What do you do with your lumpectomies?

[deschutes]

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.

And then the OR calls wanting to know why it's taking so long.

I'm so glad I don't have to cut the breast frozens.

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[CameronFrye]

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 ****.

Our green ink is thick and gummy and most people don't use it, but I kinda like it. It shows up really well under the microscope, whereas the red ink can look like blood, thick orange looks like red, etc. The blue and black inks are definitely the best.

 

[EUA]

Our histotechs are god-like, because they actually manage to make breast frozens look OK AND they don't complain the whole time. Awesome.

Runny ink is such a nightmare. It helps to make sure the specimen is DRY DRY DRY. Then ink and blot like mad. Then some Bouin's blotted all over and then some acetone blotted all over. It makes the ink stick fairly well so when you cut into it, it's not a goopy mess.

One of my old preceptors used to use tattoo inks back in the day to ink his stuff. Said he got on some pretty interesting mailing lists.

 

[CameronFrye]

Our histotechs are god-like, because they actually manage to make breast frozens look OK AND they don't complain the whole time. Awesome.

Runny ink is such a nightmare. It helps to make sure the specimen is DRY DRY DRY. Then ink and blot like mad. Then some Bouin's blotted all over and then some acetone blotted all over. It makes the ink stick fairly well so when you cut into it, it's not a goopy mess.

One of my old preceptors used to use tattoo inks back in the day to ink his stuff. Said he got on some pretty interesting mailing lists.

We use regular old vinegar as a mordant. The ink usually sticks pretty good after that.

 

[Aubrey]

We use regular old vinegar as a mordant. The ink usually sticks pretty good after that.

Or some of us use methanol, because vinegar stinks (literally, not as a mordant).

 

[Neddy]

Has anyone ever worked with a surgeon who inked their own lumpectomies? I was sitting in at signout the other day when a breast surgeon came by and suggested to my attending that she was interested in doing it - apparently some vender was hawking six-color ink kits at a recent surgery conference. She proposed it really delicately - like she was worried about nosing in on a particularly valued bit of pathology turf (never seemed like the most fascinating part to me). Has anyone run into this? And would anyone actually be opposed to it?

 

[Mrbojangles]

For those who receive the primary lumpectomy and then additional margins why do you have to ink the primary lumpectomy and submit the "margins"? Just as an experiment to the surgeon on how good they are?

At my place we used to submit 2mm shave margins. I've always thought shave margins are a much better representation of the true margin. With inked margins I'll always be surprised how my nice rectangular sections with ink on one surface turn out all distorted with ink diving deep. I geuss it's the nature of the tissue.

And green, orange, yellow, and red ink all suck.

 

[djmd]

Usually we don't get the new margins with the original lumpectomy.
And then there is the 5 x 5 x 5 cm lumpectomy. New lateral margin is 2 x 1 x 1 cm...?

Shave margins aren't going to help you with DCIS margins.. Unless you step section through the block.

and I agree with the bad inks. Usually we just interpret where needed...
If the ink is 'real' ink...
However, I blame part of the problem on people not knowing how to ink.
Would you paint a wall by slapping on a huge glob of paint and then not spreading it out and trying to let it dry before you touch it?

 

[deschutes]

Has anyone ever worked with a surgeon who inked their own lumpectomies?

Standard practice at my current workplace (high-volume private practice diagnostics, also a breast center). No oppositions, although it can bring up a whole new set of issues. I got a lump that had 5 colours and no space for a 6th. But I do like the fact that the person most familiar with the orientation chooses how they designate the 6 faces of the "cube".

I've never encountered a "2mm shave margin". Is this en face?

 

[Mrbojangles]

Shave margins aren't going to help you with DCIS margins.. Unless you step section through the block.

You mean if DCIS is within 2mm of the margin --> radiation? Shaves do work if you take ~2mm sections and put the cut side down in the cassette. And if you distrust the grosser, at most you can shove in 5mm of tissue. Also if the surgeon manipulates the breast tissue alot during surgery that creates alot of cracks and you get a floppy mess. There is no way to avoid getting ink to run deep into the tissue.

Shaves margins are en-face.

 

[deschutes]

How the hell do you cut breast tissue 2mm thick?

Oh wait is this fixed tissue??

 

[djmd]

I don't think I buy 2mm shaves for DCIS. Or you mean like serial 2mm shaves?
How many serial shaves do you do?

I guess with serial shaves it could work, but then I dont see how that is easier than regular margins.

With out serials it seems too easy for a 5 micro thick section to not have DCIS in it, making a margin seem negative.


Everyone gets ink down into fissures. It doesn't seem very hard to ignore ink which is clearly away from the resection line...

 

[yaah]

I knew one surgeon who inked on his own specimens. It was fine. I don't think it really matters as long as someone does it.

I disagree with the whole concept of shave margins. The only way to really see the margin is to see it perpendicular. It is true that you can see "more" of it if you shave, but more room for error IMHO. Obviously if it's on the section of shave margin it's at least close and there isn't any room for misinterpretation (unlike perpendicular sections which may fragment or have ink seep where it shouldn't be), but still, don't like it.

 

[Mrbojangles]

It's just a single shave. And of course you wont have a 2mm section all the time, somtimes 3, sometimes 4, sometimes 5 if you're in a rush. I think it's a little faster than inking with your six colors, blotting, waiting the ink to dry(especially for the red, orange, and yellow inks), fixing, and then taking your transverse sections. I think it really saves time in the signing out process, where you don't have to measure every focus of DCIS from ink and where you don't have to hem and haw if where you see ink is really the margin. But my department went back to inking. Except the surgeons are now submitting separate margins which we ink and take tranverse sections.