Breast Pathology Report

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:

1. Histology: The type of cancer found and the arrangement of the breast cells.

1. Stage: The size of the cancer and the extent to which it has spread.

1. 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

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.
• Benign: Non-cancerous. Benign breast conditions may or may not need treatment.
• Calcifications: Tiny calcium deposits that may indicate breast cancer.
• Carcinoma: Any cancerous tumor that lines the inner surfaces of the breasts. For example, ductal carcinoma in situ (DCIS) is an early stage cancer that starts in the breast ducts.
• 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.
• Malignant: Cancerous.
• 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