BMC Cancer 2009, 9:254 http://www.biomedcentral.com/1471-2407/9/254 Skin L IL I IM BCS Cavity DP Breast Tissue M M Tumor SM S BCS Cavity DP SL L BCS Specimen lscFCepoifogetnmcusbiemprreuveatin2sentrgr-egsseuunrlgeteirnragytef(rdBoCrmeSp)arreBesCseenScttpaitroiooncnbedoedufrtcehaevpierteyrfsoaunrltmdanethtdeborBneCaasSt- Computer-generated representation of the resultant breast-conserving surgery (BCS) resection bed cavity and the BCS specimen resulting from a BCS proce- dure performed on a left breast. In this example, the area of the BCS resection bed cavity has been bisected along its long axis to illustrate the exact spatial location from where the nine standardized re-resection margins were sam- pled from the superior (S), superior-medial (SM), superior- lateral (SL), medial (M), lateral (L), inferior (I), inferior-medial (IM), inferior-lateral (IL), and deep-posterior (DP) aspects of the BCS resection bed cavity. approximately 5 mm for each serial section and in an anterior skin surface to posterior direction) along the entire long axis length of the BCS specimen (i.e., by a standard perpendicular margins/radial margins tech- nique). The macroscopic three-dimensional measure- ments (length, height, and width) of the tumor, residual tumor, or previous diagnostic excisional biopsy cavity identified within each BCS specimen were recorded, as well as the microscopic distance of the tumor, residual tumor, or previous diagnostic excisional biopsy cavity from the superior, medial, lateral, inferior, deep-posterior, and anterior-skin inked surfaces of the BCS specimen. Along the periphery of each BCS specimen, six standard- ized locations were sampled as BCS specimen margins, and were designated as the superior, medial, lateral, infe- rior, deep-posterior, and anterior-skin margins of the BCS specimen. All submitted BCS specimen tissue sections were processed for permanent histopathologic evaluation with routine Hematoxylin and Eosin (H&E) staining. No intraoperative frozen section analysis was undertaken for microscopic evaluation of the BCS specimen margins. The six designated BCS specimen margin locations along the periphery of each BCS specimen were microscopically assessed at the time of permanent histopathologic evalua- tion for the presence or absence of invasive carcinoma or DCIS. The six designated BCS specimen margin locations along the periphery of each BCS specimen were then each defined as a "positive" BCS specimen margin, a "close" BCS specimen margin, or a "negative" BCS specimen mar- gin, based upon the finding of invasive carcinoma or DCIS at the six designated BCS specimen margin loca- tions. A "positive" BCS specimen margin was defined as tumor cells seen at the inked edge of the BCS specimen [3,8]. A "close" BCS specimen margin was defined as tumor cells seen within 1 mm or less of the inked edge of the BCS specimen, but no tumor cells seen at the inked edge of the BCS specimen. A "negative" BCS specimen margin was defined as no tumor cells seen within 1 mm or less of the inked edge of the BCS specimen. For the six designated BCS specimen margin locations along the periphery of each BCS specimen, the exact distance to the closest BCS specimen margin was determined. However, for those individuals who had undergone a previous sur- gical (excisional) biopsy as their initial diagnostic breast biopsy and had no residual disease within the BCS speci- men, the exact distance to the closest BCS specimen mar- gin could not be determined. For all cases in which BCS specimen margins were reported generically as "close" (and not reported as an exact numerical measurement) in the original official pathology report, repeat microscopic histopathologic evaluation was subsequently performed by a pathologist (REJ) to more precisely determine the exact numerical measurement of the distance between tumor and the inked edge of the BCS specimen. The pres- ence of only LCIS, atypical lobular hyperplasia, or atypical ductal hyperplasia within any one of the six designated BCS specimen margin locations along the periphery of each BCS specimen was not considered a "positive" find- ing for margin definition purposes. The nine standardized re-resection margin specimens col- lected on each BCS case were inked with black ink, serially sectioned, and submitted in entirety for processing for permanent histopathologic evaluation with routine H&E staining. No intraoperative frozen section analysis was undertaken for intraoperative microscopic evaluation of any of the nine standardized re-resection margin speci- mens. All nine standardized re-resection margin speci- mens were assessed for the presence ("positive") or absence ("negative") of invasive carcinoma or DCIS. The presence of only lobular carcinoma in situ, atypical lobu- lar hyperplasia, or atypical ductal hyperplasia within a standardized re-resection margin specimen was not con- sidered a "positive" finding. The electrocautery artifact on each of the nine standardized re-resection margin speci- mens was specifically used by the pathologist to evaluate the relationship any focus of invasive carcinoma or DCIS within each standardized re-resection margin specimen to that of its actual margin surface (non-cauterized surface) and its non-margin surface (cauterized surface). Page 4 of 23 (page number not for citation purposes)