Download Breast benign Macroscopic reporting dictation template

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Breast benign
Macroscopic reporting dictation template
Data element
Fresh tissue received
Response
No
Yes
Number of specimens received
__
Laterality
Left
Procedure
Specimen orientation
As stated by the clinician
Not orientated
Orientated
Specimen weight
__g
Specimen size
__x__x__mm
If orientated, record as follows:
Medial-lateral length __mm
Superficial-deep length__mm
Skin
Skin dimensions
Skin abnormalities
Nipple
For each specimen, record the following:
Absent
__x__mm
Absent
Absent
Lesion(s)
Number of macroscopically visible lesions
For each lesion (if >1 designate accordingly):
Lesion description
Location
Lesion dimensions
Distance of lesion to nearest margin
Absent
__
Slice number involved by lesion
Other relevant macroscopic information
__
Text
Block identification key
Text
Breast benign dictation template
If yes, describe any additional tests/ frozen sections/biobanking performed
Right
If orientated, list markers & locations and colours used.
Record the plane of dissection in orientated specimens (e.g.
medial to lateral/ superior to inferior/ superficial to deep).
Superior-inferior length __mm
Present
Present, describe
Ulceration
Present, describe
Normal
Other, specify
Other, specify
Present
Abscess
Cyst
Text
__x__x__ mm
__ mm
Specify margin
Calcification
Fibrosis
Other, specify
See illustration in protocol
E.g. any additional orientation; specimen integrity (if disrupted)
Describe nature and site of blocks
Date: 21 October 2015
Version: 1.1