HCLSIG/Terminology/PathRadCorrelation/ExamplePathReport5
DETAIL TEST SPCH
Right breast mass.
DETAIL TEST SPCPT
Container A-G: 88307/FR
DETAIL TEST SPGD
A. "Sentinel node number one". Received fresh and placed in formalin is a 1.5
x 1.0 x 0.3 cm fragment of adipose tissue submitted entirely in block A1. A
cytokeratin stain has been prospectively requested on block A1.
B. "Sentinel node number two". Received fresh and placed in formalin is a 2.0
x 1.5 x 1.0 cm adipose tissue dissected for lymph nodes. One bisected lymph
node is submitted in block B1. A cytokeratin stain is prospectively requested
on block B1.
C. "Sentinel node number three". Received fresh and placed in formalin is a
2.5 x 1.0 x 0.2 cm fragment of adipose tissue submitted entirely in block C1.
A cytokeratin stain has been previously requested on block C1.
D. "Sentinel node number four". Received fresh and placed in formalin are
three fragments of fibroadipose tissue measuring 1.5 x 1.5 x 0.3 cm in
aggregate submitted entirely in block D1. A cytokeratin stain is prospectively
requested on block D1.
E. "Sentinel node number five". Received fresh and placed in formalin is a 2.0
x 1.0 x 0.3 cm fragment of fibroadipose tissue submitted entirely in block E1.
A cytokeratin stain has been prospectively requested on block E1.
F. "Right breast mass needle localization", received fresh and placed in
formalin. A 7.7 (A-P) x 1.6 (M-L) x 6.6 (S-I) cm breast biopsy is oriented
long suture lateral and short suture superior. The specimen is inked
superior-red, inferior-yellow, medial-blue, and lateral-black. Sectioning from
anterior to posterior demonstrates an approximately 2.6 x 0.7 x 0.7 cm white
mass located in the center of the specimen abutting the black ink, 0.8 cm from
the yellow margin, 0.5 cm from the blue and 2.3 cm from the red margin.
Radiograph reveals a clip in the middle of the mass. The breast tissue
adjacent to the mass is discolored by blue dye. Approximately half of the
specimen is submitted as follows (note that some of the slices have been
further sectioned due to thickness):
BLOCK SUMMARY:
F1- tangential anterior margin.
F2-F5- representative sections anterior to mass.
F6-F17- mass (clip in F12)
F19- representative section posterior to mass.
F20- tangential posterior margin.
G. "Right breast mass inferior margin", received fresh and placed in formalin.
A 4.5 x 3.0 x 1.0 mm fragment of adipose tissue is marked with suture at final
margin which inked blue, tangentially removed and submitted in blocks G1-G3.
H. "Right breast superior margin", received fresh and placed in formalin. A
3.5 x 3.0 x 1.2 cm fragment of adipose tissue is marked with suture at final
margin which is inked blue, tangentially removed and submitted in blocks
H1-H2.
I. "Right breast inferior margin", received fresh and placed in formalin. A
3.5 x 2.0 x 0.7 cm fragment of adipose tissue is marked with a suture on final
margin which is inked blue, tangentially removed, and submitted in block I1.
J. "Right breast lateral margin", received fresh and placed in formalin. A 4.0
x 2.0 x 1.5 cm fragment of adipose tissue is marked with suture on final
margin which is inked blue, removed tangentially and submitted in block J1.
Also in the container is a 2.5 x 2.0 x 0.3 cm fragment of freely floating
adipose tissue submitted entirely in block J2.
Dr. White/Dr. Green/slides to Dr. Brown
DETAIL TEST SPMI
Microscopic examination is performed.
DETAIL TEST SPDX
A. "SENTINEL NODE #1" (EXCISION):
NO CARCINOMA IDENTIFIED IN ONE LYMPH NODE (0/1).
IMMUNOHISTOCHEMICAL STAIN FOR CYTOKERATIN IS NEGATIVE.
B. "SENTINEL NODE #2" (EXCISION):
NO CARCINOMA IDENTIFIED IN ONE LYMPH NODE (0/1).
IMMUNOHISTOCHEMICAL STAIN FOR CYTOKERATIN IS NEGATIVE.
C. "SENTINEL NODE #3" (BIOPSY):
NO CARCINOMA IDENTIFIED IN ONE LYMPH NODE (0/1).
IMMUNOHISTOCHEMICAL STAIN FOR CYTOKERATIN IS NEGATIVE.
D. "SENTINEL NODE #4" (BIOPSY):
NO CARCINOMA IDENTIFIED IN TWO LYMPH NODES (0/2).
IMMUNOHISTOCHEMICAL STAIN FOR CYTOKERATIN IS NEGATIVE.
E. "SENTINEL NODE" (BIOPSY):
NO CARCINOMA IDENTIFIED IN ONE LYMPH NODE (0/1).
IMMUNOHISTOCHEMICAL STAIN FOR CYTOKERATIN IS NEGATIVE.
F. "RIGHT BREAST MASS, NEEDLE LOCALIZATION BIOPSY":
INVASIVE ADENOCARCINOMA OF THE BREAST.
HISTOLOGIC TYPE: DUCTAL.
NOTTINGHAM COMBINED HISTOLOGIC GRADE: 2 OF 3.
TUBULE FORMATION SCORE: 3
NUCLEAR PLEOMORPHISM SCORE: 2
MITOTIC RATE SCORE: 1
GROSS TUMOR SIZE: 2.6 X 0.7 X 0.7 CM.
SIZE OF INVASIVE COMPONENT: 2.4 CM.
LYMPHATIC/VASCULAR INVASION: ABSENT.
MULTIFOCAL TUMOR: ABSENT.
IN-SITU CARCINOMA: PRESENT.
TYPE OF IN-SITU CARCINOMA: SOLID.
NUCLEAR GRADE OF IN-SITU CARCINOMA: 2 OF 3.
NECROSIS: ABSENT.
DCIS EXTENDING OUTSIDE INVASIVE TUMOR MASS: PRESENT.
SIZE OF IN-SITU CARCINOMA: NOT APPLICABLE.
STATUS OF NON-NEOPLASTIC BREAST TISSUE: PRIOR BIOPSY SITE CHANGE,
PROLIFERATIVE FIBROCYSTIC CHANGES.
SIZE OF BIOPSY: 7.7 X 1.6 X 6.6 CM.
MICROCALCIFICATIONS: ABSENT.
SURGICAL MARGIN STATUS: CLOSE, INVASIVE CARCINOMA IS LESS THAN 0.3 MM FROM
THE LATERAL (BLACK INKED) MARGIN.
DCIS IS CLOSE (LESS THAN 0.2 CM) FROM THE LATERAL (BLACK INKED) MARGIN.
PLEASE REFER TO NEW LATERAL MARGIN BELOW (SPECIMEN J).
ESTROGEN/PROGESTERONE RECEPTOR, CELL CYCLE, AND HER2/NEU ANALYSIS:
PENDING.
PARAFFIN BLOCK NUMBER: F15.
RESULTS WILL BE ISSUED IN SEPARATE REPORT FROM THE IMAGE CYTOMETRY LAB
G. "RIGHT BREAST MASS, INFERIOR MARGIN":
NO CARCINOMA IDENTIFIED.
H. "RIGHT BREAST, SUPERIOR MARGIN":
NO CARCINOMA IDENTIFIED.
I. "RIGHT BREAST, INFERIOR MARGIN":
NO CARCINOMA IDENTIFIED.
J. "RIGHT BREAST, LATERAL MARGIN":
NO CARCINOMA IDENTIFIED.