Being diagnosed with breast cancer is a life-changing event. There may be many different emotional reactions to deal with and an enormous amount of information to learn. A call to the Y-ME Hotline can help with both.

Newly diagnosed women and men, their families and friends, need information that will tell them about their breast cancer, the possible outcomes and treatments. The pathology report can be a major source of this information. Unfortunately the pathology report is sometimes written in terms that frequently only pathologists and other medical professionals can understand. The pathology report is a collection of information that describes your breast cancer. Please do not become concerned about any one or two findings on your pathology report.

We have put together this brochure in an effort to make this important document more clearly understood by all. Because pathology reports sometimes follow different forms, we have tried to describe the terms that may be used on the report in a general way.

Specific questions about your pathology report should be directed to your doctor or the pathologist.

Purpose of the Pathology Report

The purpose is to provide the health care team with information about a surgical specimen or tissue sample. The information is then used to determine the exact nature of the specimen (non-cancerous vs. cancerous) and the characteristics of a tumor. If the tissue sample is cancerous, the description of its characteristics will give you and your physician(s) information about size and local extent of the tumor, prognosis or staging and possible treatment options.

Parts of the Pathology Report

Demographics
This section contains identifying information. Your name, doctor(s) name, medical record number and other identifying information may be included.

Gross Description
In this section you will find the description of the specimen or tissue sample based on what the naked eye can see. Included here will be the size and weight of the specimen and other visual observations made by the pathologist. Information about how the sample was handled (how it was sectioned and what materials were used) in preparation for the microscopic examination.

Microscopic Description
This part of the report points out the features of the tumor or tissue sample seen under a microscope. These features will lead to the specific diagnosis and will be discussed later.

Prognostic Report
This contains the results of the specific tests done on the specimen.

Summary and Diagnosis
This section should contain all of the important data concerning the diagnosis and the various tests carried out on the specimen. The most helpful part of this section is a list of characteristics and the findings for the specific specimen.

Information Found on the Report

Anatomic site, for example: “breast, right, mastectomy” or “right breast upper outer quadrant lumpectomy”.

Size, reported in centimeters (one inch = 2.54 centimeters).
In general, the smaller the tumor the better the prognosis. The larger a tumor grows the greater the chance it may have spread to other areas of the body.

Invasive vs. Noninvasive
Invasive breast cancer is cancer that has broken through the wall (basement membrane) of either a duct or a lobule. (Breast tissue is made up of lobules that produce milk and ducts that carry the milk to the nipple). The most common form of breast cancer is invasive ductal carcinoma or a cancer that began in a duct and has spread outside the duct. Noninvasive breast cancer, lobular or ductal, is referred to as in situ. It is considered Stage 0.

Histolopathologic Grade
This measure is often reported using some version of the Bloom Richardson or the Scarff-Bloom-Richardson scale. It is based on a combined score for nuclear grade, mitotic rate, and histologic grade or architectural differentiation. Each characteristic is given a score of 1 to 3, resulting in a total score ranging from 3 to 9.

·         Nuclear Grade
Nuclear grade is based on how closely the nuclei of cancer cells resemble normal cells. A grade of I (low) indicates that the cells’ nuclei closely resembles normal cells and are well differentiated. Grade II (intermediate) indicates moderately differentiated and grade III (high) are poorly differentiated. Higher nuclear grade tumors are more aggressive.

·         Mitotic Rate
This rate indicates the number of malignant cells that are actively dividing. The mitotic rate is reported with numbers from 1 to 3. The higher the score more aggressive the tumor cells.

·         Cellular Differentiation
This measure is based on how close the specimen resembles normal breast tissue. This measure refers to tubular formation of the cells. A grade of 1 indicates a well-differentiated tissue with many tubulars, grade 2 moderately differentiated and grade 3 poorly differentiated tissue with few or no tubules.

Surgical Margins

When a specimen is received from surgery, the edges or borders are marked with ink. Later, when cross sections of the specimen are viewed under the microscope, the pathologist can report whether the tumor goes right up to the inked border (positive) or whether the margin is “clear” or negative. Positive margins sometimes indicate the need for another surgical procedure in an attempt to remove any remaining cancer cells and get “clear margins”.

Lymph Node Status
Our bodies have a network of lymph nodes and lymph vessels that carry and remove fluid, similar to the way blood vessels circulate blood to all parts of the body. The lymph fluid has white blood cells, which help fight infection. In invasive breast cancer tumor cells may spread through the lymph vessels. Therefore, during surgery for invasive breast cancer, the doctor usually removes some of the lymph nodes and vessels from the underarm (axilla) to see if the cancer has spread. If cancer cells are found in any of the lymph nodes, it is reported as positive. The report will tell how many lymph nodes were removed and how many are positive, e.g. 0/11 is no positive nodes out of 11; 3/15 is three positive nodes out of 15 removed. In general, negative lymph node status is better than positive and a lower number of positive nodes are better than a higher number.

In a newer procedure called sentinel node mapping (SNM), only one or two nodes are removed. The lymphatic drainage system from the breast to the underarm is not random. It follows pathways that can be mapped by injecting dye or a radioactive material into the site of the tumor. The first or sentinel node that shows dye or radioactivity can them be removed and analyzed. At this time the finding of a positive sentinel lymph node is usually followed by the standard removal of more nodes.

Hormone Receptor Status
There are some breast cancer cells that have a high proportion of hormone (estrogen and /or progesterone) receptors in the nucleus. These cells are sensitive to hormones that can promote cell growth. If your cancer cells have a high proportion of estrogen (ER) or progesterone (PR) receptors, the report will say you are ER positive or PR positive. If your cells have a lower number of receptors your report will say you are ER or PR negative. This has implications for treatment and is one of the most important pieces of information on the pathology report. Being ER/PR positive means that you might benefit from what is commonly called hormonal therapy. Hormone therapy is actually therapy with a drug, usually tamoxifen, which blocks hormone receptors in the cancer cell.

Her2 Status
The Her2 (Her2/neu or cerb-2) gene produces a protein that acts as a receptor on the surface of the cell. This receptor is sensitive to a growth factor, a signal to the cell to grow. If the cancer cells have more receptors than normal, they are receiving more messages to grow and divide. There are two ways to measure Her2 status. One is an immunohistochemistry (IHC) test, which measures the overexpression of the protein (number of receptors on the surface of the cancer cell) and is reported using the numbers 0 to +3. Scores of zero and +1 are Her2 negative and +2 and +3 are Her2 positive. The other method of testing is fluorescent in situ hybridization (FISH), which measures the amplification of the HER-2 gene (the number of copies of the HER-2 genes present in a cancer cell). The results of this test are reported as positive or negative. Her2 positive status is associated with tumors that are fast growing and aggressive. Only 25 to 30% of women with breast cancer are Her2 positive.

Lymphovascular Invasion
This is the penetration of cancerous cells (often seen as small clusters under the microscope) into the interior of blood vessels and/or lymph channels. Lymphovascular invasion may indicate a more aggressive tumor.

DNA Studies
One piece of information that comes from DNA studies is the amount of DNA in a cell. If the cells have the correct amount of DNA they are called diploid. If they have an abnormal amount of DNA they are called aneuploid. Most breast cancer cells (70%) are aneuploid.

The other test of DNA measures the percentage of cells that are dividing at any one time. This is reported as the S phase fraction or S phase. If there are many cells dividing at one time, the S phase number is higher. The higher the S phase the more aggressive the tumor may be. There are many situations in which the S phase cannot be measured for technical reasons. These tests give similar information as the nuclear grade but are done by a computer and do not depend on the pathologist interpretation of how cells look.

Staging

Staging is the assessment of how far a patient’s breast cancer has progressed and determines treatment decisions and prognosis. Knowing the patient’s stage helps the doctor decide what kind of treatment would be best for the patient and may predict prognosis (how patients will do) for the patient and their families.

Staging is done using the TNM system. T is Tumor size, N is lymph Node status (cancer cells found in the lymph nodes is called positive status) and M is Metastasis (the tumor has spread to other parts of the body). In general the lower the stage the better the prognosis. Below is an abbreviated table to help you understand the relationship of these three factors.

This brochure was written Judy Perotti, Director of Patient Services, Y-me National Breast Cancer Organization. The help and advice of the Medical Advisor Committee members and the Y-me Hotline staff is much appreciated. Special thanks to Dr. Judith Wolfman, Chair of the Y-me Medical Advisory Committee for her detailed review and to June Adler, Y-me Hotline Coordinator for her proof reading skills.                      

© 2000 Y-me National Breast Cancer Organization