Template:Reporting of invasive breast cancer

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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


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]

For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.

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 the 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 of non-neoplastic breast glands.
Microcalcifications: Present in non-neoplastic tissue
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)
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


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