Pathology Accession No; Patient Name; Label;
The specimen received (in formalin / fresh) consists of a (lumpectomy / partial mastectomy / segmentectomy / mastectomy) sample from the (right / left) breast, with (attached / separate / absent) axillary fat tissue containing lymph nodes. The overall integrity of the specimen is (maintained / partially disrupted / markedly disrupted). The breast tissue measures __ cm in the superior–inferior dimension, __ cm in the medial–lateral dimension, and __ cm in the superficial–deep dimension. The overlying skin measures __ × __ cm, and the axillary fat measures __ (superior–inferior) × __ (medial–lateral) × __ (superficial–deep) cm. The entire specimen weighs __ gm. The nipple is (absent / normal without ulceration or nodules / ulcerated / nodular / retracted), and muscle is (absent / present). The specimen is (intact / opened / disrupted) on receipt and is (not oriented / oriented by _ indicating the _ aspect). Previous biopsy or surgical intervention is (not identified / identified by scar / identified by suture).
The tumor or lesion is (palpable / marked by wire / non-palpable without wire). On sectioning, a (single / multiple) lesion(s) is/are identified. The lesion measures __ × __ × __ cm and is situated in __ o’clock area. The cut surface shows a (firm / rubbery / gritty / soft / cystic / hemorrhagic / necrotic / fibrotic) area with (well-circumscribed / ill-defined / infiltrative) borders, and the color is (white / tan-white / grey-white / yellow / hemorrhagic / mixed) with a (homogeneous / heterogeneous) appearance. The distance of the tumor to the closest margin is __ cm, (without involvement of / with involvement of) (superior / inferior / medial / lateral / superficial / deep) margin. The overlying skin shows (no evidence of involvement / adherence to tumor / retraction / thickening / ulceration), and the nipple is (not involved and located __ cm from the nearest tumor edge / directly involved by the tumor). Underlying muscle is (not observed / observed and not involved by tumor / observed and abutted by tumor / observed and invaded by tumor). Additional findings within the breast parenchyma include (fibrocystic change / biopsy cavity / organizing hematoma / scars / foreign-body material / none).
The axillary fat contains __ lymph nodes on dissection, ranging from __ up to __ cm. Sectioning reveals (tan / grey / firm / soft) nodal cut surfaces with (no grossly visible metastatic nodules / areas suspicious for metastasis measuring up to _ x _ cm / near-complete or complete replacement by tumor up to _ x _ x _ cm).
Representative sections are submitted, including (tumor with closest margin / all margins / nipple–areolar complex / lymph nodes / skin / biopsy site).
Number of cassettes;
Slide keys;
Ink code; blue - superior, green - inferior, black - deep, red - anterior, yellow - lateral, orange - medial
Pathology Accession No; Patient Name; Label;
The specimen received (in formalin / fresh) consists of a (simple hysterectomy / radical hysterectomy / other, specify). The uterus is received (intact / opened) with (no attached structures / attached vaginal cuff / bilateral ovaries / bilateral fallopian tubes / parametria / other__). Accompanying specimens (are absent / peritoneal biopsies / lymph nodes / omentum / other such as __). The uterus measures __ × __ × __ cm from the midline fundal serosa to the ectocervix, across the maximum intercornual distance, and in the maximum anterior–posterior dimension. Cervix measures _ x _ cm (anterior-posterior x transverse). The uterus weighs __ gm. The serosal surface is (normal /nodular with deposits / roughened / adhesions). The integrity of the specimen is (maintained / partially disrupted / markedly disrupted), (with no additional abnormalities / adhesions / disruption / distortion / prior surgical manipulation).
On opening, the endometrial cavity contains a (single / multiple) lesion(s). The tumor is located in the (fundus / body / isthmus / cervix) and measures __ × __ × __ cm in greatest dimensions. The tumor demonstrates an (exophytic / endophytic / hemorrhagic / necrotic / mixed) appearance. The cut surface of the tumor is (tan-white / grey-white / soft / firm / friable / necrotic / hemorrhagic) with (well-circumscribed / ill-defined / infiltrative) borders. Myometrial invasion is (not identified / present), with a maximum depth of invasion measuring __ mm, and the thickness of the adjacent uninvolved myometrium measuring __ mm. The endometrial thickness in uninvolved areas is __ mm. The distance of the tumor from the inferior surgical margin is __ mm. Cervical involvement is (not identified / present and is __ mm from the inferior cervical surgical margin with the maximum depth of cervical wall invasion of __ mm). The thickness of the uninvolved cervical wall measures __ mm. Additional endometrial or myometrial abnormalities are (not identified / present such as a polyp measuring _ x _ cm / leiomyoma measuring up to _ x _ cm). Additional findings within the uterus include (leiomyomas / adenomyosis / polyps / cysts / hemorrhage / necrosis / prior surgical changes / none).
The right ovary measures __ × __ × __ cm and the surface is (smooth whitish without tumor involvement / partly rough surface with involvement of tumor measuring __ x __ x __ cm). The cut section shows (gray white color without cysts or nodules / gray white color with luteal cyst measuring __ x __ cm / gray white color with a nodule measuring __ x __ cm)
The left ovary measures __ × __ × __ cm and the surface is (smooth whitish without tumor involvement / partly rough surface with involvement of tumor measuring __ x __ x __ cm). The cut section shows (gray white color without cysts or nodules / gray white color with luteal cyst measuring __ x __ cm / gray white color with a nodule measuring __ x __ cm)
The right fallopian tube measures __ × __ × __ cm and shows (smooth serosal surface and pinpoint lumen / abnormal findings __).
The left fallopian tube measures __ × __ × __ cm and shows (smooth serosal surface and pinpoint lumen / abnormal findings __).
An omentum is (not submitted / submitted and measures __ × __ × __ cm with no obvious tumor involvement / with __% of the fat replaced by tumor).
Lymph nodes are (not received / received from pelvic / para-aortic / other __), with __ total nodes identified, measuring up to __ to __ cm, showing (no grossly visible tumor on section / suspicious foci measuring up to __ × __ × __ cm / nodes partially or completely replaced by tumor).
Peritoneal biopsies (are not received / received and measure __ × __ × __ cm.
Representative sections are submitted, including (tumor with deepest invasion / tumor–myometrial interface / background normal endometrium and myometrium / cervix / serosa / all margins / adnexa / lymph nodes / omentum / peritoneal biopsies).
Number of cassettes;
Slide keys;
Ink code; red – anterior, black – posterior, orange - right parametrium/paracervix, yellow – left parametrium/paracervix, green – vaginal cuff/cervix
Patient Name; Pathology Accession No;
The specimen is received (fresh / in formalin) labeled “_____” and designated as (right ovary / left ovary / right ovarian cystectomy / left ovarian cystectomy / right fallopian tube / left fallopian tube / uterus with adnexa / omentum / peritoneal biopsies / lymph nodes / other specified organs). If received fresh, additional procedures performed include (frozen section / ancillary studies / biobanking / none). The ovarian/adnexal mass weighs __ g and measures __ × __ × __ mm. If uterus is included, it measures __ × __ × __ mm (superior–inferior × cornu-to-cornu × anterior–posterior).
The ovarian capsule is (intact / ruptured / tumor present on surface / fragmented specimen). The fallopian tube serosa is (intact / tumor present on serosal surface / fragmented), and fimbriae are (identified / not identified).
A total of __ tumor(s) is/are identified. For each tumor, the lesion measures __ × __ × __ mm and is located in the (right ovary / left ovary / right fallopian tube – fimbrial / non-fimbrial / left fallopian tube – fimbrial / non-fimbrial / peritoneum / other specified site). The cut surface is (solid / cystic / papillary / hemorrhagic / necrotic / mucoid / multiloculated / unilocular / mixed), with (smooth / irregular / friable / infiltrative) internal surfaces and (well-circumscribed / ill-defined) borders. The external surface shows (no surface involvement / surface tumor deposits present).
The omentum measures __ × __ × __ mm and is (grossly unremarkable / involved by tumor), with __ metastatic deposit(s), the largest measuring __ mm. Additional peritoneal or organ involvement is (not identified / identified in _____).
Lymph nodes are (not received / received); __ lymph nodes are identified from _____ (site specified), with cut surfaces (unremarkable / suspicious / replaced by tumor up to __ mm).
Additional macroscopic findings include (peritoneal washings submitted / ascitic fluid / bowel involvement / bladder involvement / other). Representative sections are submitted, including tumor with capsule and surface, fallopian tube with fimbrial end (SEE-FIM if indicated), omentum (including deposits), background ovary and tube, lymph nodes, and any additional involved organs. A block identification key is provided separately.
Number of cassettes;
Slide keys;
Ink code;
Patient Name; Pathology Accession No;
The specimen is received (fresh / in formalin) labeled “_____” and designated as _____ (as stated by the clinician). Orientation markers are (not present / present and designated as _____). The specimen consists of a uterus measuring __ × __ × __ mm (superior–inferior × cornu-to-cornu × anterior–posterior). The cervix measures __ × __ × __ mm (anterior–posterior [12–6 o’clock] × transverse [3–9 o’clock]). A vaginal cuff is (absent / present measuring __ × __ mm). Parametrial tissues are (absent / present), measuring __ × __ mm on the right and __ × __ mm on the left. The ovaries are (absent / present), measuring __ × __ × __ mm (right) and __ × __ × __ mm (left). The fallopian tubes are (absent / present), measuring __ mm in length (right and/or left).
A macroscopically visible tumour is (absent / present). If present, __ tumour(s) is/are identified. The lesion is located within the (ectocervix / endocervix / involving both) and situated radially at the __ o’clock position. The tumour measures __ × __ mm on the mucosal surface. Grossly, it appears (ulcerated / exophytic / infiltrative / nodular / diffusely thickening) with a (firm / friable / necrotic / hemorrhagic) cut surface. The tumour thickness measures __ mm from the surface to the deepest point of invasion, out of a total cervical wall thickness of __ mm in this region. The closest distance to a resection margin is __ mm (specify margin: vaginal cuff / radial / parametrial / other). The distance between tumours is __ mm, with an outermost span of __ mm.
The invasion into adjacent structures is (not identified / identified involving vaginal cuff / uterine body / parametrium / other organs specified). The endometrium is (unremarkable / abnormal, described as _____) with a thickness of __ mm.
Lymph nodes are (not received / received); if received, __ node(s) from _____ (site and laterality specified) are identified, appearing (grossly uninvolved / grossly involved).
Additional findings include (specimen disruption / orientation sutures / involvement of adjacent structures / other relevant features). Representative sections are submitted, including tumour with deepest invasion, tumour with closest margins, parametrial tissue, vaginal cuff margin, endometrium, adnexa, and all lymph nodes. A block identification key is provided separately.
Number of cassettes;
Slide keys;
Ink code;
Patient Name; Pathology Accession No;
The specimen is received (fresh / in formalin) labeled “_____” and designated as _____ (as stated by the clinician). If received fresh, additional procedures performed include (frozen section / ancillary studies / biobanking / none). The procedure is a (cervical biopsy / cervical excision type 1 / type 2 / type 3) performed by (electrosurgical loop excision such as LLETZ/LEEP / cold-knife cone biopsy / laser cone biopsy / endocervical curettage / other). Orientation markers are (not present / present and designated as _____).
A total of __ piece(s) is/are received. For each piece, the specimen measures __ mm in maximum dimension. For non-conical excisions, the specimen measures __ × __ × __ mm. For conical excisions, the specimen measures __ mm in length (external os to apex), with an overall length of __ mm. The diameter of the ectocervix measures __ × __ mm (for unoriented specimens), or __ mm in the 3–9 o’clock plane and __ mm in the 6–12 o’clock plane (for oriented specimens). The endocervical canal length measures __ mm.
The specimen consists of tan-pink cervical tissue with a smooth to slightly irregular ectocervical surface and a central endocervical canal. Macroscopically visible lesions are (absent / present), numbering __ and described as _____ (e.g., acetowhite area, ulceration, nodularity). The cut surface is (firm / soft / hemorrhagic / cystic / otherwise described).
Additional findings include (fragmentation / thermal artifact at margins / orientation sutures / inked margins specified as _____ / other relevant findings). Representative sections are submitted sequentially or radially to include the entire transformation zone, endocervical canal, and all margins as appropriate. A block identification key is provided separately.
Number of cassettes;
Slide keys;
Ink code;
Patient Name; Pathology Accession No;
The specimen is received (fresh / in formalin) labeled “_____” and designated as a (total thyroidectomy / near-total thyroidectomy / hemithyroidectomy / lobectomy / isthmectomy / partial excision / other). Additional procedures were (not performed when received / performed: frozen section / ancillary studies / biobanking). The specimen consists of (right lobe / left lobe / right and left lobes with isthmus / isthmus only / unoriented thyroid tissue) and weighs __ grams. The right lobe measures __ × __ × __ mm, the left lobe __ × __ × __ mm, and the isthmus __ × __ × __ mm (as applicable). The external surface is (smooth / nodular / bosselated / disrupted) and the capsule is (intact / disrupted). Parathyroid glands are (identified / not identified).
On serial sectioning, the thyroid parenchyma is (homogeneous reddish-brown / multinodular / fibrotic / cystic / colloid-rich / other). A (unifocal / multifocal) tumor is identified. The lesion is located in the (right lobe / left lobe / isthmus / pyramidal lobe / other), measuring __ mm in greatest dimension (__ × __ × __ mm). The cut surface is (firm / soft / rubbery / gritty / cystic / hemorrhagic / necrotic / fibrotic), (well-circumscribed / encapsulated / partially encapsulated / ill-defined / infiltrative), and (homogeneous / heterogeneous) in appearance, with a (tan-white / grey-white / yellow / hemorrhagic / mixed) coloration. The tumor is __ mm from the nearest (isthmic resection / perithyroidal soft tissue) margin, which is (grossly free of tumor / grossly involved). Gross extrathyroidal extension is (not identified / identified extending into _____). The remaining thyroid shows (multinodular hyperplasia / colloid nodules / thyroiditis / fibrosis / cystic change / no significant abnormality / other).
Lymph nodes are (not identified / identified); if present, __ nodes are recovered, measuring up to __ mm, with cut surfaces (unremarkable / suspicious for metastasis measuring up to __ mm / largely replaced by tumor).
Representative sections are submitted, including tumor with capsule and closest margin, background thyroid, and any lymph nodes or additional abnormal areas.
Number of cassettes;
Slide keys;
Ink code;
Patient Name; Pathology Accession No;
The specimen is received (fresh / in formalin) labeled “_____” and designated as a (subtotal gastrectomy – proximal / distal / total gastrectomy / oesophago-gastrectomy / other). If received fresh, additional procedures performed include (frozen section / ancillary studies / biobanking / none). The specimen consists of a portion of stomach measuring __ mm along the greater curvature and __ mm along the lesser curvature, with an attached oesophagus measuring __ mm and/or duodenum measuring __ mm (as applicable). The external serosal surface is (smooth / congested / dull / nodular / indurated / tumor-involved / otherwise described).
On opening, a (unifocal / multifocal / cannot be assessed) tumor is identified (__ lesions if multifocal). The tumor is located in the (upper / middle / distal third) of the stomach, along the (greater / lesser curvature) and involving the (anterior / posterior wall / other specified site). The tumor measures __ mm in maximum dimension (__ × __ mm additional dimensions, or range __ mm to __ mm if multiple). Grossly, it appears as a (polypoid mass / ulcerative lesion / infiltrative ulcerative lesion / diffuse infiltrative lesion / other), with a (firm / soft / friable / indurated) cut surface and (well-defined / ill-defined / infiltrative) borders. The tumor extends through the wall to a depth of (mucosa / submucosa / muscularis propria / subserosa / serosa) and the serosal surface is (uninvolved / congested / puckered / grossly penetrated by tumor).
The tumor is located __ mm from the nearest proximal (oesophageal) margin and __ mm from the distal (duodenal) margin; the closest margin is (proximal / distal) and is (grossly free of tumor / grossly involved). The distance to the circumferential (radial) margin is __ mm (if applicable / not applicable). Adjacent organs are (not involved / grossly involved – specify organ). Distant metastatic deposits are (not identified / identified – specify site).
Lymph nodes are (not identified / identified); if present, __ lymph nodes are recovered and submitted, with cut surfaces (unremarkable / suspicious for metastasis / replaced by tumor up to __ mm).
Representative sections are submitted, including tumor with deepest invasion, tumor with closest margins (proximal, distal, and radial as applicable), background gastric mucosa, serosa, and all lymph nodes.
Number of cassettes;
Slide keys;
Ink code;
Patient Name; Pathology Accession No;
The specimen is received (fresh / in formalin) labeled “_____” and designated as _____ (as stated by the clinician). If received fresh, additional procedures performed include (frozen section / ancillary studies / biobanking / none). The placenta consists of a single disc measuring __ × __ × __ mm and weighing __ g (trimmed weight __ g after removal of membranes and umbilical cord). The disc is (round / oval / irregular / bilobed / fragmented / with accessory lobe measuring __ × __ × __ mm).
The membranes are (complete with a single point of rupture located __ mm from the placental edge / incomplete, stripped, or ragged) and are (translucent / opaque / thickened) with a (tan / grey / green / hemorrhagic / other) coloration and (smooth / dull / fibrotic) texture. Membrane insertion is (marginal / circummarginate / circumvallate involving __% of the circumference / other). Additional membrane findings include (plaques / nodules / visible vessels / other).
The umbilical cord measures __ mm in length and __ mm to __ mm in diameter. It contains __ vessels at both ends. The cord insertion is (central / eccentric / marginal / velamentous, with membranous vessels extending up to __ mm), located __ mm from the placental edge. The cord is (normal in color / abnormal with discoloration involving _____). The coiling index is __ coils per __ mm of cord, with (no localized abnormal coiling / focal areas of abnormal coiling). Additional cord abnormalities are (not identified / present, including knot / stricture / thrombosis / hematoma / edema measuring __ mm located at _____). If tethered to the fetal surface, the length of tethering is __ mm.
The fetal surface is (smooth and glistening / abnormal with focal lesions involving chorionic vessels described as _____) and involves approximately __% of the disc surface. The maternal surface is (complete / incomplete / ragged) with cotyledons (intact / disrupted). Blood clots are (not identified / present involving __% of the surface, located centrally/peripherally).
On sectioning, the placental parenchyma is (spongy and red-brown / pale / congested / infarcted / firm / cystic) with (no focal lesions identified / focal lesions identified, number __, measuring up to __ mm, located in the central 2/3 or peripheral 1/3, involving approximately __% of the placental volume). Iatrogenic changes are (not identified / present, described as _____).
Representative sections are submitted, including membranes with rupture site, umbilical cord sections (including insertion), full-thickness placental disc sections, and any focal lesions. A block identification key is provided separately.
Number of cassettes;
Slide keys;
Ink code;
Patient Name; Pathology Accession No;
The specimen is received (fresh / in formalin) labeled “_____” and designated as _____ (as stated by the clinician). If received fresh, additional procedures performed include (frozen section / ancillary studies / biobanking / dye injection – specify). Identifying clamps are (absent, twins arbitrarily designated Twin A and Twin B / present and described as _____). Placentation is (not fused dichorionic diamniotic connected by dividing membranes / fused dichorionic diamniotic / monochorionic diamniotic / monochorionic monoamniotic).
The placenta consists of (separate discs / fused discs) with a combined trimmed weight of __ g and overall dimensions of __ × __ × __ mm. The disc(s) are (round / oval / irregular / bilobed / fragmented / with accessory lobe measuring __ × __ × __ mm). The maternal surface is (complete / incomplete / ragged) with cotyledons (intact / disrupted). Blood clots are (not identified / present involving __% of the surface, located centrally/peripherally). The fetal surface is (smooth and glistening / abnormal with focal lesions including chorionic vessel abnormalities described as _____).
Twin A
The membranes are (complete with a single point of rupture __ mm from the placental edge / incomplete, stripped, or ragged) and are (translucent / opaque / thickened) with a (tan / grey / green / hemorrhagic / other) coloration and (smooth / dull / fibrotic) texture. Membrane insertion is (marginal / circummarginate / circumvallate involving __% of the circumference / other). Additional membrane findings include (plaques / nodules / visible vessels / other).
The umbilical cord measures __ mm in length and – mm in diameter, containing __ vessels. The insertion is (central / eccentric / marginal / velamentous with membranous vessels extending up to __ mm), located __ mm from the placental edge. The cord is (normal in color / abnormal with discoloration involving _____). The coiling index is __ coils per __ mm, with (no abnormal coiling / focal abnormal coiling). Additional cord abnormalities are (not identified / present, including knot / stricture / thrombosis / hematoma / edema measuring __ mm at _____). If tethered to the fetal surface, tethering measures __ mm.
The parenchyma allocated to Twin A comprises approximately __% of the placental disc volume and is (spongy red-brown / pale / congested / infarcted / firm / cystic), with (no focal lesions / focal lesions identified, number __, measuring up to __ mm, located in central 2/3 or peripheral 1/3, involving __% of volume).
Twin B
The membranes are (complete with a single point of rupture __ mm from the placental edge / incomplete, stripped, or ragged) and are (translucent / opaque / thickened) with a (tan / grey / green / hemorrhagic / other) coloration and (smooth / dull / fibrotic) texture. Membrane insertion is (marginal / circummarginate / circumvallate involving __% of the circumference / other). Additional membrane findings include (plaques / nodules / visible vessels / other).
The umbilical cord measures __ mm in length and – mm in diameter, containing __ vessels. The insertion is (central / eccentric / marginal / velamentous with membranous vessels extending up to __ mm), located __ mm from the placental edge. The cord is (normal in color / abnormal with discoloration involving _____). The coiling index is __ coils per __ mm, with (no abnormal coiling / focal abnormal coiling). Additional cord abnormalities are (not identified / present, including knot / stricture / thrombosis / hematoma / edema measuring __ mm at _____). If tethered to the fetal surface, tethering measures __ mm.
The parenchyma allocated to Twin B comprises approximately __% of the placental disc volume and is (spongy red-brown / pale / congested / infarcted / firm / cystic), with (no focal lesions / focal lesions identified, number __, measuring up to __ mm, located in central 2/3 or peripheral 1/3, involving __% of volume).
Representative sections are submitted, including dividing membrane (if present), full-thickness placental sections from each twin’s territory, umbilical cord sections including insertion sites, membranes with rupture sites, and any focal lesions. A block identification key is provided.
Number of cassettes;
Slide keys;
Patient Name; Pathology Accession No;
The specimen is received (fresh / in formalin) labeled “_____” and designated as _____ (as stated by the clinician). If received fresh, additional procedures performed include (frozen section / ancillary studies / biobanking / none). The gallbladder measures __ × __ mm in length and maximum diameter. Additional anatomical components include (cystic duct length __ mm / attached liver tissue __ × __ × __ mm / bile duct segment __ mm / other tissues specified).
The external serosal surface is (unremarkable / congested / fibrotic / fibrinopurulent / nodular / with adhesions / perforated at _____ / tumor present / other specified). Gallstones are (not present / present), described as __ in number, measuring up to __ mm, with coloration (mixed / yellow cholesterol / pigmented green-black) and located (free in bile / embedded in mucosa / impacted in neck or cystic duct).
On opening, the mucosa is (velvety / roughened / eroded / ulcerated / fibrotic / trabeculated) and the wall thickness measures __ mm. If a tumor is present, __ lesion(s) is/are identified measuring up to __ mm in maximum dimension and located in the (cystic duct / neck / body / fundus). The tumor appears as a (polyp / nodule / diffuse wall thickening / ulcerated lesion) with a (firm / friable / infiltrative) cut surface. The tumor involves the (serosal surface / gallbladder bed/hepatic aspect / not assessable) and is located __ mm from the closest margin (specify cystic duct margin / hepatic bed margin).
Lymph nodes are (not received / received); if received, __ node(s) are identified and submitted, with gross appearance (unremarkable / suspicious for involvement).
Additional macroscopic findings include (perforation with bile leakage / specimen disruption / orientation sutures / other relevant findings). Representative sections are submitted, including cystic duct margin, tumor with deepest invasion and relation to hepatic bed, background mucosa, and any lymph nodes. A block identification key is provided separately.
Number of cassettes;
Slide keys;
Ink code;