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BreastFor Information Only

b.Biopsy site, needle track, if identified

c.Margin(s), as appropriate

d.Nipple

e. Additional breast tissue (quadrants not involved by tumor)

f. Other lesions

g.Lymph nodes (Note K)

h.Frozen section tissue fragment(s) (unless saved for special studies)

6.Special studies (specify) (Note B)

C.Microscopic Evaluation

1.Tumor

a. Histologic type(s) (Note C)

b. Histologic grade (Note D)

c. Mitotic figure count

d.DCIS, if present (Note E)

e.Microcalcifications (Note F)

f.Verification of tumor size (Notes J and M)

g.Extent of invasion (Note M)

h.Vascular invasion (Note G)

i.Involvement of other tissues (eg, skin, chest wall) (Note M)

2.Regional lymph nodes, if appropriate (Note K)

a.Total number examined (specify location, if indicated by surgeon)

b.Number involved by tumor (note extranodal extension of tumor, if present)

c.Size(s) of the largest nodal metastasis

3.Additional pathologic findings, if present (specify)

4.Distant metastasis (specify site[s]) (Note M)

5.Results/status of special studies (specify) (Note B)

a.Hormonal receptors

b.Other(s)

6.Comments, as appropriate, including correlation with intraprocedural consultation, results of other specimens, and clinical information

Explanatory Notes

A.Clinical Information

Elements of the history that are important for breast cancer include family history, previous therapeutic irradiation to the breast, history of collagen vascular disease, nipple discharge, previous biopsy or other treatment, and, especially, whether the patient is currently pregnant or nursing.1 In order to ensure that mammographic abnormalities have been sampled and examined microscopically, the pathologist must correlate the histologic features with the physical and mammographic findings, such as whether the lesion was palpable or detected only by imaging studies, whether suspicious microcalcifications were seen, or whether the tumor is solid or cystic.

B.Special Studies

Fresh tissue should not be used for special studies (eg, hormone receptor analysis by ligand binding assay) unless the neoplasm is of sufficient size such that histologic evaluation will not be compromised. When needed, hormone receptor analysis by immunohistochemistry and many other studies can be performed on routinely fixed, paraffin-embedded tissue. Besides a formal interpretation, each pathology report should specify the fixative used, if other than formalin; the antibody clone and vendor; and the results of control stains. Any deviation from the laboratory’s standard staining and

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