Sample Dictation: 

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PLEASE NOTE: The example listed below is the format commonly used/encountered at my institution. Please check with your institution to see if a recommended format is preferred.

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Gross Examination:

This case is received [FRESH, IN FORMALIN] in [NUMBER] separate containers, each labeled with the patient's name, medical record number and site designation.

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PART A: " [CONTAINER LABEL- EXAMPLE: RIGHT NEEDLE LOCALIZED LUMPECTOMY]"

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The specimen consists of a _ g fragment of yellow, lobulated, fibrofatty soft tissue (_ cm anterior-posterior; _ cm medial-lateral and _ cm superior-inferior) [WITH/ WITHOUT] an attached [COLOR, UNREMARKABLE (OR DESCRIBE LESION)] skin ellipse (_ x _ x _ cm). The specimen is oriented by surgical sutures (see below) and contains a needle wire in-situ coursing from the _ to the _ aspect. The specimen radiograph is reviewed showing [LIST RADIOLOGY FINDINGS; microcalcifications; densities; intact needle localization wire etc]. 

 

The specimen is inked and then serially sectioned to reveal _ (CHOOSE FROM BELOW AS APPROPRIATE).

a [CENTRAL/ ECCENTRIC] _ x _ x _ cm [SOLID/ CYSTIC/ HEMORRHAGIC/ FIBROTIC] lesion corresponding to the radiographically-identified area. The lesion has a [STELLATE/ INFILTRATE/ ROUNDED] margin and comes within _ cm of the the nearest (ORIENTATION; COLOR-inked) margin;  _ cm of the (ORIENTATION; COLOR-inked margin(s) (LIST THE DISTANCE OF ANY MARGIN LOCATED WITHIN 2 CM OF THE LESION) ; it is greater than 2 cm from all other margins.

 

A second, separate [SOLID/ CYSTIC/ HEMORRHAGIC/ FIBROTIC]  lesion (_ x _ x _ cm) with a  [STELLATE/ INFILTRATE/ ROUNDED] margin is identified in the [DIRECTION] aspect of the specimen, _ cm from the first lesion and _ cm from the closest [ORIENTATION, COLOR]-inked margin.

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DESCRIBE ANY ADDITIONAL FINDINGS.

 

The remaining cut surface is yellow and fatty with no additional lesions grossly identified. [REPRESENTATIVE SECTIONS ARE/ THE SPECIMEN IS ENTIRELY] submitted for histological evaluation as per block summary.

 

ORIENTATION (per requisition sheet) & INK CODE:

Black = Posterior/deep (2 Sutures)

Blue = Medial 

Green = Inferior

Red = Anterior 

Orange = Superior (1 Short suture)

Yellow = Lateral (1 Long suture)

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PART B. "[CONTAINER LABEL]"

Gross description

NOTE: The surgeon will oftentimes send the "true surgical margins" separately from the lumpectomy specimen. These margins often contain a surgical clip on one aspect of the fatty, cauterized tissue representing the true surgical margin; (usually, this is the more curved edge). This aspect should be inked  (trying not to get ink on the opposing aspect). The specimen should then be serially (perpendicularly) sectioned and entirely submitted.

 

Basically, we want to be able to tell the surgeon how far a lesion, if present, is located from the true margin. See an example dictation below

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PART C. "Right breast needle localized lumpectomy, final anterior margin, clip marks true margin"

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The specimen consists of a fragment of yellow lobulated fibrofatty tissue (_ x _ x _ cm) containing a single surgical clip along a more convex-shaped, cauterized surface; the corresponding tissue is inked black. Serial sectioning reveals homogeneous, yellow, lobulated, fibrofatty, glandular breast parenchyma. The specimen is entirely submitted per block summary.

 

etc etc etc

 

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Block Summary:

A: [CONTAINER LABEL- EX: Right breast needle localized lumpectomy]

Typically, you should submit the ENTIRE SPECIMEN if it is a small lumpectomy specimen, no lesion is grossly seen or the prior biopsy showed only DCIS or ADH (must rule out cancer). When in doubt, just submit the entire lumpectomy specimen to avoid going back to the bucket!

The specimen is entirely and sequentially submitted from the [LIST] to [LIST] direction

1. Tissue at [LIST] margin (slice #1), perpendicularly sectioned; _ piece(s)

2. Slice #2; _ piece(s)

3. Slice #3; _ piece(s)

4. Slice #4; _ piece(s)

5. Slice #_ etc. etc. etc

6. Tissue at [LIST] margin (final slice #_), perpendicularly sectioned; _ piece(s)

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For LARGE lumpectomies with a CLEARLY DEFINED LESION you may choose to submit only REPRESENTATIVE SECTIONS. If you choose this method, make sure you sample every margin. Ideally, you want a perpendicular section of the lesion to the nearest inked margin. If the lesion is widely free of a margin (>2 cm away), then you can submit a representative shave of the margin nearest the lesion (put the inked side FACE DOWN in the cassette)

1.  Lesion to nearest anterior margin, perpendicularly sectioned

2. Lesion to nearest posterior margin, perpendicularly sectioned

3. Lesion to nearest medial margin, perpendicularly sectioned

4. Lesion to nearest lateral margin, perpendicularly sectioned

5. Lesion to nearest superior margin, perpendicularly sectioned

6. Lesion to nearest inferior margin, perpendicularly sectioned

7. Remaining lesional tissue (If possible, try to submit the entire lesion)

8. Normal, representative section

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B1. Right breast, final superior margin

C1-2. Right breast, final anterior margin

etc etc etc.