BMC Cancer 2009, 9:254 http://www.biomedcentral.com/1471-2407/9/254 gPFehigroyutor(BgerCa1Sp)hsopfecaimtyepnicatalkeexna mfrpolmeoaf laefbtrberaesats-ctonserving sur- Photograph of a typical example of a breast-conserv- ing surgery (BCS) specimen taken from a left breast. affected breast was used in this rationale for the extent of the BCS procedure, but rather this rationale was based upon the determination of the appropriateness of the extent of resection, and when determined necessary, to include all layers comprising the field of the affected breast (i.e., skin, breast parenchyma, pectoralis major muscle fascia, and pectoralis major muscle) in order to maximize the likelihood of surgical resection margin clearance. Each BCS specimen (Figure 1) was marked with black silk sutures on the skin ellipse for specimen orienta- tion. This generally consisted of a long black silk suture marking the lateral edge of the skin ellipse and a short black silk suture marking the superior edge of the skin ellipse. Once the BCS specimen was removed, rectangular-shaped pieces of breast tissue were then systematically sampled from nine standardized locations within the perimeter of the resultant BCS resection bed cavity using curved Mayo scissors and/or a #24 surgical blade (Figure 2). These rec- tangular-shaped pieces of breast tissue were excised with the curved Mayo scissors and/or a #24 surgical blade, instead of with the coagulation mode of the electrocau- tery, in order to generate no evidence of cautery artifact on that particular surface of each sampled piece of breast tis- sue. Therefore, in the end, the non-cauterized aspect of each rectangular-shaped piece of breast tissue sampled would represent the surface of the rectangular-shaped piece of breast tissue that was furthest from the corre- sponding resection margin of the originally submitted BCS specimen that was removed from the affected breast with the coagulation mode of the electrocautery and the cauterized aspect of each rectangular-shaped piece of breast tissue sampled would represent the surface of the rectangular-shaped piece of breast tissue that was abutting the corresponding resection margin of the originally sub- mitted BCS specimen that was removed from the affected breast with the coagulation mode of the electrocautery. In this fashion, the distribution of electrocautery artifact on each rectangular-shaped piece of breast tissue sampled was used by the pathologist to help distinguish the actual true margin surface (non-cauterized surface) from that of the non-margin surface (cauterized surface) of each rec- tangular-shaped piece of breast tissue sampled. These rec- tangular-shaped pieces of breast tissue that where systematically sampled from nine standardized locations within the perimeter of the resultant BCS resection bed cavity were designated as originating from the superior, superior-medial, superior-lateral, medial, lateral, inferior, inferior-medial, inferior-lateral, and deep-posterior aspects of the resultant BCS resection bed cavity (Figures 2 and 3). These rectangular-shaped pieces of breast tissue that were systematically sampled from nine standardized locations within the perimeter of the resultant BCS resec- tion bed cavity were designated as the nine standardized re-resection margin specimens, as they are referred to throughout the remainder of the current paper. Since the anterior aspect of the BCS specimen was covered by an overlying skin ellipse (in all but two cases), there was no anterior re-resection margin designation for the resultant BCS resection bed cavity. Intraoperative sectioning and subsequent intraoperative gross assessment of BCS margins on the BCS specimens were not undertaken by the operating surgeon within the operating room for any of the 204 BCS cases. This was done in this fashion at the request of the Surgical Pathol- ogy Department in order to maintain the integrity of the intact BCS specimen for standard tissue processing that would be subsequently performed in the Surgical Pathol- ogy Department. However, in appropriately selected cases, verification of the relationship of the tumor, mark- ing clip, and/or biopsy cavity to the edges of the BCS spec- imen was evaluated on non-compression specimen mammography and/or on intraoperative specimen sonography of the intact BCS specimen. Both the BCS specimen and the nine standardized re- resection margin specimens for each BCS case were sent to the Surgical Pathology Department for standard tissue processing. The three-dimensional measurements (length, height, and width) of each submitted specimen were recorded. After standard tissue processing, each BCS specimen was inked in a color-specific fashion using multiple colored inks to designate the superior, medial, lateral, inferior, deep-posterior, and anterior-skin surfaces. Each BCS spec- imen was then grossly serially sectioned (at a thickness of Page 3 of 23 (page number not for citation purposes)