From W3C Wiki
Jump to: navigation, search
         DETAIL TEST   SPCH                                                                                                       
                   Not provided.                                                                                                  
         DETAIL TEST   SPCPT                                                                                                      
                   Container A-B: 88305/FR                                                                                        
                   Container C-D: 88307/FR                                                                                        
                   Representative carcinoma in blocks C8-14.                                                                      
         DETAIL TEST   SPGD                                                                                                       
                   A. "Sentinel node number one (hot and blue)-level one", received fresh and                                     
                   placed in formalin is a 2.0 x 1.9 x 1.5 cm aggregate of brown-tan fibrofatty                                   
                   tissue which is bisected for lymph node candidates. Four lymph node candidates                                 
                   are found up to 0.5 cm in greatest dimension and are submitted entirely in                                     
                   block A1. A cytokeratin stain is prospectively requested.                                                      
                   B. "Sentinel node number two (hot not blue)-level one", received fresh and                                     
                   placed in formalin is a 1.7 x 1 x 0.6 cm aggregate of yellow-tan fibrofatty                                    
                   tissue which is dissected for lymph node candidates. One lymph node candidate                                  
                   is found (0.8 x 0.6 x 0.4 cm), and is submitted entirely in block B1. A                                        
                   cytokeratin stain is prospectively requested.                                                                  
                   C. "Right partial mastectomy", received fresh and placed in formalin is an                                     
                   oriented lumpectomy specimen (long suture-lateral, short suture-superior).                                     
                   Based on this orientation, the specimen dimensions are as follows: medial to                                   
                   lateral-4.5 cm,  superior to inferior-1.3 cm, anterior to posterior-1 cm. The                                  
                   specimen is inked as follows: anterior-blue, posterior-black, superior-red,                                    
                   inferior-yellow. The specimen is serially sectioned from medial to lateral to                                  
                   reveal an approximately 1.7 x 0.6 x 0.3 cm well defined white-tan firm lesion                                  
                   which is 0.9 cm from the medial margin, 1.2 cm from the lateral margin, 0.3 cm                                 
                   from the anterior margin, 0.4 cm from the posterior margin, 1.4 cm from the                                    
                   superior margin and 1.3 cm from the inferior margin. There is a cystic area                                    
                   (0.6 cm in length x 0.2 cm in diameter) which is consistent with a previous                                    
                   biopsy site. The remainder of the tissue is lobulated tan-yellow with focal                                    
                   areas of blue consistent with sentinel node mapping dye. No biopsy clip is                                     
                   grossly observed. The specimen is entirely submitted from medial to lateral in                                 
                   blocks C1-C17, with the lesion located in blocks C5-C13. Please see                                            
                   accompanying photograph with block diagram.                                                                    
                   D. "Additional margin-medial", received fresh and placed in formalin is a 4 x                                  
                   3 x 1.4 cm portion of unoriented tan-yellow fibroadipose breast tissue. One                                    
                   surface has an approximately 2.5 x 1.3 cm area of blue discoloration,                                          
                   consistent with lymph node mapping. This surface is inked blue, the opposite                                   
                   side is inked black, and the specimen is serially sectioned and submitted                                      
                   entirely in blocks D1-D6.                                                                                      
                           A. Jones/slides to Dr. Smith/                                            
         DETAIL TEST   SPMI                                                                                                       
                   Microscopic examination is performed.                                                                          
         DETAIL TEST   SPDX                                                                                                       
                   A. "SENTINEL NODE #1, HOT AND BLUE, LEVEL ONE" (BIOPSY):                                                       
                       POSITIVE FOR CARCINOMA, TWO OF FOUR LYMPH NODES (2/4).                                                     
                       AN IMMUNOHISTOCHEMICAL STAIN FOR CYTOKERATIN IS POSITIVE.                                                  
                   B. "SENTINEL NODE #2, HOT NOT BLUE, LEVEL ONE" (BIOPSY):                                                       
                       NEGATIVE FOR CARCINOMA, ONE LYMPH NODE (0/1).                                                              
                   C. "RIGHT PARTIAL MASTECTOMY" (EXCISIONAL BIOPSY):                                                             
                       INVASIVE ADENOCARCINOMA OF THE BREAST.                                                                     
                          HISTOLOGIC TYPE: DUCTAL WITH LOBULAR FEATURES.                                                          
                          NOTTINGHAM COMBINED HISTOLOGIC GRADE: 2 OF 3.                                                           
                             TUBULE FORMATION SCORE: 3                                                                            
                             NUCLEAR PLEOMORPHISM SCORE: 2                                                                        
                             MITOTIC RATE SCORE: 1                                                                                
                          GROSS TUMOR SIZE: 1.7 X 0.6 X 0.3 CM.                                                                   
                          SIZE OF INVASIVE COMPONENT: 1.7 X 0.6 X 0.4 CM.                                                         
                          LYMPHATIC/VASCULAR INVASION: ABSENT.                                                                    
                          MULTIFOCAL TUMOR: ABSENT.                                                                               
                       IN-SITU CARCINOMA: PRESENT.                                                                                
                          TYPE OF IN-SITU CARCINOMA: SEE COMMENT.                                                                 
                          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 CHANGES, SCLEROSING                                    
                                                               ADENOSIS, FIBROADENOMA.                                            
                       SIZE OF BIOPSY: 4.5 X 1.3 X 1 CM.                                                                          
                       MICROCALCIFICATIONS: ABSENT.                                                                               
                       SURGICAL MARGIN STATUS: NEGATIVE.                                                                          
                       ESTROGEN/PROGESTERONE RECEPTOR, CELL CYCLE, EGFR AND HER2/NEU ANALYSIS:                                    
                          PREVIOUSLY PERFORMED.                                                                                   
                   COMMENT: An addendum report will follow immunoperoxidase stains to help                                        
                   evaluate the histologic type of the in situ carcinoma.
                   D.  "ADDITIONAL MARGIN-MEDIAL":
                        BENIGN BREAST TISSUE, NEGATIVE FOR IN SITU OR INVASIVE CARCINOMA.                                         
                        MARGINS NEGATIVE FOR TUMOR.                                                                               
         DETAIL TEST   SPSTAGE                                                                                                    
                   PROCEDURE: Excisional biopsy                                                                                   
                   PATHOLOGIC STAGE: pT1c  pN0(i+)  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.