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Pathology Reporting of Breast Disease

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Pathology Reporting of Breast Disease Pathology Reporting of Breast Disease Version History Version Date Summary of Change/Process 1.1 December Reviewed by Breast Network Site Specific Group where it 2011 was agreed to continue with the National document for a further 18 months 2.0 February Prepared for distribution and uploaded to Pan Birmingham 2012 Cancer Network website Date Approved by Network Governance February 2012 Date for Review July 2013 This is a national document produced by the Royal College of Pathologists (www.rcpath.org) and is the latest version. ENDORSED BY GOVERNANCE COMMITTEE S:\Guidelines\Guidelines And Pathways By Speciality\Breast\Current Approved Versions (Word And PDF)\Pathology Reporting Of Breast Disease (Front Sheet) - Version 2 0.Doc Page 1 of 3 1. Scope of the guideline This guidance has been produced to support the following: This document is intended to provide guidance when reporting Breast Disease pathology. 2. Guideline background At Breast Network Site Specific Group (NSSG) meetings, the group acknowledged the need for pathology guidance for breast disease. The NSSG recommended the guidance produced by the Royal College of Pathologists and the NHS Breast Screening Programme and the Breast NSSG agreed to adopt this guidance. Monitoring of the guideline Adherence to the Network guidelines may from time to time be formally monitored. Authors NHS Breast Screening Programme and The Royal College of Pathologists. References http://www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp58- lowresolution.pdf ENDORSED BY GOVERNANCE COMMITTEE S:\Guidelines\Guidelines And Pathways By Speciality\Breast\Current Approved Versions (Word And PDF)\Pathology Reporting Of Breast Disease (Front Sheet) - Version 2 0.Doc Page 2 of 3 Approval Signatures Pan Birmingham Cancer Network Governance Committee Chair Name: Karen Deeny Signature Date: February 2012 Pan Birmingham Cancer Network Manager Name: Karen Metcalf Signature: Date: February 2012 Network Site Specific Group Clinical Chair Name: Alan Jewkes Signature: Date: February 2012 ENDORSED BY GOVERNANCE COMMITTEE S:\Guidelines\Guidelines And Pathways By Speciality\Breast\Current Approved Versions (Word And PDF)\Pathology Reporting Of Breast Disease (Front Sheet) - Version 2 0.Doc Page 3 of 3 PATHOLOGY REPORTING OF BREAST DISEASE A Joint Document Incorporating the Third Edition of the NHS Breast Screening Programme’s Guidelines for Pathology Reporting in Breast Cancer Screening and the Second Edition of The Royal College of Pathologists’ Minimum Dataset for Breast Cancer Histopathology NHSBSP Publication No 58 January 2005 Published by the NHS Cancer Screening Programmes jointly with The Royal College of Pathologists NHS Cancer Screening Programmes The Manor House 260 Ecclesall Road South Sheffield S11 9PS Tel: 0114 271 1060 Fax: 0114 271 1089 Email: [email protected] Web site: www.cancerscreening.nhs.uk The Royal College of Pathologists 2 Carlton House Terrace London SW1Y 5AF Tel: 020 7451 6700 Fax: 020 7451 6701 Email: [email protected] Web site: www.rcpath.org © NHS Cancer Screening Programmes and The Royal College of Pathologists 2005 The contents of this document may be copied for use by staff working in the public sector but may not be copied for any other purpose without prior permission from the NHS Cancer Screening Programmes and The Royal College of Pathologists. Permission to reproduce the Minimum Dataset for Breast Cancer Histopathology should be sought from The Royal College of Pathologists. Permission to reproduce any other content should be sought from the NHS Cancer Screening Programmes. ISBN 1 84463 015 3 A copy of this publication is available as a PDF on the NHS Cancer Screening Programmes website (www.cancerscreening.org.uk) and The Royal College of Pathologists’ website (www.rcpath.org). Further copies of this publication are available from the Department of Health Publications Orderline quoting NHSBSP Publication No 58. Tel: 08701 555 455 Fax: 01623 724 524 Email: [email protected] Typeset by Prepress Projects Ltd, Perth (www.prepress-projects.co.uk) Printed by Charlesworth, Wakefield Pathology Reporting of Breast Disease CONTENTS Page No WRITING GROUP vii PREFACE 1 1. SPECIMEN HANDLING 5 2. SURGICAL HANDLING 6 3. LABORATORY HANDLING 8 4. DIAGNOSTIC LOCALISATION BIOPSIES 9 5. THERAPEUTIC WIDE LOCAL EXCISIONS 10 5.1 Method 1: serial slicing perpendicular to the medial–lateral plane 10 5.2 Method 2: serial slicing perpendicular to the superficial–deep plane 12 5.3 Method 3: radial block examination, with or without shave margin 12 6. RE-EXCISION SPECIMENS 14 7. MASTECTOMY SPECIMENS 15 8. PATHOLOGICAL EXAMINATION OF LYMPH NODES 16 8.1 Background 16 8.2 Lymph node sample specimens, including sentinel node samples 16 8.3 Axillary clearance specimens 16 8.4 Sentinel lymph node biopsy samples 17 8.5 Additional techniques for the examination of lymph nodes 17 8.6 Frozen section examination 18 9. NHSBSP HISTOPATHOLOGY REPORTING FORM 19 10. MINIMUM DATASET FOR BREAST CANCER HISTOPATHOLOGY 22 11. RECORDING BASIC INFORMATION 24 11.1 Pathologist 24 11.2 Date 24 11.3 Side 24 11.4 Specimen radiograph seen? 24 11.5 Mammographic abnormality present in specimen? 24 11.6 Histological calcification 24 NHSBSP January 2005 iii Pathology Reporting of Breast Disease 11.7 Specimen type 24 11.8 Specimen weight 24 11.9 Benign/malignant lesion present 24 12. CLASSIFYING BENIGN LESIONS 25 12.1 Complex sclerosing lesion/radial scar 25 12.2 Fibroadenoma 25 12.3 Papilloma 29 12.4 Periductal mastitis/duct ectasia (plasma cell mastitis) 33 12.5 Fibrocystic change 34 12.6 Sclerosing adenosis 35 12.7 Solitary cyst 37 12.8 Columnar cell change 37 12.9 Other (specify) 40 13. CLASSIFYING EPITHELIAL PROLIFERATION 41 13.1 Not present 41 13.2 Present without atypia 41 13.3 Present with atypia (ductal) 44 13.4 Atypical lobular hyperplasia and lobular carcinoma in situ (in situ lobular neoplasia) 44 14. CLASSIFYING MALIGNANT NON-INVASIVE LESIONS 50 14.1 Ductal carcinoma in situ 50 14.2 Paget’s disease of the nipple 59 14.3 Microinvasive carcinoma 59 15. CLASSIFYING INVASIVE CARCINOMA 61 15.1 No special type 61 15.2 Pure special type 61 15.3 Mixed tumour type 61 15.4 Morphological type 61 15.5 Other malignant tumour 69 15.6 Not assessable 69 16. TUMOUR SIZE 70 16.1 Invasive tumour size 70 16.2 In situ (DCIS) size 72 16.3 Whole tumour size 72 16.4 Tumour extent 72 17. HISTOLOGICAL GRADE 74 17.1 Tubule/acinar formation 76 17.2 Nuclear atypia/pleomorphism 77 17.3 Mitoses 78 17.4 Overall grade 79 NHSBSP January 2005 iv Pathology Reporting of Breast Disease 18. VASCULAR INVASION 81 19. LYMPH NODE STAGE 83 19.1 Reporting and definitions of micrometastatic disease and isolated tumour cells 83 20. EXCISION MARGINS 84 20.1 Invasive carcinoma 84 20.2 DCIS and invasive carcinoma with an extensive in situ component 84 21. STEROID RECEPTORS 86 21.1 Recommendations for steroid receptor testing 86 21.2 Principles 86 21.3 Scoring 87 21.4 Ductal carcinoma in situ 87 21.5 Testing predictive factors 87 22. COMMENTS/ADDITIONAL INFORMATION 88 23. FINAL HISTOLOGICAL DIAGNOSIS 89 24. SNOMED CODING 90 REFERENCES 91 APPENDIX 1: UPDATED RCPath GUIDELINES ON WORKLOAD FOR BREAST PATHOLOGY 97 APPENDIX 2: WIDE BORE NEEDLE BIOPSY FORM 99 APPENDIX 3: SYNOPTIC REPORTS 103 APPENDIX 4: INDEX FOR SCREENING OFFICE PATHOLOGY SYSTEM 109 APPENDIX 5: TNM CLASSIFICATION OF TUMOURS OF THE BREAST 114 APPENDIX 6: Updated RECOMMENDATIONS FOR HER2 TESTING IN THE UK 118 APPENDIX 7: QUALITY ASSURANCE FOR OESTROGEN RECEPTORS AND PROGESTERONE RECEPTORS 127 APPENDIX 8: QUALITY ASSURANCE FOR HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2 (HER2) IMMUNOHISTOCHEMICAL ASSAYS 129 APPENDIX 9: NOTTINGHAM PROGNOSTIC INDEX 131 APPENDIX 10: SUGGESTED SNOMED CODES FOR BREAST PATHOLOGY 132 NHSBSP January 2005 v Pathology Reporting of Breast Disease NHSBSP January 2005 vi Pathology Reporting of Breast Disease WRITING GROUP Chairman Professor IO Ellis Professor of Cancer Pathology University of Nottingham Department of Histopathology Nottingham City Hospital Hucknall Road Nottingham NG5 1PB Deputy Chairman Dr SE Pinder Consultant Pathologist Histopathology Department Addenbrooke’s Hospital Hills Road Cambridge CB2 2QQ Dr L Bobrow Consultant Pathologist Addenbrooke’s Hospital Hills Road Cambridge CB2 2QQ Dr ID Buley Consultant Pathologist Department of Cellular Pathology (Level 1) The John Radcliffe Hospital Headington Oxford OX3 9DU Dr J Coyne Consultant Pathologist Withington Hospital West Didsbury Manchester M20 8LR Dr JJ Going Consultant Pathologist University Department of Pathology Glasgow Royal Infirmary 84 Castle Street Glasgow G4 0SF Dr S Humphreys Consultant Pathologist Department of Cellular Pathology Preston Hall Hospital Maidstone Kent ME20 7NH Dr B Jasani Consultant Pathologist Department of Pathology University of Wales College of Medicine Heath Park Cardiff CF4 4XN NHSBSP January 2005 vii Pathology Reporting of Breast Disease Professor S Lakhani Consultant Pathologist Breakthrough Toby Robins Breast Cancer Research Centre Institute of Cancer Research Mary Jean Mitchell Green Building Chester Beatty Laboratories Fulham Road London SW3 6JB Dr J Lowe Consultant Pathologist Bradford Royal Infirmary Duckworth Lane Bradford West Yorkshire BD9 6RJ Mr K Miller UK NEQAS for Immunocytochemistry Department of Histopathology University College London Medical School University Street London WC1E 6JJ Dr A Rhodes UK NEQAS for Immunocytochemistry Consultant Pathologist Department of Histopathology University College London Medical School University Street London WC1E 6JJ Professor RA Walker Consultant Pathologist Department of Histopathology University of Leicester School of Medicine Robert Kilpatrick Clinical Sciences Building Leicester Royal Infirmary PO Box 65 Leicester LE2 7LX Dr CA Wells Consultant Pathologist St Bartholomew’s Hospital West Smithfield London EC1A 7BE The authors of this document are members of the Guidelines Working Group of the National Coordinating Committee for Breast Pathology, which is responsible for pathology quality assurance for the National Health Service Breast Screening Programme (NHSBSP) and for prepa- ration of minimum dataset standards in breast cancer histopathology for The Royal College of Pathologists.
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