Breast - Pathology

This is the site specific section for additional breast cancer specific data items to be recorded. These will be aligned within the schema to form a single report.

May be up to one occurrence per pathology report (0..1)

Multifocal Tumour Indicator (Breast)

Is there more than one discrete tumour identified in the same breast?

Note:

• all the national code definitions have been updated to meet the ‘RCPath Core’ data set

DCIS grade

If ductal carcinoma in situ is present, record the DCIS grade. This is the cytonuclear grade.

Note:

• the national code definition for ‘X’ has been updated meet the ‘RC Path Core’ data set

DCIS/pleomorphic or DCIS like LCIS Size

Record the size of the non-invasive tumour in mm. This is only required if there is no invasive component.

Notes:

• for COSD reporting purposes, this data item can be submitted to 2 decimal places
• the data item name has been updated in v4 to match the ‘RCPath Core’ data set

Whole Tumour (Invasive + DCIS) Size

Record the whole size of the tumour (invasive + surrounding DCIS, if DCIS extends >1mm beyond invasive) (mm) (For tumours without a DCIS component this will be the same as invasive lesion size).

Notes:

• for COSD reporting purposes, this data item can be submitted to 2 decimal places
• the data item name has been updated in v4 to match the ‘RCPath Core’ data set

Metastasis Extent Code

For single node positivity, specify micrometastatic status as follows: Greater than 2mm = Metastases, 2mm to greater than 0.2mm = Micrometastasis, less than or equal to 0.2mm = Isolated tumour cells.

Notes:

• ‘1 - Metastasis’ has been removed from the data set from v4
• ‘3 - Isolated tumour cells (ITCs)’ national code definition has been updated meet the ‘RCPath Core’ data set
• ‘4 - Macrometastasis’ is a new attribute in v4

Distance to Margin

Distance to closest relevant margin (mm). Distance to nearest radial margin whether invasive or non-invasive. (For COSD measurement to the nearest mm is sufficient but may be recorded to nearest tenth of mm).

ER Allred Score

ER Allred score (range 0, 2 -8). This is now an optional data item from v4 as it is not in the ‘RC Path Core’ data set.

ER Status

Oestrogen Receptor (ER) status. (A positive score means that oestrogen is causing the tumour to grow, and a negative score means that the tumour is not driven by oestrogen).

Note:

• ‘P’ and ‘N’ national code definitions have been updated meet the ‘RCPath Core’ data set

PR Allred Score

Record the 'PR Allred score' if known. (Range 0, 2-8). This is now an optional data item from v4 as it is not in the ‘RC Path Core’ data set.

PR Status

Progesterone Receptor Status. Record the PR status if known. This is now an optional data item from v4 as it is not in the ‘RC Path Core’ data set.

HER2 Status

HER2 Immunohistochemical status (Human Epidermal Growth Factor Receptor 2). Where the initial result of this test is ‘Borderline’, a further report will follow with result of the ISH test.

Notes:

• ‘N - Negative’ has been removed from the data set from v4
• ‘N1’ and ‘N2’ are new attributes for v4
• ‘B’ and ‘P’ national code definitions have been updated meet the ‘RCPath Core’ data set

HER2 ISH Status

Record the result of the ISH (in situ hybridization) test. This is only required if the initial HER2 status is ‘Borderline’.

Notes:

• ‘P’ and ‘N’ national code definitions have been updated meet the ‘RCPath Core’ data set
• ‘B’ and ‘X’ are new attributes for v4

Cytology (Breast)

Cytology opinion (Breast).

Cytology (Node)

Cytology opinion on axillary lymph node.

Core Biopsy (Breast)

Needle core biopsy opinion.

Notes:

• ‘B1’ national code definition has been updated meet the ‘RCPath Core’ data set
• ‘B3’ has been removed from the data set from v4
• ‘B3a’ and ‘B3b’ are new attributes for v4

Core Biopsy (Node)

Needle biopsy opinion on axillary lymph node.

Notes:

• ‘B1’, ‘B2’, ‘B3’, ‘B4’ and ‘B5’ have been removed from the data set from v4
• ‘LB1’, ‘LB2’, ‘LB3’, ‘LB4’ and ’LB5’ are new attributes for v4