Surgical Pathology Cancer Case Summary

BREAST:             Report

BREAST: Complete excision less than total mastectomy (includes wire-guided localization excisions), total mastectomy, modified radical mastectomy, radical mastectomy

MACROSCOPIC (check all that apply)

SPECIMEN TYPE

___ Complete excision, less than total mastectomy

___ Without axillary contents

___ With axillary contents

___ Total mastectomy

___ Modified radical mastectomy

___ Radical mastectomy

SPECIMEN SIZE (for excisions less than total mastectomy): ___ x ___ x ___ cm

TUMOR SITE

___ Right breast

___ Upper outer quadrant

___ Lower outer quadrant

___ Upper inner quadrant

___ Lower inner quadrant

___ Central

___ Left breast

___ Upper outer quadrant

___ Lower outer quadrant

___ Upper inner quadrant

___ Lower inner quadrant

___ Central

TUMOR SIZE (largest dimension): ___ cm

MICROSCOPIC (check all that apply)

HISTOLOGIC TYPE

___ 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

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

EXTENT OF INVASION

___ TX: Cannot be assessed

___ T0: No evidence of primary tumor

___ Tis: Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ, or Paget’s disease of the nipple with no tumor

___ T1: Tumor < 2 cm in greatest dimension

___ T1mic: Microinvasion < 0.1 cm in greatest dimension

___ T1a: > 0.1 cm but < 0.5 cm in greatest dimension

___ T1b: > 0.5 cm but < 1 cm in greatest dimension

___ T1c: > 1 cm but < 2 cm in greatest dimension

___ T2: Tumor > 2 cm but < 5 cm in greatest dimension

___ T3: Tumor > 5 cm in greatest dimension

___ T4: Tumor of any size with direct extension to chest wall or skin

___ T4a: Extension to chest wall

___ T4b: Edema (including peau d’orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast

___ T4c Inflammatory carcinoma

MARGINS

___ Margins uninvolved by tumor

Distance of tumor from closest margin: ___ cm

___ Margin(s) involved by tumor

Specify which margin(s): ___________________

MICROCALCIFICATIONS

___ Absent

___ Present

VASCULAR INVASION

___ Absent

___ Present

___ Indeterminate

REGIONAL LYMPH NODES

___ NX: Cannot be assessed (previously removed or not removed for pathologic study)

___ N0: No regional lymph node metastasis

___ N1: Metastasis to movable ipsilateral axillary lymph node(s)

___ N1a: Only micrometastasis, none > 0.2 cm in greatest dimension

___ N1b: Metastasis to lymph node(s), any > 0.2 cm in greatest dimension

___ N1bi: Metastasis in 1 to 3 lymph nodes, any > 0.2 cm and all < 2 cm in greatest dimension

___ N1bii: Metastasis to 4 or more lymph nodes, any > 0.2 cm and all < 2 cm in greatest dimension

___ N1biii: Extension of tumor beyond the capsule of a lymph node, metastasis < 2 cm in greatest dimension

___ N1biv: Metastasis to a lymph node > 2 cm in greatest dimension

___ N2: Metastasis to ipsilateral axillary lymph node(s) fixed to one another or to other structures

___ N3: Metastasis to ipsilateral internal mammary lymph node(s)

DISTANT METASTASIS

___ MX: Cannot be assessed

___ M0: No distant metastasis

___ M1: Distant metastasis [includes metastasis to ipsilateral supraclavicular lymph node(s)]

ADDITIONAL PATHOLOGIC FINDINGS

___ None identified

___ Microcalcifications

___ Fibrocystic changes

___ Atypical hyperplasia

___ Other (specify: _____________________)

COMMENT

___________________________________________

___________________________________________

___________________________________________

___________________________________________