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

1. Tubules: >75% = 1

10-75% = 2

< 10 % = 3

1. Nuclear features:

Small, uniform, few nucleoli = 1

Larger, still uniform, nucleoli = 2

Pleomorphic = 3

1. 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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