Hallo all,

nein, es wurde bei der OP kein Lymphknoten entfernt, nur der Tumor in der Brust großflächig entnommen.

Unten wurde ein Lletz entnommen, was übersetzt eine Gewebeprobe ist, so der unter Zipfel von beiden Seiten des Gebärmutterhalses.

Die histologischen Berichte kann ich gerne stellen, sie sind aber in englisch.

Clinical History:

Lletz bx - extensive CIN III, incompletely excised due to the extent of the superficial involvement.

A: Unlabelled w.r. t site: a 3 scoop Lletz biopsy, the main scoop contains the endocervical canal and measures 16 x 15 mm x 7mm deep. The remaining 2 measure 18 mm and 15 mm in diameter respectively. A1 = smallest scoop.

B. Unlabelled w.r.t. site: a mass of breast tissue measuring 70 x 65 x 40 mm and overlying ellipse of skin measuring 55mm in length. B1 = nodule to deep margin; B3 = nodule to superior margin.

Macroscopy:

A: @P229Y CERVIX - Cone and Lletz Proforma:

Lletz biopsy of cervix - measurd macroscopy

Microscopy:

Wart virus (HPV) infection:
- HPV associated features
- 6 out of 6 blocks involved

CIN (cervical intra-epithelial neoplasia)
- (HSIL) CIN III

Number of locks involed:
- 6 out of 6

Enocervical epithelium:
- normal

Endocervical edge:
- involved (CIN III - into crypts)

Endocervical edge:
- involved (CIN III)

Deep lateral edge:
- clear

Extension down crypts:
- present

Transformation zone identified in 5 of 6 blocks

Additional findings:
- chronic inflamation

B: @P243C BREAST - Lumpectomy:

Lumpectomy
Tumour location:
- left Breast

Tumour Quadrant:
sannot be assessed

Tumour size:
Gross = 33mm
microscopic = 33mm

Tumour type:
- Ductal carcinoma (NOS):

Grade:
Tubule formation: = 3/3
Mitotic count = 2/3
nuclear grade = 2/3
Total = 7/9, corresponds to a grade II infiltrating ductal carcinoma (revised bloom and richardson)

Resection margins of invasive tumour: clear
closest resection margin:
Deep 3mm
superior margin = 5mm away from infiltrative tumour.

nipple: (if present) no present

skin infiltration: absent
lymphovascular infiltration: present (several foci are noted)

perineural infiltration: absent
multifocal: (more than one quadrant) one quadrant only

receptors: tissue will be sent to Cape Town for relevant receptor analysis and an addendum report will follow.

Carcinoma in-situ: Carcinoma in situ present

Type: Ductal carcinoma in situ, solid
Comedonecrosis: absent
% of whole tumour represented by carcinoma in situ: <10%

resection margins of carcinoma in situ: clear

Rest of Breast: fibrocystic change
axiliary dessection: not done

A: The presence of high grade intra-epithelial dysplasia (CIN II - III) is confirmed in all fragments of the cervix submitted. The endocervical resection margin of the Lletz biopsy and the extocervical margins of the remaining biopsies are all involved by high grade intra-epithelial dysplasia. Further resection is therefore advesid.

B: The features present are those of a Grade 2 infiltrating duct carcinoma of the (l) breast. The tumour has been completly excised. A small component of duct carcinoma in-situ is noted, but has also been fully exxcised. An addendum report regarding receptor analysis will follow.

Diagnosis
a - cervical lletz biopsy:
CIN II - III & HPV features, not fully exised.

b - left breast lumpectomy: infiltrative grade 2 duct carcinoma & carcinoma in-situ, fully excised.

Ich hoffe mal da sind jetzt keine Rechtschreibfehler drin, mit lieben Grüßen

Karin