Breast Cancer Reporting

Breast Invasive Ca   AJCC 6th Edition; CAP 2005  
  2006-12-04 Cancer Case Summary
  Singh, U. Colorado  
  HER2 etc Helsinki
Incisional Biopsy, Lumpectomy, Mastectomy (See Separate format for Core Biopsy)  
Diagnosis Example: Right Breast Biopsy (Excision) - Invasive Ductal Carcinoma. See Cancer Case Summary
  Right Axillary Lymph Nodes - Metastatic Carcinoma in 5 / 12 nodes
# Report Header Dictation Options   Note
Surgical Pathology Cancer Case Summary  
1 Specimen Type Wire localization bx Lumpectomy  
    Re-excision Mastectomy (Total, Modified Radical, Radical)  
    Incisional Bx    
2 Lymph Node Sampling No LN sampling SLN with axillary dissection  
    Sentinel LN only Axillary Dissection  
3 Side Right / Left    
4 Tumour Site UOQ LIQ  
    LOQ Central  
    UIQ Not specified  
5 Specimen Size Greatest Dimension __ cm  
    Cannot be determined (comment)  
  *** For DCIS ONLY Cases, delete "Inv Tumour Size" to "Inv Tumour Necrosis"  ***
6 Invasive Tumour Size ___ x ___ x ___ cm or ___ cm diameter  If there is a discrepancy betw. gross & micro tumor size,  micro size of the invasive component takes precedence & is used for staging If invasive & in-situ in same tumour, state inv. size only.   If  => two inv. tumours, state each size.
    Invasive ductal ca Invasive lobular Inv. Lob. only if low gr nuclei; otherwise IDC w. Lobular Features
    Other Types Invasive ductal ca with an extensive intraductal component  
8 Distribution of Tumour Unifocal    
    Multifocal   2 or more foci in same quadrant
    Multicentric   2 or more foci in different quadrants of the breast OR foci located 5 cm apart.
9 Histologic Score Components     Grade all Inv. Ca except Medullary
  Tubule formation 1 1 Majority of tumour: >75% tubule forming
    2 2 Moderate: 10% to 75 %
    3 3 Minimal: <10%
  Nuclear pleomorphism 1 1 Small regular nuclei
    2 2 Moderate increase in size & variability
    3 3 Marked incr in size & variability, nucleoli
  Mitosis Count # /10 HPF    
  Field Diamter ___ mm   Olympus Mitosis Ct & Score
  Mitosis Score 1,2,3    Leitz, Nikon Mit Ct & Score
10 Combined Score Components 3 to 9   /9   Sum of above 3 component scores
11 Nottingham Grade I, II or III   /III   Score 3-5 /9  = Grade I / III
        Score 6-7 /9  = Grade II / III
        Score 8-9 /9  = Grade III / III
12 Venous (Large Vessel) Inv. Absent Indeterminate V0
    Present   V1
    Gross Venous inv.   V2
13 Lymphatic (Small Vessel) Inv. Absent Indeterminate L0
    Present   L1
14 Invasive Tumour Necrosis Present or Absent    
15 Resection Margins of  Invasive Carcinoma Negative w __ mm to closest margin (specify)  
    Positive at (specify margin)  
16 Extent of Margin Involvement for Invasive Carcinoma NA Unifocal Specify margin that is involved and extent
    Multifocal Extensive  
17 Nipple Involvement Not in specimen Paget's Disease  
    No involvement  DCIS  
18 Skin Involvement No involvement  Not in specimen  
    Present with skin ulceration  
    Present with Dermal lymphatic invasion  
19 Chest Wall Involvement Positive / Negative / Not Applicable / Not in specimen Chest wall (skeletal muscle)
  *** Resume DCIS Only Cases Here ***      
20 DCIS Not Present    
    Present, largest focus __ cm or __ % of specimen  
  DCIS Architectural Type Comedo, Solid, Papillary Micropapillary, Cribriform Only if DCIS present
  DCIS Nuclear Grade 1 Monotonous nuclei, 1.5 to 2.0 RBC diameters, with finely dispersed chromatin
      and only occasional nucleoli.  
    2 Neither nuclear grade 1 nor nuclear grade 3.
    3 Markedly pleomorphic nuclei, usually greater than 2.5 RBC diameters, with
      coarse chromatin and prominent or multiple nucleoli.
  Necrosis in DCIS None, Punctate (Non-zonal) or Comedo (Zonal)  
  EIC Status Positive or Negative   Positive = Mostly DCIS w. focal invasion -OR- DCIS >25% in inv. tumour and extends into surrounding breast
  DCIS Resection Margin Negative w __ mm to closest margin (specify)  
    Positive at (specify margin)  
  DCIS Extent of Margin Involvement NA Unifocal Specify margin that is involved and extent
    Multifocal Extensive  
21 Calcification Not present Present in DCIS  
    Present in benign breast Present in Invasive tumour  
    Present in both tumour and benign tissue  
22 Abnormalities in Remaining Breast Absent or Specify    
23 Hormone Receptors (IHC Method) Requested Block # Clip H+E slide to form for ER/PR pathologist Indicated: Inv Ca:ER, PR, HER2/neu; DCIS:ER, PR only
    Reporting ER PR HER2 Not on core biopsies unless requested
24 Sentinel LN by H+E Not in specimen   SN Protocol: H+E one level
    # positive / # SLN ( pos. by IHC or H+E)  
    Largest focus ___ cm diameter  Only if SLN Positive
    Extranodal extension Present / Absent  
25 Non-Sentinel Lymph Nodes Not in specimen # positive LN / Total LN Note extranodal extension if present
    Largest focus ___ cm diameter  Only if LN Positive
26 Correlation Intra-op Consult Agree or Disagree (specify)  Not applicable Explain differences if present.
27 Correlation Prior Bx or Cy Give Surgical / Cytology No.   Explain differences if present.
28 Internal Consultation Not applicable / Pathologist name  
29 Comments NA or specify    
30 pTNM AJCC 6th Ed     Note re y, (m), r
  Tumour pTX   Primary tumour cannot be assessed.
    pT0   No evidence of primary tumour
    pTis   DCIS, LCIS, Paget's disease
    pTis (DCIS)    
    pTis (LCIS)    
    pTis (Paget's)   Paget's wo tumour. Paget's w tumour pT is according to the size of the tumour.
    pT1 pT = invasive size only, not including DCIS size =<2 cm greatest dimension
    pT1mic   Microinvasion is inv. w. no focus >0.1 cm greatest dimension
    pT1a   >0.1 and =<0.5 cm
    pT1b   >0.5 and =<1.0 cm
    pT1c   >1.0 and =<2.0 cm
    pT2   >2.0 and =<5.0 cm
    pT3   >5.0 cm
    pT4   Tumour of any size with direct extension to chest wall or skin.
    pT4a   Extension to chest wall, not incl pectoralis
    pT4b   Edema (incl. peau d'orange) or ulceration breast skin or satellite skin nodules confined to the same breast.
    pT4c   Both (T4a and T4b).
    pT4d   Inflammatory carcinoma
  Lymph Nodes   Only SLN, wo AxLN, "pN__(sn)" ITC <= 0.2 mm,
        Micromet  >0.2 mm and =< 2 mm
        Met > 2 mm
    pNX LN cannot be assessed  
    pN0 No regional LN mets, no exam for isolated tumour cells (ITC). Note re ITC
    pNO(i-) No LN mets, negative ITC This is the usual LHC report for neg LN
    pN0(i+) No LN mets, pos ITC  
    pN0(mol-) No LN mets, neg RT-PCR  
    pNO(mol+) No LN mets, pos RT-PCR  
    pN1 Mets 1-3 LN (axil. or int. mammary) w positive SLN, but not clinically apparent. Note re Clinically Apparent
    pN1mi Micrometastasis >0.2 mm, none > 2.0 mm  
    pN1a Metastasis in 1 to 3 axillary LN At least one met > 2.0 mm
    pN1b Mets in int. mammary LN w microscopic disease in SLN, but not clinically apparent. Note re Clinically Apparent
    pN1c Mets in 1-3 axil. LN & int. mammary w microscopic disease in SLN, but not clinically apparent. If associated with more than 3 positive axillary LN, the internal mammary LN are classified as pN3b to reflect increased tumour burden.
    pN2 Mets in 4-9 axil. LN, or in clinically apparent int. mammary LN in the absence of axil. LN mets. Note re Clinically Apparent
    pN2a Mets in 4-9 axillary LN (at least 1 tumour deposit > 2.0 mm).  
    pN2b Mets in clinically apparent int mammary LN in the absence of axil LN mets  
    pN3 >= 10 axil LN mets, or infraclavicular LN, or in clinically apparent ipsilateral int mammary LN in the presence of >=1 axil LN OR >3 axil LN w clinically neg microscopic mets in int mammary LN or in ipsilateral supraclavicular LN
    pN3a >= 10 axil LN mets (at least 1 tumour deposit >2.0 mm), or mets to infraclavicular LN.  
    pN3b Mets in clinically apparent ipsilateral int mammary LN in presence of >=1 pos axil LN;  OR >3 axil LN and in int mammary LN w microscopic disease in SLN, but not clinically apparent.
    pN3c Mets in ipsilat supraclavicular LN  
  Metastases pMX Distant mets cannot be assessed.  
    pM0 No distant mets.  
    pM1 Distant mets  
  Histologic Grade G1 Same as Elston modified SBR grade
  Residual Tumour RX Residual tumour cannot be assessed
    R0 All margins are free of tumor  
    R1 Incomplete resection, microscopic tumour present at margin
    R2 Incomplete resection, gross tumour present at margin
  Venous /  Lymphatic Invasion   V, L - see note