Template:Reporting of invasive breast cancer

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Report

Breast excision

  • Tumor size, if not already given from gross report.[1] Give 3 dimensions or greatest dimension.[1]
  • Histopathologic subtype if apparent, but "invasive carcinoma" is acceptable.
  • Stage[1]
  • Grade, preferably by overall BRE grade. Optionally, give scores for the components thereof.[1]
  • Extent of any angiolymphatic invasion.[1]
  • Margins of resection,[1] either as minimal distance to margin, or as radical vs. not radical excision.
  • Results of any immunohistochemistry and other tests[1]
  • HER2 as a score or status.
  • Ki-67, preferably as labeling index

Example:

Breast excision with 70 x 55 x 18 mm ductal invasive breast cancer. Nottingham grade II. Estrogen receptor positive, progesterone receptor negative, HER2 receptor score 0, Ki-67 index 17%, T1b. Radically removed.

Needle or core biopsy

  • Histopathologic subtype if apparent, but "invasive carcinoma" is acceptable.
  • Results of any immunohistochemistry and other tests, as per excision[1]
  • Presence of absence of angiolymphatic invasion[1]
  • Optionally: Provisional grading. Grading can alternatively be deferred to excision.[1]
  • State if studies are deferred for a later excision sample[1]
Synoptic report example
TUMOR TYPE:  Invasive ductal carcinoma with micropapillary pattern
TUMOR SIZE:  Greatest microscopic measurement of invasive carcinoma in positive core(s)):  0.7 cm
IN-SITU COMPONENT: No
MICROSCOPIC GRADING (NOTTINGHAM MODIFICATION OF BLOOM-RICHARDSON SYSTEM):
  • Only applies to infiltrating ductal and lobular carcinoma:  
TUBULE FORMATION:
Little or none (score =3)
NUCLEAR PLEOMORPHISM:
Marked variation in size, nucleoli, chromatin clumping, etc. (score =3)
MITOTIC COUNT :
Less than 6 mitoses per 10 HPF (score =1)
COMPOSITE SCORE:   7 points  (APPLIES TO INFILTRATING DUCTAL AND LOBULAR CARCINOMA ONLY
HISTOLOGIC GRADE:
Grade II: 6-7  points
NUCLEAR GRADE:      Grade 3
MICROCALCIFICATIONS: Absent
LYMPHOCYTIC HOST RESPONSE:    Absent
NECROSIS:  Absent
BLOOD VESSEL INVASION:  Absent
LYMPHATIC PERMEATION:  Indeterminate
SKIN INVOLVEMENT:  Not Applicable
Results of immunohistochemical stains for prognostic markers (as per original report):
Estrogen Receptor (ER) Status:  Positive (greater than 10% of cells demonstrate nuclear positivity)
Percentage of Cells with Nuclear Positivity:  91-100%
Average Intensity of Staining:  Strong
Progesterone Receptor (PgR) Status:  Positive
Percentage of Cells with Nuclear Positivity:  51-60%
Average Intensity of Staining:  Strong, moderate and weak
HER-2 by IHC:  2+ / Equivocal
REFLEX HER-2 FISH TEST:  Nonamplificed (ratio 1.5;  3.5 Her-2 signals/cell)
Ki-67:
Percentage of Cells with Nuclear Positivity: 43%
Primary Antibody:  MIB1
Cold Ischemia and Fixation Times:  3 minutes
Fixation Time (hours):  14 hours and 33 minutes
Fixative:  formalin

Notes


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