HCLSIG/Terminology/PathRadCorrelation/ExamplePathReport1
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.
METASTATIC TUMOR DEPOSITS ARE LESS THAN 0.2 MM.
B. "SENTINEL NODE #2, HOT NOT BLUE, LEVEL ONE" (BIOPSY):
NEGATIVE FOR CARCINOMA, ONE LYMPH NODE (0/1).
AN IMMUNOHISTOCHEMICAL STAIN FOR CYTOKERATIN IS NEGATIVE.
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.