What do you do with your lumpectomies?

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How do you evaluate for positive margins on lumpectomies?

  • Total voters
    26
I don't know if I am at a "Breast cancer center" but both residency and fellowship in heavy cancer volume centers has been Fresh gross interoperative (with almost no frozens).
 
We're considered a breast center.

We don't freeze breast tissue. Just sentinel nodes.
 
Wow...looks like the Permanents are up 3-0,

It's like an entertaining soccer match now.
 
Bierstiefel said:
We're considered a breast center.

We don't freeze boobs. Just sentinel nodes.
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Yep, we let those lumps fix before messing with them.

We sometimes freeze sentinel nodes, but others are sent for permanent (on those cases, the definitive surgery is scheduled for the next week).
 
Have you all lost you %$#@ing minds? Or are you so permanently out of touch with your humanity? You are doctors--can you please start acting like it?

Have you forgotten that patients can read this forum as easily as residents? Hell, let's leave common decency, professionalism, and compassion out of this. Have you forgotten that your peers read this? Program directors? Other doctors? Is it any wonder that clinicians think pathologists are schizoid after comments like these?

I can understand the discussions on clinical medicine disintegrating into rants. But there is no justification any one of you who posted those comments can produce to rationalize this.

I didn't think I would ever have to resort to reminding residents of something so fundamental: these patients are facing life threatening diagnoses. They are facing losing their breasts, part of their identities. They are terrified. They deserve our heartfelt support. You should be ashamed of yourselves for such childish behavior.
 
Anna Plastic said:
Is it any wonder that clinicians think pathologists are schizoid after comments like these?
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I would wager that most of us learned how to be bastards and say non-compassionate things from our clinical counterparts, probably while on surgery (I know I heard a few doozies during those 12 weeks). Right or wrong, making things humorous is a coping mechanism that many use, including myself. This kind of reminds me of that Gomer thread over in the General Residency forum. I believe that a consensus was never reached as to whether it was appropriate to use when referring to some patients, and I doubt that one will be reached regarding the use of "TittyFreezer" (which I think is hilarious, btw).

Quick question: how does the use of any of those terms automatically make one schizoid? You need at least three other DSM criteria to qualify, none of which I have seen here as of yet.
 
There should be a fourth option: juggle them. :meanie:
 
Let's keep the colloquial and juvenile terms to a minimum, please. Anna Plastic makes some important points.

And yes, while humor is a good coping mechanism, it's important to remember that the definition of humor varies widely, especially in terms of what constitutes appropriate topics. What one person finds amusing another can be devastated by - for various reasons.

At the same time though, I don't think we should confuse humor with lack of compassion. In order to be a kind, humane, intelligent, and excellent doctor one does not have to treat every patient/specimen/case with intense gravitas at all times.
 
Anna Plastic said:
Have you forgotten that your peers read this? Program directors? Other doctors? Is it any wonder that clinicians think pathologists are schizoid after comments like these?

I can understand the discussions on clinical medicine disintegrating into rants. But there is no justification any one of you who posted those comments can produce to rationalize this.

These patients are facing life threatening diagnoses. They are facing losing their breasts, part of their identities. They are terrified. They deserve our heartfelt support. You should be ashamed of yourselves for such childish behavior.
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It's called a J-O-K-E. You have never heard anyone JOKE about how rubbery fibro-adenomas. Clearly, one should never play hacky sack with anything except an actual hacky sack.

And I have heard those non-schzoid physicians make jokes. Yes, around patients that would be wrong.

I'm sorry is it just breast cases that demand this rigorous somber attitude or maybe we treat all cases that way, and joking around about them does not affect our handling.
 
djmd said:
It's called a J-O-K-E. You have never heard anyone JOKE about how rubbery fibro-adenomas. Clearly, one should never play hacky sack with anything except an actual hacky sack.

And I have heard those non-schzoid physicians make jokes. Yes, around patients that would be wrong.

I'm sorry is it just breast cases that demand this rigorous somber attitude or maybe we treat all cases that way, and joking around about them does not affect our handling.
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As I said, joking is in the eye of the beholder. Just because you think it's funny doesn't mean everyone else has to. And just because you don't think it isn't inappropriate doesn't mean it isn't. Personally, I thought it was bordering on inappropriate, but as I said, I can see the point. It's important for all of us as we go through training to re-examine our own opinions and I can see how this terminology would bother lots of people, many of whom would not speak up.
 
yaah said:
As I said, joking is in the eye of the beholder. Just because you think it's funny doesn't mean everyone else has to. And just because you don't think it isn't inappropriate doesn't mean it isn't. Personally, I thought it was bordering on inappropriate, but as I said, I can see the point. It's important for all of us as we go through training to re-examine our own opinions and I can see how this terminology would bother lots of people, many of whom would not speak up.
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Damn it Yaah. I started my post before your's was up there, but your calm and rational suggestions showed up before mine... Now I seem like a loon after you called for a reasonable attitude... And of course I agree with what Yaah is saying.
 
Anna Plastic said:
"Hacky Sack"
"TittyFreezer"
"boobs"

Have you all lost you %$#@ing minds? Or are you so permanently out of touch with your humanity? You are doctors--can you please start acting like it?

Have you forgotten that patients can read this forum as easily as residents? Hell, let's leave common decency, professionalism, and compassion out of this. Have you forgotten that your peers read this? Program directors? Other doctors? Is it any wonder that clinicians think pathologists are schizoid after comments like these?

I can understand the discussions on clinical medicine disintegrating into rants. But there is no justification any one of you who posted those comments can produce to rationalize this.

I didn't think I would ever have to resort to reminding residents of something so fundamental: these patients are facing life threatening diagnoses. They are facing losing their breasts, part of their identities. They are terrified. They deserve our heartfelt support. You should be ashamed of yourselves for such childish behavior.
Click to expand...

Okay, b/c of your reprimand, I went back and changed some of my wording b/c some of the things said on this board probably go farther than they should on a public forum. That being said, we are pathologists, so we hand out more death sentences in one day than your average family doc will hand out in a year. I've made a diagnosis of metastatic pancreatic adenocarcinoma in a 23 year old, told a surgeon that his 5-year-old patient has an abysmal prognosis, and too many other bad situations to even remember. That doesn't even count autopsies, where I have seen some pretty horrific stuff. There has to be some level of detachment or you can't function. I've lost friends and family at very young ages to various disorders (leukemia, Ewing's, etc.). My little cousin was treated for Hodgkin's and was just recently diagnosed with colon cancer at the ripe old age of 27. I'm well aware of what some of these diagnoses can do to patients and families, but I can't go getting teary-eyed over every case of AML or colonic adenocarcinoma that I come across. What I can do, is make sure that I treat all of those cases like they are a family member's and make sure that I find every damn lymph node in that colon or every biopsy clip in that breast or whatever.

As an aside, you ought to spend more time around forensic pathologists, b/c they can have really grotesque senses of humor (although I'm sure Mindy doesn't). After that, you wouldn't have anymore problems with this board.
 
I've been through medical school and pathology residency, and I'm sure my experience is pretty close to most everyone else's—residents, even attendings saying some pretty crude things. Sometimes about patients. I know we see things in this profession that are traumatic and disheartening, and that we need humor to get us through. Gallows humor has gotten us to laugh when we needed a laugh to keep our own humanity.

Having said that, the reason why I complained so loudly about the comments (yes I get it was a J-O-K-E) is the PLACE these comments were made. In a public internet forum. If you think this was the right time and place to make these comments, please relieve the captain of your brain-ship of duty. That captain has had a serious loss of judgement and is a menace.

Any person on the internet can see these comments. I'm not saying we should shed a tear over every surgical pathology specimen. But if a woman with breast cancer was doing a Google search on lumpectomy specimens and came across this page and sees "someone from the Program X Pathology" program joking that you play Hacky Sack with them…well, I can understand why she would feel like doctors are a bunch of callous a$$holes.

If Don Imus made a joke in the privacy of his home about the Rutgers womens basketball team, he probably would still have his job. But he made 1) an insensitive racist, sexist comment in 2) the wrong venue. A public venue. So you guys are now trying to justify making 1) insensitive comments about breast tissue in 2) the wrong venue. Sorry—didn't work for him, and it doesn't work for you either.

And no, it isn't that breast tissue is sacred above any other specimen. It is just that there are proportionately more derogatory terms and social hang-ups on this because breasts are sexualized. I'd feel as strongly if public insensitive comments were made on penectomy specimens, colon specimens, what have you.

I don't care how many residents, fellows, attendings, etc. make jokes about this stuff. Ten thousand people doing something wrong doesn't make it right.

I've spent well over four months in one coroner's office or another--that is a field where they really do need humor. Do you think they are so stupid as to make crude jokes on the stand? Nope. Forensic pathologists are pretty darn good at knowing *when* to make those jokes.

If you need humor like this to get you through your day, fine. But please keep it out of public view. We are professionals, or at least allege to be. That means we put patients needs ahead of our own. Oh, your life is so tough that you need to make jokes like this on the Internet? Try telling that to the woman whose breast is on your grossing room table—I'm sure she would be just heartbroke over how difficult your life is.
 
I don't disagree with you. The thing is, while these forums are on the Internet, each member employs a nickname for a reason - to be detached from their official titles, names or affiliations while they are here. The use of the nickname is intended to represent that they are not here in their official guise and therefore these boards are "semi"-public. Anonymity is what encourages guests to use SDN. As a rule we never reveal any user's identity on these boards without their consent. (Of course if they have it in their forum profile, then it is their choice and out of our hands 🙂 )

Many use these forums to let off steam for that very reason. We recognize that every individual's tolerance of gallows humour varies. I'm certainly not discouraging posters to be mindful of what they say. But we are not here in our professional capacity, SDN is not and was never for the purpose of providing professional medical advice and any patient seeking medical advice on here is violating the Terms of Service. There are many better resources for that elsewhere.
 
Deschutes, the reason for the anonymity here is to encourage honest, open discussion about issues which may otherwise not be discussed openly. For example: Is pathology residency program X a worthwhile program to apply for? Residents at Program X can tell you their honest opinion without fear of retribution. Other topics which usually we can't discuss: salary ranges, approaches to controversial diagnoses, etc.

The anonymity here is to protect the discussants so we can discuss matters of importance, NOT so we can hide behind a shield of anonymity to make horrific comments about patient specimens. That is an abuse of what this forum's anonymity is about.

If you think you can take off your professional hat whenever you want and say whatever you want sometimes--good luck with that. The public will have a different opinion on that. Yes, there are other resources, but do you think that somehow this forum doesn't influence the attitudes of medical students? Of other residents?

If this forum is the only place where people can let off steam, and the form of this steam letting off is discussions like this--you guys are in bad shape. Get a therapist. DO primal scream therapy. Take up jogging. But for God's sake, stop trying to defend behavior that is unaccepable.

And to be sure people understand what I'm protesting: I'm not protesting humor. I'm not protesting blowing off steam. I'm protesting making insensitive jokes about patient body parts in a public Internet forum where any patient is able to read this discussion.
 
Look, let's put this to rest. Anna, I'm sorry to have offended you. I agree that we shouldn't be too reckless with our language. My apologies.
 
Yes, and frankly continuing with the discussion is detracting from my original post.

The one option I left out was "Intraoperative radiologic examination of the specimen for margin involvement". I forgot, though in my defense I only know of one place that does this.

I've been reading that "Gross examination of the resection specimen does not reflect margin status in at least 25 per cent of women undergoing partial mastectomy for breast malignancy", which is not surprising. (Am Surg. 2005 Jan;71(1):22-7)

The last report I can find about frozen section evaluations of lumpectomy margins is from 1997, which claimed SN/SP of 91% and 100% respectively. (Cancer J Sci Am. 1997 Sep-Oct;3(5):266-7.)

I wonder about that sensitivity of 91%... I haven't read further to see if it was correlated with gross margin involvement.
 
Bierstiefel said:
Look, let's put this to rest. Anna, I'm sorry to have offended you. I agree that we shouldn't be too reckless with our language. My apologies.
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And I'm sorry too, Bierstiefel (and others), if I came across stridently and harshly in my criticisms. Now that my emotions have died down, even though I still stand by the points I was trying to make, I'm a little embarrassed in how I conveyed them. Many thanks for your gracious apology.

Deschutes, as for your original lumpectomy question--at the program where I trained, we did post-lumpectomy radiographs looking for calcifications, including radiographs of the serially-sectioned specimen. We did no frozens (except on sentinel nodes). And we would either submit the entire thing for permanents or would submit all radiographically and grossly suspicious sections plus about half of the normal stuff (the latter strategy was to prevent one lumpectomy from turning into a 144 slide case).
 
Yeah, I looked at your choices and just couldn't quite make a vote fit. There was needle localization pre-op I b'lieve, and then the lumpectomy specimen was fixed overnight to make it firmer for cutting, with multiple inkings to orient all margins (superior, inferior, medial, lateral). We would put in our gross description which blocks contained calcifications or needles. So the margins were all evaluated on permanents.
 
KentW said:
Be glad you don't have to do it face-to-face.
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Believe me, Im very glad of that fact. As a med student, I was present for that conversation a couple times, and I honestly didnt handle it very well. Its one of the reasons I dont like FNAs. It puts a face and a family to that diagnosis.
 
Anna Plastic said:
Yeah, I looked at your choices and just couldn't quite make a vote fit. There was needle localization pre-op I b'lieve, and then the lumpectomy specimen was fixed overnight to make it firmer for cutting, with multiple inkings to orient all margins (superior, inferior, medial, lateral). We would put in our gross description which blocks contained calcifications or needles. So the margins were all evaluated on permanents.
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Ah. Therefore it belongs in the "Permanents only" category, since I believe most places have pre-op needle localizations and ink before sectioning.

But since beary and yaah have both voted in that category, my numbers still hold up!
 
Only four colors of ink? For shame. We have to use six. And then sometimes they separately submit additional margins. Insanity!

A not uncommon situation is that we get the following specimens

1) Oriented lumpectomy (~15-20 blocks maybe, depending on size)
2) Additional inferior margin (3-4 blocks)
3) Additional superior margin (same)
4) Additional Deep margin
5) Additional lateral margin
6) Sentinel lymph node #1
7) Sentinel lymph node #2
8) Sentinel lymph node #3

Repeat x4 daily sometimes.
 
Same thing happens here yaah. Lots of slides to look at! And each sentinel node gets 3 levels.
 
No keratin here. We do stains on melanoma sentinel nodes (and merkel cell) but not breast. It's such a bizarre thing, as one of our residents put it, "we have to make sure we follow this protocol correctly in order to increase our chances of finding small micromets that don't matter." But such is clinical medicine - lots of overkill and unnecessary tests.
 
yaah said:
Only four colors of ink? For shame. We have to use six. And then sometimes they separately submit additional margins. Insanity!
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🙂 Just this last week a lumpectomy came pre-inked by the surgeon with FIVE colours. And no there wasn't a bare spot to put orange on... *facepalm*

yaah said:
A not uncommon situation is that we get the following specimens

1) Oriented lumpectomy (~15-20 blocks maybe, depending on size)
2) Additional inferior margin (3-4 blocks)
3) Additional superior margin (same)
4) Additional Deep margin
5) Additional lateral margin
6) Sentinel lymph node #1
7) Sentinel lymph node #2
8) Sentinel lymph node #3

Repeat x4 daily sometimes.
Click to expand...
Yup, that's my gross/frozen day at the high-volume private practice diagnostics (hereinafter abbreviated to HVPPD) place I'm at now. And imagine specimens 1-5 inked, cross-sectioned fresh and grossly evaluated for margin involvement, with possible frozen section for suspicious areas. Makes for a busy frozen service!
 
Yep, 6 colors for us too (with other margins often submitted). Our sentinel nodes are serially sliced and submitted entirely, but we don't routinely order levels. We also don't order immunos on sentinel nodes (including melanoma sentinel nodes).
 
Bierstiefel said:
Exactly...we don't routinely get a keratin.
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I've never seen keratins ordered on sentinel nodes. Once we ordered it on a node that had 4 or 5 atypical cells that the attending wasn't sure about which ended up being positive with keratin. We did have a protocol for Melanoma sentinel nodes (S-100). Not sure why I added that nice touch re: keratin. Thats what I get for drunk posting at 6am. :meanie:
 
CameronFrye said:
Yep, 6 colors for us too (with other margins often submitted). Our sentinel nodes are serially sliced and submitted entirely, but we don't routinely order levels. We also don't order immunos on sentinel nodes (including melanoma sentinel nodes).
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Is it really necessary to ink in 6 colors? I never used more than three for a lumpectomy and didn't have any problems sorting out which margin is which. I think spotting small groups of melanoma cells in sentinel nodes is pretty challenging, hence my past use of S-100 as a crutch in said setting.
 
DarksideAllstar said:
Is it really necessary to ink in 6 colors? I never used more than three for a lumpectomy and didn't have any problems sorting out which margin is which. I think spotting small groups of melanoma cells in sentinel nodes is pretty challenging, hence my past use of S-100 as a crutch in said setting.
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No of course 6 isn't needed. One will actually work as long as you designate where your sections come from. My residency trained us for one color (always bet on black!), my first lumpectomy at my fellowship program I inked like that, and a MSIII who followed the lumpectomy up ratted me out. (actually I'm sure he just was telling what happened not realizing the difference) The surgeon called up and very upset and wanted to know how we were going to orient the margins...

It was not a problem to orient.
 
I think we had a couple of cases where the gross dictation got lost or something, and the margins weren't otherwise specified, and they couldn't tell which one was positive. So we have designated colors for everything. Thus, you always know if you see blue, it's superior, etc.
 
Oh it has its advantage, I agree. Easy to look at under the scope and know which margin is positive, that's for sure.
 
DarksideAllstar said:
Is it really necessary to ink in 6 colors? I never used more than three for a lumpectomy and didn't have any problems sorting out which margin is which. I think spotting small groups of melanoma cells in sentinel nodes is pretty challenging, hence my past use of S-100 as a crutch in said setting.
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No, six probably isn't completely necessary, since two of the margins are amputated and transversely sectioned in anyway, but I think it does help keep things straight. Plus, transverse sections through the lump have 4 margins, so for smaller lumps, you end up with multiple margins in one cassette.
 
CameronFrye said:
No, six probably isn't completely necessary, since two of the margins are amputated and transversely sectioned in anyway, but I think it does help keep things straight. Plus, transverse sections through the lump have 4 margins, so for smaller lumps, you end up with multiple margins in one cassette.
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Aside from medial and lateral (which would need to be specifically noted in which block they were in), you can get the deep, ant, sup and inf margins with 3 colors. We were told to ink our lumpectomies like this: anterior aspect= sky over grass (superior blue, inferior green), deep =black. Not sure about how people actually processed their lumps, but I did something like this:
Fix. Orient and ink as described above. Serially section into x number of slices from medial to lateral. Note which slice contained loc wire, hemorrhage (previous bx sites), etc. Measure tumor in 3 dimensions. Measure closest approach to deep margin, ant, sup, inf, med, and lat margins and note which slice the closest approach was in. Get sections of the closest approach to each margin. Usually I'd do perpendicular sections for the lateral or medial margins if the tumor was within 0.5 cm of either one (just so I could show the attending it was free of tumor microscopically), otherwise I'd use the standard en face for the medial and laterals. One representative section of tumor per 1 cm in size (ie: 2 cm= 2 representative sections).
 
DarksideAllstar said:
Aside from medial and lateral (which would need to be specifically noted in which block they were in), you can get the deep, ant, sup and inf margins with 3 colors. We were told to ink our lumpectomies like this: anterior aspect= sky over grass (superior blue, inferior green), deep =black. Not sure about how people actually processed their lumps, but I did something like this:
Fix. Orient and ink as described above. Serially section into x number of slices from medial to lateral. Note which slice contained loc wire, hemorrhage (previous bx sites), etc. Measure tumor in 3 dimensions. Measure closest approach to deep margin, ant, sup, inf, med, and lat margins and note which slice the closest approach was in. Get sections of the closest approach to each margin. Usually I'd do perpendicular sections for the lateral or medial margins if the tumor was within 0.5 cm of either one (just so I could show the attending it was free of tumor microscopically), otherwise I'd use the standard en face for the medial and laterals. One representative section of tumor per 1 cm in size (ie: 2 cm= 2 representative sections).
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Ok, I follow you. When I receive them, I ink them in 6 colors, and let them fix (for at least a little while). Depending on the shape of the lump, usually the medial and lateral (or the superior and inferior) margins are amputated and then perpendicularly sectioned and submitted entirely. The remainder of the specimen is transversely sectioned and submitted. As long as the lump isn't too large (which they usually aren't), I submit the whole thing. Even though it means more blocks, it usually is less of a headache. For example, the last time I was on service, the PA grossed in a lump for me and just submitted representative sections b/c there was a discrete "tumor". Well, on microscopy, the "tumor" ended up just being scar and biopsy site changes from her previous needle core. No residual disease was identified. Back to the bucket for me! Although, obviously, I only submit representative sections for mastectomies. However, I still submit perpendicular reps of the margins and not en face margins.
 
All this talk of lumps has made Fergie's ****eous song go running through my head. Argh!

I ink the lumps five colors (with medial and lateral sharing the same color, as we are only blessed here with blue/black/red/yellow/green) and serially section and freeze a radial section of the closest margin. It can be rather difficult when fresh as you know. Then freeze the sentinel nodes. Then, inevitably, the surgeon will send "new margins" from the lumpectomy site for perms (!), which makes me wonder why we just froze four blocks from the original lump. Oh well.......

For a laugh, go to YouTube and look up Alanis Morrissette's version of "My Lumps" or "My Humps" or whatever it's called. It is hysterical!!!
 
Is the green ink universally ****ty? I have done surg path at a couple of places and the green ink is always the worst in terms of being either real thick or real runny. Note, I have never routinely used orange, red, or yellow.

I've never tried freezing breast tissue, but I can imagine it freezes like ****.
 
I think it depends on what you define as ****ty. In my experience the orange and yellow are worst - they look like one another, or flake off and disappear from the slides.

Btw next time you're at USCAP go up to the ink vendor booth and give them feedback. The girl said they never got feedback and gave one of our residents orange and yellow ink samples, promising they'd work. I haven't heard anything subsequent to that.
 
DarksideAllstar said:
Is the green ink universally ****ty? I have done surg path at a couple of places and the green ink is always the worst in terms of being either real thick or real runny. Note, I have never routinely used orange, red, or yellow.

I've never tried freezing breast tissue, but I can imagine it freezes like ****.
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Wish I'd paid attention to who was the manufacturer of our green ink, but I'm with you on my loathing of the green ink. By far the worst, and everyone agreed to that.

I had to freeze breast tissue in my post-sophomore fellowship. I don't think I've ever cussed so much in my entire life as trying to get SOMETHING onto the glass slide during those frozen sections. I think feces would actually freeze and cut much better that fat (but I'm really not going to do that experiment).
 
Anna Plastic said:
Wish I'd paid attention to who was the manufacturer of our green ink, but I'm with you on my loathing of the green ink. By far the worst, and everyone agreed to that.

I had to freeze breast tissue in my post-sophomore fellowship. I don't think I've ever cussed so much in my entire life as trying to get SOMETHING onto the glass slide during those frozen sections. I think feces would actually freeze and cut much better that fat (but I'm really not going to do that experiment).
Click to expand...

Luckily no breast surgeon during my PJF asked for a frozen on their lumpectomies. I saw a resident trying to get a good section that was something of the nature of "r/o liposarc". That was a pissed off 10 minutes.
 
I don't mind green ink actually, although it tends to run more than the other inks (one dab and it's everywhere) - but you can minimize this by using less ink or blotting it.

I hate yellow ink - we have tried a couple of yellow inks, there are two extremes, either they run even worse than the green (one little dab and it spreads out 2 cm in every direction) or it doesn't stick well at all and it's useless. Once it runs, it mixes with blue and becomes green, or it mixes with green and becomes blue, or it mixes with black and becomes black, or it mixes with yellow or orange and becomes black.

VILE YELLOW INK. DIE.
 
deschutes said:
I think it depends on what you define as ****ty. In my experience the orange and yellow are worst - they look like one another, or flake off and disappear from the slides.

Btw next time you're at USCAP go up to the ink vendor booth and give them feedback. The girl said they never got feedback and gave one of our residents orange and yellow ink samples, promising they'd work. I haven't heard anything subsequent to that.
Click to expand...

I agree with you re: the visibility of the orange/yellow/red-- its poor and that's one of the reasons that I don't use it. The green ink is crappy because it runs everywhere. The blue and black were great-- they'd stay where I put them, but green would find a way to run everywhere on my specimens no matter what I tried to get it to stick better.
 
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