Cancer Synoptic Report (Breast Resection)

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Accession Number: [Pathology accession number]

Specimen Collection Date: [Collection date]

Report Date: [Sign-out date]

Pathologist: [Pathologist name, credentials]

Specimens Submitted

(List each specimen part with label as received, specimen type, laterality, and orientation markers if provided.)

• [Part label as received]: [breast excision / total mastectomy / skin-sparing mastectomy / nipple-sparing mastectomy / re-excision cavity / sentinel lymph node(s) / axillary contents / margin shaves / other: [specify]]; Laterality: [left / right / bilateral / Not specified]; Orientation markers: [sutures/clips/inks as stated / Not provided]
• (Repeat for additional parts as needed)

Clinical Information

Prior biopsy accession and diagnosis: [accession and diagnosis / Not provided]

Neoadjuvant therapy status: [Yes / No / Unknown] (Do not infer from histologic findings alone.)

Clinical tumor location: [quadrant / clock position / distance from nipple / Not provided]

Synoptic Report

(Use element-response pairs, one per line. Use millimeters for all measurements and percentages for biomarker positivity. For unavailable data, use "Not specified," "Not identified," "Not applicable," or "Cannot be determined" with brief explanation. Omit entire conditional subsections when trigger conditions are not met.)

Specimen

Procedure: [excision / total mastectomy / skin-sparing mastectomy / nipple-sparing mastectomy / modified radical mastectomy / re-excision cavity / other: [specify]]

Specimen laterality: [left / right / bilateral / Not specified]

Tumor site: [quadrant / clock position / subareolar / distance from nipple / Not specified]

Tumor - Invasive Carcinoma

(Include if invasive carcinoma is identified. If microinvasion only or no residual invasive carcinoma, state so and mark grade as Not applicable.)

Invasive carcinoma: [Present / Not identified]

Histologic type (WHO): [type / Not applicable]

Nottingham grade: Tubule formation [1 / 2 / 3]; Nuclear pleomorphism [1 / 2 / 3]; Mitotic rate [1 / 2 / 3]; Overall grade: [1 / 2 / 3 / Not applicable]

Largest invasive tumor size (mm): [measurement / Microinvasion only (≤1 mm) / No residual invasive carcinoma]

Tumor focality: [Single focus / Multiple foci]

If multiple foci, sizes of individual foci (mm): [list sizes / Not applicable]

Tumor - Ductal Carcinoma In Situ (DCIS)

(Include if DCIS is present, whether alone or associated with invasive carcinoma. Omit if DCIS not identified.)

DCIS: [Present / Not identified]

DCIS size/extent estimate (mm): [measurement]

Architectural patterns: [cribriform / solid / papillary / micropapillary / comedo / other: [specify]]

Nuclear grade: [I / II / III / Cannot be determined]

Necrosis: [None / Focal / Comedo-type / Cannot be determined]

Associated Findings

LCIS: [Not identified / Present]

Microcalcifications: [Not identified / Present]; Location: [within DCIS / within invasive carcinoma / in benign tissue / multiple locations]

Tumor Extent

(Include only if relevant structures are present in the specimen and involved. Omit entire subsection if not applicable.)

Skin involvement: [Not identified / Direct invasion / Ulceration / Satellite nodules]

Nipple involvement: [Not identified / Paget disease / Direct invasion]

Skeletal muscle involvement: [Not identified / Present]

Lymphovascular Invasion

Lymphovascular invasion (LVI): [Not identified / Present / Cannot be determined]

LVI extent (if present): [Focal / Extensive / Not applicable]

Dermal LVI (if skin present in specimen): [Not identified / Present / Not applicable]

Treatment Effect

(Include only if neoadjuvant therapy is explicitly documented.)

Treatment effect in breast: [No definite response / Partial response / Marked response / No residual invasive carcinoma (complete pathologic response)]

Treatment effect in lymph nodes: [No residual carcinoma / Residual carcinoma present / Not applicable]

Residual Cancer Burden (optional): RCB score: [value]; RCB class: [0 / I / II / III] (Include only if all parameters are available.)

Margins - Invasive Carcinoma

(Include if invasive carcinoma is present.)

Margin status (invasive): [All margins negative / Invasive carcinoma at margin / Cannot be determined]

Distance to closest margin (mm): [measurement / Not applicable]

Closest margin(s): [specify named margin(s) / Not applicable]

If positive, involved margin(s) and extent: [specify margin(s) and linear extent / Not applicable] (Positive margin = ink on invasive carcinoma.)

Margins - DCIS

(Include if DCIS is present. If specimen not oriented, state "Cannot orient specimen" and limit margin reporting accordingly.)

Margin status (DCIS): [All margins negative / DCIS at margin / Cannot be determined]

Distance to closest margin (mm): [measurement / Not applicable]

Closest margin(s): [specify named margin(s) / Not applicable]

Margins within 2 mm of DCIS: [specify margin(s) / None / Cannot be determined]

If positive, involved margin(s): [specify / Not applicable] (Positive margin = ink on DCIS.)

Regional Lymph Nodes

(If no nodes submitted, state "Not applicable" and omit remaining elements.)

Total lymph nodes examined: [number / Not applicable]

Sentinel lymph nodes examined: [number / Not applicable]

Number with macrometastases (>2 mm): [number]

Number with micrometastases (>0.2–2 mm): [number]

Number with isolated tumor cells (≤0.2 mm or ≤200 cells): [number] (Include ITCs only when no macro/micrometastases are present.)

Size of largest metastatic deposit (mm): [measurement / Not applicable]

Extranodal extension: [Not identified / Present / Cannot be determined]

Pathologic Stage (AJCC 8th Edition)

(Apply y prefix if post-neoadjuvant therapy.)

pT category: [pTis (DCIS) / pT1mi / pT1a / pT1b / pT1c / pT2 / pT3 / pT4a / pT4b / pT4c / pT4d]

pN category: [pN0 / pN0(i+) / pN0(mol+) / pN1mi / pN1a / pN1b / pN1c / pN2a / pN2b / pN3a / pN3b / pN3c]

pM category: [pM1 (specify site) / Not assessed - requires clinical correlation]

Stage group: [Stage [specify] / Cannot be assigned - requires clinical M status]

Biomarkers

(Report biomarkers from current specimen, prior specimen, or both. Clearly distinguish source. Do not imply retesting unless performed.)

Current specimen biomarkers: (Include only if performed on current specimen.)

ER: [Positive / Low Positive (1–10%) / Negative]; Percent positive: [%]; Intensity: [Weak / Moderate / Strong]; Internal control (required if low positive or negative): [Adequate / Inadequate]

PR: [Positive / Low Positive (1–10%) / Negative]; Percent positive: [%]; Intensity: [Weak / Moderate / Strong]; Internal control (required if negative): [Adequate / Inadequate]

HER2 IHC: [0 (Negative) / 1+ (Negative) / 2+ (Equivocal) / 3+ (Positive)]

HER2 ISH (if performed): [Amplified / Not amplified / Equivocal]; HER2/CEP17 ratio: [value]; Average HER2 signals per cell: [value]

Ki-67 (optional): [% labeling index / Not performed]

Cold ischemia/fixation compliance: [Meets guidelines / Does not meet guidelines / Unknown]

Biomarkers from prior specimen: (Include if applicable.)

Prior specimen: Accession [number]; Specimen type: [type]; Test date: [date]

ER (prior): [Positive / Low Positive / Negative]; Percent: [%]

PR (prior): [Positive / Low Positive / Negative]; Percent: [%]

HER2 (prior): [IHC score and ISH results if performed]

Comments

(Include only when needed: discordant biomarker results and action taken, multifocal tumors with differing characteristics, margin assessment limitations, nodal artifact concerns, basis for neoadjuvant context assumptions.)

[Comment text]

Addendum

(Use when results are pending at initial sign-out. Title appropriately and reference original report date.)

Addendum - [Title, e.g., Breast Biomarkers]: [Date of addendum, complete test results, method, pathologist name and credentials]