Utility of Four-Quadrant Random Sections in Mastectomy Specimens

Abstract

Standard practice in surgical pathology dictates that random sections from the four quadrants of the breast be taken in mastectomy specimens. These sections are obtained in addition to sampling of any grossly visible lesions within the breast specimen. While tradition dictates the submission of these sections, we are unaware of any study supporting their efficacy. We have investigated the utility and significance of these random sections in a series of 78 mastectomy specimens. This retrospective study identified mastectomy specimens from pathology files of Magee Woman's Hospital, the University of Pittsburgh, and the University of Utah School of Medicine between 1997 and 2000. Clinical data (palpable versus nonpalpable), radiographic features (mammographic diagnosis, presence of mass density and/or calcification), and pathologic features (size, histopathologic type, etc.) were studied. The histologic sections of the cases were reviewed and the random sections were specifically studied for pathologic findings. Diagnosis and clinically significant features obtained from examining these random sections, but not demonstrable in grossly selected sections, were tabulated. A total of 78 mastectomy specimens were analyzed. Diagnoses rendered were infiltrating ductal carcinoma (23), infiltrating ductal carcinoma with ductal carcinoma in situ (DCIS) (16), DCIS (25), infiltrating lobular carcinoma (4), biopsy cavity with no residual malignancy (4), infiltrating lobular carcinoma with lobular carcinoma in situ (3), invasive ductal and lobular carcinoma (1), adenoid cystic carcinoma (1), and atypical ductal hyperplasia (1). The number of random sections ranged from 2 to 17 (mean 9). Random sections provided additional information in 21 of 78 mastectomies (27%). The multifocal/multicentric nature of the lesion was diagnosed in 20 cases: DCIS (6), lobular carcinoma in situ and invasive (2), invasive ductal carcinoma (6), invasive and in situ ductal carcinoma (5), invasive lobular carcinoma (1), invasive ductal and lobular carcinoma (1). Additional findings include lymphovascular invasion (2 cases), atypical ductal hyperplasia (1), DCIS at the operative margin (1), DCIS within less than 1 mm of an operative margin (1), and atypical lobular hyperplasia (1). In the remaining 57 cases, random sections did not provide any additional information. Histologic examination of random sections from breast quadrants yielded important information about the presence of multifocality, multicentricity, vascular invasion, and margin involvement by carcinoma in only a minority of cases, many of which had a lobular morphology.

Sections of the nipple and quadrants in mastectomy specimens for carcinoma are of limited value: Table 1

“…3 The only previous study of sampling of mastectomy specimens reported that additional information was derived from the quadrant sections in 21 of 78 mastectomy specimens, particularly the identification of multifocal or multicentric disease. 4 This figure is much higher than we would have expected from our experience in Nottingham. The purpose of our current study was to investigate the value of sampling of the nipple and quadrants from routine mastectomy specimens for primary operable breast carcinoma.…”

“…4 Cases with macroscopically identified multifocal disease were excluded, so the difference between that study and our present study is even larger. Potential explanations for the higher rate of multifocality in Gupta's study include the higher number of quadrant blocks taken (range, 4-17; mean, 9) and the relative inexperience of the dissectors (half the specimens were examined by first year residents), who may not have identified some macroscopic abnormalities.…”

Review on Practical Approach in Multiple Breast Carcinomas: Does Each Focus Matter?

“…There are two sampling methods which are generally used in diagnosing multiple breast carcinomas: 1. the randomized biopsy of each breast quadrant not involved by the tumor, along with sampling the principal tumor, which is histologically examined (15,18,31,32) and 2. the serial gross section method in which the entire breast tissue is examined, allowing a more precise determination of the relationships between lesions, with or without radiologic examination (5,8,9,21,33). The incidence of multiple tumors when using the serial section method varies between 21% and 63%, with a mean value of 43%, while when using randomized quadrant biopsy, the incidence of multifocality varies between 11% and 41.6% (with a mean value of 26%) (25).…”

Cost-Effectiveness Analysis of Whole-Mount Pathology Processing for Patients with Early Breast Cancer Undergoing Breast Conservation

“…Furthermore, lumpectomy specimens are representatively sampled in 10-40 small slides, thereby characterizing only 0.007% -0.02% of the entire volume of resected tissue 8 . Under-sampling of disease can affect the accurate determination of tumour size and the presence and extent of positive margins 9,10 .…”