HCLSIG/Terminology/PathRadCorrelation/ExamplePathReport3

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         DETAIL TEST   SPCH                                                                                                       
                                                                                                                                  
                   Malignant neoplasm left breast.  Core biopsies showed invasive ductal                                   
                   adenocarcinoma.  Patient with history of atypical hyperplasia                                       
                   excised.                                                              
                                                                                                                                  
                                                                                                                                  
         DETAIL TEST   SPCPT                                                                                                      
                                                                                                                                  
                   Container A-B:88307/FR                                                                                         
                   Container C-D:88305/FR                                                                                         
                   Carcinoma in blocks D10, D12-13.                                                                                
                                                                                                                                  
                                                                                                                                  
         DETAIL TEST   SPGD                                                                                                       
                                                                                                                                  
                   A. "Sentinel node #1, hot, not blue", received fresh and placed in formalin. A                                 
                   1.5 x 0.7 x 0.5 cm lymph node is bisected and submitted entirely in A1.  A                                     
                   cytokeratin stain has been prospectively requested on A1.                                                      
                                                                                                                                  
                   B. "Sentinel node #2, hot, not blue", received fresh and placed in formalin. A                                 
                   2.5 x 2.0 x 0.6 cm lymph node is bisected and submitted entirely in B1-2.  A                                   
                   cytokeratin immunostain have been prospectively requested on B1-2.                                             
                                                                                                                                  
                   C. "Re-excision of medial margin", received fresh and placed in formalin.  A                                   
                   7.0 x 5.0 x 1.0 cm fragment of adipose tissue is oriented with a stitch on the                                 
                   final margin, which is inked blue and the opposite inked black.  No masses are                                 
                   identified.  Representative sections are submitted in Blocks C1-5.                                             
                                                                                                                                  
                   D. "left partial mastectomy", received fresh and placed in formalin.  An 9.0                                  
                   (ML) x 8.5 (SI) x 3.0 (AP) cm excisional breast biopsy is oriented short                                       
                   suture-superior, long suture-lateral, and white suture-anterior.  The specimen                                 
                   is inked anterior-blue, posterior-black, superior-red, and inferior-yellow.                                    
                   Sectioning from lateral to medial demonstrates an approximately 1.3 x 0.5 x                                    
                   0.3 cm blue dyed, firm mass in the central lateral portion of the biopsy,                                      
                   located 0.8 cm from the black margin, 2.0 cm from the blue margin, 3.0 cm from                                 
                   the red margin, and 4.0 cm from the yellow margin.  Radiograph demonstrate a                                   
                   small clip immediately medial to this mass is a larger clip near the medial                                    
                   margin.  Approximately half of the specimen is submitted as follows:                                           
                                                                                                                                  
                   BLOCK SUMMARY:                                                                                                 
                                                                                                                                  
                   D1-     tangential lateral margin                                                                              
                   D2-10-  representative sections lateral to mass                                                                
                   D11-14- mass                                                                                                   
                   D15-    small clip                                                                                             
                   D16-26- representative sections medial to mass (large clip in 25)                                              
                   D27-    tangential medial margin                                                                               
                                                                                                                                  
                   Dr. White/Dr. Green/slides to Dr. Brown                                                                        


         DETAIL TEST   SPMI                                                                                                       
                                                                                                                                  
                   Microscopic examination is performed.                                                                          
                                                                                                                                  
                                                                                                                                  
         DETAIL TEST   SPDX                                                                                                       
                                                                                                                                  
                   A. "SENTINEL NODE # 1 HOT NOT BLUE" (LYMPH NODE DISSECTION):                                                   
                                                                                                                                  
                       NO EVIDENCE OF MALIGNANCY IN ONE LYMPH NODE EXAMINED (0/1).                                                
                       CYTOKERATIN IMMUNOHISTOCHEMICAL STAIN IS NEGATIVE.                                                         
                                                                                                                                  
                                                                                                                                  
                   B. "SENTINEL NODE # 2 HOT NOT BLUE" (LYMPH NODE DISSECTION):                                                   
                                                                                                                                  
                       NO H&E EVIDENCE OF MALIGNANCY IN ONE LYMPH NODE EXAMINED (0/1).                                            
                       CYTOKERATIN IMMUNOHISTOCHEMICAL STAIN FOR BLOCK B2 IS NEGATIVE.                                            
                                                                                                                                  
                       AN ADDENDUM WILL BE ISSUED FOR CYTOKERATIN IMMUNOHISTOCHEMICAL STAIN ON                                    
                          BLOCK B1 FOLLOWING REPROCESSING.                                                                        
                                                                                                                                  
                                                                                                                                  
                   C. "REEXCISION OF MEDIAL MARGIN":                                                                              
                                                                                                                                  
                       BENIGN BREAST TISSUE.                                                                                      
                       NO EVIDENCE OF MALIGNANCY.                                                                                 
                                                                                                                                  
                                                                                                                                  
                   D. "LEFT PARTIAL MASTECTOMY":                                                                                 
                                                                                                                                  
                       INVASIVE ADENOCARCINOMA OF THE BREAST.                                                                     
                          HISTOLOGIC TYPE: DUCTAL.                                                                                
                          NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.                                                           
                             TUBULE FORMATION SCORE: 1                                                                            
                             NUCLEAR PLEOMORPHISM SCORE: 2                                                                        
                             MITOTIC RATE SCORE: 1                                                                                
                          GROSS TUMOR SIZE: 1.3 X 0.5 X 0.3 CM.                                                                   
                          SIZE OF INVASIVE COMPONENT: 1.1 CM IN MAXIMUM DIMENSION.                                                
                          LYMPHATIC/VASCULAR INVASION: ABSENT.                                                                    
                          MULTIFOCAL TUMOR: ABSENT.                                                                               
                                                                                                                                  
                       IN-SITU CARCINOMA: PRESENT.                                                                                
                          TYPE OF IN-SITU CARCINOMA: CRIBRIFORM.                                                                  
                          NUCLEAR GRADE OF IN-SITU CARCINOMA: 1 OF 3.                                                             
                          NECROSIS: ABSENT.                                                                                       
                          DCIS EXTENDING OUTSIDE INVASIVE TUMOR MASS: ABSENT.                                                     
                          SIZE OF IN-SITU CARCINOMA: NOT APPLICABLE.                                                              
                                                                                                                                  
                       STATUS OF NON-NEOPLASTIC BREAST TISSUE: BIOPSY SITE AND FIBROCYSTIC                                        
                                                               CHANGES.                                                           
                       SIZE OF BIOPSY: 9.0 X 8.5 X 3.0 CM.                                                                        
                       MICROCALCIFICATIONS: PRESENT IN ASSOCIATION WITH CARCINOMA AND BENIGN                                      
                                            BREAST TISSUE.                                                                        
                       SURGICAL MARGIN STATUS: NEGATIVE.                                                                          
                                                                                                                                  
                       ESTROGEN/PROGESTERONE RECEPTOR, CELL CYCLE, AND HER2/NEU ANALYSIS:                                         
                       PENDING.                                                                                                   
                          PARAFFIN BLOCK NUMBER D11.                                                                              
                          RESULTS WILL BE ISSUED IN A SEPARATE REPORT FROM THE IMAGE CYTOMETRY                                    
                          LAB.                                                                                                    
                                                                                                                                  
                                                                           
         DETAIL TEST   SPSTAGE                                                                                                    
                                                                                                                                  
                   PROCEDURE: Left partial mastectomy and lymph node dissection.                                                 
                                                                                                                                  
                   PATHOLOGIC STAGE (AJCC 6th Edition): pT1c  pN0  pMX                                                            
                                                                                                                                  
                   NOTE: Information on pathology stage and the operative procedure is                                            
                   transmitted to this Institution's Cancer Registry as required for                                              
                   accreditation by the Commission on Cancer. Pathology stage is based solely                                     
                   upon the current tissue specimen being evaluated, and does not incorporate                                     
                   information on any specimens submitted separately to our Cytology section,                                     
                   past pathology information, imaging studies, or clinical or operative                                          
                   findings. Pathology stage is only a component to be considered in determining                                  
                   the clinical stage, and should not be confused with nor substituted for it.                                    
                   The exact operative procedure is available in the surgeon's operative report.