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CAP ApprovedBreast

Surgical Pathology Cancer Case Summary (Checklist)

Protocol revision date: January 2005

Applies to invasive carcinomas only

Based on AJCC/UICC TNM, 6th edition

BREAST: Excision Less Than Total Mastectomy (Includes Wire-Guided Localization Excisions), Total Mastectomy, Modified Radical Mastectomy, Radical Mastectomy

Patient name:

Surgical pathology number:

Note: Check 1 response unless otherwise indicated.

MACROSCOPIC

Specimen Type

___ Excision

___ Mastectomy

___ Other (specify): ____________________________

___ Not specified

Lymph Node Sampling

___ No lymph node sampling

___ Sentinel lymph node(s) only

___ Sentinel lymph node with axillary dissection

___ Axillary dissection

Specimen Size (for excisions less than total mastectomy)

Greatest dimension: ___ cm

*Additional dimensions: ___ x ___ cm

___ Cannot be determined (see Comment)

Laterality

___ Right

___ Left

___ Not specified

Tumor Site (check all that apply)

___ Upper outer quadrant

___ Lower outer quadrant

___ Upper inner quadrant

___ Lower inner quadrant

___ Central

___ Not specified

* Data elements with asterisks are not required for accreditation purposes for the Commission on Cancer. These elements may be clinically important, but are not yet validated or regularly used in patient management. Alternatively, the necessary data may not be available to the pathologist at the time of pathologic assessment of this specimen.

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