简直就是一份完美的病历
！甚至超越病历！值得学习和借鉴！ | 图片： | |
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- B1753Breast invasive carcinoma template cqz (9)浸润性乳腺癌报告模板
I am sending here generally how we sign out the invasive carcinoma for excision or mastectomy specimens. Below you can see what we describe in our final report. It is not neccesary for you to do the same also. Just for your referecne. I once studied and work in several hospitals in the US. Every one is different in term of the report. However, the priniciples are same.
Breast (Re-)excision/mastectomy for invasive and in situ carcinoma
SECTION A (INVASIVE CA)
-Invasive ductal carcinoma, _________,(no special type, pure mucinous type, pure tubular type etc.) type.
-Invasive ductal carcinoma, mixed __________(__%) and _________(___%) types.
-Invasive lobular carcinoma, classical type, with a solid / alveolar / trabecular growth pattern(s).
-Invasive lobular carcinoma, pleomorphic type.
-Invasive lobular carcinoma, mixed pleomorphic (___%) and classical (_____%) types.
-Invasive mixed ductal and lobular carcinoma.
SECTION B (Grade)
Nottingham Grade I / II / III (tubule formation: _____, nuclear pleomorphism: ________, mitotic activity: _______; total score: ___/9).
SECTION C (Size)
The invasive tumor measures __________cm in largest dimension (give microscopic size if it is a small tumor; use the gross dimension for large tumor).
SECTION D (In-situ CA)
Ductal carcinoma in situ (DCIS), nuclear grade 1 / 2 / 3, solid / cribriform / papillary / micropapillary / apocrine type(s)
with minimal / moderate / comedo necrosis.
Lobular involvement by DCIS is present.
The DCIS constitutes ____% of the total tumor mass, and is present admixed with and away from the invasive component / and is present admixed with the invasive component / and is present away from the invasive component.
The DCIS is present in _____ of ______ slides (Give this information in cases of extensive intraductal component).
Lobular carcinoma in situ (LCIS) is also identified, with pagetoid extension into ducts.
SECTION E (Lympho-vascular space Invasion)
Lympho-vascular space invasion is identified.
No lympho-vascular space invasion is noted.
SECTION F (Surgical Margins)
Negative:
Resection margins are negative for carcinoma.
Resection margins are negative for invasive carcinoma.
Resection margins are negative for ductal carcinoma in situ.
Invasive carcinoma is _____cm from the nearest ____________________marigin.
Ductal carcinoma in situ is ______cm from the nearest ____________________marigin.
Pleomorphic lobular carcinoma in situ is _______ cm from the nearest ____________________marigin.
Positive:
Rare / A few / Multiple focus/foci of invasive carcinoma extends to the ____________________ margin(s).
Rare / A few / Multiple foci of ductal carcinoma in situ extends to the _____________________ margin(s).
Rare / A few / Multiple foci of pleomorphic lobular carcinoma in situ extends to the _________________ margin(s).
Do not report the margin for classic lobular carcinoma in situ.
Negative inked margins but tumor <1mm from margin:
Inked margins are negative for carcinoma. However, rare / a few / multiple focus/foci of invasive carcinoma is/are <1mm to the _________________ margin(s).
Inked margins are negative for carcinoma. However, rare / a few / multiple focus/foci of ductal carcinoma in situ is/are <1mm to the _________________ margin(s).
标签：乳腺浸润性导管癌 报告模板
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本帖最后由 于 2010-07-10 20:11:00 编辑
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×参考诊断
浸润性乳腺癌的病理报告格式
姓名，年龄，左右侧，病理号
乳腺浸润癌或原位癌，乳房切除活检/部分乳房切除术或二次切除术标本
A 浸润癌
浸润性导管癌， _________（非特殊类型，单纯粘液型，单纯导管型，等）型。
浸润性导管癌，混合型，含有有__________(__%)和_________(___%)型。
浸润性小叶癌，经典型，呈实性/腺泡状/小梁状生长。
浸润性小叶癌，多形性亚型。
浸润性小叶癌，混合型，含有多形性（ %）和经典型（ %）型。
浸润型混合性导管癌和小叶癌。
B 组织学分级
诺丁汉分级I/II/III（小管形成： 分，核多形性： 分；核分裂活性： 分。总分 /9）。
C 肿瘤大小
浸润性肿瘤的最大径为 cm（如果肿瘤较小，提供显微镜下尺寸；如果肿瘤较大，使用大体测量）。
D 原位癌
导管原位癌，核级别
出现导管原位癌累及小叶。
全部肿瘤中导管原位癌占____%，原位癌与浸润成分既有混杂又有分隔/原位癌与浸润成分混杂/原位癌与浸润成分相分隔。
导管原位癌出现在____张切片中____张（如果有广泛性的导管内成分，提供这一信息）。
也有小叶原位癌，呈派杰样扩展进入导管。
E 淋巴-血管浸润（有，无）
F 手术切缘
手术切缘阴性：
手术切缘未见癌。
手术切缘未见浸润癌。
手术切缘未见导管原位癌。
浸润癌距离最近___切缘____cm。
导管原位癌距离最近___切缘____cm。
多形性小叶原位癌距离最近___切缘____cm。
手术切缘阳性：
极少/少量/小灶/多灶性浸润癌扩展到____切缘。
极少/少量/多灶性导管原位癌扩展到____切缘。
极少/少量/多灶性多形性小叶原位癌扩展到____切缘。
经典型小叶原位癌不报告切缘。
墨汁标记的切缘阴性，但肿瘤距离切缘小于
墨汁标记的切缘未见癌。但是，极少/少量/小灶/多灶性浸润癌距离__切缘小于
墨汁标记的切缘未见癌。但是，极少/少量/小灶/多灶性导管原位癌距离__切缘小于
墨汁标记的切缘未见癌。但是，极少/少量/小灶/多灶性多形性小叶癌距离____切缘<
G 肿瘤位置（仅乳房切除标本）
浸润性癌位于外上象限/内上象限/外下象限/内下象限/中央部位(或提供时钟位)。
H 乳头（仅乳房切除标本）
乳头无肿瘤
乳头表皮被DCIS累犯（Paget病）。
乳头被浸润性癌累犯。
I 皮肤
皮肤无肿瘤。
皮肤被浸润性癌累犯，直接扩散。
皮肤的真皮淋巴管内见肿瘤栓子。
J 骨骼肌
附属的骨骼肌无肿瘤。
附属的骨骼肌被浸润性癌累犯，直接扩散。
K 不典型增生
不典型导管增生。
不典型小叶增生。
L 良性病变
原位癌/浸润癌或良性乳腺实质伴钙化。
非肿瘤性乳房呈________病变。
以前活检部位引起的改变。
M 淋巴结（仅MRM标本）
共__枚腋窝淋巴结，无转移性肿瘤（0/__）。
转移性癌累犯__枚淋巴结中的__枚（__/__）。
最大转移灶大小__cm。
未见包膜外扩散。
见包膜外扩散。
N 受体研究
浸润性肿瘤细胞：ER____，PR____，HER2____，参见以前的病理报告（病理号_____）。
如果以前未做过，请做这些免疫染色。
华夏病理/粉蓝医疗
为基层医院病理科提供全面解决方案，
努力让人人享有便捷准确可靠的病理诊断服务。
谢谢Dr.cqzhao，重新学习了，觉得8楼基本概念很重要，翻译如下：
所有这些手术方式都是采取相似方法切取一部分乳腺组织
切除活检：用于诊断，如果粗针穿刺活检为乳头状瘤、不典型导管增生、不典型小叶增生、放射状瘢痕等。切取以前活检部位和一部分周围乳腺组织，检查是否有更严重病变，例如癌。
乳房区段切除、局部切除（肿块切除）、部分乳房切除：意思相近。我们一般称为乳房区段切除（segmental mastectomy）用于记帐。如果粗针穿刺活检诊断了导管原位癌或浸润性癌，这些手术方式具有治疗目的，要达到切缘阴性。
二次切除/二次乳房区段切除：第一次区段切除标本中手术切除为阳性或靠近导管原位癌或浸润性癌病灶，采用第二次区段切除术。
切除活检或区段切除标本均涂抹6种颜色墨水以确定方位：上、下、内、外、前（表）、后（基底）。病理医生必须报告每个切缘状况（阴性或阳性）。手术医生从而知道哪个部位、采取何种方式进行二次切除。
华夏病理/粉蓝医疗
为基层医院病理科提供全面解决方案，
努力让人人享有便捷准确可靠的病理诊断服务。
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本帖最后由 于 2008-12-17 08:59:00 编辑
It is ok if some of your guys do not know how to sign out breast pathology reports in details. We often receive consult cases from many other hospitals or companies. In fact a lot of general pathologists in this country do not know neither.
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本帖最后由 于 2008-12-17 04:25:00 编辑
| 以下是引用abin在2008-12-16 23:35:00的发言：
Dr.cqzhao, how to translate these words correctly, please? excision or mastectomy Breast (Re-)excision/mastectomy |
Good questions:
All these procedures are to take off fragments of breast tissue by similar methods.
excisional biopsy: It is for diagnosis if breast core biopsy is papillom, atypical ductal hyperplasia, ALH, radial scar et. Previous biopsy site with surrounding breast tissue was cut off to see if there are more serious lesions such as cancer, present.
Segmental mastectomy, segmental excision, lumpectomy, partial mastectomy. all share similar meaning. Generally we call segmental mastectomy for billing. These procedures are for treatment and for clear margins when the patients have DCIS or invasive carcinoma diagnosed by core biopsy already.
Re-excision/re-segmental mastectomy (or re-excision segmentectomy): Patients have second segmental mastectomy procedure when surgical margins are positive or close to DCIS or invasive carcinoma in first segmental mastectomy specimen.Physician assistants or residents will inked segmental mastectomy or excisional biopsy specimens in 6 colors for superior, inferior, medial, lateral, anterior and posterior margins. Pathologists have to report the margin negative or positive in which margins. The surgeons know how and where they will do the re-excision.
Hope it helps.
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本帖最后由 于 2008-12-17 11:47:00 编辑
Breast invasive carcinoma template cqz (9)浸润性乳腺癌的病理报告格式
姓名，年龄，左右侧，XXXX
I am sending here generally how we sign out the invasive carcinoma for excision or mastectomy specimens.给大家看看，我们如何签发浸润性乳腺癌的乳房切除或切取标本的病理报告。
Below you can see what we describe in our final report.大家可以看一下我们在最终病理报告中描述哪些内容。
It is not neccesary for you to do the same also. Just for your referecne. 大家没有必要和我们完全一样，仅供参考。
I once studied and work in several hospitals in the US. 我曾经在美国的多家医院学习和工作过。
Every one is different in term of the report.每家医院的报告的形式和内容各有不同。
However, the priniciples are same.但是基本原则不变。
Breast (Re-)excision/mastectomy for invasive and in situ carcinoma
乳腺浸润癌或原位癌的乳房（二次）切取/乳房切除术
SECTION A (INVASIVE CA)
A 浸润癌
-Invasive ductal carcinoma,浸润性导管癌， _________,(no special type, pure mucinous type, pure tubular type etc.) type.（非特殊类型，单纯粘液型，单纯导管型等）型。
-Invasive ductal carcinoma, mixed __________(__%) and _________(___%) types.浸润性导管癌混合型，含有有 （%）和 （%）。
-Invasive lobular carcinoma, classical type, with a solid / alveolar / trabecular growth pattern(s).浸润性小叶癌，经典型，呈实性/腺泡状/小梁状生长。
-Invasive lobular carcinoma, pleomorphic type.浸润性小叶癌，多形性亚型。
-Invasive lobular carcinoma, mixed pleomorphic (___%) and classical (_____%) types.浸润性小叶癌，混合型，含有多形性（ %）和经典型（ %）型。
-Invasive mixed ductal and lobular carcinoma.浸润型混合性导管癌和小叶癌。
SECTION B (Grade)
B 分级
Nottingham Grade I / II / III (tubule formation: _____, nuclear pleomorphism: ________, mitotic activity: _______; total score: ___/9).诺丁汉分级I / II / III（小管形成： 分，核多形性： 分；核分裂活性： 分。总分 /9）。
SECTION C (Size)
C 肿瘤大小
The invasive tumor measures __________cm in largest dimension (give microscopic size if it is a small tumor; use the gross dimension for large tumor).浸润性肿瘤的最大径为 CM（如果肿瘤较小，提供显微镜下尺寸；如果肿瘤较大，使用大体测量）。
SECTION D (In-situ CA)
D 原位癌
Ductal carcinoma in situ (DCIS), nuclear grade
Lobular involvement by DCIS is present.出现导管原位癌累及小叶，The DCIS constitutes ____% of the total tumor mass, and is present admixed with and away from the invasive component / and is present admixed with the invasive component / and is present away from the invasive component.全部肿瘤中导管原位癌占____%，原位癌与浸润成分混杂以及分隔/原位癌与浸润成分混杂/原位癌与浸润成分相分隔。The DCIS is present in _____ of ______ slides (Give this information in cases of extensive intraductal component).导管原位癌出现在多少张切片中的几张（如果有广泛性的导管内成分，提供这一信息）。Lobular carcinoma in situ (LCIS) is also identified, with pagetoid extension into ducts.也有小叶原位癌，呈pagetoid样扩展进入导管。
SECTION E (Lympho-vascular space Invasion)
E 淋巴-脉管腔浸润
Lympho-vascular space invasion is identified.有淋巴-血管腔浸润
No lympho-vascular space invasion is noted.无淋巴-血管腔浸润
SECTION F (Surgical Margins)
F 手术切缘
Negative:
手术切缘阴性：
Resection margins are negative for carcinoma.手术切缘未见癌。
Resection margins are negative for invasive carcinoma.手术切缘未见浸润癌。
Resection margins are negative for ductal carcinoma in situ.手术切缘未见导管原位癌。
Invasive carcinoma is _____cm from the nearest _________marigin.浸润癌距离最近___切缘____cm。
Ductal carcinoma in situ is ______cm from the nearest ____________________marigin. 导管原位癌距离最近___切缘____cm。
Pleomorphic lobular carcinoma in situ is _______ cm from the nearest ____________________marigin. 多形性小叶原位癌距离最近___切缘____cm。
Positive:
手术切缘阳性：
Rare / A few / Multiple focus/foci of invasive carcinoma extends to the ____________________ margin(s).偶见/少许/单灶/多灶性浸润癌扩展到____切缘。
Rare / A few / Multiple foci of ductal carcinoma in situ extends to the _____________________ margin(s). 偶见/少许/单灶/多灶/导管原位癌扩展到____切缘。
Rare / A few / Multiple foci of pleomorphic lobular carcinoma in situ extends to the _________________ margin(s). 偶见/少许/单灶/多灶/多形性小叶原位癌扩展到____切缘。
Do not report the margin for classic lobular carcinoma in situ.经典型小叶原位癌不报告切缘。
Negative inked margins but tumor <
墨汁标记的切缘阴性，但肿瘤距离切缘小于
Inked margins are negative for carcinoma.墨汁标记的切缘未见癌。 However, rare / a few / multiple focus/foci of invasive carcinoma is/are <
Inked margins are negative for carcinoma. 墨汁标记的切缘未见癌。However, rare / a few / multiple focus/foci of ductal carcinoma in situ is/are <
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本帖最后由 于 2008-12-18 21:17:00 编辑
Continue:
Inked margins are negative for carcinoma. However, rare / a few / multiple focus/foci of pleomorphic lobular carcinoma in situ is/are <1mm to the _________________ margin(s).
墨汁标记的切缘未见癌。但是，少许/一些/多灶/局灶的多形性小叶癌距离____切缘<1mm。
SECTION G (Tumor Location, for mastectomy only)
G 肿瘤位置（仅乳房切除标本）
The invasive carcinoma is located in the UOQ / UIQ / LOQ / LIQ / central area (or give clock position).
浸润性癌位于外上象限 / 内上象限 /外下象限 /内下象限 / 中央部位 (或提供时钟位)。
SECTION H (Nipple, for mastectomy only)
H 乳头（仅乳房切除标本）
Nipple is negative for tumor
乳头无肿瘤
The nipple epidermis is involved by ductal carcinoma in situ (Paget disease).
乳头表皮被DCIS累犯（Paget病）。
The nipple is involved by invasive carcinoma.
乳头被浸润性癌累犯。
SECTION I (Skin)
I 皮肤
Skin is negative for tumor.
皮肤无肿瘤。
The skin is involved by invasive carcinoma by direct extension.
皮肤被浸润性癌累犯，直接扩散。
The skin shows tumor emboli in the dermal lymphatic channels.
皮肤的真皮淋巴管内见肿瘤栓子。
SECTION J (Skeletal muscle)
J 骨骼肌
The attached skeletal muscle is negative for tumor.
附属的骨骼肌无肿瘤。
The attached skeletal muscle is involved by invasive carcinoma by direct extension.
附属的骨骼肌被浸润性癌累犯，直接扩散。
SECTION K (Atypical proliferation)
K 不典型增生
Atypical ductal hyperplasia.
不典型导管增生。
Atypical lobular hyperplasia.
不典型小叶增生。
SECTION L (Benign lesions)
L 良性病变
Calcifications are associated with in situ carcinoma / invasive carcinoma / and/or in benign breast parenchyma.
钙化伴原位癌/浸润癌或良性乳房间质中。
The non-neoplastic breast shows ____________________________________________.
非肿瘤性乳房呈________病变。
Previous biopsy site changes.
以前活检部位引起的改变。
SECTION M (Lymph nodes for MRM specimens only)
M 淋巴结（仅MRM标本）
_____ axillary lymph nodes, negative for metastatic tumor (0/___).
共__枚腋窝淋巴结，无转移性肿瘤（0/__）。
Metastatic carcinoma involving ______ of _______ lymph nodes (___/___).
转移性癌累犯__枚淋巴结中的__枚（__/__）。
The largest metastatic focus measures______cm.
最大转移灶大小__cm。
No extracapsular extension identified.
未见包膜外扩散。
Extracapsular extension identified.
见包膜外扩散。
SECTION N (Receptor studies)
N 受体研究
The invasive tumor cells are _________ for Estrogen and Progesterone Receptors and _________ for HER2, as per previous pathology report (case number______________).
浸润性肿瘤细胞对ER和PR及HER2分别为__，__和__，见以前的病理报告（病例号____）。
Please do stains if not performed previously.
如果以前未做过，请做这些免疫染色。
（abin译）
