Download breast_work_aid_synoptic12

INVASIVE BREAST CANCER
WORK AID
Patient Name:
Hospital #:
Case/Accession #:
Diagnosis:
Specimen Laterality:
Right
Left
Not specified
Margins:
Margins cannot be assessed
Procedure:
Excision w/o wire-guided loc
Margins uninvolved by invasive carcinoma
Total mastectomy
Distance from closest margin: ______ mm *Specify margin_______________
Excision w/ wire-guided loc.
Other: _____________________
Margins involved by invasive carcinoma (*Specify margins and extent)
Lymph Node Sampling: (required only when lymph nodes are
*Superior ________
*Medial ________
*Anterior ________
present)
*Inferior ________
*Lateral ________
*Posterior ________
Margins uninvolved by DCIS
No lymph nodes
Axillary dissection
Sentinel lymph node(s)
Lymph node(s) present w/in breast
Other: ____________________________________________________
Invasive
Carcinoma Size: ________ mm
Cannot be determined
carcinoma is present)
Indeterminate
Multiple* # of foci _________
Skin invasion w/o ulceration
Skin ulceration
*Medial ________
*Anterior ________
*Inferior
*Lateral ________
*Posterior ________
_______
_____ # SLNs Examined
______ # LNs w/ Micromets
_____ # Total LNs examined
______ # LNs w/ ITCs
______ # LNs w/out tumor cells
_____ # LNs w/ Macromets
Chest wall beyond pectoralis invasion
m
r
y
pT ______
pM (if present) ______
completion)
In Situ Component:
Estrogen (ER) Receptor:
None Present
Not performed
Pending
Percentage of cells with nuclear immunoreactivity: ________________ %
DCIS
Ductal
Lobular
Only microinvasion present
Intensity of staining:
Positive
Mixed ductal and lobular
Negative
Absent
Other (specify): ____________________________
Score 1
Positive
Score 2
Score 3
Only microinvasion present
No residual invasive carcinoma after neoadjuvant therapy
Score cannot be determined
1 (>75% tubules)
2 (10 to 75% tubules)
3 (<10 tubules)
Only microinvasion present (not graded)
1
Pending
Absent
Weak
Medium
Strong
Other: _____________________________
Not performed
Pending
Negative (Score 0)
Negative (Score 1+)
Equivocal (Score 2+)
Positive (Score 3+)
Other: ___________
Unknown
Not Amplified
Not performed
Pending
Equivocal
Amplified
*Average number of chromosome 17 per cell: ____________
Unknown
2
Not performed
*Ratio: ____________________________________________
Mitotic Rate:
3
Strong
*Average number of HER2 gene copies per cell: ___________
No residual invasive carcinoma after neoadjuvant therapy
Score cannot be determined
Nuclear Pleomorphism:
Negative
Her-2/Neu IHC:
Her-2/Neu FISH:
Glandular/Tubular Differentiation:
Medium
Percentage of cells with nuclear immunoreactivity: ________________ %
Intensity of staining:
Histologic Grade (SBR/Nottingham):
Weak
Other: _____________________________
Progesterone (PgR) Receptor:
2
pN ______
Ancillary Studies: (required only if available at time of report
Nipple Paget disease
1
______Size of largest metastatic deposit (if
present)
Pathologic Staging: (Descriptors: m-multiple, r-recurrent, y-post tx)
Skin Satellite nodules
Histologic
Type:
*Superior _______
*size of largest focus: _____________
Extent of Tumor: (required only if structures are present and involved)
Pectoralis muscle invasion
Margins involved by DCIS (*Specify margins and extent)
Lymph nodes (if present):
Tumor Focality: (required only if more than 1 focus of invasive
Single
Distance from closest margin: ______ mm *Specify margin_______________
3
Other: _______________________________________
Comments:
Only microinvasion present
No residual cancer after neo tx
Score cannot be determined
If the patient has received neo-adjuvant therapy, or if only microinvasion is present, refer to the Invasive Breast Carcinoma protocol.
* Data elements with asterisks are not required.
Breast Work Aid 3.1.0.0
Synoptic Report Example
BREAST CARCINOMA
Specimen laterality:
Specimen:
Procedure:
Lymph node sampling:
Invasive carcinoma size:
Tumor focality:
Extent of tumor
Skin
Chest wall
In situ component:
Histologic type:
Histologic grade:
Nuclear score:
Tubule score:
Mitosis score:
Margins
Invasive carcinoma
Right
Partial breast
Excision with wire guided localization
Sentinel lymph node(s), Axillary dissection
1.5 mm
Single
No skin present
No skeletal muscle present
DCIS present, EIC positive
Ductal
2 (6 -7 points)
2
2
2
Margins uninvolved by invasive carcinoma
Distance from closest margin: 4 mm
Margin(s) positive for DCIS
DCIS
Lymph nodes
# of Sentinel LNs
4
# of Total LNs
9
# of LNs with macrometastases
3
# of LNs with micrometastases
1
# of LNs with ITCs
1
Size of largest metastasis
8 mm
Pathologic TNM classification:
pT1c pN2a
Estrogen and Progesterone Receptors
ER
Percentage of cells with nuclear immunoreactivity:
Intensity of staining:
Interpretation:
PgR
Percentage of cells with nuclear immunoreactivity:
Intensity of staining:
Interpretation:
HER2/neu Immunohistochemistry Result: Negative (score 0)
HER2/neu FISH Result: Not amplified
30%
Medium
Positive
20%
Medium
Positive
Pathologic Staging [AJCC 7th edition TNM Staging System] Key:
Primary Tumor (Invasive Carcinoma) (pT)
pTX: Primary tumor cannot be assessed pT0: No evidence of primary tumor pTis (DCIS): Ductal carcinoma in situ pTis (LCIS): Lobular carcinoma in
situ pTis (Paget): Paget disease of the nipple not associated with invasive carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in the underlying
breast parenchyma pT1: Tumor ≤20 mm in greatest dimension pT1mi: Tumor ≤1 mm in greatest dimension (microinvasion) pT1a: Tumor >1 mm but
≤5 mm in greatest dimension pT1b: Tumor >5 mm but ≤10 mm in greatest dimension pT1c: Tumor >10 mm but ≤20 mm in greatest dimension pT2:
Tumor >20 mm but ≤50 mm in greatest dimension pT3: Tumor >50 mm in greatest dimension pT4: Tumor of any size with direct extension to the chest
wall and/or to the skin (ulceration or skin nodules). Note: Invasion of the dermis alone does not qualify as pT4. pT4a: Extension to chest wall, not
including only pectoralis muscle adherence/invasion pT4b: Ulceration and/or ipsilateral satellite nodules and/or edema (including peau d’orange) of the
skin which do not meet the criteria for inflammatory carcinoma pT4c: Both T4a and T4b pT4d: Inflammatory carcinoma
Regional Lymph Nodes (pN)
pNX: Regional lymph nodes cannot be assessed (eg, previously removed, or not removed for pathologic study) pN0: No regional lymph node
metastasis identified histologically pN0 (i-): No regional lymph node metastases histologically, negative IHC pN0 (i+): Malignant cells in regional lymph
node(s) no greater than 0.2 mm and no more than 200 cells (detected by H&E or IHC including ITC) pN0 (mol-): No regional lymph node metastases
histologically, negative molecular findings (reverse transcriptase polymerase chain reaction [RT-PCR]) pN0 (mol+): Positive molecular findings (RTPCR), but no regional lymph node metastases detected by histology or IHC pN1mi: Micrometastases (greater than 0.2 mm and/or more than 200 cells,
but none greater than 2.0 mm). pN1a: Metastases in 1 to 3 axillary lymph nodes, at least 1 metastasis greater than 2.0 mm pN2a: Metastases in 4 to 9
axillary lymph nodes (at least 1 tumor deposit greater than 2.0 mm) pN3a: Metastases in 10 or more axillary lymph nodes (at least 1 tumor deposit
greater than 2.0 mm)
Distant Metastasis (M)
cM0(i+): No clinical or radiographic evidence of distant metastasis, but deposits of molecularly or microscopically detected tumor cells in circulating
blood, bone marrow, or other nonregional nodal tissue that are ≤0.2 mm in a patient without symptoms or signs of metastasis pM1: Distant detectable
metastasis as determined by classic clinical and radiographic means and/or histologically proven >0.2 mm
Breast Work Aid 3.1.0.0