
Deep – black

21. Specimen orientation
• Orienting stitches are placed on the specimen during surgery to allow
reorientation by pathologist.
• Suture identification (long lateral and short superior)

22. (We use black for posterior)

23. 3) SLICING : The specimen is serially sliced at intervals of approximately 3-5mm.
• While sectioning the complete tumour must be exposed and the slice should
demonstrate the closest margin radially.
• Palpating the intact specimen to locate the lesion, holding it between thumb and
forefinger to anchor it, and making a slice through the centre of the lesion
The techniques used for slicing a lumpectomy are:
a) Sagittal slicing
b) Coronal slicing
c) En block method
d) Crucial slicing or radial block

24. b) Coronal slicing:
This involves serial slicing of
specimen from superficial to the
deep plane(anteroposteriorly).
It is preferred for a small
specimen <3cm sized and for
Microdochectomy specimen.
a) Sagittal slicing:
 This method is commonly
used for examination of
impalpable lesions, such as
those with
microcalcification.
 It is used for small lumps <
3cms..
 In this, the specimen is
sliced from medial to lateral
aspect serially

25. c) En block method: for
lumps >3cms
 Cut the two corner disc
from a lumpectomy
specimen.
 The central portion is
serially sliced while the
corner discs are cut in
perpendicular manner.
 This method ensures that
the entire tumour surface is
blocked and submitted
entirely.

26. d) Crucial slicing or radial block method:
 This method is commonly followed.
 Used for specimen containing a large palpable mass or a visible
abnormality.
 In this method, two cruciate incisions(superior to inferior and medial
to lateral) are made on the posterior aspect perpendicular to each other.
 Four radial sections can be taken from the centre of the mass lesion to
each of the radial/circumferential margins each having the designated
surfaces

28. 4) Sampling & measurement of margins:
• Distances of the inked surface from the tumour are measured as the tumour
margins.
• Atleast sample six surfaces- anterior,posterior,medial,lateral,superior and inferior.
• Types of margin of a lumpectomy could be a radial margin or a shave margin.
• A shave margin is an irregular three dimensional disc like breast tissue shaved off
from the inked surface while A Radial margin is a radially taken section with
tumour at one end and is usually in a single plane.
• Shave margins are taken when the margin is far from tumour while radial margins
are taken when it is possible to have tumour and margin in one section(<2cm)

29. Margins in lumpectomy
• It is always better to take the margins (radial or shave ,as required) in
the following order:
S—superior I—inferior M—medial L—lateral A—anterior(skin, if present)
P—posterior . Remember the mnemonic SIMLAP
• Margin evaluation
• Margin evaluation is an exercise in probabilities (not absolutes)
• Patients with positive margins are more likely to have residual disease at or
near the primary site than those with negative margins
• A positive margin does not guarantee residual disease
• A negative margin does not preclude extensive residual disease

30. Radial and shave margin

31. 5) Tumour evaluation and sectioning:
• After slicing record the details of the tumour, including size, cut surface
and include brief comment on the adjacent breast.
• Tumour size is one of the important thing in grossing specimens from
breast cancer that determines stage of d/s and hence the need for adjuvant
therapy.
• Measure tumour in three dimensions, but for staging purpose ,the largest
dimension is recorded.
• Samples of approx less than 3cm or lesser in maximum dimension should
be completely sliced ,embedded and submitted entirely.

32. 6) Sections from tumour:
• Take 4 sections of tumour with the adjacent breast parenchyma.
• The later is important to document extensive intraductal
component(EIC) & lymphovascular emboli.
• The normal breast also serves as an internal control for hormone
receptor evaluation.
• one section from uninvolved quadrant in the lumpectomy is also
taken to look for associated precancerous lesions.

33. 7) Lymph node evaluation:
• The Axillary tissue is usually separately sent in a breast conservative
surgery or lumpectomy sp.
• Make nicks in the specimen to ensure proper fixation of nodes.
• Lymph nodes >5mm in max size should be sliced at intervals of
approx 3mm or less perpendicular to the long axis chiefly to detect
small metastatic deposits.
• Nodes <5mm in size should be submitted in their entirety.

35. Grossing a mastectomy specimen
1. Sample identification in mastectomy is same as for
lumpectomy.
2. Mastectomy specimens may be oriented by the
surgeon , by placing a suture in the Axillary tail. A
diagram indicating site of lesion. If not orient the
specimen by placing Axillary contents laterally.

36. 3. Measurements:
Note the dimensions of the specimen, skin and breast
parenchyma.
4. Describe the skin surface for previous scars, puckering, peau
d’orange, ulceration etc.
• Nipple and areola are carefully examined for retraction,
inversion or ulceration.
5) FIXATION :
Done in 10% NBF in an adequate size of container for no less
than 6 hr & no more than 72 hr before processing
Under fixation of breast tissue may lead to false negative ER
results and over fixation may lead to false positive HER2
results

37. 6) Sectioning :
• Ink the base.
• The breast is dissected by a series of parallel incisions
through posterior surface into 1cm slices.
• Identify the tumour or the surgical defect in case of
previous lumpectomy

38. 7) Tumour evaluation :
• After slicing record the details of the tumour, including
size, cut surface and include brief comment on the
adjacent breast.
• Tumour size is one of the important thing in grossing
specimens from breast cancer that determines stage of d/s
and hence the need for adjuvant therapy.
• Measure tumour in three dimensions, but for staging
purpose ,the largest dimension is recorded.
• Tumour examination: document tumour dimensions,
quadrant, consistency, borders, necrosis, haemorrhage and
distance from overlying skin/nipple and also from the base
of resection.
• Samples of approx less than 3cm or lesser in maximum
dimension should be completely sliced ,embedded and
submitted entirely.

39. 8) Sections from tumour:
• Take 4 sections of tumour with the adjacent breast parenchyma.
• The later is important to document extensive intraductal component
(EIC) & lymphovascular emboli.
• The normal breast also serves as an internal control for hormone
receptor evaluation.

40. 9)Take a disc of nipple and serially section in longitudinal or
coronal sections.
10) Adjacent breast examination:
• Examine all the quadrants of the breast to look for satellite
nodules and fibrocystic changes.
• Carefully look for micro calcifications in and around the main
tumour.
• Sample any grossly seen abnormality
• There are no margins in a mastectomy except base.

42. 11)Axillary node dissection:
• The axilla may be fixed in continuation with the mastectomy or
we cut off the axilla & fix it separately in case of large specimen
• Dissect out lymph nodes and describe the largest node and its cut
surface, no. of grossly metastatic nodes
• Remember to include a thin rim of perinodal fat around each
node so that microscopic extra nodal extension may be
commented upon.
• A minimum of 20 lymph nodes should be found in the usual
radical mastectomy

45. GROSSING MAMMOLOCALIZATION
• The radiologist puts a needle in situ and then the patient goes to the OT and has lump
excised.
• The guide wire is in situ and area around it important for histologic evaluation.
• However this needle sometimes shifts and hence grossing under mammography
supervision is essential.
• Hence mammography of the whole specimen is done, ink the specimen, fix the ink.
• Slice it from medial to lateral (sagitally). Uniform slicing at 2 to 3 mm is must so that the
medial and lateral margin assessment is simplified. Examine slices and see if the
mammographically seen lesion has any gross appearances. If visible than measure size
and margin distances. Mammograph the slices and localize the lesion and identify the
slices of importance.
• The slice where the lesion is seen is submitted entirely for histology.
• Submit random sections from the mammographically normal appearing slices.
• If non visualized than measure lesion size and margins in the mammographic slices.

46. GROSSING A MICRODOCHECTOMY SPECIMEN
• Done for nipple discharge
• Be careful not to section this specimen harshly as a tiny papilloma
may fall off.
• These excisions generally are <3 cm in size , they are inked externally,
sliced serially from the superficial to deep plane(coronally) and
submitted entirely for histological examination.

47. • Scenarios where more extensive tissue sampling may be required:
• Expected lesions are not grossly apparent
Invasive lobular carcinoma and other invasive patterns with minimal gross
findings
• Multiple lesions (need to sample in between them if close)
• DCIS (or extensive LCIS)
• Tumor bed sampling after neoadjuvant chemotherapy

48. Thank you

49. GROSS PATHOLOGY

50. •Depressed nipple: -
May be congenital (go into the
history)
• Depressed and puckered
nipple: - Involvement by
carcinoma
• Nipple eczema: - Pagets
disease of nipple
• Peau d’ orange appearance of
skin: - Lymphatic involvement
in carcinoma breast. Skin
appears like the peel of an
orange with multiple pits.

51. Several biopsy
specimens showing
fibrocystic change of
the breast. The
scattered, poorly
demarcated white areas
represent foci of
fibrosis. The biopsy
specimen at the lower
right reveals a
transected empty cyst;
those on the left have
unopened blue dome
cysts.

52. Fibroadenoma.
A rubbery, white,
well-circumscribed
mass is clearly
demarcated from
the surrounding
yellow adipose
tissue.

53. A benign fibroadenoma; note the circumscribed outline and a lobulated cut su
• Grossly, the usual
fibroadenoma is a sharply
demarcated, firm mass,
usually no more than 3 cm in
diameter.
• cut surface is solid, grayish
white, and bulging, with a
whorl-like pattern and slit-
like spaces.
• Necrosis is absent .

54. PHYLLODES TUMOR;-
well circumscribed large
mass, firm in consistency.
Cut surface is solid and
gray white with cleft like
spaces

55. Invasive ductal carcinoma a)irregular( crab-like) shape of the tumor, white
fibrous appearance b) retraction of the overlying skin

56. MUCINOUS CARCINOMA
(mucoid, colloid or gelatinous
carcinoma)
Grossly it is well circumscribed,
and formed by a currant jelly
like mass held together by
delicate septa. Foci of
hemorrhage are frequent.

57. Message points
• For lumpectomy most important
• Negative margins ensure complete excision(avoid re-excision)
• Take sections from adjacent breast with tumor to assess extensive intraduct
component. EIC+ and margin+ patients need re-excision.
• Tumor size and nodal status determine need for adjuvant therapy.
• For mastectomy
• Tumor size , nodal status important
• Skin or nipple areola involvement documents advanced stage
• Base is the only relevant margin
• For mammographic localization
• Size of lesion and margins are important
• Mammoguided grossing is important

58. Final histopathology report essentials
• Grossing- Tumor size , nodes
• Tumor type
• Tumor grade
• EIC
• Margins
• Nodes- total number, number of positive nodes, size of largest
positive node, perinodal extension
• ER/PR
• HER2/neu