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The Sections of a Breast
Pathology Report
The pathology report is usually divided
into several sections:
- Demographics: This information
appears at the top of the report and identifies the patient and the physician. The
patient’s name, address, birth date, and date of procedure are usually included.
- Anatomic Pathology Diagnosis: This
is most important section of the report. It gives the pathologist’s diagnosis and
other clinical information that is necessary to determine treatment.
The following are included in this section:
- Histology: The
type of cancer found and the arrangement of the breast cells.
- Stage: The
size of the cancer and the extent to which it has spread.
- Grade:
The nature of the cells and their aggressiveness.
- Clinical History/Pre-Operative
Diagnosis: The patient’s initial diagnosis prior to the pathologist's diagnosis.
For example, a breast lump was found, a suspicious nipple discharge
was experienced, etc.
- Specimen(s) Obtained: What was
received by the pathologist following the procedure (cells, tissues) and when it was
received.
- Gross Description or
"The Gross:" Characteristics of the specimen that the pathologist saw,
measured and felt when examining the tissue with the naked eye (without a microscope).
- Microscopic Description: What the
tissues looked like to the pathologist upon examination under the microscope.
- *Source: Breastpath.com
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Understanding the
Terminology of a Pathology Report
The following are terms commonly found
on a breast pathology report:
- Abscess: A
closed pocket containing pus (a creamy, thick, pale yellow or yellow-green fluid that
comes from dead tissue; most commonly caused by a bacterial infection).
- Atypical:
Literally, "not typical." Exhibits unusual characteristics. For example,
atypical hyperplasia is a dangerous increase in the number of breast cells; a sign that
breast cancer may develop.
- Calcifications:
Tiny calcium deposits that may indicate breast cancer.
- Dysplasia:
An atypical increase in the number of cells, much like hyperplasia.
- Hyperplasia:
A dangerous increase in the number of breast cells; a marker for breast cancer.
Hyperplasia does not spread to other organs but can develop into localized cancer.
- Inflammation:
The clinical signs are breast swelling, pain, tenderness, redness, and/or heat.
Pathologists may see inflammatory white blood cells during their examination.
- In situ:
Literally, "in place." The cancer has not invaded surrounding tissues or spread
to distant organs.
- Lesion: Term
used to describe a tumor, area of inflammation, or other breast abnormality.
- Metastatic:
Term used to describe cancer that has spread from its original site to distant body
organs. For example, metastatic breast cancer often spreads
first to bone.
- Necrosis: The
death of tissue. Fat necrosis is a benign
(non-cancerous) breast condition that may occur when fatty breast tissue swells or becomes
tender spontaneously or as the result of an injury to the breast. However, necrosis within
a cancerous tumor may indicate that the tumor is growing so rapidly that blood vessels are
not able to multiply fast enough to nourish some of the cancer cells. Necrosis usually
indicates that the tumor is very aggressive and can spread quickly.
- Neoplasm or
Neoplasia: An uncontrollable growth of the body’s own cells, either benign
(non-cancerous) or malignant (cancerous).
- Tumor: A mass
of tissue or lump. May be caused by swelling, hyperplasia, or anything that causes an
increase in volume. Tumors may be either cancerous or non-cancerous.
Additional Resources and
References
- Pathologist J.B. Askew, Jr., MD helps
women decipher their breast surgical pathology reports by providing detailed written
explanations of all sections: http://www.breastpath.com/
- The Biopsy Report: A Patient's Guideis
maintained by Edward O. Uthman, MD, a board certified pathologist (Diplomat,
American Board of Pathology). The site discusses pathologic examination and provides a
glossary of important diagnostic terms: www.neosoft.com/~uthman/biopsy.asp.
Updated: May 4, 2008
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