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PATIENT INFORMATION

JANE DOE

Age: 25 years
Date of Birth: 03/22/81

Location/ID: 123456

PHYSICIAN

JOHN SMITH, M.D

1234 JOHN WAY
HERCULES, CA 94547

SPECIMEN INFORMATION

Accession # WCC-06-99999
Collected:09/19/2006
Received:09/20/2006
Reported:09/21/2006

SPECIMEN SITE / COMMENTS


1. SPECIMEN SITE - RIGHT BREAST
2. SPECIMEN SITE - LEFT BREAST

GROSS DESCRIPTION


1. Designated "right breast tissue" is 375 gm consisting of multiple fragments of breast tissue, some with skin. The largest fragment is 16 x 9 cm. No skin lesions are present. No nipple is represented. There is one mass measuring 2 cm in diameter identified by a suture as a separate fragment. The specimen is submitted in Cassettes "R1" through "R5" with the mass submitted in Cassette "R5."

2. Designated "left breast tissue" is 375 gm consisting of multiple fragments of breast tissue, some with skin. The largest fragment is 17 x 12 cm. No skin lesions are present. No nipple is represented. No indurated masses are detected. The specimen is submitted in Cassettes "L1" through "L4."

MICROSCOPIC DESCRIPTION


Sections of this tissue from the right and left breast show benign fibrosis with lobular and ductal atrophy. No evidence of malignancy is identified. No evidence of ductal hyperplasia or neoplasia is found. Paget`s disease is not identified in sections from the overlying areola.


FINAL DIAGNOSIS


1. Right breast, right mastectomy
- BENIGN BREAST TISSUE WITH FOCAL FIBROADENOMA (1.2 CM).
2. Left breast, left mastectomy
- BENIGN BREAST TISSUE.



JOHN COMPAGNO M.D.,MEDICAL DIRECTOR
Original Report Reviewed and Verified
712 Alfred Nobel Drive . Hercules, CA 94547 . toll free 800.794.9737 . fax 510.662.5240 . www.wcpl.com . John Compagno, M.D., Medical Director
PATHOLOGY/CYTOPATHOLOGY CONSULTATION REPORT