Overview: Breast

Introduction In breast pathology, the gross characteristics of lesions can be especially subtle and nonspecific, and you will need practice to develop the skills required for an accurate gross examination. Furthermore, the histological analysis depends more on the recognition of the processes at work in the tissue than on the identification of specific microscopical patterns. To develop the ability to make accurate diagnoses, you will need to understand certain basic concepts, to appreciate subtle changes in cell structure and arrangement, to recognize alterations in tissue organization, and to weigh information. We offer these few general, philosophical points to guide you.

1. Make a conscious effort to develop your skills in gross evaluation. Work methodically, and take the time needed to examine the tissues carefully. Give free rein to your curiosity, and sample puzzling lesions so you can learn the microscopic correlates of macroscopical changes.

2. Prepare your cases for signout. You will find signout most profitable if you prepare your cases and yourself thoroughly. Always check the slides and paperwork for errors. Retrieve slides from previous specimens as appropriate. Use a dotting pen to mark pertinent findings and foci that puzzle you -- and write down why. Attendings will find it easier to teach you if you ask specific questions.

3. Commit yourself to a diagnosis. On the breast service, we often turn to the writing of Dr. JG Azzopardi for guidance. He offers the following opinions:
“One must be willing, even anxious, to learn from one’s errors. This requires a degree of humility, a readiness to listen to the arguments of others, including those of one’s juniors, and the inclination to re-examine cases in which a mistaken diagnosis has been made, and to analyze the reasons for the original mistake; otherwise there is a grave danger of repeating that same mistake. Perhaps worse than making a preventable error is the easily acquired of sitting on the fence and not committing oneself: there is no better way of learning nothing.”

4. Develop you knowledge in a systematic way and keep your educational expectations realistic. Do not try to master the subtlest differential diagnoses during the first few weeks on the breast pathology service. Instead, concentrate on developing dissecting and organizational skills, understanding normal anatomy and the range of appearance of normal tissue, and recognizing the classical characteristics of commonplace lesions. After you have learned the basics, you can build on them to understand the fine points and rare lesions.

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Daily Activities The evaluation of breast specimens requires especially careful attention to detail. To insure accurate diagnoses, everyone involved with these specimens must first verify the accuracy of the work that has gone on before and then work carefully so as to facilitate the work to come. We hope that the following policies will result in an efficient and accurate flow of work.

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Before your begin... Photography: Take photographs of lesions that seem unusual by either appearance or history and those that represent particularly illustrative examples of common lesions. You must take at least one gross photograph during each week on the breast service.

Radiology: Review the radiographs that accompany needle localization biopsy specimens. By referring to the radiograph, you can make certain that you have the appropriate specimen and you can identify the position of the lesion(s) within the specimen.

Check that the specimens correlate both in number and labeling with those listed on the requisition.

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At the grossing bench We expect the afternoon grossing hours to be uninterrupted, and to allow residents time to examine, describe, and process several specimens completely and thoroughly. The staff pathologist will determine which specimens you gross and it is worthwhile to consult with him/her in regard to what kinds of specimen you may learn the most from. We recommend that you prioritize specimens in the following list:

• Mastectomy specimens (including prophylactic mastectomy specimens)
• Excisional biopsy specimens from patients with suspected or known cancer
• Specimens containing uncommon lesions (such as phyllodes tumors)
• Specimens obtained in uncommon clinical settings (such as from men, women in their teens or twenties, or pregnant women)
• Specimens requiring special attention.

Instructions on how to properly gross are available on the Hub and in the Residents’ Manual. Follow these instructions exactly unless the specifics of the case indicate that you should deviate from them. Do not hesitate to consult with a staff pathologist, senior resident, or PA.

Remember to record measurements of all specimens and all lesions in three dimensions and their distance to margin. Cut the tissue into thin, small sections (1.5 x 1.0 x 0.3 cm) in order to produce quality histology that will avoid unnecessary reprocessing of tissues, cutting of levels, and delays in issuing reports.

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Prior to Signout (Previewing)

1. Review the requisitions and worksheets. Double check the names on the worksheet and make certain that the specimen has been appropriately accessioned. Mistakes involving confusion of “left” and “right” occur frequently and must be corrected. Complete or correct the clinical history.
2. Review the gross description. Correct transcription errors and make certain that the section code matches the slides prepared.
3. Organize the slides. Try to account for missing slides as soon as you discover the problem and bring incomplete cases to the attention of the staff pathologist. The staff pathologist will usually want to look at small cases, those establishing a primary diagnosis, and those requiring immunohistochemical staining first.
4. Familiarize yourself with the clinical details of the case. What type of procedure did the surgeon perform? How many parts does the current specimen have, and what are they? Has the patient undergone other surgical procedures pertinent to the current one and what did they show?
5. Study the slides carefully. Dot all pertinent findings and subtle abnormalities such as foci of atypical lobular hyperplasia, lymphatic invasion, or small metastatic deposits. Measure the distances to margins. Dot lesions about which you have questions. Choose blocks appropriate for hormone receptor studies.
6. Write your diagnoses on the pathology worksheet. Use coded comments. Complete synoptic report tables to the best of your ability.

Remember that the more you write and the closer you get to producing a final report on your own, the more you learn!