HCLSIG/Terminology/PathRadCorrelation/ExamplePathReport4

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         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.