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DETAIL TEST SPCH
ICD-9 CODE: 611.72
Right breast mass
DETAIL TEST SPGD DRH
A. "Left breast mass", in formalin. Received is an unoriented 6.4 x 4.3 x
3.4 cm irregular mass of dense white fibrous tissue and adipose. Inked blue
and sectioned to demonstrate an ill defined pink to white lobulated mass
approximately 1.7 cm in greatest dimension. The mass abuts the blue ink. The
remainder of the specimen consists of dense white fibrous tissue and grossly
unremarkable adipose. Representative A1-A10. Approximately 60% of the
specimen is submitted. The mass is submitted entirely. The tissue is fixed
between six and forty-eight hours. A quadrant is not specified. AB:cde
DETAIL TEST SPCPT
GLOBAL 88307, PQR3260F
DETAIL TEST SPMI
Microscopic examination performed by Dr. Smith.
DETAIL TEST SPDX
A. LEFT BREAST MASS, EXCISION:
INVASIVE ADENOCARCINOMA OF THE BREAST.
HISTOLOGIC TYPE: POORLY DIFFERENTIATED DUCTAL CARCINOMA.
NOTTINGHAM COMBINED HISTOLOGIC GRADE: 3.
TUBULE FORMATION SCORE: 3.
NUCLEAR PLEOMORPHISM SCORE: 3.
MITOTIC RATE SCORE: 3.
TUMOR SIZE: 1.7 CM.
LYMPHATIC/VASCULAR INVASION: PRESENT.
MULTIFOCAL TUMOR: ABSENT.
IN-SITU CARCINOMA: A SMALL AMOUNT OF DCIS IS PRESENT ADJACENT TO
INVASIVE TUMOR REPRESENTING A VERY MINOR
COMPONENT OF THE MASS.
TYPE OF IN-SITU CARCINOMA: COMEDO, CLINGING, AND CRIBRIFORM.
NUCLEAR GRADE OF IN-SITU CARCINOMA: 3.
COMEDO NECROSIS: ABSENT.
STATUS OF NON-NEOPLASTIC BREAST TISSUE: ATYPICAL DUCTAL HYPERPLASIA
SURGICAL MARGIN STATUS: POSITIVE. INVASIVE CARCINOMA EXTENDS
TO THE INKED MARGIN. THE SURGICAL MARGIN IS NEGATIVE FOR DCIS.
ESTROGEN/PROGESTERONE RECEPTOR AND HER2/NEU ANALYSIS: PENDING,
AJCC CANCER STAGE: T1C, NX, MX.