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  • Michael Misialek, MD

The Role of Pathology in Breast Cancer


The discovery of a breast mass or an abnormality on mammogram is understandably a very distressing experience. Knowing what to expect can be helpful in navigating the often confusing sequence of events that follows. Knowledge is power and is one’s ally in taking control of your health.

Often the first step in working up an abnormal breast finding is to sample the tissue using a stereotactic needle biopsy. This is typically done by a radiologist. A small core of tissue will be removed. The specimen is then sent to the pathology lab.

Upon reaching the lab, the tissue is carefully examined and described by a pathologist or pathologist assistant. The biopsy is placed into a cassette then processed in an instrument to prepare it for cutting. Next, the specimen is embedded into paraffin, cut and placed on a slide. This is stained, cover slipped and delivered to the pathologist.

A pathologist will then examine the specimen under a microscope and make a diagnosis. Often in challenging cases, it will be shared with colleagues for consultation. Additional slides and/or stains may be performed to clarify any uncertainty in order to reach the most accurate and precise diagnosis. Consultation is also available from pathologists who are experts in breast pathology. Often the pathologist will discuss the case with the submitting provider, particularly in cases where clinical correlation is needed and may even review radiographic images. A report is then prepared and finalized.

The pathologist’s involvement does not end there. Clinicians may call for an explanation if anything is unclear, or the pathologist may call proactively to prepare them for what to expect.

Your pathologist will stay with you throughout your care. They will likely participate in a multi-disciplinary conference with other specialists where all current cases are discussed. If additional procedures are performed, the specimens will be compared with prior material. Sometimes neoadjuvant therapy will be offered where chemoradiation is given for a period of time before surgery. In this scenario, comparison of the pre and post treatment tissue samples is vitally important in determining response.

The pathologist will perform testing on the tumor for estrogen and progesterone receptors along with HER2 status. Again, this provides crucial information in order to select the right chemotherapy regimen. In some instances, genetic testing for BRCA or molecular testing of the tumor with prognostic biomarkers may also be done, i.e. Oncotype DX.

Patients can take steps to help ensure their breast biopsy is read accurately:

Inquire about the pathology laboratory that will examine your tissue sample. Is the laboratory accredited? The CAP accredits more than 7,600 laboratories worldwide and provides an online directory for patients.

Make sure the pathologists who are examining your tissue samples are board-certified.

Find out if your hospital has a multidisciplinary breast conference. This is a team of physicians and other health care professionals that meets regularly to discuss diagnosis and management of patients with breast disease, guaranteeing more consultation about the best approach for your care.

If your hospital doesn’t have a multidisciplinary breast conference, consider getting a second opinion. Second opinions are always welcome. Have your doctor send the biopsy slides to another laboratory and request they be read by a pathologist who specializes in breast pathology. Insurance typically covers second opinions.

Seek out accurate and credible resources to help you understand your pathology report and diagnosis, such as the CAP’s resource, “How to Read Your Pathology Report.”

Most accredited surgical pathology laboratories include second opinion slide review as part of their quality management program. Ask about this.

The pathologist is a vital member of the health care team. You know your other doctors. Now meet us.

#breastcancer #pathology #biopsy

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