This talk was created to set expectations and standardise language among MDT members in Demerdash Hospital aiming to improve practice and enhance reproducibility of inter- disciplinary communication

1. Optimizing breast MDT practice
in CNB and frozen section
Lobna S. Shash.MD
AssociateProfessorofSurgicalPathology
FacultyofMedicine-AinShamsUniversity

2. •CORE NEEDLE BIOPSY

3. Factno.1:CNBis a limitedtissuesample
Complex
sclerosing
ductal
proliferation
with uncertain
malignant
potential
DCIS
IDC
Adenosis
with
columnar
cell
change
Factno.2:Breastcancercarriesmarked
spatialheterogeneity

5. Core needle biopsy categories
B4:Suspiciousbutnotdefiniteofmalignancy
= Focally worrisome/ CNB quality-quantity defect
B3:Uncertainmalignantpotential=Diagnosticdifficulty
Spindle cell lesions Papillary lesions
Atypical intraductal proliferations Mucoceole & others
B2:Benign
B5:Malignant
Non conclusive result???
B1:Un-interpretable/normalbreasttissue=Inadequate
Quantitatively Qualitatively
→Tiny biopsy → Crushed, fragmented, not properly targeted
(fibrous/ adipose tissue/ blood …etc)

6. Howtooptimizethe reproducibilityofCNB?
• Radiology role
1.Quantityassurance:
-If >1 suspicious lesion →
representative from
each+ separately labeled
-Presentation of each
lesion ≥ 2 cores,
each=1cm
2.Qualityassurance:
-Proper targeting: skilled
operator, +/- MRI??
-Fixation, x crushing ..ect.
-Specimen radiographing
• Pathology role
1.Objectivereportinglanguage
→ CNB categories
- Avoid B1, B3 and B4 categories
beyond specified indications
2.UtilityofIHC:
A)Diagnostic:
-Ca vs. lymphoma or sarcoma
-IDC vs. ILC
-Myoepith. markers?(Small lesion,
large CNB)
- Others
B) Predictive/ prognostic:
ER, PR, Her2 neu, ki67

7. Howtooptimizethe reproducibilityofCNB?
• Clinician role
1. Fulfill request data about patient, CP, nature of specimen
2. Confirm specimen (s) labeling
3. Confirm all radiology reports are included
4. Specify any special concern
5. Management plan:
B1→ Repeated biopsy B2→  B3→ B4→ B5→
Role of MDTM

10. • FROZEN SECTION

11. Factno.1:Frozensectionpavestheway
tosuccessfulbreast oncoplasty

12. Factno.2:Frozensectionina costly
procedurewith suboptimumoutcome
•Frozensectionsallowsynchronouspathologicevidenceattimeof
operationthusofferbesttimedinsightoftheextentofthesurgery
•BUT:
-Cost=underanesthesiatime+/-%oferror+/-tumorcompromise
Time=
Timeofspecimendelivery
+ Timeofspecimenorientationandgrossing
+Timeoffreezingprocedure+timeofslidespreparationbyslicing
andstaining
+Timeofmicroscopicevaluation
+Timeofconsensusfinalreporting)
..xNO.OFBLOCKSNEEDED
%ofError=
-Manystepscarryartefactualfallacies→dependsontechnicianskills
-UsuallyinthezoneofintraductalproliferationsDD
-Unjustifiedincontextofpapillarylesions(needforIHCisthedefault)
-Effectonsurgeryplan:UDHvs.ADH/FEAvs.DCIS/microinvasion
especiallyinmarginsevaluation.(whatsequel?doesitdifferfromone
margintoanother?Doestheextentmatter?)
-Infavorofdoubt?Infavorofcaution?Equivocal??
-Thusofsupremeimportantto includethepathologistinthedecision
PREOPERTAIVELY
Tumorcompromise=
-Ifsmalltumor,it’sunrecommendedtosampleinfrozensection
becauseitinterfereswithhormonereceptorstatus,thustumorsize
mustallow2sectionsofpropertumortissue(frozen+paraffin)
-IfpostNAT,totalmessupwithpostNATevaluationofresponse→
samplingtumorbedisBANNEDinfrozensectionsBUTmargins
assessmentisanestablishedindicationoffrozensectionIF
conservationsurgeryisSETTLED

13. 1.Preoperativecommunication:
Establishindicationoffrozensection(discussionof
reproducibilitybyassessingconsandpros→set
expectationsandplanaheadforplanBscenarios).
PostNATCBSisNONSENSEiflocalizationisn’tdefinite
2.Intraoperativecommunication:
Addnewclarificationsandpreventunnecessarydelay.
3.Standardizedspecimenmarginslabelingprotocol
4.Technicaldifficultiesrequireskillfultechnicians:
Practice
5.Avoidextendedmargins…palpation,pre+/-
intraoperativeradiographing-rapiddelivery
How to optimize frozen section practice?