pathology sampling technique of mastectomy specimen with DCIS

dancetrancer · January 2012

Hello all,

I'm writing because I want to find out what is the standard approach for preparing a mastectomy specimen for pathology analysis. Is it typical to just take a representative sample of slices of the specimen to analyze, not examining the entire tissue block?

Here is why I ask. I had my slides looked at by 3 places (long story) who all gave the diagnosis of DCIS only on the left side, no signs of invasion (varying diagnoses were given on the R). I went to a 4th facility for a 3rd opinion on radiation due to close margins after BMX, and that facility insisted on doing their own analysis.

Well, I'm very glad they did. They saw one small spot on my slides that looked a bit "suspicious" but wasn't clear. So they ordered more samples of my tissue block which was held at the original pathology lab and stained those new samples themselves. Low and behold, they found a 3 mm spot of IDC in that new section of tissue that had never been sampled b/c it was sitting stored away, never looked at.

Now I know people say it would be impossible to look at all of the tissue, and the SNB is supposed to rule out invasion...but all 3 of my nodes were clear, so this didn't rule it out for me. I just am so thankful this was caught so that my treatment can be modified. I'm upset, though, that there has been a 4 month delay.

So can anyone answer the initial question...is it typical to not examine the entire block of tissue???

Beesie · January 2012

"is it typical to not examine the entire block of tissue??? "

Not to my understanding. Areas of invasion that are found in DCIS often are very small - either microinvasions (1mm or smaller) or T1a tumors (<1mm to 5mm). It would be pretty easy to miss these areas of invasion if all the tissue was not examined.

Hindsfeet · January 2012

I'm also considering to get a second opinion on my final pathology report. I love how the Legacy path reports reads...giving pics of slides and more information. Does it cost more to do a second path report...or does insurence cover it?

2012 · January 2012

After reading the post, I feel even I should ask for a retest as the report stated "sections studied". So that is very clear that not the entire slide was studied.

Any idea of Oncotype Dx test studies the whole block?

dancetrancer · January 2012

Interesting Beesie.

I called my original pathology place to find out if there was more tissue block still unexamined, and they said that yes, there was, but that my 4th facility had just requested more of it, so they sent them the entire block.

My 4th facility did not tell me they were doing this. They did say they are testing the 3 mm area of IDC for HER2-neu, but that they could not test it for Oncotype Dx b/c the IDC area was too small for that. I'm wondering perhaps if they ordered more of the block to see if they can find more IDC to test for Onco. I've already badgered them with questions, and they've done such an amazing above and beyond job already that I'm just gonna trust them and let them do their thing and tell me what is what. It's nice to find a facility I can just implicitly trust to do their job fully. What a feeling of relief! (So 2012, does that answer your Onco question? From what I understand, only the areas of IDC are worth testing for Oncotype DX, not the DCIS areas. And...yeah...I'd find out if areas weren't tested if I were you...maybe have it sent somewhere else for a 2nd opinion to be safe, based upon my story...)

Evebarry, so far my insurance has covered all my 2nd, 3rd, 4th opinions...I had checked the policy for 2nd opinions to be safe ahead of time. I would check your policy and also would call whoever is doing the 2nd opinion to ask them about coverage with your plan. Obviously I would say it is worth it.

Sorry if I'm making anyone paranoid about their path analysis, but...it is what it is...I'd rather others make sure they get the right diagnosis and not have a delay in treatment like me.

dancetrancer · January 2012

OK, so I've done some more research...it appears Beesie is correct, as always :-)the American College of Pathology set new guidelines in 2009 advising the entire specimen be analyzed:

"The changes in pathology practice, generated by the necessity of examining and detecting minute foci of disease in a large resection, were dramatic and culminated in a new set of formal guidelines by the American College of Pathology in 2009 (1). The new guidelines required serial, sequential tissue processing of the entire specimen, minimizing the likelihood of missing microinvasion, and permitting accurate assessment of size and margin width. The serial subgross technique had been an integral part of prospective nonrandomized studies (2, 3, 4, 5, 6, 7) for some time, and had been validated in a formal registration trial by Hughes et al (2009)8. Arguments against this approach were that it was too costly and/or too cumbersome, and not "randomized" but have not hindered widespread acceptance of the new guidelines.." from: Perspectives in Breast Cancer Pathology

And from the Archives of Pathology (1) referenced above: "For specimens with a known diagnosis of DCIS (eg, by prior core needle biopsy), it is highly recommended that the entire specimen be examined by using serial sequential sampling to exclude the possibility of invasion, to completely evaluate the margins, and to aid in determining extent."7-9 Archives of Pathology.

My initial pathology report said that my specimen was "serially sectioned lateral to medial" so I thought it was fully analyzed. However later it said "sections submitted as follows"...I didn't realize that meant not all sections were submitted.

Hoping this helps others make sure their pathology is handled properly. I'm feeling pretty dismayed about what happened to me and hoping nothing worse is found in my pathology.

dancetrancer · January 2012

Ok, I tried to read a bit more to understand what is done. I think they slice the entire specimen serially in small sections (perhaps 1 cm slices I read in one reference). Then they use a microtome to shave off a very small slice from each section which is made into a slide.

Problem is, with DCIS, microinvasions can be small (aka mine at 3 mm), and if the invasion is in the middle of that 1 cm slice, it gets missed. My guess is this is why some women (a very, very small percentage) who are diagnosed initially as pure DCIS end up with metastatic cancer 5 or 10 years later. The invasion was never caught.

If you have widespread DCIS, like I did, you are supposed to have more slides taken than normal to try and minimize the chance that something is missed.

Once again, this is just my summation as I try to understand why this was almost missed in my case. I could be wrong. I'm just glad someone caught it and feel very, very lucky they did, so that I can be treated and monitored properly.

If someone has a better understanding of how this works, feel free to educate me...

ZTeam · January 2012

Hi Dance,

When I spoke to my RO about this, she said that they don't look at every bit of tissue, that it is sampled (at least in Vancouver, Canada). I did have a second review of my tissue, which confirmed the results of the first - 9 cm of DCIS. Given the size of it, my RO said that there was a small chance that there was some small area(s) of invasion that was missed in the sampling. This was one of the reasons she offered, but didn't recommend radiation.

Reading your experience makes me even more comfortable with my decision to do radiation. At least if something was missed in my tissue, I've done the more aggressive treatment anyways.

All the best,

Lisa

dancetrancer · January 2012

Yes, Z team, I totally agree!!! Especially with having an extensive amount of DCIS like we both had...just WAY too easy for them to miss something. This bit of info definitely makes the rads call much easier.

pathology sampling technique of mastectomy specimen with DCIS

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