Surgical Pathology Cancer Case Summary

BREAST:             Report

BREAST: Cytology/Biopsy

MACROSCOPIC (check all that apply)

SPECIMEN TYPE

___ Cytology

___ Biopsy

___ Percutaneous core biopsy (eg, Tru-Cut™)

___ Image-guided core biospy

___ Incisional biopsy

___ Other (eg, ABBI procedure)

TUMOR SITE

___ Right breast

___ Left breast

___ Unknown

SPECIMEN SIZE: ___ x ___ x ___ cm

TUMOR SIZE (largest dimension), if appropriate: ___ cm

MICROSCOPIC (check all that apply)

HISTOLOGIC TYPE

___ Cannot be determined

___ Noninvasive carcinoma (NOS)

___ Ductal carcinoma in situ

___ Lobular carcinoma in situ

___ Invasive carcinoma (NOS)

___ Invasive ductal

___ Invasive ductal carcinoma with an extensive intraductal component

___ Invasive lobular

___ Mucinous

___ Medullary

___ Papillary

___ Tubular

___ Adenoid cystic

___ Secretory (juvenile)

___ Apocrine

___ Cribriform

___ Paget’s disease of the nipple

___ With invasive carcinoma

___ Without invasive carcinoma

___ Carcinoma with metaplasia

___ Squamous type

___ Spindle cell type

___ Cartilaginous and osseous type

___ Mixed type

___ Inflammatory

___ Other(s) (specify: _____________________)

HISTOLOGIC GRADE

___ Cannot be determined

Tubule formation:

___ Majority of tumor >75% (score = 1)

___ Moderate 10% to 75% (score = 2)

___ Minimal <10% (score = 3)

Nuclear pleomorphism:

___ Small regular nuclei (score = 1)

___ Moderate increase in size, etc. (score = 2)

___ Marked variation in size, nucleoli, chromatin clumping, etc. (score = 3)

Mitotic count:

For a 25x objective with a field area of 0.274 mm2

___ <10 mitoses per 10 HPF (score = 1)

___ 10-20 mitoses per 10 HPF (score = 2)

___ >20 mitoses per 10 HPF (score = 3)

or

For a 40x objective with a field area of 0.152 mm²

___ 0-5 mitoses per 10 HPF (score = 1)

___ 6-10 mitoses per 10 HPF (score = 2)

___ >10 mitoses per 10 HPF (score = 3)

Total score:

___ Grade I: 3-5 points

___ Grade II: 6-7 points

___ Grade III: 8-9 points

ADDITIONAL PATHOLOGIC FINDINGS

___ None identified

___ Microcalcifications

___ Fibrocystic changes

___ Atypical hyperplasia

___ Other (specify: _____________________)

COMMENT

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