general surgery pathology report *rl;mmr; stpl · 2013. 8. 2. · batch#: 22395 general surgery...

GENERAL SURGERY PATHOLOGY REPORT 1 of 1STPL*RL;MMR;Batch#: 22395

Accession: Received: Obtained: 05/05/20XX

05/05/20XX 8:22 pm

Supplemental Date

Final Report Date

Specimen

05/07/XX

A

05/08/XX 05/06/XX

B

N/A Submitted: 2 vials-A,B

DR. JANE DOE 456 SAMPLE BLVD NEW YORK, NY 10011

1234 ANYWHERE

Age:

ANYWHERE, NY 11554 Acct#:

PATIENT: BETSY JONES

1012 79 DOB:

(516) 123-4567 06/05/19XX

Female Sex:

ABC SURGERY CENTER PHYSICIAN: JOHN Y SMITH

NEW YORK, NY 10016 1234 FIRST AVE, Suite: 8A

(212) 123-4568352-549-7 Acct # (212) 123-4567

28 South Terminal Drive

Tel#:

www.acupath.com Fax#:

1-888-ACUPATH Plainview, NY 11803

1-516-326-3452

A Copy was sent to: 000000-20XX

Client Comments: PARTIAL MAST.

DIAGNOSISA LT BREAST

DIAGNOSIS: INVASIVE DUCTAL CARCINOMA, WELL DIFFERENTIATED; DUCTAL CARCINOMA IN SITU, HIGH GRADE, COMEDO PATTERN Notes: Invasive carcinoma is present focally 1 mm from lateral margin of resection. DCIS is present focally at the lateral margin. Receptor studies will be performed and reported separately. Immunohistochemical stains for breast markers are: Estrogen receptors are negative in tumor cells. Progesterone receptors are positive in approximately 30% of tumor cells. HER2/neu - 0/negative. Ki-67 is positive in approximately 10% of tumor cells. Stains for E-cadherin and P63 confirm the diagnosis. THIS IS A SUPPLEMENTARY REPORT BASED ON ADDITIONAL INFORMATION. CASE DISCUSSED WITH DR. SMITH ON 05/07/20XX. Microscopic Description: Sections reveal invasive ductal carcinoma, well differentiated, with micropapillary features; SRB score 5/9 (tubular formation 2/3, nuclear grade 2/3, mitoses 1/3). Invasive carcinoma measures 1.5 cm in the greatest dimension. Focal lymphovascular invasion is identified. DCIS, high grade comedo pattern is present around the invasive tumor and elsewhere in the breast. Microcalcifications associated with DCIS are identified. Proliferative fibrocystic change is present. Preliminary Reasons: In House Review

Grossing Information: Received in 10% Formalin is a specimen measuring 95x65x40 mm, color is yellow tan, shape is Irregular and submitted in 36 blocks, 1 piece. Grossing Comments: Picture taken. The specimen is inserted by guide wire near the inferior margin. The tip of the guide wire is located 25mm to the inferior margin. There is a gray white mass near the guide wire tip measuring 1.5x10x05mm in size and 08mm to the anterior margin; 08mm to the lateral margin; 20mm to the inferior margin, 30mm to the posterior margin and 20mm to the lateral margin. There are also multiple local hemorrhagic areas near the posterior margin. The specimen is orientated as follows. long suture-lateral margin (yellow). short suture-superior margin ( green). medial suture- medial margin (red). Inferior blue, anterior orange and posterior black. The specimen is totally submitted in series section. C1-C3-superior margin The following section represents lateral/medial/anterior/posterior margin C4-c5-same section. C6-C7-same section.C8-C10-same section. C11-C12-same section. C15-C17-same section. C18-posterior margin.C19-C22-same section. C23-C25-same section.C26-C28-same section-mass with adjcent tissue. C29-C30-same section-mass with adjcent tissue. C31-C32-same section.C33-C34-same section. C35-C36-inferior margin. Picture taken.

B LT AXILLA DIAGNOSIS: METASTATIC CARCINOMA IN TWO OF SIX LYMPH NODES (2/6)

John Brown, M.D.

B A

Olga Falkowski, M.D., Medical Director

A: (LT BREAST) INVASIVE DUCTAL CARCINOMA, WELL DIFFERENTIATED; DUCTAL CARCINOMA IN SITU, HIGH GRADE, COMEDO PATTERN B: (LT AXILLA) METASTATIC CARCINOMA IN TWO OF SIX LYMPH NODES (2/6)


000000-20XX

BETSY JONES

000000-20XX

(516) 123-4567 06/05/19XX 05/05/20XX

BETSY JONES 000000-20XX

(516) 123-4567 06/05/19XX 05/05/20XX05/05/20XX

BETSY JONES

BETSY JONES

Submitted: 2 vials-A,B


BA

DOB:

DOB: See report for notes

See report for notes

Page 1 of 1

Microscopic Description: Sections reveal metastatic carcinoma in 2 of 6 lymph nodes. Largest focus measures 0.6 cm. No definite extracapsular extension is identified. Grossing Information: Received in 10% Formalin is a specimen measuring 55x35x10 mm, color is yellow, shape is Irregular and submitted in 3 blocks, 2 pieces. Grossing Comments: Possible five lymph nodes found. Picture taken. Largest piece measured - see above. All lymph nodes are submitted in three cassettes. Clinical Impression: SENTINEL NODE. This ASR has been prepared and validated according to manufacturer recommendations and its performance characteristics have been evaluated as to how they contribute to the global clinical applications within Acupath’s diagnostic services. With the exception of HercepTest, this reagent has not been cleared by The U.S. Food Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical applications only. This laboratory is certified under CLIA-88 amendments to perform high complexity clinical laboratory testing.

John Brown



05/05/20XX 8:22 pm

Supplemental Date

Final Report Date

Specimen

05/07/XX

A

05/08/XX 05/06/XX

B

N/A Submitted: 2 vials-A,B


1234 ANYWHERE

Age:



1012 79 DOB:

(516) 123-4567 06/05/19XX

Female Sex:



(212) 123-4568352-549-7 Acct # (212) 123-4567


Tel#:



1-516-326-3452

Duplicate Report For: 000000-20XX

Client Comments: PARTIAL MAST.

DIAGNOSISA LT BREAST

DIAGNOSIS: INVASIVE DUCTAL CARCINOMA, WELL DIFFERENTIATED; DUCTAL CARCINOMA IN SITU, HIGH GRADE, COMEDO PATTERN Notes: Invasive carcinoma is present focally 1 mm from lateral margin of resection. DCIS is present focally at the lateral margin. Receptor studies will be performed and reported separately. Immunohistochemical stains for breast markers are: Estrogen receptors are negative in tumor cells. Progesterone receptors are positive in approximately 30% of tumor cells. HER2/neu - 0/negative. Ki-67 is positive in approximately 10% of tumor cells. Stains for E-cadherin and P63 confirm the diagnosis. THIS IS A SUPPLEMENTARY REPORT BASED ON ADDITIONAL INFORMATION. CASE DISCUSSED WITH DR. SMITH ON 05/07/20XX. Microscopic Description: Sections reveal invasive ductal carcinoma, well differentiated, with micropapillary features; SRB score 5/9 (tubular formation 2/3, nuclear grade 2/3, mitoses 1/3). Invasive carcinoma measures 1.5 cm in the greatest dimension. Focal lymphovascular invasion is identified. DCIS, high grade comedo pattern is present around the invasive tumor and elsewhere in the breast. Microcalcifications associated with DCIS are identified. Proliferative fibrocystic change is present. Preliminary Reasons: In House Review

Grossing Information: Received in 10% Formalin is a specimen measuring 95x65x40 mm, color is yellow tan, shape is Irregular and submitted in 36 blocks, 1 piece. Grossing Comments: Picture taken. The specimen is inserted by guide wire near the inferior margin. The tip of the guide wire is located 25mm to the inferior margin. There is a gray white mass near the guide wire tip measuring 1.5x10x05mm in size and 08mm to the anterior margin; 08mm to the lateral margin; 20mm to the inferior margin, 30mm to the posterior margin and 20mm to the lateral margin. There are also multiple local hemorrhagic areas near the posterior margin. The specimen is orientated as follows. long suture-lateral margin (yellow). short suture-superior margin ( green). medial suture- medial margin (red). Inferior blue, anterior orange and posterior black. The specimen is totally submitted in series section. C1-C3-superior margin The following section represents lateral/medial/anterior/posterior margin C4-c5-same section. C6-C7-same section.C8-C10-same section. C11-C12-same section. C15-C17-same section. C18-posterior margin.C19-C22-same section. C23-C25-same section.C26-C28-same section-mass with adjcent tissue. C29-C30-same section-mass with adjcent tissue. C31-C32-same section.C33-C34-same section. C35-C36-inferior margin. Picture taken.

B LT AXILLA DIAGNOSIS: METASTATIC CARCINOMA IN TWO OF SIX LYMPH NODES (2/6)

John Brown, M.D.

B A




000000-20XX

BETSY JONES

000000-20XX

(516) 123-4567 06/05/19XX 05/05/20XX


(516) 123-4567 06/05/19XX 05/05/20XX05/05/20XX

BETSY JONES

BETSY JONES



BA

DOB:



Page 1 of 1

Microscopic Description: Sections reveal metastatic carcinoma in 2 of 6 lymph nodes. Largest focus measures 0.6 cm. No definite extracapsular extension is identified. Grossing Information: Received in 10% Formalin is a specimen measuring 55x35x10 mm, color is yellow, shape is Irregular and submitted in 3 blocks, 2 pieces. Grossing Comments: Possible five lymph nodes found. Picture taken. Largest piece measured - see above. All lymph nodes are submitted in three cassettes. Clinical Impression: SENTINEL NODE. This ASR has been prepared and validated according to manufacturer recommendations and its performance characteristics have been evaluated as to how they contribute to the global clinical applications within Acupath’s diagnostic services. With the exception of HercepTest, this reagent has not been cleared by The U.S. Food Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical applications only. This laboratory is certified under CLIA-88 amendments to perform high complexity clinical laboratory testing.

John Brown

ABC SURGERY CENTER JOHN Y SMITH, M.D.

1234 First Avenue, Suite 8A New York, NY 10016

212-123-4567

May 8, 20XX

Dear Dr. Doe:

Re: Betsy J. Jones456 Sample Blvd New York, NY 10011

Dr. Jane Doe

I had the pleasure of treating your patient Betsy J Jones, a 79 year old female, on May 5, 20XX. The specimens were sent for pathologic interpretation to Acupath Laboratories, Inc. The histopathologic interpretation of the specimen from the (A) LT BREAST revealed invasive ductal carcinoma, well differentiated; ductal carcinoma in situ, high grade, comedo pattern. Invasive carcinoma is present focally 1 mm from lateral margin of resection. DCIS is present focally at the lateral margin. Receptor studies will be performed and reported separately. Immunohistochemical stains for breast markers are: Estrogen receptors are negative in tumor cells. Progesterone receptors are positive in approximately 30% of tumor cells. HER2/neu - 0/negative. Ki-67 is positive in approximately 10% of tumor cells. Stains for E-cadherin and P63 confirm the diagnosis. THIS IS A SUPPLEMENTARY REPORT BASED ON ADDITIONAL INFORMATION. CASE DISCUSSED WITH DR. SMITH ON 05/08/20XX.The histopathologic interpretation of the specimen from the (B) LT AXILLA revealed metastatic carcinoma in two of six lymph nodes(2/6).

I would like to personally thank you for your kind referral. If you have any additional questions, please do not hesitate to contact me at 212-123-4567.

Sincerely,

JOHN Y SMITH, M.D.



05/30/20XX 7:54 pm

Final Report Date

Preliminary Date

Specimen 06/04/XX

06/04/XX

A

Submitted: 1 vial-A


1234 ANYWHERE

Age:



1012 78 DOB:

(516) 123-4567 06/05/19XX

Female Sex:



(212) 123-4568352-549-7 Acct # (212) 123-4567


Tel#:



1-516-326-3452


DIAGNOSISA

DIAGNOSIS: INVASIVE DUCTAL CARCINOMA, WELL-DIFFERENTIATED, 0.8 CM IN DIAMETER, EXTENDING TO WITHIN 1 MM OF THE INKED MARGIN; FOCAL DUCTAL CARCINOMA IN-SITU (DCIS), INTERMEDIATE NUCLEAR GRADE, CRIBRIFORM PATTERN, WITH LOBULAR INVOLVEMENT Notes: The carcinoma measures 0.8 cm in greatest dimension and extends to within 1 mm of the inked margin. DCIS comprises less than 5% of the tumor volume. Histologic grade (modified SBR score): 4 of 9- well differentiated (tubules: 1, nuclear: 2, mitoses: 1). No lymphovascular or perineural invasion is identified. Receptor status- ER: 100%, PR: 80%, Her-2-neu: 1+/negative; FISH analysis will be performed and the results given in a separate report. Ki-67: 0%. E-cadherin is positive, supporting ductal origin of tumor cells. P63 is negative, supporting the diagnosis. Pathologic stage (AJCC, 2002): pT1b Nx Mx (Stage 1).

Microscopic Description: Sections reveal neoplastic glands infiltrating through fibrous stroma. Preliminary Reasons: ER/PR HER2 NEU, KI-67, P63, E-CADHERIN

HER2NEU test performed on FFPE tissue with baseline fixation time of 8 hours.

Grossing Information: Received in 10% Formalin is a specimen measuring 4.5 X 3 X 1.5 cm, color is yellow tan, shape is Irregular, procedure is Excision and submitted in 8 blocks, 1 piece. Grossing Comments: No sutures are seen. The specimen is inked entirely black. Cut sections reveal an ill-defined, 0.8 cm nodule with fibrous and adipose tissue. Entirely submitted.

Clinical Impression: R/O CA.

This ASR has been prepared and validated according to manufacturer recommendations and its performance characteristics have been evaluated as to how they contribute to the global clinical applications within Acupath’s diagnostic services. With the exception of HercepTest, this reagent has not been cleared by The U.S. Food Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical applications only. This laboratory is certified under CLIA-88 amendments to perform high complexity clinical laboratory testing.

John Brown, M.D.

A


A: INVASIVE DUCTAL CARCINOMA, WELL-DIFFERENTIATED, 0.8 CM IN DIAMETER, EXTENDING TO WITHIN 1 MM OF THE INKED MARGIN; FOCAL DUCTAL CARCINOMA IN-SITU (DCIS), INTERMEDIATE N...See Report

A: INVASIVE DUCTAL CARCINOMA, WELL-DIFFERENTIATED, 0.8 CM IN DIAMETER, EXTENDING TO WITHIN 1 MM OF THE INKED MARGIN; FOCAL DUCTAL CARCINOMA IN-SITU (DCIS), INTERMEDIATE N...See Report

000000-20XX

BETSY JONES

000000-20XX

(516) 123-4567 06/05/19XX 05/30/20XX


(516) 123-4567 06/05/19XX 05/30/20XX05/30/20XX

BETSY JONES

BETSY JONES

Submitted: 1 vial-A

Submitted: 1 vial-A

A

DOB:



Page 1 of 1

John Brown

FISH ANALYSIS REPORT Page 1 of 1 NHC;STPL

(212) 123-4568(212) 123-4567

Suite: 1 NEW YORK, NY 10001

ABC SURGERY CENTER

Account # 352-549-7

PHYSICIAN: JOHN B. SMITH

DOB:Age: 04/16/19XX 66

BETSY JONES

NEW YORK, NY 10001

Female 7XXXX0 Acct:Sex:

ACCESSION:

Received: Obtained:

15 Rte

1234 ANY STREET


Tel#:


1-888-ACUPATH 1-516-326-3452

Plainview, NY 11803

123 ANYWHERE STREET

PRACTICE: PATIENT:

Phone #:

08/17/20XX

08/15/20XX 3 :00 PM 000000-20XX

Indications:

Date Reported FISH:

Breast Ca Biopsy Source of Tissue: R/O Breast Cancer; Left Breast

08/21/20XX 11:34 AM

FISH ANALYSIS DATA Assay # 1 Probe Region: HER2 amplification 50 No. of Cells Scored: Process and limitations of use: This test is approved by the U.S. Food and Drug Administration for use in conjunction with, and not in lieu of, current standard diagnostic procedures. Performance characteristics have been verified by Acupath Laboratories. Chromosome or Locus: Modal signals per cell:

HER-2 10 cep17 3

TEST RESULT: PATIENT SAMPLE: nuc ish(D17Z1x2~4,HER2x4~10)[50] Amplification ratio is 2.6. POSITIVE for HER-2 amplification. POSITIVE CONTROL: nuc ish(D17Z1x2,HER2x12~30)[25] Amplification ratio is 10.9.

INTERPRETATION: Fluorescence in situ hybridization (FISH) with DNA probes (Abbott Molecular Inc., Des Plaines, IL) for the HER2 locus and the centromere of chromosome 17 was performed on the submitted Formalin Fixed Paraffin Embedded Left Breast Stero Biopsy The observed HER2:CEP17 ratio yielded an amplification ratio of 2.6. This is POSITIVE for HER2 amplification. Reportable ranges of HER2:CEP17 ratio are: 2.2 - Positive for HER2 amplification

Electronically signed by: John Brown, M.D. Olga Falkowski, M.D., Medical Director

CYTOPATHOLOGY REPORT 1 of 1*RL;MMR;Batch#: 13870


07/18/20XX 12:00 am

Final Report Date

Specimen

07/18/XX

A


1234 ANYWHERE

Age:



1012 78 DOB:

(516) 123-4567 06/05/19XX

Female Sex:

ABC SURGERY CENTER PHYSICIAN: JOHN G. SMITH


6 (212) 123-4568352-549-10 Acct # Rte (212) 123-4567


Tel#:



1-516-326-3452

Duplicate Report was faxed to: 000000-20XX

DIAGNOSISA RT BREAST

DIAGNOSIS:DUCTAL CARCINOMA Microscopic Description: The smears are hypercellular with clusters and dishesive aggregates as well as individual malignant cells with large nuclei, high N/C ratio, and pleomorphism in a necrotic background.

ADEQUACY: SATISFACTORY FOR EVALUATION. RECEIVED 1 SLIDE - ASP Clinical Impression: R/O CA.

John Brown, M.D.

Photomicrograph of A

Color KeyCancer BenignSuspiciousOther AtypicalNon-Diagnostic

A


A: (RT BREAST) DUCTAL CARCINOMA

A: (RT BREAST) DUCTAL CARCINOMA

000000-20XX

BETSY JONES

000000-20X X

(516) 123-4567 06/05/19XX 07/18/20XX

BETSY JONES 000000-20X X

(516) 123-4567 06/05/19XX 07/18/20XX07/18/20XX

BETSY JONES

BETSY JONES

Submitted: 1 vial-A

Submitted: 1 vial-A

A

DOB:

DOB:

Page 1 of 1

John Brown

CYTOPATHOLOGY REPORT 1 of 1STPLRL;MMR;Batch#: 42845


07/18/20XX 12:05 am

Final Report Date

Specimen

07/18/XX

A

07/18/XX

B


1234 ANYWHERE ST

Age:


PATIENT: BETSY J. JONES

Chart/A/C#70XX 1012 34 DOB:

(516) 123-4567 06/05/19XX

Female Sex:

ABC SURGERY CENTER PHYSICIAN: JOHN G. SMITH


6 (212) 123-4568352-549-10 Acct # Rte (212) 123-4567


Tel#:



1-516-326-3452


Client Comments: NIPPLE DISCHARGE, PREVIOUS ATYPIA ON HALO 20XX

DIAGNOSISA RIGHT BREAST

DIAGNOSIS: NEGATIVE FOR ATYPICAL OR MALIGNANT CELLS (CATEGORY 0) Microscopic Description: Thin prep slide reveals numerous macrophages. No evidence of atypical or malignant cells is identified.

Rec’d 9ml of fixed clear fluid in Cytolyt/PreservCyt. Prepared 1 HALO slide. Procedure: HALO This test cannot exclude a diagnosis of breast cancer

B LEFT BREAST

DIAGNOSIS: ATYPICAL CELLS (CATEGORY III), SUSPICIOUS SEE NOTE Notes: There are numerous atypical papillary clusters present raising a possibility of a papillary lesion. Further studies are recommended. Microscopic Description: Thin prep slide reveals numerous papillary clusters of atypical ductal cells.

Rec’d 10ml of fixed clear fluid in Cytolyt/PreservCyt. Prepared 1 HALO slide. Procedure: HALO This test cannot exclude a diagnosis of breast cancer

John Brown, M.D.

Photomicrograph of B

NeoMatrix HALO System for reporting nipple aspirate fluid cytology:

Negative for atypical or malignant cells (Category 0)

Benign-normal ductal epithelial cells identified (Category I)

Benign-hyperplastic ductal epithelial cells identified (Category II)

Atypical (Category III)

Suspicious for malignancy (Category IV)

Color Key: Cancer B enign Suspicious Negative Atypical No n-Diagnostic

A B


A: (RIGHT BREAST) NEGATIVE FOR ATYPICAL OR MALIGNANT CELLS...See Report B: (LEFT BREAST) ATYPICAL CELLS (CATEGORY III), SUSPICIOUS SEE NOTE

A: (RIGHT BREAST) NEGATIVE FOR ATYPICAL OR MALIGNANT CELLS...See Report B: (LEFT BREAST) ATYPICAL CELLS (CATEGORY III), SUSPICIOUS SEE NOTE

000000-20XX

BETSY J. JONES

000000-20XX

(516) 123-4567 06/05/19XX 07/17/20XX

BETSY J. JONES 000000-20XX

(516) 123-4567 06/05/19XX 07/17/20XX07/17/20XX

BETSY J. JONES

BETSY J. JONES



1234 ANYWHERE ANYWHERE, NY 11554

DOB:



A B

Page 1 of 1

The HALO test is NOT a diagnostic test and cannot be used to exclude breast cancer. Patients should continue to undergo other clinical breast screening procedures (such as mammography, clinical breast examination and self breast examination) as recommended by their health care provider. These results are not intended to be used for clinical diagnosis.

John Brown

Breast REQ.pdfSlide Number 1

general surgery pathology report *rl;mmr; stpl · 2013. 8. 2. · batch#: 22395 general surgery...

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