[Appropriate identification]
NEOADJUVANT SPECIMEN REQUISITION FORM (to be completed by surgeon)
Fill in blank or circle appropriate
CLINICAL TRIAL: ___________________________ / Not applicable
Note to pathologist: If a trial, please verify if trial
requires a particular grading system.
PRE-TREATMENT:
Lesion 1: Location: ______o’clock, ______cm from nipple
Size: __________ Depth: Superficial Mid-depth Deep
Calcifications
Clip
Ink
Marked with suture
Lesion 2: Location: ______o’clock, ______cm from nipple
Size: __________ Depth: Superficial Mid-depth Deep
Calcifications
Clip
Ink
Marked with suture
Lesion 3: Location: ______o’clock, ______cm from nipple
Size: __________ Depth: Superficial Mid-depth Deep
Calcifications
Clip
Ink
Marked with suture
Primary tumor biopsy: Lab ref. number: ________________ At this / Different institution
If at different institution, please complete this box:
Slides requested for review : Yes No (Slides from the prior biopsy are needed for comparison of pre- and pos- treatment cellularity.)
Diagnosis: Invasive ductal carcinoma
ER: pos/ neg
PR: pos/ neg
Other type: _________________________________ Grade: 1 2 3
HER2 (IHC): 0 1+ 2+ 3+
HER2 (FISH/ CISH): Not amplified
Pretreatment lymph node biopsy/ sampling performed: No
Ratio:___ / Copy number: ___
Yes
If “Yes”: Lab ref. number: ________________ At this / Different institution
Clip(s) placed in biopsied lymph node(s)? Yes No
If at different institution, please complete this box:
Slides requested for review: Yes
No
Biopsy procedure: SLN FNA Core
Number of lymph nodes: Examined:__ Positive:__ (Size of largest metastasis:________)
POST-TREATMENT:
Clinical residual disease in breast: No
Yes
If “Yes” please indicate on diagram.
Post-treatment imaging of breast: Mammography US MRI
PET
Cycle # at imaging: ___
Post-treatment imaging of axilla?: No Yes (If “Yes”: US Mammography MRI
PET
Cycle #: ____)
Clinically positive nodes in axilla present post-treatment?: No Yes If “Yes”: number of positive nodes: ____
Lesion 1: Location: ______o’clock, ______cm from nipple
Size: __________ Depth: Superficial Mid-depth Deep
Describe response: concentric/ scattered/ ______________
Lesion 2: Location: ______o’clock, ______cm from nipple
Size: __________ Depth: Superficial Mid-depth Deep
Describe response: concentric/ scattered/ ______________
Lesion 3: Location: ______o’clock, ______cm from nipple
Size: __________ Depth: Superficial Mid-depth Deep
Describe response: concentric/ scattered/ ______________
Intraoperative findings: Close margin(s): No Yes
If “Yes”: Describe:_________________________________________
Suggested template requisition form for neoadjuvant breast specimens
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