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pathology-report.pdf

Viewer

JSON

report_date

2024-03-22

accession_number

S24-12345

patient_name

Margaret A. Wilson

patient_dob

1958-02-14

patient_gender

Female

medical_record_number

MRN-2024-55678

ordering_physician

Dr. Steven Richards, MD

ordering_physician_npi

1593572468

specimen_received_date

2024-03-20

specimen_source

Right breast, lumpectomy

clinical_history

56-year-old female with suspicious mass detected on mammogram. BIRADS 4C. Core biopsy positive for invasive ductal carcinoma.

procedure_performed

Lumpectomy with sentinel lymph node biopsy

procedure_cpt

19301

gross_description

Received fresh, labeled 'right breast lumpectomy' is an oriented breast specimen measuring 6.5 x 4.2 x 3.8 cm. Inked margins: superior-blue, inferior-green, medial-black, lateral-orange. Serial sectioning reveals a firm, stellate, tan-white mass measuring 2.1 x 1.8 x 1.5 cm.

microscopic_description

Sections show infiltrating ductal carcinoma, moderately differentiated. Tumor cells arranged in cords and nests with moderate nuclear pleomorphism. Mitotic figures present (8/10 HPF). No lymphovascular invasion identified. Surgical margins negative, closest margin 0.5 cm (inferior).

Diagnosis

2 items

finding

icd10_code

Invasive ductal carcinoma, moderately differentiated (Grade 2)

C50.911

Sentinel lymph node negative for metastasis (0/2)

C77.3

tumor_staging

tumor_size_cm: 2.1, pathologic_t_stage: pT2, pathologic_n_stage: pN0(sn), histologic_grade: Grade 2 (Nottingham score 6/9), margins: Negative, closest 0.5 cm

biomarkers

er_status: Positive (95%), pr_status: Positive (80%), her2_status: Negative (IHC 1+), ki67_index: 15%

pathologist_name

Dr. Jennifer Lee, MD

pathologist_npi

1357924680

electronically_signed_date

2024-03-22

{ "report_date": "2024-03-22", "accession_number": "S24-12345", "patient_name": "Margaret A. Wilson", "patient_dob": "1958-02-14", "patient_gender": "Female", "medical_record_number": "MRN-2024-55678", "ordering_physician": "Dr. Steven Richards, MD", "ordering_physician_npi": "1593572468", "specimen_received_date": "2024-03-20", "specimen_source": "Right breast, lumpectomy", "clinical_history": "56-year-old female with suspicious mass detected on mammogram. BIRADS 4C. Core biopsy positive for invasive ductal carcinoma.", "procedure_performed": "Lumpectomy with sentinel lymph node biopsy", "procedure_cpt": "19301", "gross_description": "Received fresh, labeled 'right breast lumpectomy' is an oriented breast specimen measuring 6.5 x 4.2 x 3.8 cm. Inked margins: superior-blue, inferior-green, medial-black, lateral-orange. Serial sectioning reveals a firm, stellate, tan-white mass measuring 2.1 x 1.8 x 1.5 cm.", "microscopic_description": "Sections show infiltrating ductal carcinoma, moderately differentiated. Tumor cells arranged in cords and nests with moderate nuclear pleomorphism. Mitotic figures present (8/10 HPF). No lymphovascular invasion identified. Surgical margins negative, closest margin 0.5 cm (inferior).", "diagnosis": [ { "finding": "Invasive ductal carcinoma, moderately differentiated (Grade 2)", "icd10_code": "C50.911"}, { "finding": "Sentinel lymph node negative for metastasis (0/2)", "icd10_code": "C77.3"} ], "tumor_staging": { "tumor_size_cm": 2.1, "pathologic_t_stage": "pT2", "pathologic_n_stage": "pN0(sn)", "histologic_grade": "Grade 2 (Nottingham score 6/9)", "margins": "Negative, closest 0.5 cm"}, "biomarkers": { "er_status": "Positive (95%)", "pr_status": "Positive (80%)", "her2_status": "Negative (IHC 1+)", "ki67_index": "15%"}, "pathologist_name": "Dr. Jennifer Lee, MD", "pathologist_npi": "1357924680", "electronically_signed_date": "2024-03-22"}

pathology-report.pdf

Viewer

JSON

report_date

2024-03-22

accession_number

S24-12345

patient_name

Margaret A. Wilson

patient_dob

1958-02-14

patient_gender

Female

medical_record_number

MRN-2024-55678

ordering_physician

Dr. Steven Richards, MD

ordering_physician_npi

1593572468

specimen_received_date

2024-03-20

specimen_source

Right breast, lumpectomy

clinical_history

56-year-old female with suspicious mass detected on mammogram. BIRADS 4C. Core biopsy positive for invasive ductal carcinoma.

procedure_performed

Lumpectomy with sentinel lymph node biopsy

procedure_cpt

19301

gross_description

Received fresh, labeled 'right breast lumpectomy' is an oriented breast specimen measuring 6.5 x 4.2 x 3.8 cm. Inked margins: superior-blue, inferior-green, medial-black, lateral-orange. Serial sectioning reveals a firm, stellate, tan-white mass measuring 2.1 x 1.8 x 1.5 cm.

microscopic_description

Sections show infiltrating ductal carcinoma, moderately differentiated. Tumor cells arranged in cords and nests with moderate nuclear pleomorphism. Mitotic figures present (8/10 HPF). No lymphovascular invasion identified. Surgical margins negative, closest margin 0.5 cm (inferior).

Diagnosis

2 items

finding

icd10_code

Invasive ductal carcinoma, moderately differentiated (Grade 2)

C50.911

Sentinel lymph node negative for metastasis (0/2)

C77.3

tumor_staging

tumor_size_cm: 2.1, pathologic_t_stage: pT2, pathologic_n_stage: pN0(sn), histologic_grade: Grade 2 (Nottingham score 6/9), margins: Negative, closest 0.5 cm

biomarkers

er_status: Positive (95%), pr_status: Positive (80%), her2_status: Negative (IHC 1+), ki67_index: 15%

pathologist_name

Dr. Jennifer Lee, MD

pathologist_npi

1357924680

electronically_signed_date

2024-03-22

{ "report_date": "2024-03-22", "accession_number": "S24-12345", "patient_name": "Margaret A. Wilson", "patient_dob": "1958-02-14", "patient_gender": "Female", "medical_record_number": "MRN-2024-55678", "ordering_physician": "Dr. Steven Richards, MD", "ordering_physician_npi": "1593572468", "specimen_received_date": "2024-03-20", "specimen_source": "Right breast, lumpectomy", "clinical_history": "56-year-old female with suspicious mass detected on mammogram. BIRADS 4C. Core biopsy positive for invasive ductal carcinoma.", "procedure_performed": "Lumpectomy with sentinel lymph node biopsy", "procedure_cpt": "19301", "gross_description": "Received fresh, labeled 'right breast lumpectomy' is an oriented breast specimen measuring 6.5 x 4.2 x 3.8 cm. Inked margins: superior-blue, inferior-green, medial-black, lateral-orange. Serial sectioning reveals a firm, stellate, tan-white mass measuring 2.1 x 1.8 x 1.5 cm.", "microscopic_description": "Sections show infiltrating ductal carcinoma, moderately differentiated. Tumor cells arranged in cords and nests with moderate nuclear pleomorphism. Mitotic figures present (8/10 HPF). No lymphovascular invasion identified. Surgical margins negative, closest margin 0.5 cm (inferior).", "diagnosis": [ { "finding": "Invasive ductal carcinoma, moderately differentiated (Grade 2)", "icd10_code": "C50.911"}, { "finding": "Sentinel lymph node negative for metastasis (0/2)", "icd10_code": "C77.3"} ], "tumor_staging": { "tumor_size_cm": 2.1, "pathologic_t_stage": "pT2", "pathologic_n_stage": "pN0(sn)", "histologic_grade": "Grade 2 (Nottingham score 6/9)", "margins": "Negative, closest 0.5 cm"}, "biomarkers": { "er_status": "Positive (95%)", "pr_status": "Positive (80%)", "her2_status": "Negative (IHC 1+)", "ki67_index": "15%"}, "pathologist_name": "Dr. Jennifer Lee, MD", "pathologist_npi": "1357924680", "electronically_signed_date": "2024-03-22"}

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