| GROSS: |
|
| Breast– laterality:
weight & size: |
( ) right ( ) left ( ) not specified
weight __g ; __x___x__cm |
| Markings intra-operatively: |
( ) with ( ) at 12 hrs ( ) “SIM” type ( ) without markings |
| Cutaneous flap: |
of __x__cm |
| Surgical incision: |
( ) with ( ) without ( ) recent ( ) old, of __x__cm |
| Other skin lesions: |
( ) retraction ( ) ulceration ( ) lesion: __________, which measures _x_cm, a distance of _cm from the nipple |
| Nipple: |
( ) protrusive ( ) flat ( ) retracted, ( ) with lesion ( ) without lesion and measures _x_cm |
| Surgical cavity sections, location: |
( ) absent ( ) present, measures _x_cm, localised _,
filled ( ) by clots ( ) gauze, with walls ( ) soft ( ) white ( ) hardened |
| Tumor: |
( ) absent ( ) single ( ) multiple ( ) residual ( ) multifocality |
| Local: |
( ) UQlat ( ) UQInf ( ) UQsup ( ) UQmed ( ) QSL ( ) QSM ( ) QIL ( ) QIM ( ) RRA |
| Color: |
( ) white-ish ( ) yellow-ish ( ) reddish ( ), with dots ( ) yellow-ish ( ) reddish |
| Consistency: |
( ) firm ( ) soft ( ) elastic ( ) friable |
| Contours: |
( ) spiculated ( ) lobulated |
| Margins: |
( ) imprecise ( ) precise |
| Measure and distance: |
of __x__cm, distance _cm from the closet surgical margin ( ) superior ( ) inferior ( ) medial ( ) lateral ( ) deep |
| Multicentricity in: |
( ) UQlat ( ) UQInf ( ) UQsup ( ) UQmed ( ) QSL ( ) QSM ( ) QIL ( ) QIM ( ) RRA, a distance of _cm from the main lesion |
| Surrounding parenchyma: |
( ) yellowed or untuous, with ( ) whitened and elastic areas, ( ) cysts ( ) and separated by trabeculae |
| Axillary adipose tissue: |
measures _x_x_cm |
| Lymph nodes and number:
|
( ) none ( ) isolated _ (number), the greatest measure _x_cm, measure _x_x_cm |
| Conglomerates: |
measure _x_x_cm
( ) Absent ( ) Present |
| Small pectoral muscle: |
measures _x_x_cm, brownish and fasciculated |
| mIcroscopIC: |
|
| Carcinoma type: |
( ) ductal ( ) lobular ( ) mixed ( ) medular ( ) other: _ |
| In situ or infiltration: |
( ) in situ ( ) infiltrate ( ) residual |
| Final histological grade: |
( ) affected by autolysis, _(1-3) by Nottingham modified by ELSTON & ELLIS (1991) (tubular formation:_(1=>75%, 2=10-75%; 3=>75%); atypia: _(1=small, 2=moderate; 3=extensive); mitoses:_ (1=<7/10hpf, 2=10/15hpf; 3=>15hpf), measures _cm at the greatest axis |
| Measures: |
( ) UQlat ( ) UQInf ( ) UQsup ( ) UQmed ( ) QSL ( ) QSM ( ) QIL ( ) QIM ( ) RRA ( ) multifocal |
| Location and multifocality: |
( ) Absent ( ) Present, ( ) including the dermis |
| Invasion of skin: |
( ) Absent ( ) Present |
| Paget disease: |
( ) Absent ( ) Present |
| Lymphatic emboli: |
( ) Absent ( ) Present |
| Blood vessel emboli: |
( ) Absent ( ) Present |
| Perineural invasion: |
( ) Absent ( ) Present |
| Microcalcifications: |
( ) Absent ( ) Present |
| Necrosis: |
( ) Absent ( ) Present ( ) mild ( ) moderate ( ) severe |
| Lymphoplasmocitaric infiltrate: |
( ) Absent ( ) Present ( ) mild ( ) moderate ( ) severe |
| Areas of in situ carcinoma: |
( ) Absent ( ) Present in the main lesion ( ) Present outside the main lesion at a ( ) low ( ) intermediate ( ) high degree |
| Multicentricity: |
( ) Absent ( ) Present |
| Other quadrants: |
( ) Fibrocystic mastopathy ( ) adenosis ( ) apocrine metaplasia ( ) epithelial hyperplasia ( ) others:_____ |
| Surgical margins: |
( ) free ( ) compromised ( ) distance _cm from the closest surgical margin ( ) superior ( ) inferior ( ) medial ( ) lateral ( ) deep |
| Lymph nodes: |
( ) free of neoplasia ( ) _ (Nº) of compromised neoplastic lymph nodes between _ (Nº) isolates, ( ) with neoplastic capsular invasion ( ) extracapsular extension to extranodal tissue ( ) neoplastic lymphatic emboli ( ) blood vessels. The greatest metastasic focus _cm in diameter |
| Small pectoral muscle: |
( ) free ( ) compromised |
| Immunohistochemistry test |
After microscopic analysis (preferably of the histological block most representative of the infiltrate tumor) |
| Oestrogen receptor |
( ) 0% ( ) 1-10% ( ) 10-25% ( ) 25-50% ( ) 50-75% ( ) >75% |
| Progesterone receptor |
( ) 0% ( ) 1-10% ( ) 10-25% ( ) 25-50% ( ) 50-75% ( ) >75% |
| Cerb-B2/ Her2 |
( ) 0 ( ) 1( ) 2 ( ) 3 ( ) |
| pTNM |
_____pT ______N______M |
| _________________________ _______________________
Signature resident pathologist |