Non-Malignant Dissection Copy —
Training activity: 8

Details

Dissect breast specimens, received for a range of non-malignant pathologies, to include:

• Cyst
• Excision

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Local SOPs
• Specimen orientation, inking, block sampling and macroscopic description
• Quality of blocks
• RCPath tissue pathways
• Macroscopic pathological features specific to the disease entity

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to dissecting these breast specimens, specifically learning outcomes related to dissecting specimens and employing appropriate technique based on history.
• Discuss with your training officer to gain clarity, potentially reviewing the listed specimen types: cyst, excision.

What is your prior experience of this activity?

• Think about your previous dissection experience, particularly with breast tissue.
• Consider possible challenges you might face e.g., handling fatty tissue, identifying subtle lesions in excisions and how you might handle them.
• Recognise the scope of your own practice; know when and from whom you will need to seek advice or help. For example, you will need to seek advice from your Training Officer or a Breast Pathologist/Radiologist link when required:
  • When needing to correlate an excision specimen with radiological markers e.g., wires, clips, or calcifications on mammogram where confirmation is difficult.
  • If margins on a benign excision are uncertain or exceptionally close, requiring immediate input before block sampling is finalized.
  • When the specimen contains unexpected or ambiguous macroscopic changes that could potentially represent malignancy e.g., an area of firmness not typical of a benign cyst.
• Acknowledge how you feel about dissecting breast specimens for a range of non-malignant pathologies.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop in dissecting non-malignant breast specimens, such as inking margins, sectioning techniques, and identifying benign lesions like cysts or fibroadenomas.
• Identify the specific insights you hope to gain into the macroscopic appearance and dissection rationale for common non-malignant breast pathologies.

What additional considerations do you need to make?

• Consult actions identified following previous dissection experiences, especially with breast specimens.

Identify important information you need to consider, such as specific inking protocols or requirements for mammographic correlation if relevant.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst inking or sectioning the breast excision?
• Are you encountering situations such as:
  • Difficulty correlating the gross finding (e.g., a fibroadenoma) with pre-operative markers (e.g., clips or wires), compromising the required radiological correlation?
  • The specimen consistency is unusually firm or fatty, making thin, uniform sectioning for margin assessment challenging?
  • Unexpected calcification or an area of haemorrhage is encountered within the lesion, requiring immediate alteration of the block sampling strategy?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to sectioning interval or block selection in the moment?
• Consider the steps you are taking in the moment, such as:
  • Immediately halting the dissection and seeking advice from the supervisor/pathologist regarding the required correlation with radiological images?
  • Adapting the inking method to clearly mark all six surfaces of an excision despite challenging tissue texture?
• How are you feeling in that moment? For instance, are you finding it difficult to maintain accuracy in sectioning through dense tissue? Is it affecting your confidence in ensuring clear margins are represented?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully applying the required inking protocol? Or are you needing support because the uncertainty regarding clip correlation requires input from the imaging team?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective strategy for grossing fatty tissue to preserve margins? Or gaining insight into the specific requirements for sampling benign breast calcifications?

On action

What happened?

• Begin by summarising your dissection of this breast specimen (e.g., cyst, excision).
• Consider specific events, actions, or interactions which felt important, such as how you applied the inking protocol and how you sectioned through fatty tissue to find the lesion.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately consulting the radiological images when encountering unexpected calcifications not noted on the clinical form. How did you feel during this experience, e.g., did you feel pressure to ensure the margins were clear despite challenging tissue consistency?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience. What strengths did you demonstrate, e.g., accurate application of inking techniques? What skills and/or knowledge gaps were evident, e.g., difficulty in macroscopically distinguishing subtle benign lesions from surrounding breast parenchyma?
• Compare this experience against previous engagement with similar activities – Has your practice improved in ensuring the margin relationships are clearly demonstrated in block sampling for excisions?
• Identify any challenges you experienced, such as needing to seek advice on block selection for a specific ambiguous feature, and how this improved your technical knowledge.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received with regards to your dissection technique related to breast specimens, specifically for cyst and excision.
• What will you do differently or focus on more intensely in future breast dissections, for instance, dedicating more time to palpation and macroscopic correlation with any imaging provided to accurately locate benign lesions?
• Do you need to practise any aspect of the activity further, such as reviewing benign breast pathology criteria or departmental protocols for handling breast calcifications?

Beyond action

Have you revisited the experiences?

• How has your evolving understanding of specific non-malignant breast pathologies and the required dissection techniques for diagnosis and assessment, since completing this specific training activity led you to revisit your initial dissection technique or rationale during that activity? For example, how a subsequent experience with wire-guided excisions led you to realise the importance of meticulous inking and sectioning specific to radiological findings, which was a less emphasised component of your first reflection on a simple cyst excision.
• Considering what you understand about the importance of accurate dissection, inking, and block sampling for breast specimens and their clinical significance now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your dissection technique for these specimens based on further learning and experiences? For example, how you have implemented a standardised protocol for handling fatty tissue to ensure thinner, more uniform sections for block sampling to improve margin visibility.
• Has discussing challenging breast dissections or their clinical pathway with colleagues, peers, or in multidisciplinary team meetings or clinics changed how you now view your initial experience in this training activity? For example, how a discussion in a breast MDT about close benign margins reinforced the necessity of pre-dissection radiological correlation, changing your view of the importance of this step even for presumed benign excisions.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent breast dissection experiences, contributed to your overall confidence and competence in dissecting non-malignant specimens from the breast and employing appropriate techniques while adhering to quality standards, particularly in preparing for assessments? For example, how your ability in dissecting breast specimens now allows you to efficiently perform the required inking and orientation components of a DOPS assessment related to excision dissection.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to dissecting breast specimens? How does this evolved understanding help you identify when something is beyond your scope of practice? For example, your current approach of always seeking radiologist or senior pathologist input if an area of palpable firmness in a benign excision does not correspond clearly with clinical or radiological findings, recognising the differential diagnosis includes occult malignancy.
• Looking holistically at your training journey, how has this initial dissection experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to dissecting non-malignant specimens, employing appropriate techniques, and practicing safely? For example, how the focus on quality standards and procedural adherence developed in this training activity is a foundation for managing the high-stakes procedures later in the module.

Relevant learning outcomes

#	Outcome
# 2	Outcome Dissect non-malignant specimens from a range of organ systems.
# 3	Outcome Employ the appropriate specimen preparation, orientation, inking, block sampling and dissection rationale based on the clinical history for non-malignant specimens.
# 5	Outcome Practice safely in accordance with quality management and accreditation standards.