Medical Pathology Report Form

Basic Report Information

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Specimen Number

Age

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Received Date

Date Reported

Nature of Specimen

Report Status

Clinical Data

Gross Description

Microscopic Description

Diagnosis

<ul><li>Procedure: Right Radical mastectomy.</li><li>Tumor site: mid-upper aspect.</li><li>Tumor size (greatest dimension in mm): 70 mm.</li><li>Histologic type: Invasive carcinoma (NST).</li><li>Histologic grade: grade 2.</li><li>Extension to skin: None, nipple and areola are free of tumor and Paget cells.</li><li>Chest wall (pectoral muscle) involvement: No.</li><li>Margin status (distance in mm): 45 mm, 65 mm, 70 mm, 80 mm and 15 mm from superior, inferior, medial, lateral and deep margins, respectively.</li><li>Lymphovascular invasion: Present.</li><li>Perineural invasion: present.</li><li>Multifocality / multicentricity (number of foci and dimensions): Unifocal, 7 x 5 x 3 cm.</li><li>Presence/extent of DCIS (if concurrent)—grade and extent: minor, intermediate grade with comedo necrosis.</li><li>Number of lymph nodes examined (total): 25 Lymph Nodes.</li><li>Number positive for metastasis: 22 Lymph Nodes.</li><li>Greatest dimension of lymph nodes: 23 mm.</li><li>Extra-nodal / extracapsular extension (present/absent): Present.</li><li>Pathologic stage: pT3N3Mx.</li></ul>

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