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
Prophylactic mastectomy (Option 2)
Received: In formalin labeled ” “ and consists of a simple mastectomy
Size: [x x] cm
Weight: [] g
Skin: not present
Nipple: Absent
Orientation: Long suture lateral, short suture superior
Inking:
Anterior: Blue
Posterior: Black
Cut Surface: Yellow-tan soft fibrofatty tissue with no evidence of discrete masses, stellate areas or chalky streaks
Additional Comments: There is a dense fibrous area on the [anterior/posterior] surface of the breast measuring [ x x ]cm possibly representing subareolar tissue. This tissue is inked orange.
Submitted: Representative sections in [ x ] cassettes:
1A-1B: Possible subareolar fibrous tissue, en face degenerative facet
1C-1D: Upper outer quadrant
1E-1F: Upper inner quadrant
1G-1H: Lower outer quadrant
1I-1J: Lower inner quadrant
Time of Collection:
Cut Surface Exposed to Formalin:
Ischemic Time: =
Total Fixation Time in Formalin: =
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.)
Lumpectomy (option 2)
Received: Fresh labeled ” “, consisting of an oriented lumpectomy specimen
Radiograph: radiograph available in EMR shows presence of a “ shape “ clip
Size: [ x x ]cm
Orientation: Long suture lateral, short suture superior
Localization Wire: [Absent/present]
Inking:
Superior: Red
Inferior: Green
Medial: Orange
Lateral: Yellow
Anterior: Blue
Posterior: Black
Sectioning: the specimen is serially sectioned from medial to lateral into [ #] slices
Area of Interest – Lesion
Size: [ x x ] cm, tan-white, irregularly shaped, ill defined
Distance to Margins: To superior, inferior, medial, lateral, anterior, and posterior margins
MammoClip: ” shape of clip”
SAVI Scout: Not present/present
Remaining Breast Tissue: Yellow-tan soft fibrofatty
Submitted: Representative sections in [ #] cassettes:
1A: Slice one, perpendicular, medial margin
1B: Slice two
1C: Slice three
1D: Slice four
1E-2F: Slice five (area of clip 1 in 2E)
1G: Slice six (entire area of interest)
1H-I: Slices lateral to the area of interest
Time of Collection:
Cut Surface Exposed to Formalin:
Ischemic Time:
Total Fixation Time in Formalin:
Note: The breast specimen processed meets the fixation time standards of 6-72 hrs., which have been set by the American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP), to ensure appropriate tissue quality for effective Her2 receptor testing.
Note: The breast specimen ischemic time exceeds the standard of less than 60 minutes.
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.}
Mastectomy for Cancer (Option 2)
Received: Fresh labeled ” “ and consists of a total mastectomy
Size: [x x ]
Weight: [] g
Skin: [ x x ] cm, tan, elliptical
Scar: Not Present
Nipple: Everted, central, [x x]
Provided Orientation: Long suture lateral, short suture superior
MammoClip: ” shape of clip”
Inking:
Anterior superior: Blue
Anterior inferior: Green
Posterior: Black
Sectioning: the specimen is serially sectione from superior to inferior into [x] slices.
Area of Interest – Lesion
Size: [ x x ] cm, tan-white, firm, round, ill-defined lesion with hemorrhagic area consistent with biopsy site measuring [ x x ] cm and bearing the “shaped” clip.
Location: [x] o’clock, [x] cm from the nipple
x cm from posterior margin, x cm from anterior margin
Remaining Breast Tissue: Yellow-tan soft fibrofatty
Possible Lymph Node(s): Not identified
Additional Comments: There is an area of tan-white, dense fibrous tissue at [ x ] o’clock, [ x] cm from the nipple.
Submitted: Representative sections in [ x ] cassettes:
5A: Skin and nipple
5B: Retroareolar tissue
5C: Section of breast tissue medially adjacent to mass
5D: Nearest deep margin to mass
5E-5I: Mass (possible biopsy site in 5H and 5I)
5J: Adjacent normal tissue with hemorrhagic area
5K: Section of breast tissue laterally adjacent to mass
5L: Dense fibrous area from 6 o’clock
5M-5N: Upper outer quadrant
5O-5P: Upper inner quadrant
5Q-5R: Lower outer quadrant
5S-5T: Lower inner quadrant
Time of Collection:
Cut Surface Exposed to Formalin:
Ischemic Time:
Total Fixation Time in Formalin:
Note: The breast specimen processed meets the fixation time standards of 6-72 hrs., which have been set by the American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP), to ensure appropriate tissue quality for effective Her2 receptor testing.
Note: The breast specimen ischemic time meets the standard of 60 minutes or less, to ensure appropriate tissue quality for effective ER/PR and Her 2 receptor testing.