Undertsanding Your Pathology Report

Histological grade is reported using the "Bloom Richardson Scale" or "Nottingham Score". It is a combination of nuclear grade, mitotic rate, and tubule formation, which are characteristics of the tumor cells seen under a microscope that predict its aggressiveness. Now, this scoring system is very detailed and usually does not affect treatment decisions, so it is not particularly helpful in the big picture. However, you will see it on the report and may be interested in what it means. In general, high grade tumors are more likely to recur when compared to low grade tumors.

* Nuclear Grade: a score is given from 1 to 3, based on the appearance of the nucleus of the cancer cells, with 1 being the closest to normal cells (better), 3 being the most variation (worse).

* Mitotic Rate: describes how quickly the cancer cells are multiplying or dividing using a 1 to 3 scale, 1 being the slowest, 3 the most rapid.

* Tubule formation: this score represents the percent of cancer cells that are in tubule formation. A score of 1 means greater than 75% of cells are in tubule formation (better), a score of 3 is used when less than 10% of cells are in tubule formation (worse), a score of 2 is in between 10 and 75%.

The three scores are then combined for a total score between 3 (1+1+1) and 9 (3+3+3). This score translates to a histological grade. You may see the three values and total score or just the final grade.

* Score of 3,4 or 5: Well differentiated or low grade (Grade 1)

* Score of 6 or 7: Moderately differentiated or intermediate grade (Grade 2)

* Score of 8 or 9: Poorly differentiated or high grade (Grade 3)

Tumor Size

The size of the tumor is reported in centimeters. One inch equals about 2 ½ centimeters. It is not uncommon for the pathologist to find additional tumor(s) in the specimen that you did not know were there. If multiple tumors are found, the size and location of each will be noted. Tumor locations are often given based on the quadrant it was found in. Imagine the breast is divided with a "+" sign into 4 parts or quadrants. They are named upper inner quadrant (UIQ), upper outer quadrant (UOQ), lower outer quadrant (LOQ), lower inner quadrant (LIQ) and "axillary tail" is used to describe the breast tissue that extends under the armpit.

Margins

Your report will give some information about the margins. These are the edges of the surgical specimen and the report will tell you how close the tumor comes to the edge. When performing a cancer surgery, the surgeon attempts to remove the entire tumor and some normal tissue surrounding it. This area of "normal tissue" is important because any stray cancer cells may be included in this. If the edge (or margin) contains tumor, there may have been cancer cells left behind. The goal of surgery is to achieve a "clear margin", that is, clear of any cancer cells. A "clean" or "clear" margin is defined as no tumor cells within 1-2 millimeters (depending on the pathologist) of the edge of the specimen. If the tumor cells are closer than this to the margin, additional surgery or radiation may be needed.

Lymphovascular Invasion

When the pathologist examines the tumor and surrounding tissue available to them, they look at the tiny blood vessels and lymphatic drainage to see if any tumor cells have invaded them. This is different from the lymph nodes and would be reported as whether or not lymphatic or vascular invasion is seen. The presence of this may be a sign of a more aggressive tumor.

Lymph Nodes

The lymph system is essentially the "housekeeping system" of the body. It is a network of vessels (tubes) which connect lymph nodes. These nodes can vary in size, but are normally up to about 2 centimeters in width. They contain cells that clear bacteria and other foreign debris from the body. Lymph is a watery liquid that flows between cells in the body, picking up foreign debris and taking it into the lymph node for filtering and ultimately, elimination by the liver.

Cancer cells use the lymph system as a first step to traveling to other areas of the body. During a breast cancer surgery, lymph nodes are removed and checked for the presence of cancer cells. This will be reported as the number of lymph nodes that contained cancer cells and how many were examined. For example, the report might state "ten benign lymph nodes (0/10)" (no cancer seen) or "tumor seen in ten of twelve lymph nodes (10/12)."

In some cases, sentinel lymph node biopsy may be used. This procedure involves injecting a dye and/or radioactive tracer into the area of the tumor and allowing it to naturally drain to the lymph nodes. The first 1 or 2 lymph nodes it travels to are called the sentinel node(s). The theory is that the cancer cells would travel the same path, so if cancer cells are not present in the sentinel node, it can be safely assumed that they did not spread into the lymph system. If the pathologist finds cancer cells in the sentinel node, a full axillary lymph node dissection is recommended.

Hormone Status

Hormone receptors for estrogen and progesterone are present in high numbers in some breast cancers, making the growth of these tumors reliant on hormones. These tumors are referred to as hormone receptor positive, ER+/PR+, ER+/PR- or ER-/PR+. The receptors are present on the cancer cells and when the hormone attaches to the receptor, it allows the cancer cell to grow and divide. Hormone therapy can be used to interfere with theses receptors, slowing or stopping tumor growth or preventing recurrence.

There is no standard for reporting the receptor status, so you may see anyone of the following:

* A percentage of the cells that reacted positive for receptors (from 0% to 100%).

* A number between 0 and 3, with 0 being no receptors and 3 being the most receptors.

*An Allred score is a combination of the percent positive and their intensity. The score is from 0-9, with 9 being the most strongly receptor positive.

* Positive or negative.

In the case of just a positive or negative result, the percentage should be requested. This is because research has shown that even tumors with very low positivity can benefit from hormone therapy, yet some labs report low results (<10%) as negative. Therefore, the only true negative is a result that is zero percent of receptors positive.

Her-2 Status

The Her-2/neu gene stimulates production of a protein found on the surface of breast cancer cells that tells the cells to grow and divide. In about 25-30% of breast cancers, there are too many copies of the gene or the protein is over expressed on the cell surface, causing the cancer to grow faster and be more aggressive. Breast tumors are routinely tested, by one of two available tests, to see if they have too many copies of the gene or over express the protein. The immunohistochemistry (IHC) test looks for over expression of the protein and is reported as a number from 0 to +3. Zero and +1 are considered Her 2 negative, +2 is borderline and +3 is considered Her 2 positive. The second test, called FISH (or fluorescent in situ hybridization), examines the tumor for extra copies of the Her 2 gene and is reported as positive or negative. Patients with a +2 (borderline) result on IHC, should have the FISH test done in addition to clarify the borderline result as positive or negative. Her 2 positive tumors may be treated with medications, called monoclonal antibodies, targeting the Her 2 protein.

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Last Updated on Thursday, 21 January 2010 10:13