Procedure Type:

Lymph Node Sampling:

Specimen Integrity:

Specimen Size (for excisions less than total mastectomy)

Specimen Laterality:

Tumor Site:


Size (Extent) of DCIS:

Histologic Type: Ductal carcinoma in situ,

Architectural Patterns:

Nuclear Grade:



Treatment Effect: Response to Presurgical (Neoadjuvant) Therapy:

Pathologic Staging (pTNM)

TNM Descriptors (required only if applicable) (select all that apply)

Primary Tumor (pT):

Regional Lymph Nodes (pN) (choose a category based on lymph nodes received with the specimen; immunohistochemistry and/or molecular studies are not required)
Note: If internal mammary lymph nodes, infraclavicular nodes, or supraclavicular lymph nodes are included in the specimen, consult the AJCC Staging Manual for additional lymph node categories.

Modifier (required only if applicable)

Category (pN):

# Approximately 1000 tumor cells are contained in a 3-dimensional 0.2-mm cluster. Thus, if more than 200 individual tumor cells are identified as single dispersed tumor cells or as a nearly confluent elliptical or spherical focus in a single histologic section of a lymph node, there is a high probability that more than 1000 cells are present in the lymph node. In these situations, the node should be classified as containing a micrometastasis (pN1mi). Cells in different lymph node cross-sections or longitudinal sections or levels of the block are not added together; the 200 cells must be in a single node profile even if the node has been thinly sectioned into multiple slices. It is recognized that there is substantial overlap between the upper limit of the ITC and the lower limit of the micrometastasis categories due to inherent limitations in pathologic nodal evaluation and detection of minimal tumor burden in lymph nodes. Thus, the threshold of 200 cells in a single cross-section is a guideline to help pathologists distinguish between these 2 categories. The pathologist should use judgment regarding whether it is likely that the cluster of cells represents a true micrometastasis or is simply a small group of isolated tumor cells.

Distant Metastasis (M):

Note: The presence of distant metastases in a case of DCIS would be very unusual. Additional sampling to identify invasive carcinoma in the breast or additional history to document a prior or synchronous invasive carcinoma is advised in the evaluation of such cases.

Ancillary Studies

Estrogen Receptor (results of special studies performed on this specimen or a prior core needle biopsy):

Progesterone Receptor (results of special studies performed on this specimen or a prior core needle biopsy):


Clinical History:
The current clinical/radiologic breast findings for which this surgery is performed include: