Pathology: Grade 1 infiltrating ductal carcinoma with associated DCIS, Lymphvascular invasion present. ER+, PR+. Her 2/ IHC 1+, negative

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1 GATRA 2016 Breast Case Demographics Name: Autumn Leaf Sex: F Date of Birth: 3/26/75 SSN: Race: African American Marital Status: Single Address: 3615 Burnt Hickory Trail, Helen, GA 37285, White County Phone: Insurance: AETNA PPO Reporting Hospital 39 year old single black female presents for MMG/Ultrasound of selfpalpated mass in right breast. Physical exam demonstrates a palpable mass in the upper outer quadrant of the right breast with no visible skin changes. No palpable lymphadenopathy. Reporting Hospital MMG/US Patient has palpable lump right breast MMG calcifications upper outer quadrant right breast, left breast wnl. Ultrasound multiple solid masses right breast 10:00, 7 cm from nipple. Largest 1.4 cm, second mass 1.2 cm. Mildly prominent lymph node in right axilla. Reporting Hospital/Dr XXXX right breast stereotactic core bx Pathology: Grade 1 infiltrating ductal carcinoma with associated DCIS, Lymphvascular invasion present. ER+, PR+. Her 2/ IHC 1+, negative Reporting Hospital Breast MRI clumped non mass enhancement lateral right breast extending into low axillary tail/posterior lateral chest wall, total extent of disease measures approximately 6 cm. Areas of enhancement on right pectoralis muscle suspicious for muscle invasion. Prominent right axillary lymph node. 1.4 cm lesion hepatic dome. Reporting Hospital PET/CT negative for mets; hypodensity in liver likely benign. Dr XXXX Ms. Leaf presents for consultation status post right breast biopsy positive for infiltrating ductal carcinoma with imaging suspicious for regional lymph node involvement. Due to multifocal disease a mastectomy is recommended. Ms. Leaf will follow with Dr. YYYY for reconstruction options. Surgery will be scheduled for next month. Reporting Hospital/Dr XXXX/Dr YYYY Right nipple sparing mastectomy/sln bx/reconstruction w/ tissue expander Dye injected, breast removed; at uoq right breast, it appears to include some axillary contents as there were multiple palpable areas in this area; however, there was no blue dye identified. No blue dye identified in the right axilla, though the level 1 & 2 regions were evaluated, no nodes were

2 seen & none dyed blue. There was a nodular area in level1 that was excised suspected to be a lymph node. Pathology: Right sentinel lymph node frozen section: positive for infiltrating ductal carcinoma, not certain it represents lymph node tissue. Gross description: 3 possible lymph nodes. Final dx for sentinel lymph node specimen: Infiltrating ductal carcinoma in breast tissue w/ associated dcis. No lymphoid tissue identified. Right breast specimen: 4.6 cm infiltrating ductal carcinoma, Nottingham score 5. DCIS present, multiple foci of invasive carcinoma. No skin or muscle invasion. No lymphvascular invasion. Margins negative. 6/30/15 Outside Medical Oncologist Taxotere, Cytoxan x 4 10/6/15 Reporting Hospital/Dr ZZZZ Right breast/right axilla 6/18 mv photons 50.4 Gy/28 fx + 6 mv photon boost 14 Gy/7 fxs. Total 64.4 Gy/35 fxs Outside Medical Oncologist Tamoxifen

3 FIELD# FIELD NAME CODE AND RATIONALE/DOCUMENTATION Last Name First Name Address at DX-No and Street Address at DX-City Address at DX-State Address at DX-Postal Code County at DX Telephone Primary Payer at DX Sex Date of Birth Age at Diagnosis Birthplace Social Security Number Marital Status at DX Race 1 Race 2 Race 3 Race 4 Race 5 Spanish Surname or Origin CANCER IDENTIFICATION Date of 1 st Contact Sequence Number Class of Case Date of Diagnosis Primary Site Laterality Histology: Behavior Grade Lymph-vascular invasion Diagnostic Confirmation COLLABORATIVE STAGE CS Tumor Size CS Extension CS Tumor Size/Ext Eval CS Lymph Nodes CS Lymph Nodes Eval Regional Nodes Positive Regional Nodes Examined CS Mets at Dx CS Mets Eval CS Mets at Dx -- Bone CS Mets at Dx Lung CS Mets at Dx Liver CS Mets at DX Brain SSF1 Estrogen Receptor Assay SSF2 Progesterone Receptor Assay SSF3 # Pos Ipsi Level I-II Axill

4 LNs SSF4 IHC of Reg LNs SSF5 MOL Studies of Reg LNs SSF6 Size of Tumor Invasive Component SSF7 Nottingham (BR) Score SSF8 HER2 IHC Lab Value SSF9 HER2 IHC Test Interpretation SSF10 HER2 FISH Lab Value SSF 11 HER2 FISH Interpretation SSF 12 HER2 CISH Lab Value SSF 13 H2 CISH Interpretation SSF 14 HER2 Other/Unk Test Result SSF 15 HER2 Summary Result Test SSF 16 Combination ER, PR, HER2 SSF 21 Respone to Neoadjuvant TX SSF 22 Multigene Signature Method SSF 23 Multigene Signature Results Clinical TNM Pathologic TNM Derived TNM Summary Stage TREATMENT FIRST COURSE Date of Initial RX SEER Date of 1 st Crs RX COC RX Hosp Surg Prim Site RX Hosp Scope RegLN Sur RX Hosp Surg Oth Reg/Dis RX Hosp Chemo RX Hosp Hormone RX Hosp BRM RX Hosp-Transplnt/Endo RX Hosp Other Reason for No Surgery RX Date Surgery RX Summ Surg Prim Site RX Summ Scope Reg LN RX Summ Surg Oth Reg/Dist Site RX Summ Radiation Reason for No Radiation Rad Regional RX Modality Rad Boost RX Modality RX Date Radiation RX Summ Surg/Rad Seq RX Date Chemo

5 RX Summ Chemo RX Date Hormone RX Summ Hormone RX Date BRM RX Summ BRM RX Summ-Transplnt/Endo RX Date Systemic RX Summ Sys/Sur Seq RX Summ Other RX Date -- Other RX Summ Treatment Status