Medical Pathology Report Form

Basic Report Information

Patient Name

Specimen Number

Age

Gender

Male Female

Ref By

Received Date

Date Reported

Nature of Specimen

Report Status

Clinical Data

Gross Description

Microscopic Description

Diagnosis

<h3>Tumor summary:</h3>Specimen: Left breast, excision biopsy.Tumor (primary)<ul><li>Diagnosis (histologic): Invasive carcinoma of no special type (NST, invasive ductal carcinoma).</li><li>Histologic grade (Nottingham/Elston-Ellis): Grade 3 (high grade).</li><li>Largest tumor dimension: 2.5 cm (greatest dimension).</li><li>Pathologic T category: pT2 (tumor >2 cm and <5 cm).</li></ul>Margins (closest measured distances)<ul><li>Closest deep (posterior) margin: 0.6 cm — negative for tumor.</li><li>Closest lateral margin: 0.5 cm — negative for tumor.</li></ul>Lymphovascular / Perineural invasion<ul><li>Lymphovascular invasion (LVI): Present.</li><li>Perineural invasion (PNI): Not identified.</li></ul>Associated non-invasive / other features<ul><li>DCIS: Present (about 5%) — intermediate and high grade components.</li><li>Foci of necrosis noted.</li><li>Extent/relationship: Invasive tumor extend to involve the dermis of the overlying skin.</li><li>Tumor-infiltrating lymphocytes (TILs): Moderate.</li><li>Additional finding: Lobular cancerization present.</li><li>Lymph nodes: Not submitted, N status: pNx.</li></ul>

Image Width (px)

Image Height (px)

Image Position

Template

المسافة الفارغة من أعلى الصفحة عند عدم استخدام قالب Header Space (mm)

Generate PDF