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For Information OnlyBreast

3.Additional pathologic findings, if present

4.Regional lymph nodes (Note K)

a.Total number examined (specify location, if indicated by surgeon)

b.Number involved by tumor (note extranodal extension, if present)

c.Size(s) of the largest nodal metastasis

5.Distant metastasis (specify site[s]) (Note M)

6.Results/status of special studies (specify) (Note B)

a.Hormonal receptors

b.Other(s) (specify)

7.Comments, as appropriate, including correlation with intraprocedural consultation, results of other specimens, and clinical information

IV.Mastectomy (Total, Modified Radical, Radical)

A.Clinical Information

1.Patient identification

a.Name

b.Identification number

c.Age (birth date)

d.Sex

2.Responsible physician(s)

3.Date of procedure

4.Other clinical information (Note A)

a.Relevant history

b.Physical or mammographic findings

c.Clinical diagnosis, if known

d.Procedure (eg, simple mastectomy, modified radical mastectomy)

e.Operative findings, as appropriate

f.Anatomic site of specimen (eg, right breast)

B.Macroscopic Examination

1.Specimen

a.Unfixed/fixed (specify fixative)

b.Tissue(s) included

c.Size of breast

d.Dimensions and description of skin

e. Location of biopsy site or tumor (eg, quadrant, relation to deep margin)

f.Single tumor or multiple tumors

g.Results of intraoperative consultation

2.Tumor

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

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

c.Relation to surgical margins (Note I)

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

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.Tissues submitted for microscopic evaluation (Note L)

a.Tumor (Notes F and L)

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