Last modified on 16 August 2010, at 16:28
DETAIL TEST SPCH ICD-9 CODE: 611.72 Right breast mass DETAIL TEST SPGD DRH A. "Left breast mass", in formalin. Received is an unoriented 6.4 x 4.3 x 3.4 cm irregular mass of dense white fibrous tissue and adipose. Inked blue and sectioned to demonstrate an ill defined pink to white lobulated mass approximately 1.7 cm in greatest dimension. The mass abuts the blue ink. The remainder of the specimen consists of dense white fibrous tissue and grossly unremarkable adipose. Representative A1-A10. Approximately 60% of the specimen is submitted. The mass is submitted entirely. The tissue is fixed between six and forty-eight hours. A quadrant is not specified. AB:cde DETAIL TEST SPCPT GLOBAL 88307, PQR3260F DETAIL TEST SPMI Microscopic examination performed by Dr. Smith. DETAIL TEST SPDX A. LEFT BREAST MASS, EXCISION: INVASIVE ADENOCARCINOMA OF THE BREAST. HISTOLOGIC TYPE: POORLY DIFFERENTIATED DUCTAL CARCINOMA. NOTTINGHAM COMBINED HISTOLOGIC GRADE: 3. TUBULE FORMATION SCORE: 3. NUCLEAR PLEOMORPHISM SCORE: 3. MITOTIC RATE SCORE: 3. TUMOR SIZE: 1.7 CM. LYMPHATIC/VASCULAR INVASION: PRESENT. MULTIFOCAL TUMOR: ABSENT. IN-SITU CARCINOMA: A SMALL AMOUNT OF DCIS IS PRESENT ADJACENT TO INVASIVE TUMOR REPRESENTING A VERY MINOR COMPONENT OF THE MASS. TYPE OF IN-SITU CARCINOMA: COMEDO, CLINGING, AND CRIBRIFORM. NUCLEAR GRADE OF IN-SITU CARCINOMA: 3. COMEDO NECROSIS: ABSENT. STATUS OF NON-NEOPLASTIC BREAST TISSUE: ATYPICAL DUCTAL HYPERPLASIA PRESENT. MICROCALCIFICATIONS: NONE. SURGICAL MARGIN STATUS: POSITIVE. INVASIVE CARCINOMA EXTENDS TO THE INKED MARGIN. THE SURGICAL MARGIN IS NEGATIVE FOR DCIS.
ESTROGEN/PROGESTERONE RECEPTOR AND HER2/NEU ANALYSIS: PENDING, ADDENDUM TO FOLLOW. AJCC CANCER STAGE: T1C, NX, MX.