ANATOMICAL PATHOLOGY DEPARTMENT

DR. CIPTO MANGUNKUSUMO HOSPITAL

Jl. Salemba Raya No. 6, Tromolpos 3225, JAKARTA 10002
_____________________________________________________________________________________
REGISTRATION DATA
Medical record :- Name : Tjia Fuk Sin, MRS.
Date of receipt : , 2021 Gender/Age : Female/58-year-old
Date of payment : , 2021 Registration number : 2210710/H210700
Date of result : , 2021 Hospital origin :MRCCC Siloam Hospital
Doctor : Dr. dr. Rinaldi L., SpPD

We are received block paraffin without sufficient clinical information. No information about clinical
history. Mrs Tjia Fuk Sin already have breast cancer before. Last night Prof. Dr. dr. Aru W. Sudoyo, SpPD-
KHOM discussed this patient and let me know that the patient had breast cancer before.

History / Clinical diagnosis : Liver nodule suspect malignancy

Histopathology diagnosis : Adenocarcinoma dd/

- Cholangiocarcinoma
- Tumour metastasis

Immunohistochemistry result:
CK7, CK20, CDX2 non-reactive
Ca-125 non-reactive
PAX8 positive
CIC1a and CAM5.2 positive
ER strong positive diffusely

We received additional clinical data about previous history of breast cancer and then an additional IHC
staining was performed.

GATA3 positive diffusely

GCDFP15 positive focal
PR positive 10%
HER2 positive membranous 30%, score HER2 3+
Conclusion:
IHC staining suspects the diagnosis of breast carcinoma with ER and PR positive, HER2 score of 3+.

Jakarta, June 3 rd, 2021

Pathologist

Ening Krisnuhoni MS, dr, SpPA(K)