Features to report

Last author update: 1 August 2012
Last staff update: 18 September 2020

Revised: 30 January 2019

Copyright: (c) 2001-2019,, Inc.

Editor's note

Monika Roychowdhury, M.D.
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Cite this page: Roychowdhury M Features to report. website. Accessed July 6th, 2022.
Required features to report
  • Specimen type / procedure
  • Lymph node sampling (specify)
  • Specimen size (third dimension is not required)
  • Laterality (if known)
  • Tumor site (if known)
  • Invasive tumor size (at least one dimension is required)
  • Invasive tumor histologic type
  • Invasive tumor grade (Nottingham modification of Bloom-Richardson), including tubule formation, nuclear pleomorphism and mitotic activity (should grade lobular carcinoma and colloid carcinoma, do not need to grade medullary carcinoma)
  • Note: if another grading system is used, must still specify mitotic count
  • TNM staging
  • Number of lymph nodes examined, number involved by tumor, maximal metastasis size and presence of extracapsular spread
  • Margins (distance of invasive and in situ tumor from closest margin, specify margin)
Optional features to report, but recommended
  • Angiolymphatic invasion (note: tumor in dermal lymphatics may be due to benign mechanical transport, Hum Pathol 2005;36:310)
  • Perineural invasion
  • Involvement of nipple, skin (epidermis or dermis) and chest wall
  • Multifocality
  • Presence of microcalcifications and correlation with mammography
  • Correlation of other findings with mammography
  • Extent of margin involvement (if positive)
  • DCIS (particularly if no invasive carcinoma present): size, morphologic type (architectural pattern), nuclear grade (high, intermediate, low), presence of comedocarcinoma (necrosis) and % of carcinoma represented by DCIS (25% or more is "extensive"); also margin involvement (focal or diffuse and distance to margin), presence of microcalcifications (within DCIS or elsewhere) and correlate with mammographic findings
  • For invasive carcinoma: % of cells staining for ER and PR and intensity of staining (weak, moderate, strong)
  • For invasive carcinoma: HER2 staining (0 / negative, 1+ / weak, 2+ / partial circumferential staining and 3+ / strong circumferential staining visible at low power)
  • Fibrocystic disease
  • Presence of ADH, ALH or LCIS
Optional features to report
Quality of reporting
  • Improved in Australia after guidelines were issued; synoptic reports are more complete (Pathology 2009;41:361)
Microscopic (histologic) images

AFIP images

DCIS close to inked margin

DCIS with a positive margin

DCIS at (or a basement
membrane away from)
the inked margin

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