Surgical Pathology Cancer Case Summary (Checklist)

Specimen

____ Partial breast

____ Total breast (including nipple and skin)

____ Other (specify): _________________

____ Not specified

Procedure

____ Excision without wire-guided localization

____ Excision with wire-guided localization

____ Total mastectomy (including nipple and skin)

____ Other (specify): _________________

____ Not specified

Lymph Node Sampling (select all that apply)

____ No lymph nodes present

____ Sentinel lymph node(s)

____ Axillary dissection (partial or complete dissection)

____ Lymph nodes present within breast specimen (i.e., intramammary lymph nodes)

____ Other lymph nodes (e.g., supraclavicular or location not identified)

Specify location, if provided: ______________________

Specimen Integrity

____ Single intact specimen (margins can be evaluated)

____ Multiple designated specimens (e.g., main excisions and identified margins)

____ Fragmented (margins cannot be evaluated with certainty)

____ Other (specify): ________________________

Specimen Size (for excisions less than total mastectomy)

Greatest dimension: ________________ cm

^*Additional dimensions: __________ × __________ cm

____ Cannot be determined

Specimen Laterality

____ Right

____ Left

____ Not specified

^*Tumor Site (select all that apply)

^*____ Upper outer quadrant

^*____ Lower outer quadrant

^*____ Upper inner quadrant

^*____ Lower inner quadrant

^*____ Central

^*____ Nipple

^*Position: ________ o’clock

^*____ Other (specify): _________________

^*____ Not specified

Size (Extent) of DCIS

Estimated size (extent) of DCIS (greatest dimension using gross and microscopic evaluation): At least__________ cm

^*Additional dimensions __________ × __________ cm

^*Number of blocks with DCIS:______________

^*Number of blocks examined: __________

Note: Size (extent) of DCIS is an estimation of volume of breast tissue occupied by DCIS

Histologic Type

____ Ductal carcinoma in situ; classified as Tis (DCIS) or Tis (Paget)

^*Architectural Patterns (select all that apply)

^*____ Comedo

^*____ Paget disease (DCIS involving nipple skin)

^*____ Cribriform

^*____ Micropapillary

^*____ Papillary

^*____ Solid

^*____ Other (specify): ______________________

Nuclear Grade

____ Grade I (low)

____ Grade II (intermediate)

____ Grade III (high)

Necrosis

____ Not identified

____ Present, focal (small foci or single cell necrosis)

____ Present, central (expansive “comedo” necrosis)

Margins (select all that apply)

____ Margins cannot be assessed

____ Margin(s) uninvolved by DCIS

Distance from closest margin: __________ mm

^*Specify margins:______________

^*Distance from superior margin: __________ mm

^*Distance from inferior margin: __________ mm

^*Distance from medial margin: __________ mm

^*Distance from lateral margin: __________ mm

^*Distance from anterior margin: __________ mm

^*Distance from posterior margin: __________ mm

^*Distance from other specified margin: __________ mm

^*Designation of margin: ________________________

____ Margin(s) positive for DCIS

^*Specify which margin(s) and extent of involvement

^*____ Superior margin

^*____ Focal

^*____ Minimal/moderate

^*____ Extensive

^*____ Inferior margin

^*____ Focal

^*____ Minimal/moderate

^*____ Extensive

^*____ Anterior margin

^*____ Focal

^*____ Minimal/moderate

^*____ Extensive

^*____ Posterior margin

^*____ Focal

^*____ Minimal/moderate

^*____ Extensive

^*____ Medial margin

^*____ Focal

^*____ Minimal/moderate

^*____ Extensive

^*____ Lateral margin

^*____ Focal

^*____ Minimal/moderate

^*____ Extensive

^*Treatment Effect: Response to Presurgical (Neoadjuvant) Therapy

^*____ No known presurgical therapy

^*____ No definite response to presurgical therapy

^*____ Probable or definite response to presurgical therapy

Lymph Nodes (required only if lymph nodes are present in specimen)

Number of sentinel nodes examined: __________

Total number of nodes examined (sentinel and nonsentinel): __________

Number of lymph nodes with macrometastases (> 0.2 cm): __________

Number of lymph nodes with micrometastases (> 0.2 mm to 0.2 cm &/or > 200 cells): __________

Number of lymph nodes with isolated tumor cells (≤ 0.2 mm and ≤ 200 cells): __________

Size of largest metastatic deposit (if present): __________

^*Extranodal extension

^*____ Present

^*____ Not identified

^*____ Indeterminate

^*Method of evaluation of sentinel lymph nodes (select all that apply)

^*____ Hematoxylin and eosin (H&E), 1 level

^*____ H&E, multiple levels

^*____ Immunohistochemistry

^*____ Sentinel lymph node biopsy not performed

^*____ Other (specify): ______________________________

Note: Sentinel node is usually the first involved lymph node. In the unusual situation in which a sentinel node is not involved by metastatic carcinoma but a nonsentinel node is involved, this information should be included in a note

Pathologic Staging (pTNM)

TNM descriptors (required only if applicable) (select all that apply)

____ r (recurrent)

____ y (post-treatment)

Primary tumor (pT)

____ pTis (DCIS): Ductal carcinoma in situ

____ pTis (Paget): Paget disease of nipple not associated with invasive carcinoma &/or carcinoma in situ (DCIS & or LCIS) in underlying breast parenchyma

Note: If there has been a prior core needle biopsy, the pathologic findings from the core, if available, should be incorporated in the T classification. If invasive carcinoma or microinvasion were present on core, protocol for invasive carcinomas of breast should be used and should incorporate this information

Regional lymph nodes (pN) (choose a category based on lymph nodes received with specimen; immunohistochemistry &/or molecular studies are not required)

Note: If internal mammary lymph nodes, infraclavicular nodes, or supraclavicular lymph nodes are included in the specimen, consult the AJCC Staging Manual for additional lymph node categories.

Modifier (required only if applicable)

____ (sn) Only sentinel node(s) evaluated; if ≥ 6 sentinel nodes &/or nonsentinel nodes are removed, this modifier should not be used Category (pN)

____ pNX: Regional lymph nodes cannot be assessed (e.g., previously removed, or not removed for pathologic study)

____ pN0: No regional lymph node metastasis identified histologically

Note: Isolated tumor cell clusters (ITC) are defined as small clusters of cells ≤ 0.2 mm or single tumor cells, or a cluster of < 200 cells in a single histologic cross-section.† ITCs may be detected by routine histology or by immunohistochemical (IHC) methods. Nodes containing only ITCs are excluded from total positive node count for purposes of N classification but should be included in total number of nodes evaluated.

____ pN0(i-): No regional lymph node metastases histologically, negative IHC

____ pN0(i+): Malignant cells in regional lymph node(s) ≤ 0.2 mm and ≤ 200 cells (detected by H&E or IHC including ITC)

____ pN0(mol-): No regional lymph node metastases histologically, negative molecular findings (reverse transcriptase polymerase chain reaction [RT-PCR])

____ pN0(mol+): Positive molecular findings (RT-PCR), but no regional lymph node metastases detected by histology or IHC

____ pN1mi: Micrometastases (> 0.2 mm &/or > 200 cells, but none > 2.0 mm)

____ pN1a: Metastases in 1-3 axillary lymph nodes, at least 1 metastasis > 2.0 mm

____ pN2a: Metastases in 4-9 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm)

____ pN3a: Metastases in 10 or more axillary lymph nodes (at least 1 tumor deposit > 2.0 mm)

Distant metastasis (M)

____ Not applicable

____ cM0(i+): No clinical or radiographic evidence of distant metastasis, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow, or other nonregional nodal tissue that are no larger than 0.2 mm in a patient without symptoms or signs of metastasis

____ pM1: Distant detectable metastasis as determined by classic clinical and radiographic means &/or histologically proven larger than 0.2 mm

Note: Presence of distant metastases in a case of DCIS would be very unusual. Additional sampling to identify invasive carcinoma in breast or additional history to document prior or synchronous invasive carcinoma is advised in evaluation of such cases

^*Additional Pathologic Findings

^*Specify: ______________________________

^*Ancillary Studies

^*Estrogen receptor (results of special studies performed on this specimen or a prior core needle biopsy)

^*____ Immunoreactive tumor cells present

^*____ No immunoreactive tumor cells present

^*____ Pending

^*____ Not performed

^*____ Other (specify): _________________

^*Name of antibody: _____________________

^*Name of vendor: _____________________

^*Type of fixative: _________________

^*Progesterone receptor (results of special studies performed on this specimen or a prior core biopsy)

^*____ Immunoreactive tumor cells present

^*____ No immunoreactive tumor cells present

^*____ Pending

^*____ Not performed

^*____ Other (specify): _________________

^*Name of antibody: __________________

^*Name of vendor: __________________

^*Type of fixative: ______________

^*Microcalcifications (select all that apply)

^*____ Not identified

^*____ Present in DCIS

^*____ Present in nonneoplastic tissue

^*____ Present in both DCIS and nonneoplastic tissue

^*Clinical History (select all that apply)

Current clinical/radiologic breast findings for which this surgery is performed include

^*____ Palpable mass

^*____ Radiologic finding

^*____ Mass or architectural distortion

^*____ Calcifications

^*____ Other (specify): ________________

^*____ Nipple discharge

^*____ Other (specify): ____________________

^*____ Prior history of beast cancer

^*Specify site, diagnosis, and prior treatment: ________________

^*____ Prior neoadjuvant treatment for this diagnosis of DCIS

^*Specify type: ________________________

^* Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management. † Approximately 1,000 tumor cells are contained in a 3-dimensional 0.2 mm cluster. Thus, if > 200 individual tumor cells are identified as single dispersed tumor cells or as a nearly confluent elliptical or spherical focus in a single histologic section of a lymph node, there is a high probability that > 1,000 cells are present in the lymph node. In these situations, the node should be classified as containing a micrometastasis (pN1mi). Cells in different lymph node cross-sections or longitudinal sections or levels of the block are not added together; the 200 cells must be in a single node profile even if the node has been thinly sectioned into multiple slices. It is recognized that there is substantial overlap between the upper limit of the ITC and the lower limit of the micrometastasis categories due to inherent limitations in pathologic nodal evaluation and detection of minimal tumor burden in lymph nodes. Thus, the threshold of 200 cells in a single cross-section is a guideline to help pathologists distinguish between these 2 categories. The pathologist should use judgment regarding whether it is likely that the cluster of cells represents a true micrometastasis or is simply a small group of isolated tumor cells. Adapted with permission from College of American Pathologists, “Protocol for the Examination of Specimens from Patients with Ductal Carcinoma In Situ (DCIS) of the Breast.” Web posting date October 2009, www.cap.org.