From W3C Wiki
DETAIL TEST SPCH Not provided. DETAIL TEST SPCPT Container A,B:88307/FR Carcinoma in blocks A6-15, 17-22, 27-47 DETAIL TEST SPGD A. "Left breast needle localization excision", received fresh and placed in formalin. A breast lumpectomy with overlying 7 x 1.1 cm ellipse of skin remarkable for a 2 cm long well-healed scar is oriented long suture-lateral and short suture-superior. The specimen measures 9.2 (ML) x 7.4 (AP) x 4.9 (SI) and is inked superior-yellow, inferior-red, anterior-blue and posterior-black. Sectioning from medial to lateral demonstrates a 3.0 x 2.2 x 1.3 cm biopsy cavity surrounded by induration, hemorrhage and fat necrosis. The biopsy cavity is located 1.6 cm from the medial, 3.6 cm from the lateral, 1.0 cm from the anterior (skin), 0.7 cm from the anterior, 2.0 cm from the posterior, 1.5 cm from the inferior, and 2.5 cm from the superior margins. Representative sections are submitted in blocks A1-50 from medial to lateral. B. "Left axillary contents", received fresh and placed in formalin is an unoriented 11.5 x 8.7 x 3.1 cm aggregate of yellow-tan fibrofatty tissue dissected for lymph nodes. B1-6 lymph node candidates B7- one lymph node bisected B8- one lymph node bisected B9-10 one lymph node sectioned J. White/Dr. Green/slides to Dr. Brown DETAIL TEST SPMI Microscopic examination is performed. DETAIL TEST SPDX A. "LEFT BREAST" (NEEDLE LOCALIZATION EXCISION): INVASIVE ADENOCARCINOMA OF THE BREAST. HISTOLOGIC TYPE: LOBULAR. NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3. TUBULE FORMATION SCORE: 3 NUCLEAR PLEOMORPHISM SCORE: 1 MITOTIC RATE SCORE: 1 GROSS TUMOR SIZE: TUMOR NOT GROSSLY SEEN. SIZE OF INVASIVE COMPONENT: 8.2 CM IN MAXIMUM DIMENSION. LYMPHATIC/VASCULAR INVASION: PRESENT. MULTIFOCAL TUMOR: ABSENT (NEARLY ENTIRE BIOPSY INVOLVED). IN-SITU CARCINOMA: PRESENT. TYPE OF IN-SITU CARCINOMA: LOBULAR AND FOCAL MICROPAPILLARY. NUCLEAR GRADE OF IN-SITU CARCINOMA: 1-2 OF 3. NECROSIS: PRESENT. DCIS EXTENDING OUTSIDE INVASIVE TUMOR MASS: ABSENT. SIZE OF IN-SITU CARCINOMA: NOT APPLICABLE (LESS THAN INVASIVE TUMOR SIZE). STATUS OF NON-NEOPLASTIC BREAST TISSUE: BIOPSY SITE, FIBROCYSTIC CHANGES (MICROCYST, SCLEROSING ADENOSIS, FLORID DUCTAL HYPERPLASIA OF THE USUAL TYPE) SKIN/NIPPLE: SCAR. NOT INVOLVED BY TUMOR. SIZE OF BIOPSY: 9.2 X 7.4 X 4.9 CM. MICROCALCIFICATIONS: PRESENT IN ASSOCIATION WITH BENIGN BREAST TISSUE. SURGICAL MARGIN STATUS: POSITIVE MULTIFOCALLY AT THE SUPERIOR, INFERIOR, ANTERIOR, POSTERIOR AND LATERAL MARGINS. ESTROGEN/PROGESTERONE RECEPTOR, CELL CYCLE, AND HER2/NEU ANALYSIS: PENDING. PARAFFIN BLOCK NUMBER: A38. RESULTS WILL BE ISSUED IN SEPARATE REPORT FROM THE IMAGE CYTOMETRY LAB B. "LEFT AXILLARY CONTENTS" (LYMPH NODE DISSECTION): METASTATIC ADENOCARCINOMA IN ELEVEN OF TWENTY ONE LYMPH NODES EXAMINED (10/21).
DETAIL TEST SPSTAGE PROCEDURE: Left breast needle localization excision and axillary lymph node dissection. PATHOLOGIC STAGE: ypT3 pN3a 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.