- Michael Misialek, MD
Understanding Your Breast Cancer Pathology Report
As National Breast Cancer Awareness Month comes to a close, a theme that Path Report has consistently stressed is an understanding of the important role of the pathologist. All treatment begins with a diagnosis. The pathology report is the culmination of a tremendous amount of work by your pathologist. Each item in the report carries both therapeutic and prognostic information. Let’s take a look at the report in detail.
Usually the final diagnosis is given at the top of the report. For a resection, i.e. lumpectomy or mastectomy, there will be a “synoptic report” that follows. This provides the important details about the tumor characteristics. A typical synoptic report follows.
MAJOR DIAGNOSES: All major diagnoses listed here
7th EDITION AJCC PATHOLOGIC STAGE: (see above chart) or follow link
TUMOR SIZE: Tumor size in MM or CM
TUMOR FOCALITY: How many tumors are present, size and type of each
SPECIMEN SIZE: The overall size of the specimen
OVERALL HISTOLOGIC GRADE (Nottingham): 1, 2, or 3 of 3 (see notes below) – microinvasion (≤ 1 MM) is not be graded.
NOTTINGHAM GRADING ELEMENTS:
Tubule Formation Score: (Score 1 to 3 – see notes below)
Nuclear Pleomorphism Score: (Score 1 to 3 – see notes below)
Mitotic Rate Score: (Score 1 to 3 – see notes below)
Total Score: (Score 3 to 9)
(key: grade 1 = score 3-5; grade 2 = score 6,7; grade 3 = score 8,9)
3 components are rated on 1 to 3 scale, including
Tubules: >75% = 1
10-75% = 2
< 10 % = 3
Nuclear features:
Small, uniform, few nucleoli = 1
Larger, still uniform, nucleoli = 2
Pleomorphic = 3
Mitotic Activity: Count in regions with highest activity (typically periphery of tumor):
- ≤ 3 mits per mm2 = 1
- 4-7 mits per mm2 = 2
- ≥ 8 mits per mm2 = 3
The scores of all 3 variables are added:
Total score 3-5 = Grade 1
Total score 6-7 = Grade 2
Total score 8-9 = Grade 3
DUCTAL CARCINOMA IN SITU (DCIS):
Extensive intraductal component (EIC): present/absent
Type of DCIS: comedo, cribriform, etc
Nuclear grade of DCIS: 1,2, or 3 of 3
Necrosis: presence/absence of cell death
Extent of DCIS:
SKIN INVOLVEMENT: present/absent
NIPPLE INVOLVEMENT: present/absent, usually DCIS/Paget’s
SKELETAL MUSCLE INVOLVEMENT: present/absent. May guide radiation if involved.
LYMPHATIC/VASCULAR SPACE INVASION: present/absent/indeterminate
LOCATION OF CALCIFICATIONS: Invasive cancer, DCIS, benign breast tissue
MARGIN ASSESSMENT: For oriented specimens, ALL MARGINS are evaluated. (for mastectomies, only the deep fascial margin)
INVASIVE CARCINOMA:
POSITIVE MARGINS: only included if there are positive margins (ink on tumor)
Anterior: number of slides
Posterior: “” “”
Superior: “” “”
Inferior: “” “”
Medial: “” “”
Lateral: “” “”
NEGATIVE MARGINS:
Anterior: the closest margin is listed if ≤3MM; otherwise >3MM
Posterior: “” “”
Superior: “” “”
Inferior: “” “”
Medial: “” “”
Lateral: “” “”
DUCTAL CARCINOMA IN SITU:
POSITIVE MARGINS: only included if there ARE positive margins –
Anterior: number of slides
Posterior: “” “”
Superior: “” “”
Inferior: “” “”
Medial: “” “”
Lateral: “” “”
NEGATIVE MARGINS:
Anterior: the closest margin is listed if ≤3MM; otherwise >3MM
Posterior: “” “”
Superior: “” “”
Inferior: “” “”
Medial: “” “”
Lateral: “” “”
MARGIN CLASSIFICATION: If positive margins are present, then one of the qualifiers is given
unifocal = 1 focal area of tumor at margin, <4 mm
multifocal = 2 or more foci of tumor at the margin
extensive = tumor present at the margin over a broad front(>5 mm)
AXILLARY LYMPH NODES:
Total number of sentinel lymph nodes examined:
Total number of non-sentinel lymph nodes examined:
Number of lymph nodes with macrometastases: (>2 MM)
Size of largest macrometastasis: If present
Number of lymph nodes with micrometastases: (<2 MM)
Number of lymph nodes with isolated tumor cells:
Number of lymph nodes with NO tumor cells identified:
Total lymph node positivity rate: X out of Y nodes are positive for metastatic carcinoma
Extracapsular invasion: the size of the tumor outside the capsule
TREATMENT EFFECTS: if neoadjuvant chemotherapy was administered then the presence of residual tumor is quantified by one or more of the following criteria:
Miller-Payne Histologic Grade:
Residual Cancer Burden:
Residual Cancer Burden Class:
Treatment Effects in Lymph Nodes:
OTHER PATHOLOGIC FINDINGS: Any benign findings present
COMMENTS: Any additional details that need further explanation will be described here
ESTROGEN RECEPTORS, PROGESTERONE RECEPTORS IMMUNOSTAIN RESULTS:
Usually done on the prior biopsy
HER2 RESULTS: Usually done on the prior biopsy
ONCOType Dx: If this was performed
The College of American Pathologists provides a helpful resource to understand the details behind your pathology report to help make informed decisions about your health. Path Report also provides a video and resource.
To learn more about the vital role of the pathologist, visit cap.org. Get the facts about your health. Get a copy of your pathology report. Understand it and ask questions. Discover the other member of your care team, the pathologist.
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