HCLSIG/Terminology/PathRadCorrelation/ExamplePathReport6

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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                                   
                                                                    PRESENT.                                                      
                           MICROCALCIFICATIONS:  NONE.                                                                            
                           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,                                        
                                                                                  ADDENDUM TO                                     
                                                                                  FOLLOW.                                         
                           AJCC CANCER STAGE:  T1C, NX, MX.