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BreastFor Information Only

d.Procedure (eg, excisional biopsy, lumpectomy, partial mastectomy, as specified by surgeon)

e.Operative findings, as appropriate

f.Anatomic site of specimen (eg, right breast, upper outer quadrant, subareolar)

B.Macroscopic Examination

1.Specimen

a.Unfixed/fixed (specify fixative)

b.Tissue(s) included

c.Received sectioned/unsectioned before receipt (Note H)

d.Size of specimen (3 dimensions, if removed in 1 piece)

e.Dimensions and description of skin, if included

f.Orientation, if specified by surgeon; and margin designation (eg, ink) (Note I)

g.Single tumor or multiple tumors

h.Results of intraoperative consultation

2.Tumor

a.Size (single greatest dimension) (Note J)

b.Descriptive features (eg, degree of circumscription, consistency, mucoid appearance)

c.Correlation with imaging studies, including specimen radiograph (Note F)

d.Relation to surgical margins (Note I)

3.Regional lymph nodes, if appropriate (Note K)

a.Number identified, if possible

b.Location, if specified by surgeon

c.Size of the largest visible nodal metastasis

4. Additional pathologic findings, if present (eg, prior biopsy, prosthetic implant, fibrocystic changes)

5.Tissue(s) submitted for microscopic evaluation (Note L)

a.Tumor (Notes F and L)

b.Margin(s), as appropriate (Note I)

c.Other lesion(s)

d.Lymph nodes (Note K)

e.Frozen section tissue fragment(s) (unless saved for special studies)

6.Special studies (specify) (Note B)

C.Microscopic Evaluation

1.Tumor

a.Histologic type(s) (Note C)

b. Histologic grade (Note D)

c.Mitotic figure count

d.Extent of any associated ductal carcinoma in situ (DCIS) (Notes E and I)

e.Microcalcifications (Note F)

f.Verification of tumor size (Notes J and M)

g.Extent of invasion (Note M)

h.Vascular invasion (Note G)

i.Involvement of skin, if possible (Note M)

2.Status of surgical margins, as appropriate (Note I)

a.No tumor (specify distance of tumor and DCIS from nearest margin[s])

b.DCIS at margin

c.Invasive carcinoma at margin (specify margin) (specify macroscopic or only microscopic)

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