09 May Translating Your Pathology Report
Pathology reports are written for other medical professionals, not patients. The terms and wording can look more unfamiliar than another language, which makes your incredibly difficult experience being diagnosed with breast cancer even more challenging. Understanding the basic parts of your report can help you be better informed about your diagnosis, and ask the right questions to your medical professionals.
If your report does not have the exact wording described here, keep this in mind:
Different pathology labs may use different terms to describe the same information, needle biopsy reports may contain less information than surgical biopsy reports, and some tests are only done when invasive breast cancer or certain types of breast cancer are found. Also, if your tissue is found to be free of cancer or if your diagnosis is ductal carcinoma in situ (DCIS), many of the sections described below will not be on your report.
Diagnosis or final diagnosis
This is the most important section of the report. It gives the pathologist’s final diagnosis and may include information on the tumor such as size, type, grade, hormone receptor status and HER2 status. If lymph nodes were removed, the status of these lymph nodes will also be included. This information may appear grouped together or as separate sections.
The microscopic description details what the pathologist saw and measured when he or she looked at the biopsy tissue under a microscope.
Tumor size is most often reported in centimeters or millimeters (1 inch = 2.54 centimeters = 25.4 millimeters). The best way to measure tumor size is under a microscope (especially for small tumors). The longest length of the tumor in the specimen (the tissue removed during surgery) is reported as the tumor size. The tumor size may be much smaller than the size of the tissue sample (the measurement of entire sample is reported in the gross description). In general, the smaller the tumor, the better the prognosis tends to be.
Non-invasive vs. invasive
Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer. With DCIS, the cancer cells are contained within the milk ducts. It’s called “in situ” (which means “in place”) because the cancer cells have not spread to nearby breast tissue. Invasive breast cancer has spread from the original site (the milk ducts or lobules) into the nearby breast tissue, and possibly to the lymph nodes and/or other parts of the body.
For invasive breast cancers, the pathologist notes the shape of the cancer cells and assigns a histologic grade, using either a number system or words. Tumor grade describes the structure of the cells and is different from tumor stage. In general, the more the cancer cells look like normal breast cells, the lower the grade and the better the prognosis tends to be. The most common grading system in current clinical practice is the Nottingham system:
- Grade 1. The tumor cells look the most like normal tissue and are slow-growing (well-differentiated).
- Grade 2. The tumor cells fall somewhere in between grade 1 and grade 3 (moderately-differentiated).
- Grade 3. The tumor cells look very abnormal and are fast-growing (poorly-differentiated).
The nuclear grade describes how closely the nuclei of cancer cells look like the nuclei of normal breast cells. In general, the higher the nuclear grade, the more abnormal the nuclei are and the more aggressive the tumor cells tend to be. The nuclear grade is a part of overall tumor grade.
Hormone receptor status
Hormone receptors are proteins found inside some cancer cells. When hormones attach to hormone receptors, the cancer cells with these receptors grow.
- Hormone receptor-negative (estrogen receptor-negative (ER-negative)/progesterone receptor-negative (PR- negative)) breast cancers do not express (have few or no) hormone receptors.
- Hormone receptor-positive (estrogen receptor-positive (ER-positive)/progesterone receptor-positive (PR-positive)) breast cancers express (have a lot of) hormone receptors.
All breast cancers should be tested for hormone receptor status. The hormone receptor status of your tumor helps guide your treatment. If the tumor is ER-positive and/or PR-positive, your treatment will include hormone therapy (such as tamoxifen or aromatase inhibitors). Hormone therapy prevents the cancer cells from getting the hormones they need to grow and may stop tumor growth. Hormone receptor-negative breast cancers are not treated with hormone therapy. Learn about hormone receptor status and prognosis.
HER2 (human epidermal growth factor receptor 2) is a protein that appears on the surface of some breast cancer cells. It may also be called HER2/neu or ErbB2. The HER2 protein is an important part of the pathway for cell growth and survival.
- HER2-negative breast cancers have little or no HER2 protein.
- HER2-positive breast cancers have a lot of HER2 protein (you also may hear the term “HER2 over-expression”).
All breast cancers should be tested for HER2 status. HER2 status helps guide your treatment. HER2-positive cancers can benefit from anti-HER2 drugs, such as trastuzumab (Herceptin), which directly target the HER2 receptor. Trastuzumab and other anti-HER2 drugs are not used to treat HER2-negative cancers. The main tests for HER2 status are: Immunohistochemistry (IHC), which detects the amount of HER2 protein on the surface of the cancer cells and Fluorescence in situ hybridization (FISH), which detects the number of HER2 genes in the cancer cells. Most often, IHC is the first test done. If the score is +2 (or borderline), the tumor is sent for FISH testing to confirm the status.
Results of an IHC test
Score is 0 or +1: Tumor is HER2-negative.
Score is +2: Results are unclear and should be confirmed by FISH.
Score is +3: Tumor is HER2-positive.
Results of a FISH test
Positive (amplified): The tumor is HER2-positive.
Negative (non-amplified): The tumor is HER2-negative.
Learn more about treatment with trastuzumab (Herceptin) and other HER2 targeted therapies.
When breast cancer is surgically removed (during a surgical biopsy, lumpectomy or mastectomy), a rim of normal tissue surrounding the tumor is also removed. This rim is called a margin. The pathologist looks at the margins under a microscope and determines whether or not they contain cancer cells. This helps show whether or not all of the tumor was removed.
Negative (also called “clean,” “not involved” or “clear”) margins
The margins do not contain cancer cells (there’s only normal tissue at the edges of the tissue removed from the breast). In most cases, no more surgery is needed.
Positive (also called “involved”) margins
The margins contain cancer cells. More surgery may be needed to get clear margins (discuss this with your surgeon). Sometimes it’s not possible or necessary to get clear margins due to its location (for example, if it’s at the chest wall).
The cancer cells approach, but don’t touch the edge of the breast tissue removed. More surgery may or may not be needed (discuss this with your surgeon). To further ensure the entire tumor was removed, the removed breast tissue may be X-rayed. This is useful when microcalcifications were found on a mammogram and are related to the cancer. Depending on the results of the X-ray, more tissue may be removed at the time of the surgery. If microcalcifications were seen on a mammogram before surgery, another mammogram may be done after surgery to ensure all the microcalcifications were removed.
Lympho-vascular invasion (angiolymphatic invasion)
Lympho-vascular invasion occurs when cancer cells enter lymph channels or small blood vessels. This may suggest a more aggressive tumor.
Lymph node status
If lymph nodes in the underarm area (axillary lymph nodes) were removed during surgery, the pathologist looks at them under a microscope and determines whether or not they contain cancer. Lymph node-negative means the axillary lymph nodes do not contain cancer, lymph node-positive means the axillary lymph nodes contain cancer. In general, lymph node-negative breast cancers have a better prognosis than lymph node-positive breast cancers.
Other information in a pathology report
The following items are included in all pathology reports, but don’t impact prognosis or treatment.
This section of the report has basic information including your name, medical record number, date of birth, age and sex, date of the biopsy and name of the health care provider who ordered the report (most often your surgeon). It’s a good idea to check all this information to make sure you have the correct pathology report.
Specimen(s) received (specimen source/specimen submitted)
This section records the location in the breast where the biopsy sample(s) was removed. It may simply state left or right breast, or may give more detail. It also includes the date the pathologist received the tissue.
Procedure (description of procedure)
This is a description of the type of biopsies used to remove the tissue sample and lymph nodes (if lymph nodes were removed). It is a needle biopsy or surgical biopsy for tumor tissue, and sentinel node biopsy or axillary dissection for lymph nodes.
Clinical history (clinical information/clinical diagnosis/pre-operative diagnosis)
The clinical history describes the initial diagnosis before the biopsy and sometimes, a brief summary of your symptoms. The location of the tumor biopsy is also noted (for example, left or right breast). If you had breast cancer in the past and the biopsy tissue is available, the pathologist often will review this tissue to distinguish the recurrence of a past tumor from a new breast cancer.
Gross description (macroscopic description)
One of the first things the pathologist does when he or she receives the biopsy tissue is to take measurements and record a description of the tissue as it appears to the naked eye (without a microscope). This gross description may include the size, weight, color, texture or other features of the tissue and any other visual notes. If there are multiple samples, there’s often a separate gross description section for each sample. In these cases, the pathologist assigns a reference number or letter to each tissue sample to avoid confusion. The gross description also includes information on how the sample was handled once it reached the pathologist.
The pathologist signs and dates the report (most often, electronically).
Information sometimes seen on a pathology report
The following items don’t impact prognosis or treatment and may not appear on your report. Some of these tests are only done for certain diagnoses. Others are not routinely done because they don’t predict prognosis better than standard measures or because they are not reliable measures for all tumors.
Immunohistochemistry (IHC) for prognostic markers
Beyond HER2 status testing, IHC can detect other molecular markers that may give information on prognosis.
Proliferation rate (Ki-67, MIB1)
The proliferation rate is the percentage of cancer cells actively dividing. In general, the higher the proliferation rate, the more aggressive the tumor tends to be. Proliferation rate could be a good predictor of prognosis. However, there are issues related to its measurement. Although it may be assessed at some medical centers, it’s not standard care. The Ki-67 test is a common way to measure proliferation rate. When cells are growing and dividing (proliferating), they make proteins called proliferation antigens. Ki-67 is a proliferation antigen. MIB1 is the antibody most often used to label the Ki-67 antigen. The more cells MIB1 attaches to in a tissue sample, the more likely the tumor cells are to grow and divide rapidly. The result of this test is reported as the percentage of Ki-67-positive cells (the proportion of cancer cells that are in the process of dividing). A higher value shows a higher proliferation rate.
Questions to ask your doctor:
Learn more about understanding your pathology report.