Breast- Gross Examination 


Breast Gross 2007-03-30 Summary
Header Dictation Options Notes
Specimen Type Wire localization | PNL biopsy  
  [Partial] | [Modified Radical] Mastectomy  
  Re-excision biopsy or completion mastectomy  
  Incisional biopsy  
Side Right | Left  
Lymph Node Sampling Not in specimen  
  SLN only | SLN with Axillary Dissection  
  Axillary Dissection  
Specimen Opened for Fixation Yes | No  
Formalin Fixation Time 6 - 48 h | >48 h | <6 h | unknown  
Orienting Sutures Present (Long Lateral, Short Superior) | Not present  
Localizing Wire Present (Medial, Lateral, Superior, Inferior) | Not present  
Specimen Mammogram Present (Calcifications, Mass) | Not present  
Markings in Pathology Not Applicable or specify  
Specimen Size (cm) SI x ML x AP or Greatest Dimension  
Skin Not in specimen | _ cm x _cm | Normal or Abnormal   
Nipple Not in specimen | Present (Normal | Abnormal describe)  
Tumour or Other Abnormality:    
Description Not identified | Scirrhous | Other (describe)  
Distribution NA | Unifocal | Multifocal | Multicentric (_cm separation)  
Site in Breast NA | UOQ etc Repeat for multiple tumours
Size (cm) NA | SI x ML x AP | Greatest Dimension Repeat for multiple tumours
Margins Clearance (cm) NA or (see below)  
Superior cm  
Inferior cm  
Medial cm  
Lateral cm  
Posterior cm  
Closest Margin NA | Superior, Inferior, Medial, Lateral, Posterior  
Extent of Margin Involvement NA | Not involved | Involved: specify  
Other Tissue or Features NA | Fatty | Fibrous | Blue-domed cysts | Pinpoint Paste-like
Lymph Nodes #, Appearance, Submitted # per block  
1 - 3 Tumour More if non-palpable
4 Superior Margin  
5 Inferior Margin  
6 Medial Margin  
7 Lateral Margin  
8 Anterior Margin if applicable  
9 Posterior Margin  
10 Skin (Nipple)  
11 - 14 Random uninvolved breast