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Figure 2. Histologic versus molecular grade. This photomicrograph of an invasive duct carcinoma in a 66-year-old woman shows a high degree of nuclear pleomorphism (Bloom-Richardson score = 3) and a completely solid growth pattern lacking tubule formation (Bloom-Richardson score = 3) but is devoid of mitotic figures (Bloom-Richardson score = 1). This tumor would total 3 + 3 + 1 = 7 in the Bloom-Richardson system, which is designated as grade 2 or intermediate grade. The Sotiriou molecular grade for this lesion would likely be high grade, and the lack of mitotic figures needed to achieve a Bloom-Richardson score of 8 or 9 (high histology grade) may reflect a delay in tumor fixation after surgical removal of the neoplasm. In such cases, a high Ki-67 labeling index of 60% by immunostaining, as shown for this case in the inset at the lower right, could be used as a surrogate of the mitotic figure count and "upscore" this tumor to high histologic grade. If this approach was generally adopted, the number of grade 2 cases would be reduced, the number of grade 3 cases would be increased, and the correlation between molecular and histologic grading would likely increase (hematoxylin and eosin, 200x; inset, immunoperoxidase, 200x).
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