Wherever Medical Center
Department of Pathology and Laboratory
Surgical Pathology Report
Patient: Mary Jones
Patient ID: 123-45-67
Alternate #:
DOB/Age/Sex: 01/01/50
Location: Surgicenter
Physicians: Dr IMA Breast Surgeon
Specimen: S99-9999
Encounter #:
Taken: 9/9/99
Received: 9/9/99
Signed out: 9/10/99
Specimen:
A. Right Breast Wide Excision (Biopsy)
B. Axillary dissection
Clinical History
49 year old female who was found to have a mass (or calcifications) on physical exam (or mammography). Stereotactic core biopsy reveale malignancy.
Clinical Diagnosis
Right breast cancer Stage I
Gross Description
Specimen is received fresh in two containers each labeled with the patient's name and hospital number.
The first container is further labeled "right breast wide excision" and consists of a piece of fibroadipose tissue with a small skin ellipse extending off to the medial side of the specimen. There is a short suture indicated to be superior and a long suture indicated to be lateral. A diagram has been submitted with the specimen to show the size and indicate the dimension. The whole specimen measures 3 x 5 cm and the skin ellipse measures 3 by 0.4 cm. The specimen is white, rubbery and irregularly shaped. There are areas of fibrosis towards the inferomedial and deep areas of the specimen. In the center of the specimen is a firm area measuring 1x2 cm. The specimen is inked and serially sectioned and submitted in its entirety in cassettes labelled A1 – A10.
Part two: Axillary tissue received fresh is a specimen of fibrofatty tissues measuring 4 x 3 cm in aggregate. Contained within the tissue are 12 lymph nodes the largest measuring 1.5 cm. Each node is bisected and placed into a cassette labelled B1-B12.
Microscopic Description
Slides A3- A4 consist of a portion of breast tissue in which is located an infiltrating ductal carcinoma of the breast. The malignancy is characterized by infiltrating nests of malignant cells in which there is only, focal tubule or glandular formation. The cells demonstrate a moderate degree of nuclear pleomorphism, with some of the cells having central nucleoli. However, the mitotic rate is less than 1 mitosis per 10 high power fields. Overall the carcinoma is grade II. Adjacent to the carcinoma are areas of ductal carcinoma in situ. Histologically the tumor is 2mm from the inked margin. No lymphatic invasion is appreciated.
Part two demonstrates two lymph nodes positive for carcinoma. There is no evidence of extranodal extension.
Diagnosis
- Infiltrating ductal carcinoma of the breast, Grade II
- Foci of ductal carcinoma in situ
- Tumor is 2 mm from the inked margins
- Fibrocystic disease of the breast
- Metastatic cancer in 2/12 lymph nodes.
Markers
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