Breast Cancer OncoGuia: surgical pathology report guidelines

Clin Transl Oncol (2010) 12:138-141 DOI

S U P L E M E N TA R Y I N F O R M AT I O N

Breast Cancer OncoGuia: surgical pathology report guidelines Fina Climent · M. Teresa Soler · Isabel Català · Eva Castellà · Josep Corominas · Paula Manchon Walsh on behalf of the Breast Cancer OncoGuia Group

Received: 21 October 2009 / Accepted: 23 November 2009

The guidelines below have been developed in the framework of the Breast Cancer OncoGuia [1] and are aimed at standardising descriptions of diagnoses in breast cancer pathology reports so these are fully comparable regardless of the pathologist who issues the diagnosis [2, 3].

Clinical and macroscopic data

Identifying data

Type of sample • Needle biopsy:

Date obtained: Biopsy no.:

Date registered: Name:

Location • Laterality: ❐ Right breast • Quadrant: ❐ Upper outer ❐ Lower outer ❐ Nipple

Health history no: Age: Sex: • •

F. Climent · M.T. Soler · I. Català Pathology Department Hospital Universitari de Bellvitge Barcelona, Spain E. Castellà Pathology Department Hospital Universitari Germans Trias i Pujol Badalona, Barcelona, Spain J.M. Corominas Pathology Department Hospital del Mar Barcelona, Spain P. Manchon Walsh Catalan Cancer Strategy Department of Health Barcelona, Spain Coordinating clinical guideline team of the Catalan Cancer Strategy: P. Manchon Walsh (쾷) · J.M. Borràs · T. Ferro · J. Alfons Espinàs Av. Gran Vía, s/n, km 2,7 ES-08907 L’Hospitalet de Llobregat, Barcelona, Spain

• • • • • • •

• • • •

❐ Left breast ❐ Upper inner ❐ Lower inner ❐ Others ...........

❐ CNB (core needle biopsy) ❐ VAB (vacuum-assisted biopsy) No. of cores: .............. Surgical biopsy: ❐ With wire-guided localisation ❐ Without wire-guided localisation Surgical treatment: ❐ Lumpectomy ❐ Quadrantectomy ❐ Simple mastectomy ❐ Modified radical ❐ Others (specify) mastectomy Sample size ........ mm Sample weight: ........ (gr) Skin involvement: ❐ Yes ❐ No Size of the lesion/tumour ......... mm Preoperative examination Resection margin (distance and specified margins): ... Lymph node sampling: ❐ No lymph nodes present ❐ Sentinel lymph node(s) present ❐ Axillary dissection (partial or complete) ❐ Lymph nodes present within the breast specimen ❐ Other lymph nodes, specify location: Macro photo: ❐ Yes ❐ No Tumour bank: ❐ Yes ❐ No Fixation time: ........ (h) Key to sections: ........

Microscopic data Malignant, non-invasive lesion of the breast ❐ Present ❐ Absent

Clin Transl Oncol (2010) 12:138-141

• Ductal – Nuclear grade: ❐ Low ❐ Intermediate ❐ High – Necrosis: ❐ Present ❐ Absent – Microcalcifications: ❐ Yes ❐ No – Size: ....... mm – Growth pattern: – Van Nuys Index [4]: • Lobular ❐ Classic ❐ Undetermined ❐ Pleomorphic • Paget’s disease (with no underlying tumour) Microinvasive lesion of the breast ❐ Present ❐ Absent • Microinvasive ductal carcinoma (6.0 or ratio>2.2) ❐ Non-amplified (HER2 gen copy1.8) ❐ Equivocal (HER2 gen copy from 4.0 to 6.0 or ratio 1.8 to 2.2) • Other determinations (specify which): Explanatory notes Pattern of growth of ductal carcinoma in situ (DCIS) • • • •

Solid Micropapillary Papillary/cribriform Cribriform

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Clin Transl Oncol (2010) 12:138-141

• Comedocarcinoma • Other (specify) Van Nuys prognostic index (for DCIS) [4] Score Size

1 15 mm or less Distance Greater to than margin 10 mm Histology Non-comedo, no necrosis

2 16–40 mm 1–9 mm

3 Larger than 41 mm 1 mm or less

Non-comedo, Comedocarcinoma necrosis

pT according to the 6th edition of the International Union Against Cancer (UICC), 2002 [6, 7] • • • • • • • • •

pTx (cannot be assessed) pTis (carcinoma in situ) pT1 mic (microinvasion) 1 mm) pT1a (>1–5 mm) pT1b (>5–10 mm) pT1c (>10–20 mm) pT2 (>20–50 mm) pT3 (>50 mm) pT4 (extension to the skin or chest wall) • pT4a (extension to the chest wall, except the pectoral muscle) • pT4b (oedema, including ‘peau d’orange’, or ulceration of the skin, or satellite skin nodules confined to the same breast) • pT4c (both pT4a and pT4b) • pT4d (inflammatory carcinoma)

pN According to the 6th edition of the UICC, 2002 [6, 7] • pNx (regional lymph nodes cannot be assessed) • pN0 (no regional lymph node metastasis, no additional examination) • pN0 (i–) (negative lymph nodes histologically, negative immunohistochemistry) • pN0 (i+) (negative lymph nodes histologically, positive immunohistochemistry, deposits