SAN PABLO DOGTORS HOSPITAL

San Pablo City, Laguna

SURGICAL PATHOLOGY CONSULTATION REPORT

Histopath No. Case/Trans No:
Name:

sPD13-307 97463
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REYES, MARILYN F" Physician: Dr.Flores Date Received: September26, 2013

Brief Clinical Summary: Operative Diagnosis.

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Age: 57
Service:

Sex: Female

Date: October3,2A13

Specimen:
Diagnosis:

Modified Radicat Mastectomy, Left

Modified Radicat Mastectomy, Left:

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,i,,istEaTlvE FoR METASTASIS, ALL 18 AxruiARY,i 'NODES AND{ LEyEL ll

NODES.

Specimen is a left MRM measuring22xlT x4 cm with axillarytail of 7 x 9 x 2 cm marked with suture tie. Theellipticalskinmeasuresl3x6cmwitha3cmincisionscarmedialtothenipple(1.5x1.3x0.7cm). No ulceration, dimpling, nor nipple inversion is seen. Sections underneath the incision scar shows a residual cavity measuring 1 .5 x2.5 x 1 .5 cm. No residual mass is seen. The cavity is 1 .5 cm from the skin and 2.5 cm from the nearest surgical (basal) margin. A total of 18 lymph nodes were harvested, with the largest measuring 2.5 x 1 x 1 cm. Also submitted separately, labeled as Level ll nodes are four lymph nodes, the largest 1 x 0.5 x 0.5 cm. Representative sections were taken labeled as A-Level ll nodes, Bcavity margin and skin, C-nipple, D-cavity margin and basal, E,F,G, H- lymph nodes. Microsections show fibrocystic change with no residualtumor. Skin, nipple, and basal margins show no tumor involvement. All axillary lymph nodes and level ll nodes are negative for tumor involvement. There is no lymphovascular invasion noted.

/, ,ZZr^ t_/ 2aq,?a.// xnieru o. BoNdAS, MD, DPSP

Pathologist