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261

Technical

A New Device for Evaluation Occult Breast Lesions Karen

K. Lindfors,1

Susan

A. Lott,1

and Mark

of Biopsy Specimens

successful

resection

of the lesion

the specimen

and

The device of breast

used for radiographic specimens

cm) layers

of radiolucent

wing

at each

nuts

examination smallest specimens

acrylic,

corner

of a wide volume

variety

of two

which

(Fig.

of tissue

including

and gross

consists

cassette

1).

those

The

size

from

of small

correspond cassette.

holes.

These

are placed

to the approximate The

positions

sizes,

mastectomies

holes

1

Diagnostic 2

August

Department

Radiology,

Department

AJR 154:261-263,

4, 1 989; accepted

of Radiology,

device

along

the

UCD Professional

In the pathology abnormality

are

by a

of Califomia,

Hospital, Bowling Green, KY 42101.

1990 0361-803X/90/1542-0261

© American

specimen

device. The four and compress the

the 2-cm

by placing

wires

square

through

area containing the

holes

in the

the upper

for histologic

examinations

in a single cassette

(Fig. 3). Thicker specimens may have to be subdivided for submission in more than one cassette. In either case, lesional tissue can be

26, 1989.

University

department,

is marked

that can be processed

by

Davis, Medical Center, Sacramento,

Bldg.,

entire

lesion is excised by cutting directly through the plastic bag around the reference wires. Thin specimens may yield a volume of tissue

so as to

the y-axis, by numbers. more flexibility in placing

September

the

the lesion in a more central location. The upper plate then is removed, allowing the wires to remain in place around the lesion. The specimen is moved to a corkboard for sectioning. The tissue containing the

posi-

designated

over

plate that surround the lesion. For lesions located eccentrically within the reference square, an intermediate square is delineated, placing

larger

tissue-processing

x-axis

after revision

of Pathology, Greenview February

intervals

markings

men.

by

is perforated

reference

of orientation.

rapher verifies the presence of the lesion within the resected tissue, and the surgeon is notified. If the lesion is identified on the radiograph, the specimen is sent as is, still compressed in the device, to the pathology department with the radiograph accompanying the speci-

the optimal after

in the top

specimen. The loaded device is then placed on top of the X-ray film cassette, and the specimen film is exposed (Fig. 2). The mammog-

allows

through

at 2-cm

University of California,

Am. 1 09A,

from

size of a histologic

of holes

device

performed

letters etched into the acrylic; those along The central location of the characters allows

Received

this

an abnormality

tive findings on needle aspiration biopsies. The top layer of the specimen-evaluation grid

of

includes

regardless

between the two layers of the specimen-evaluation corner wing nuts are tightened so as to immobilize

x 25.4

together

characters

After localization and biopsy of a mammographically suspicious area, the excised breast tissue is brought to the radiology department for specimen radiography. The specimen, in a plastic bag, is placed

evaluation

can be tightened

of specimen

containing

pathologic

and

radiograph

and in directing

10 x 10 in. (25.4

The etched

on which they might be superimposed. The 10-in. (25.4 cm) span of the device covers the standard 8 x 10 in. (20.3 x 25.4 cm) film

Methods

biopsy

within the device.

acrylic plate provide enough radiographic contrast at mammographic energies to be visualized on film, yet they do not obscure calcifications

histologic examination of nonpalpable lesions suggestive of malignancy; it has been used successfully in over 80 cases.

Materials

of

T. Alberhasky2

Specimen radiography is essential to confirm excision of clinically occult breast lesions discovered and localized by mammography [1 ]. Of equal importance is ensuring that the suspicious area within the resected tissue is examined histologically. We describe a specimen evaluation device (The Pathfinder System, Denmark Associates, Bowling Green, KY) that allows rapid, precise identification and localization of mammographic lesions within the biopsy specimen. This device is useful both in confirming

Note

Davis,

Roentgen

CA 9581 7. Address

Medical

Ray Society

Center,

Sacramento,

reprint requests CA 95817.

to K. K. Lindfors,

Division of

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262

LINDFORS

Fig. 1.-Specimen-evaluation device consists of two layera of acrylic with a grid of holes in top layer. Note x and y coordinates indicated by letters and numbers.

designated in specific tissue-processing tioned at multiple levels for detailed remainder

of

macroscopic

specimen

can

be

examined

and carefully examination. by

the

(e.g.

,

specimen-evaluation

anterior,

posterior,

device lateral)

is used,

are

using

secThe

traditional

conventional

redistributed

mar-

into

superior

and inferior margin planes surrounded peripherally by a “vertical” lateral margin. As most lesions fall within the more central portion of the specimen, the peripheral margins are usually clear. After excision of the lesion rectangle, the pathologist can ink the superior and inferior external margin surfaces. After horizontal subdivision of the

excised

square, the inked surfaces

level

tissue

of

essence

sections

a variation

represent

of the technique

are embedded the

surgical

described

so that the first

margins.

by Carter

This

is in

[2].

Discussion

Specimen radiography is an integral part of the localization and biopsy process in clinically occult breast lesions. Such films confirm the presence of the mammographic abnormality within the resected tissue. Although many techniques for specimen radiography have been described, most authors

[3-5]

now agree that the specimen

should

AJR:154,

Fig. 2.-Radiograph of tissue from needle localization that is compressed in specimen-evaluation device shows microcalcifications (arrows) in the “5,F” quadrant. Histologic diagnosis was intraductal carcinoma with microfoci of infiltrating ductal carcinoma.

techniques.

When gins

the

cassettes histologic

ET AL.

be compressed

for optimal visualization of both microcalcifications and noncalcified lesions. The removal of the suspicious area in the breast with confirmatory specimen radiography does not, however, ensure that the appropriate area will be sampled adequately by the pathologist. In standard filming of specimens, the compression is provided by one of the compression paddles used for mammography. After the film is taken, the compression is released, and the specimen usually is placed in a plastic bag for transport to the pathology department. Even when a radiograph accompanies the specimen, it may be difficult for the pathologist to reconstruct the orientation of the specimen as it appears on the film in order to determine where the lesion is located. This is especially true when the

February

1990

Fig. 3.-Tissue sample (T) is laid on a specimen radiograph to show how grid holes might be used to demarcate borders for excision. Once excised, tissue can be placed in cassette (C) for processing and eventual histologic examination.

specimen is large and the lesion is a small cluster of microcalcifications. Many solutions to this problem have been devised, but most require the input of additional time by physicians, technologists, and the mammographic unit. When using the specimen-evaluation device described here, only one radiograph is required for lesion localization. Thus, the time spent by the technologists and radiologists is minimized. This method also virtually eliminates delays for patients in departments in which patients must wait for mammography while specimens are examined. As the tissue is still compressed in the specimen-evaluation device when it is sent to the pathology department, the pathologist can refer to the radiograph to determine the exact location of the lesion within the specimen. This device is unique in that the pathologist uses the grid holes surrounding the lesion as reference markers for excision of a volume of tissue that is a 2-cm square in length and breadth. This 2-cm square corresponds to the size of a tissue-processing cassette

(Fig.

3). This

method

provides

a margin

of safety

that

allows both for minor error in excision of the lesion and for examination of adjacent breast tissue. Examination of adjacent tissue is useful because a neoplastic lesion may actually be a small distance away from the specific mammographic abnormality that directed the biopsy. The specifically designated lesional cassettes can be sectioned at multiple levels by the pathologist, allowing a very thorough examination during which even small calcific densities

can

be located,

to be examined

yet

allowing

a minimum

of the

specimen

[6]. Five to 10 slides are usually sufficient

to

examine the area of the lesion. This is a major improvement over past techniques such as submission of the whole specimen to random sectioning around the localization wire tip. Such approaches yield a larger number of tissue blocks, which are generally examined at only one histologic level; thus, even though greater numbers of slides are examined, a small lesion might be missed. In the 1 33 cases preceding our trial of this

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AJR:154,

February

1990

BREAST

BIOPSY

specimen-evaluation device at the University of California, Davis, Medical Center, two biopsies were performed because of suspicious microcalcifications but no calcifications were evident in routine random sectioning. In these cases, the paraffin blocks had to be radiographed and resectioned in an effort to examine the appropriate area. If considerable care is not used in selection of tissue to be examined microscopically, the histologic findings may be of little diagnostic relevance. Calcifications that are not shown on specimen films are routinely present in microscopic sections. Thus, an incidental microcalcification could be identified mistakenly as the lesion of mammographic interest, should the pathologist not have adequate correlation of lesion position and histologic sampling. This can result in a false sense of security, and the actual mammmographic lesion may remain unexamined. Any current discussion of breast biopsy analysis must consider examination of surgical margins so that appropriate treatment options can be offered to the patient. Use of the specimen-evaluation device allows histologic evaluation of the surgical margins. The gross impression of margin adequacy in conjunction with the histologic pattern of the lesion shown (i.e., extensive intraductal carcinoma vs a circumscribed infiltrating duct lesion) are additionalfeatures of equal importance, however, in considering conservative treatment alternatives. Another use for the specimen-evaluation device is the localization of a nonpalpable lesion in a mastectomy specimen. The use of radiographically directed needle-aspiration biopsy as an alternative to excisional biopsy is gaining popularity [7]. When carcinoma is diagnosed, a mastectomy may be performed as the first surgical procedure. In such cases, the entire specimen can be compressed in the specimen-

SPECIMEN

DEVICE

evaluation

device,

histologic

263

and localization

examination

of the occult

carcinoma

for

is simplified.

Communication between the radiologist, surgeon, and pathologist is essential for the best care of the patient with a mammographically suggestive, but clinically occult, breast

lesion. If a needle localization is performed to guide a biopsy, a specimen radiograph always should be obtained. A localization with removal of the appropriate area is of no value, however,

picious

if the pathologist

area for histologic

cannot

positively

evaluation.

identify

the sus-

The specimen-evalua-

tion device described in this report facilitates efficient and accurate mammographic, surgical, and pathologic correlation for occult breast lesions.

REFERENCES 1 . Gallager tigative.

HS. Breast specimen radiography: obligatory, adjuvant and invesAm J Clin Pathol 1975:64:749-755 2. Carter D. Margins of “lumpectomy” for breast cancer. Hum Pathol 1986; 17:330-332 3. Aebner M, Pennes DA, Baker DE, Adler DO, Boyd P. Two-view specimen radiography in surgical biopsy of nonpalpable breast masses. AJR 1987;149:283-285 4. Kopans DB. Localization of nonpalpable breast lesion prior to surgical excision. In: Feig SA, ed. ARRS categorical course syllabus in breast imaging. Aeston, VA: American Roentgen Ray Society, 1988:69-78 5. Stomper PC, Davis SP, Sonnenfeld MA, Meyer JE, Greenes RA, Eberlein

TJ. Efficacy of specimen radiography

ofclinically

occult noncalcifled

breast

lesions. AJR 1988;151 :43-47 6. Alberhasky MT. Mammographic and gross pathologic analysis of breast needle localization specimens: use of a tissue analysis device. Am J Clin Pathol (in press) 7. Dowlatshahi K, Gent HJ, Schmidt A, Jokich PM, Bibbo M, Springer E. Nonpalpable breast tumors: diagnosis with stereotaxic localization and fine-needle aspiration. Radiology 1989;170:427-433

A new device for evaluation of biopsy specimens of occult breast-lesions.

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