Medical Pathology Report Form

Basic Report Information

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Clinical Data

Gross Description

Microscopic Description

Diagnosis

Tumor summary:Specimen: Excision biopsy.Histologic type: Invasive breast carcinoma of no special type (NST).Invasive tumor size: Greatest dimension 35 mm (3.5 cm); additional dimensions 27 × 15 mm (2.7 × 1.5 cm).Histologic grade (Nottingham histologic score): Grade 2.Tumor-infiltrating lymphocytes (TILs): High.Lymphovascular invasion: Present.Perineural invasion: Not identified (absent).Ductal carcinoma in situ (DCIS): Present.<ul><li>Estimated extent: Minor component.</li></ul>Nuclear grade: Intermediate<ul><li>Necrosis: Present (comedo necrosis).</li></ul>Margin status: Positive.Regional lymph nodes: Not submitted / cannot be assessed (pNx).Pathologic stage classification (AJCC 8th edition): pT2 pNx.<ul><li>Primary tumor (pT): pT2 (tumor >20 mm but ≤50 mm in greatest dimension).</li><li>Regional lymph nodes (pN): pNx (cannot be assessed).</li><li>Distant metastasis (pM): pMx.</li></ul>

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