Many of these grossing templates were made with generous help from Dr. Zarrin Hossein-Zadeh. Others are based on templates from institutions I’ve practiced at. For some, you’ll see that there are different versions/options. As with all templates, these must be customized for each case–no two cases are the same!
Prophylactic mastectomy
Received fresh, labeled with the patient’s name (initials: *** ) and medical record number, designated as “{right/left} breast mastectomy”, is a *** g, *** cm (medial to lateral) x *** cm (superior to inferior) x *** cm (anterior to posterior) {total/nipple sparing} mastectomy specimen. The anterior margin is surfaced by a *** x *** cm skin ellipse {without a nipple and areolar} OR with a *** cm circular areola and a *** cm {everted/inverted} nipple.
The specimen is oriented as follows: {long suture = lateral, short suture = superior.}
The specimen is inked as follows: anterior/superior = blue, anterior/inferior = green, and deep margin = black, {nipple bed = red}.
The specimen is serially sectioned from {lateral} to {medial} into *** slices.
. The cut surface shows {no gross lesions or nodules/ describe lesion/s}.
{A biopsy clip is identified in slice *** in the *** quadrant. }
Gross photographs {are/are not} taken.
Collection Time: ***
In Formalin: ***
Cold ischemic time: ***
Total fixation time: ***
Representative sections are submitted as follow:
CASSETTE SUMMARY:
*** nipple ({bisected/trisected})
*** deep nipple tissue
*** additional findings
*** to *** uninvolved upper outer quadrant
*** to *** uninvolved lower outer quadrant
*** to *** uninvolved upper inner quadrant
*** to *** uninvolved lower inner quadrant
Lumpectomy
Received without fixative, labeled with the patient’s name, medical record number, and designated as “***”, is a *** g portion of fibroadipose tissue measuring *** cm (medial to lateral) x *** cm (superior to inferior) x *** cm (anterior to posterior). {#One/Two/Three, etc. localization needles is/are present.} There {is/isn’t} an ellipse of skin present on the anterior surface. {If present, give measurements}
The specimen is oriented as follows: long = lateral; short = superior. The specimen is inked as follows: anterior = red, posterior = black, superior = blue, inferior = green, lateral = violet, and medial = orange. The specimen is serially sectioned from medial*** to lateral*** into *** slices.
A *** cm {shape – ill-defined, well circumscribed, poorly circumscribed, etc.}, {color -pink-tan}, {consistency – firm, friable} {nodule, hemorrhagic area, vaguely nodular area, biopsy site, etc.} is present in slice ***. The {nodule/lesion} is located *** cm from the *** margin, *** cm from the *** margin, *** cm from the *** margin, *** cm from the *** margin, *** cm from the *** margin, and *** cm from the *** margin. A faxitron image of the specimen is taken.*** A *** shaped metallic clip is present in slice ***. {One radioactive seed is present within the specimen in slice #} ***describe additional findings here
No other masses or lesions are grossly identified. The remaining breast parenchyma is comprised of approximately ***% adipose tissue and approximately ***% {dense/finely dispersed}, white fibrous tissue. Gross photographs are taken. The specimen is entirely submitted per the summary of sections.
Collection Time: ***
In Formalin: ***
Cold ischemic time: ***
Total fixation time: ***
SUMMARY OF SECTIONS:
*** slice 1 *** margin, sectioned perpendicular to the inked surface
***
*** slice *** margin, sectioned perpendicular to the inked surface
For each cassette submitted indication the follow if present: slice number, presence of lesion, and tissue containing clip.
Mastectomy for Cancer
Received fresh, labeled with the patient’s name, medical record number, and designated “{right/left] mastectomy, long = lateral, short = superior}”, is a { } g, { } cm (medial to lateral) x { } cm (superior to inferior) x { } cm (anterior to posterior) {total/nipple sparing/skin sparing} mastectomy specimen. The specimen is oriented with a long suture designating lateral and a short suture designating superior. The anterior margin is surfaced by a {_x_} cm {grossly unremarkable/dimpled/ulcerated/puckering/edematous} skin ellipse {with/without} an {everted/inverted nipple} ({}cm diameter) and areola measuring ({ } cm diameter). The posterior fascial plane is intact and devoid of grossly identifiable skeletal muscle.
The specimen is inked as follows: superior-anterior = blue, inferior-anterior = green, and posterior = black. The specimen is serially sectioned from medial to lateral into { } slices. The specimen is X-rayed to show a clip in slice #{ } in the { } quadrant.
Sectioning reveals a {_x_x_} cm {ill-defined/well-circumscribed}, {irregular/stellate shaped}, {gritty/necrotic/color}, {firm/soft}, {bulging/lobulated/etc} {fibrotic area/nodule/lesion/tumor/mass/hemorrhagic area/biopsy cavity}, {designated as #1}. There is a {cylindrical, barbell, S-shaped, etc} biopsy clip {within, adjacent to, in the vicinity of the} {nodule/tumor/mass #1}. {Mass/lesion/nodule #1} is located in the { } quadrant in slice #{ } to slice #{ }, at approximately { } o’clock, { } cm from the closest superior-anterior margin, { } cm from the closest inferior-anterior margin, and { } cm from the closest posterior margin.
Collection Time: ***
In Formalin: ***
Cold ischemic time: ***
Total fixation time: ***
CASSETTE SUMMARY:
***: nipple {bisected/trisected}
***: deep nipple tissue
***: entire {possible tumor bed/nodule/lesion/tumor/mass/hemorrhagic area/biopsy cavity #1 including nearest margins}
***: {x2} sections from uninvolved slices adjacent to {lesion/nodule/tumor/mass #1} or tissue between {tumors/lesions}
***: entire {possible tumor bed/nodule/lesion/tumor/mass/hemorrhagic area/biopsy cavity #2 including nearest margins}
***: {any additional findings}
***: representative section of uninvolved upper outer quadrant, slice # { }
***: representative section of uninvolved upper outer quadrant, slice # { }
***: representative section of uninvolved lower outer quadrant, slice # { }
***: representative section of uninvolved lower outer quadrant, slice # { }
***: representative section of uninvolved upper inner quadrant, slice # { }
***: representative section of uninvolved upper inner quadrant, slice # { }
***: representative section of uninvolved lower inner quadrant, slice # { }
***: representative section of uninvolved lower inner quadrant, slice # { }
***: {axillary lymph nodes [specify bisected/trisected, ink color, and number per cassette] }
***: ***
1. For each cassette submitted indication the follow if present: slice number, presence of lesion, and tissue containing clip.
2. All tumor or lesions less than 3.0 cm submit entirely, for larger lesions contact attending Pathologist
3. Biopsy cavity (submit entirely.)
4. If post-neoadjuvant treatment, describe “possible tumor bed” or “discrete/diffuse fibrotic area” and include measurement and location
5. Submit 2 cassettes of uninvolved tissue from each quadrant.
6. If multiple tumors or lesions submit tissue between both in separate cassette, and designate in cassette summary.
7. If submitting lymph nodes, specify bisected/trisected, inking, and number per cassette.
8. If second mass not present, delete that paragraph.
9. If axillary region is not attached, delete last paragraph before cassette summary.}