HCLSIG/Terminology/PathRadCorrelation/ExamplePathReport4
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.
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