deschutes

Thing
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What do you do with your prophylactic BSO and mastectomies from BRCA-positive patients?

We submitted all of the tubes and ovaries (plus, one particular patient was a nurse and specifically requested that her tubes be sectioned at intervals of 2.5mm).

I'm particularly curious about what is being done out there for the boobs.
 

LADoc00

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deschutes said:
What do you do with your prophylactic BSO and mastectomies from BRCA-positive patients?

We submitted all of the tubes and ovaries (plus, one particular patient was a nurse and specifically requested that her tubes be sectioned at intervals of 2.5mm).

I'm particularly curious about what is being done out there for the boobs.
Good question. I have seen like one in my entire career, I cant believe this procedure is that popular, at least where Ive been. By the way....WHY the f--k did she care so much about her tubes?? As far as I know, BRCA has no role at all in tube carcinomas....

I cant justify putting an absurd number of sections thru, especially with zippo radiologic or clinical suspicion of a lesion.

A better ?, what are the billing codes for all that? And, what is going on these days with gyn specimens, can you separate the breasts from the uteri and bill separately for each?

People wonder why dermpath is so lucrative, by the time you even MEASURED the frickin specimen above, I would have signed out 5x88305 skins and made 3 times as much.
 
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deschutes

deschutes

Thing
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LADoc00 said:
WHY the f--k did she care so much about her tubes?? As far as I know, BRCA has no role at all in tube carcinomas....
Evidently she did her homework:

The tubal fimbria is a preferred site for early adenocarcinoma in women with familial ovarian cancer syndrome. (BWH)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16434898&query_hl=7&itool=pubmed_docsum

Occult carcinoma in prophylactic oophorectomy specimens: prevalence and association with BRCA germline mutation status. (UToronto)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11688463&query_hl=8&itool=pubmed_docsum

The latter article had the magic "2.5mm" quote.

I'm curious about the SEE-FIM protocol now.
 
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deschutes

deschutes

Thing
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LADoc00 said:
I cant justify putting an absurd number of sections thru, especially with zippo radiologic or clinical suspicion of a lesion.
I forgot to mention in the previous post - (1) the patient had a first-degree relative with BRCA(+), and (2) mum was reportedly diagnosed with breast cancer within 6 months of a normal mammo.

So I got to be the lucky bastard who put an absurd number of sections through.
 

LADoc00

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Wow, I did not know that...in my defense I have to yet to see a case of supposed fimbrial carcinoma but I have seen around 100-150 surface epithelial tumors.
 

torero

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deschutes said:
What do you do with your prophylactic BSO and mastectomies from BRCA-positive patients?

We submitted all of the tubes and ovaries (plus, one particular patient was a nurse and specifically requested that her tubes be sectioned at intervals of 2.5mm).

I'm particularly curious about what is being done out there for the boobs.
Just last week I did a frozen on a BRCA + patient who years before had undergone prophylactic bilateral mastectomy, hysterectomy and unilateral salpingo-oophorectomy. She had developed a cyst on her residual ovary. By imaging, there was no solid component, so clinicians were not worried. On gross, the ovary was replaced by a 16 cm cyst with a single 1.5 cm solid area. Frozen section showed an invasive clear cell CA. Bad luck…

Regarding your question, I do not know there is a standardized way to gross prophylactic mastectomies for BRCA positive patients. I think it all depends on your gross findings. It might be important to see what the findings on mammography were. Supposing they did not see any suspicious lesions, and you do not see any suspicious lesions, then 3-4 representative sections per quadrant is reasonable. They key though, I think, is to do a good gross inspection with approx. 1cm thick breadloafing, which is difficult if the specimen is not fixed.

When thinking about these issues you always have to consider the worse case scenario, and what the standard of practice is. Suppose you missed a small cancer that had already metastasized to axillary lymph nodes, and the case went to court. If you processed the specimen as described above, and document that in your gross description, then you would probably not be found liable, as you followed standard practice to the best of your knowledge.
 
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