HCLSIG/Terminology/PathRadCorrelation/ExamplePathReport3
DETAIL TEST SPCH
Malignant neoplasm left breast. Core biopsies showed invasive ductal
adenocarcinoma. Patient with history of atypical hyperplasia
excised.
DETAIL TEST SPCPT
Container A-B:88307/FR
Container C-D:88305/FR
Carcinoma in blocks D10, D12-13.
DETAIL TEST SPGD
A. "Sentinel node #1, hot, not blue", received fresh and placed in formalin. A
1.5 x 0.7 x 0.5 cm lymph node is bisected and submitted entirely in A1. A
cytokeratin stain has been prospectively requested on A1.
B. "Sentinel node #2, hot, not blue", received fresh and placed in formalin. A
2.5 x 2.0 x 0.6 cm lymph node is bisected and submitted entirely in B1-2. A
cytokeratin immunostain have been prospectively requested on B1-2.
C. "Re-excision of medial margin", received fresh and placed in formalin. A
7.0 x 5.0 x 1.0 cm fragment of adipose tissue is oriented with a stitch on the
final margin, which is inked blue and the opposite inked black. No masses are
identified. Representative sections are submitted in Blocks C1-5.
D. "left partial mastectomy", received fresh and placed in formalin. An 9.0
(ML) x 8.5 (SI) x 3.0 (AP) cm excisional breast biopsy is oriented short
suture-superior, long suture-lateral, and white suture-anterior. The specimen
is inked anterior-blue, posterior-black, superior-red, and inferior-yellow.
Sectioning from lateral to medial demonstrates an approximately 1.3 x 0.5 x
0.3 cm blue dyed, firm mass in the central lateral portion of the biopsy,
located 0.8 cm from the black margin, 2.0 cm from the blue margin, 3.0 cm from
the red margin, and 4.0 cm from the yellow margin. Radiograph demonstrate a
small clip immediately medial to this mass is a larger clip near the medial
margin. Approximately half of the specimen is submitted as follows:
BLOCK SUMMARY:
D1- tangential lateral margin
D2-10- representative sections lateral to mass
D11-14- mass
D15- small clip
D16-26- representative sections medial to mass (large clip in 25)
D27- tangential medial margin
Dr. White/Dr. Green/slides to Dr. Brown
DETAIL TEST SPMI
Microscopic examination is performed.
DETAIL TEST SPDX
A. "SENTINEL NODE # 1 HOT NOT BLUE" (LYMPH NODE DISSECTION):
NO EVIDENCE OF MALIGNANCY IN ONE LYMPH NODE EXAMINED (0/1).
CYTOKERATIN IMMUNOHISTOCHEMICAL STAIN IS NEGATIVE.
B. "SENTINEL NODE # 2 HOT NOT BLUE" (LYMPH NODE DISSECTION):
NO H&E EVIDENCE OF MALIGNANCY IN ONE LYMPH NODE EXAMINED (0/1).
CYTOKERATIN IMMUNOHISTOCHEMICAL STAIN FOR BLOCK B2 IS NEGATIVE.
AN ADDENDUM WILL BE ISSUED FOR CYTOKERATIN IMMUNOHISTOCHEMICAL STAIN ON
BLOCK B1 FOLLOWING REPROCESSING.
C. "REEXCISION OF MEDIAL MARGIN":
BENIGN BREAST TISSUE.
NO EVIDENCE OF MALIGNANCY.
D. "LEFT PARTIAL MASTECTOMY":
INVASIVE ADENOCARCINOMA OF THE BREAST.
HISTOLOGIC TYPE: DUCTAL.
NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
TUBULE FORMATION SCORE: 1
NUCLEAR PLEOMORPHISM SCORE: 2
MITOTIC RATE SCORE: 1
GROSS TUMOR SIZE: 1.3 X 0.5 X 0.3 CM.
SIZE OF INVASIVE COMPONENT: 1.1 CM IN MAXIMUM DIMENSION.
LYMPHATIC/VASCULAR INVASION: ABSENT.
MULTIFOCAL TUMOR: ABSENT.
IN-SITU CARCINOMA: PRESENT.
TYPE OF IN-SITU CARCINOMA: CRIBRIFORM.
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 AND FIBROCYSTIC
CHANGES.
SIZE OF BIOPSY: 9.0 X 8.5 X 3.0 CM.
MICROCALCIFICATIONS: PRESENT IN ASSOCIATION WITH CARCINOMA AND BENIGN
BREAST TISSUE.
SURGICAL MARGIN STATUS: NEGATIVE.
ESTROGEN/PROGESTERONE RECEPTOR, CELL CYCLE, AND HER2/NEU ANALYSIS:
PENDING.
PARAFFIN BLOCK NUMBER D11.
RESULTS WILL BE ISSUED IN A SEPARATE REPORT FROM THE IMAGE CYTOMETRY
LAB.
DETAIL TEST SPSTAGE
PROCEDURE: Left partial mastectomy and lymph node dissection.
PATHOLOGIC STAGE (AJCC 6th Edition): pT1c pN0 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.