Breast Core Biopsy 



Breast Ca Core Biopsy   AJCC 6th Edition; CAP 2005  
    Cancer Case Summary
  Singh, U. Colorado  
  HER2 etc Helsinki
# Report Header Dictation Options   Note
Surgical Pathology Cancer Case Summary  
1 Specimen Type Right / Left Core Bx    
2 Biopsy Site UOQ etc or o'clock    
3 Mammographic Calcifications Present / Absent    
4 Extent of Tumour in Biopsy # cores involved or % of specimen  
    Invasive ductal ca Invasive lobular Inv. Lob. only if low gr nuclei; otherwise IDC w. Lobular Features
    Other Types    
6 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
7 Combined Score Components 3 to 9   /9   Sum of above 3 component scores
8 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
9 Invasive Tumour Necrosis Present or Absent    
10 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)
11 Calcification Not present Present in DCIS
    Present in benign breast Present in Invasive tumour  
    Present in both tumour and benign tissue  
12 Abnormalities in Remaining Breast Absent or Specify    
13 Hormone Receptors (IHC Method) Not indicated for core bx unless requested by surgeon Reporting of ER PR HER2
    Requested Block # Clip H+E slide to form for ER/PR pathologist Indicated: ER, PR, HER2/neu for inv. ca
        ER, PR for DCIS
14 Correlation with Prior Biopsy or Cytology Give Surgical / Cytology No.   Explain differences if present.
15 Internal Consultation Not applicable / Pathologist name  
16 Comments NA or specify