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Breast tumour SPR*/ ICCR¡ Macroscopic reporting dictation template Data element Response If yes, describe any additional tests/ frozen sections/biobanking performed Fresh tissue received No Yes S2.01 Number of specimens received __ For each specimen, record the following: S2.03 Intraoperative consultation performed No Yes, specify type S2.03 Specimen type S2.02 S2.04 Specimen laterality Specimen orientation S2.05 Method of localisation S2.06 Specimen size S2.10 S2.10 S2.10 Skin Frozen section Gross exam. for margin assessment Imprint cytology Other, specify Diagnostic open biopsy Mastectomy Re-excision Wide local excision Mastectomy post neoadjuvant therapy Left Right Undesignated Not Orientated If orientated, list markers & locations and colours used. orientated Record the plane of dissection in orientated specimens (e.g. medial to lateral/ superior to inferior/ superficial to deep). Hookwire Carbon track Not applicable Skin dimensions Skin abnormalities __x__x__mm If orientated, record as follows: Medial-lateral length __mm Superficial-deep length __mm Superior-inferior length __mm Absent Present If present, record dimensions & describe any abnormalities. __x__mm Absent Present, select all that apply Ulceration Satellite nodules Other, specify Nipple description Absent Normal Nipple Present Paget’s disease If present, describe. Select all that apply. Peau d’orange Other, specify S2.07 Specimen weight __g S2.08 Absent S2.09 Macroscopically visible tumours? For each tumour: (if >1 designate accordingly) Nature of tumour S2.09 Tumour size __x__x__mm Tumour location If WLE state slice numbers, if mastectomy state quadrant/clockface orientation Breast tumour dictation template Present If present, record number of foci __ Text Date: 21 October 2015 Version: 2.0 Breast tumour Macroscopic reporting dictation template S2.09 Distance to nearest separate tumour foci __mm If > 1 tumour S2.09 Min. macroscopic margin clearance from any tumour deposit __mm Record distances of tumour to all margins <5mm. Specify margin. S2.11 Muscle Absent Present Lymph nodes Sentinel lymph node For each record Site Radioactive count Uptake of dye Size Non-sentinel lymph node/tissue Total number of nodes Axilla Intramammary chain __ No Yes -blue __x__x__mm S2.12 S2.12 __ Size range __to__mm Description Text G2.01 Other relevant macroscopic information Text E.g. any additional orientation; specimen integrity (if disrupted) S2.13 Block identification key Text Describe nature and site of blocks SPR*Structured Reporting of Cancer and ICCR¡ International Collaboration on Cancer Reporting Standards (S) & Guidelines (G) Breast tumour dictation template Date: 21 October 2015 Version: 2.0
