Breast Histopathology Request Form

Patient information

Name:  ______________________________________________   Gender: ______ Age: ______MRN:_____________

Address:_______________________________________Family Hx of Cancer: __________________________________

Clinical Information(relevant Hx, physical, lab and Imaging findings): ___________________________________

______________________________________________________________________________________

Pre-Op Pathology Result (diagnosis and number)

• Cytology(FNAC):______________________________________________
• Histopathology(needle-core, incisional or excisional):______________________________________________

Specimen Information

o   Laterality(Rt or Lt or Bilateral): _________________

o   Position(by quadrant or O’clock): _______________

o   Tumor size (by P/E and/or Imaging): _____________

o   Procedure: Incision/Excision (WLE, Lumpectomy)/Modified Mastectomy/Radical Mastectomy/ Partial Mastectomy/completion Mastectomy

o   Margin Marking done?(Yes or No): __________

o   Marking by (sutures, clips etc): __________________________

o   Axillary Dissection done? (Yes or No): ________

Presumptive Clinical Diagnosis:_____________________________________________________________________

Preoperative Clinical Stage: ___________ Neoadjuvant Treatment? (Yes or No):______________

New Primary Cancer or Recurrence?:________________

Receptor (ER, PR, HER2) study required?(Yes or No):________________

Physician’s Name and Signature:_____________________________________ Cell phone No: __________________

Date:___________________

Note:

• Fill request form properly to facilitate histologic interpretation
• Put tissue in ample amount (at least twice the volume of tissue) 10 % buffered formalin
• Do not transect tissue as this will interfere with critical components of interpretation like margin assessment
• If you need assistance, feel free to call the pathology laboratory

Grossing Template for Primary Mastectomy Specimen _ IBC

Right/Left Modified Mastectomyspecimen is receivedin formalin in a container labeled with the patient’s name, age and MRN (___________). Specimen measures____ × ____ × ___cm without/with axillary tail of ____ × ____ × ___cm and weighs ____grams. Ellipse of skin and nipple is ____ × ____ cm. The skin is grossly unremarkable/or is remarkable for ____________________. The nipple and areola complex are grossly unremarkable/or is remarkable for _______________.The breast is serially sectioned sequentiallyinto____ slices with the nipple located in slice number ____.The cut surface reveals one/multiple (Specify:_____) circumscribed/irregular tan white  tumor ____________________________________

on slice numbers____, ____, and ____ in the ________ quadrant (largest) measuring ____× ____ × ____cm. The lesion is ____cm from the superior margin, _____cm from the inferior margin,_____cm from the medial margin _____cm from the lateral margin, ____cm from the deep margin, and____cm from the skin. The remainder of the parenchyma is fibro-fatty that is unremarkable/remarkable for __________________________. The total number of non-sentinel axillary LNs harvested is_______with size ranging from ___ × ___ cm to ___ × ___cm.Matted LNs are present/absent. Skeletal muscleis/is not present. Other smaller tumor (in multifocal lesions) or relevant gross pathological findings include________________________________________________________

Sample Block Key

A-D: 3-4 representative areas of the tumor with rim of peritumoral tissue

E-F: Margins (include all margins less than 10mm from tumor)

G-I: Intervening tissues in multifocal lesions

J: Non-tumor lesion (if recognizable)

K-N: Non-lesional tissue from each quadrant

O-P: Nipple and abnormal skin, if present

Q+: Lymph nodes

SP Number: …………………..Histopathological Reporting of Invasive Breast Cancer in Surgical Resections

Patient Name: …………………………..………………………..…….… Age:…….… Sex: …….…. MRN:………………….. Sending Institutions: ……………………………………Date of Surgery: ………………… Date of Reporting: ………………

Laterality: Right □               Left □

Specimen type (Procedure): Incisional Biopsy  □     Excision Biopsy  □      Modified Mastectomy □    Radical Mastectomy □  Partial Mastectomy   □              Completion Mastectomy □

Largest invasive tumour Size (mm): ............

Focality:  Unifocal □    Multifocal □       Cannot be assessed □

Histologic Type:   Pure □  (select one box below)  Mixed □ (select all components present below)

Ductal/NST □   Tubular/cribriform □     Lobular □   Mucinous □   Medullary-like □    Micropapillary □

Othertype/component: .................................................................................................................................

Histological grade           1 □         2 □          3 □          Cannot be assessed □.......................................................

Lymphovascular invasion   Present □      Not identified □  Uncertain □Cannot be assessed □

Lymph node Status :

Axillary nodes:  Total present: ..........      Total positive: ...........

For single node positive:  Macrometastasis □      Micrometastasis □           ITCs □

Other nodes:     Site: .............................Total present:  ..........       Total positive:. ..........

For single node positive:  Macrometastasis □      Micrometastasis □                           ITCs □

In situ component(s)

DCIS:     Present □            Not identified □                                Cannot be assessed □

DCIS grade:         High □   Intermediate  □                Low □    Cannot be assessed □

Tumor extension (skin, nipple and/or skeletal muscle): …………………………………….……………………………………..

TNM stage (AJCC 8^th Edition)

T stage:  pTis  □    pT1mi □    pT1a □    pT1b □    pT1c □    pT2 □    pT3 □    pT4a □    pT4b □

pT4c □     pT4d  □     Cannot be assessed □

N stage:  pN0 □    pN1mi □    pN1a □    pN1b □    pN1c □    pN2a □    pN2b □    pN3a □

pN3c □   Cannot be assessed □

M stage: pM0    pM1 □ Cannot be assessed □

Surgical Margin Status   Positive □                            Negative □

Which margin is positive?   Superior □     Inferior □             Medial □              Lateral .□

Deep□  Superficial □                       Nipple margin□

Other pathological findings: ………………………………………………..……………………………………………………………………

 

Summary Diagnosis

Laterality/Procedure: Grade, Histologic Type, TNM Stage, Margin Status

 

COMMENT

When result of a receptor status study is available, a second report including the result as an addendum will be issued.

Sample Final Report

SP Number: 1234/20

Histopathological Report

Patient Name: De-identified De-identified                         Age:58  Sex: F    MRN:123456                      Sending Institutions: Ayder Comprehensive Specialized Hospital

Date of Surgery: 13/08/20                            Date of Reporting: 25/08/20

Laterality: Right

Specimen/procedure type: Modified Mastectomywith Axillary Dissection

Largest invasive tumour Size (mm): 65(greatest dimension)

Focality:Unifocal

Histologic Type:Pure, Invasive Carcinoma, NST

Histological grade: 3 (poorly differentiated)

• Tubule formation=2, Nuclear grade=3, and Mitoses=3

Lymphovascular invasion:Present

Lymph node Status :

Axillary nodes:  Total present: 12      Total positive: 4

Type of LN metastasis:  Macrometastasis

Other nodes: Not received

DCIS:Present

DCIS grade:High, solid with necrosis

Tumor extension (skin, nipple and/or skeletal muscle): Absent

TNM stage (AJCC 8^th Edition)

T stage:  pT3

N stage:  pN2a

M stage: Cannot be assessed

Surgical Margin Status:  Positive, DeepMargin

Other pathological findings: Fibrocystic change

 

Summary Diagnosis

Breast, Right Modified Mastectomy: Poorly Differentiated Invasive Carcinoma (NST), pT₃N_2aM_x(Positive deep margin)

 

 

COMMENT

When result of a receptor status study is available, a second report including the result as an addendum will be issued.