Re: [Histonet] Handling Breast Lumpectomy Specimens with radioactive seed localization

[Bob Richmond via Histonet]

Further researching the topic, I've learned that there are two recently
introduced non-radioactive alternatives, Savi Scout and Sentimag. I don't
understand how they work.

Coincidentally, I received a circular in this morning's mail with
information about a continuing medical education event on breast disease,
with presentations about both of these non-radioactive techniques.

Bob Richmond

Samurai Pathologist

Maryville TN
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Re: [Histonet] Handling Breast Lumpectomy Specimens with radioactive seed localization

[Normington Lacy via Histonet]

James,

Luckly our breast surgeons are good at notifying our Pathologists' Assistants 
when a case with radioactive seeds is sent to our laboratory.  Everything under 
the sun is labeled with radiation stickers, and additional stickers are 
provided with the tissue requisition.  We also have a chain of custody sheet 
that is delivered with the specimen.  

1.   Since the lumpectomy is obviously "hot" what precautions are taken to 
remove the seed and give it back to radiology?  

The individual removing the seed wears a radiation detection ring.  The ring is 
evaluated monthly by our radiation safety department.  The specimen is scanned 
with a survey meter to located all seeds.   Once the seed is removed, the seeds 
are placed in a lead lined PIG and stored in a locked safe within our gross 
room.  A representative from our breast center is required to pick up the seeds 
within 24 hours and document this on the chain of custody form.  

2.   Does the pathologist  or pathology assistant remove the seed?

The Pathologists' Assistants performs the removal as they are required to 
perform CBT on radioactive safety training..  

3.   After seed removal is the specimen handled similarly to a wire-located 
specimen.In other words is the specimen then fixed for a period of time 
before grossing?

Yes, normal fixation procedure is followed.  Histology staff are notified of 
the case, however, no special radiation safety precautions are needed.

4.   How is the location of the seed marked in the lumpectomy specimen when 
the seed is removed?  Do the pathologists use an ink to mark the location, do 
they then fix the tissue as before?

We follow an inking protocol for lumpectomies, whether wire or seeds.

If you are interested in our procedure, please let me know and I can email it 
to you.

Lacy Normington, HTL(ASCP)CM
Manager, Surgical Pathology Lab Services
UW Health - UW Hospital
600 Highland Avenue
Madison, WI 53792-2472
Phone: 608-890-9373


-Original Message-
From: Vickroy, James via Histonet [mailto:histonet@lists.utsouthwestern.edu] 
Sent: Tuesday, October 04, 2016 12:31 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] Handling Breast Lumpectomy Specimens with radioactive seed 
localization

Our organization is looking into the workflow necessary to handle breast 
lumpectomies with radioactive seed localization. Right now we have more 
questions than answers.  I have looked at several articles and am aware of the 
drastic changes that will need to be in place to handle the radioactive seed.   
My experience in the past has been handling a wire-located lumpectomy proceeded 
usually by a sentinel node biopsy by frozen section.   From what I read the 
sentinel node biopsy procedure will probably not be changed, however I have 
several questions regarding handling the lumpectomy specimen and would 
appreciate any thoughts from someone already handling these specimens.  I know 
there are precautions on how to handle and remove the seed as well as 
procedures in case the seed is cut during the removal.  I am trying to figure 
out how the workflow will proceed.

Wire-located lumpectomy procedure:

Currently the sentinel nodes are sent to the lab from surgery and frozen 
sections are performed.  The pathologist then calls the surgeon and depending 
on whether the sentinel nodes were positive further nodal dissections may or 
may not be necessary.   The  wire-located lumpectomy specimen is usually sent 
over to pathology after the sentinel node biopsies.  The lumpectomy specimen 
has usually been x-rayed to show the location of the wire prior to being 
received by pathology.   Pathology then usually gets a copy of the x-ray along 
with the fresh lumpectomy specimen.   Next the pathologist or pathology 
assistant would place the specimen in formalin and let it fix for sometimes 
overnight.  The next day the fixed lumpectomy specimen was grossed and 
sectioned for histologic examination.  Special care is taken to take specific 
sections where the wire was implanted.

Radioactive seed lumpectomy procedure questions:


1.   Since the lumpectomy is obviously "hot" what precautions are taken to 
remove the seed and give it back to radiology?

2.   Does the pathologist  or pathology assistant remove the seed?

3.   After seed removal is the specimen handled similarly to a wire-located 
specimen.In other words is the specimen then fixed for a period of time 
before grossing?

4.   How is the location of the seed marked in the lumpectomy specimen when 
the seed is removed?  Do the pathologists use an ink to mark the location, do 
they then fix the tissue as before?

Finally another "WRENCH"  to this new procedure is that we usually send our 
larger tissue specimens to be grossed and processed at a hospital lab.  We are 
being asked to perform the frozen section onsite and then send the fixed tissue 
left over from the frozen section

Re: [Histonet] Handling Breast Lumpectomy Specimens with radioactive seed localization

[Bob Richmond via Histonet]

Jim Vickroy, Histology Manager at Springfield [Illinois] Clinic asks: "Our
organization is looking into the workflow necessary to handle breast
lumpectomies with radioactive seed localization (RSL)".

Thanks for the heads-up - as usual, pathologists and histologists don't get
told. Nursing practice is to assume that what we do is ritual disposal of
corpse poison, and we're immune to all hazards. And "seed" is a magickal
word that shuts off thinking. Apparently RSL has been around for more than
ten years.

A titanium "seed" containing about 20 microcuries of radioactive iodine 125
is placed in the patient's breast lesion a day or so before surgery,
usually eliminating the need for wire localization or specimen radiography.
The "seed" is not removed from the specimen, which is delivered to the
pathology department.

Iodine 125 is a gamma emitter with a half-life of about 60 days (unlike the
technetium 99m used in the sentinel node biopsy, which has a half-life of
only six hours). It's a considerably more hazardous material, though I
think it's safe to briefly handle the "seed" with gloved hands. What you
don't want to do is lose the thing in your clothing or in the laboratory,
since it will take nearly two years to decay to a safe level of
radioactivity.

According to my online resource, the "seed" is recovered from the pathology
department with elaborate ceremony, in the presence of a "radiation safety
officer". I've yet to encounter a hospital that had a radiation safety
officer, and often there's nobody who knows the difference between
radiation and radioactive material.

If this procedure is thrown at you without warning, I suggest that your
pathologist stage a carefully planned hissy-fit.

I found an excellent online resource for this subject. Read the section
about laboratory procedures.

http://www.teambest.com/besttotalsolutions/PDFs/RadioactiveSeedLocalizationI125_LTDauer_et_al_Oct2013.pdf
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[Histonet] Handling Breast Lumpectomy Specimens with radioactive seed localization

[Vickroy, James via Histonet]

Our organization is looking into the workflow necessary to handle breast 
lumpectomies with radioactive seed localization. Right now we have more 
questions than answers.  I have looked at several articles and am aware of the 
drastic changes that will need to be in place to handle the radioactive seed.   
My experience in the past has been handling a wire-located lumpectomy proceeded 
usually by a sentinel node biopsy by frozen section.   From what I read the 
sentinel node biopsy procedure will probably not be changed, however I have 
several questions regarding handling the lumpectomy specimen and would 
appreciate any thoughts from someone already handling these specimens.  I know 
there are precautions on how to handle and remove the seed as well as 
procedures in case the seed is cut during the removal.  I am trying to figure 
out how the workflow will proceed.

Wire-located lumpectomy procedure:

Currently the sentinel nodes are sent to the lab from surgery and frozen 
sections are performed.  The pathologist then calls the surgeon and depending 
on whether the sentinel nodes were positive further nodal dissections may or 
may not be necessary.   The  wire-located lumpectomy specimen is usually sent 
over to pathology after the sentinel node biopsies.  The lumpectomy specimen 
has usually been x-rayed to show the location of the wire prior to being 
received by pathology.   Pathology then usually gets a copy of the x-ray along 
with the fresh lumpectomy specimen.   Next the pathologist or pathology 
assistant would place the specimen in formalin and let it fix for sometimes 
overnight.  The next day the fixed lumpectomy specimen was grossed and 
sectioned for histologic examination.  Special care is taken to take specific 
sections where the wire was implanted.

Radioactive seed lumpectomy procedure questions:


1.   Since the lumpectomy is obviously "hot" what precautions are taken to 
remove the seed and give it back to radiology?

2.   Does the pathologist  or pathology assistant remove the seed?

3.   After seed removal is the specimen handled similarly to a wire-located 
specimen.In other words is the specimen then fixed for a period of time 
before grossing?

4.   How is the location of the seed marked in the lumpectomy specimen when 
the seed is removed?  Do the pathologists use an ink to mark the location, do 
they then fix the tissue as before?

Finally another "WRENCH"  to this new procedure is that we usually send our 
larger tissue specimens to be grossed and processed at a hospital lab.  We are 
being asked to perform the frozen section onsite and then send the fixed tissue 
left over from the frozen sections with the lumpectomy specimen to the hospital 
lab. Obviously the radioactive seed has to be removed before transportation to 
the  hospital lab.

As you can see there are more questions than answers and I would appreciate 
hearing from someone  that is already handling the new radioactive seep 
lumpectomy specimens.

Jim

Jim Vickroy
Histology Manager
Springfield Clinic, Main Campus, East Building
1025 South 6th Street
Springfield, Illinois  62703
Office:  217-528-7541, Ext. 15121
Email:  jvick...@springfieldclinic.com



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