Breastpath.com breast pathology report: What is a pathology report?

What Is a Pathology Report?

The pathologist is a physician who specializes in identifying diseases by studying cells and tissues under a microscope. The pathologist who completed your report studied cells and tissue taken during your surgery.

The pathologist determines if the cells are cancerous (malignant), precancerous (premalignant: at high risk of becoming cancerous) or benign (harmless).

The pathologist then wrote a report for your surgeon detailing the findings of this study. Your surgeon and other physicians involved in your care, will use this report to assist in developing plans for your treatment.

Most pathology reports have your name listed either at the top or bottom of the report. This is followed by specific information that is standard in surgical pathology reports.

Demographics
Anatomic Pathology Diagnosis
Procedures/Addenda
Clinical History/Pre-Operative Diagnosis
Procedure
Specimen(s) Received
Gross Description
Microscopic Description

Understanding your report

Although the information is precise and clear, the pathology report is written in a language for your surgeon or physician. For example, your report may state that "in situ" disease is present, but no "invasion." What does that mean to you? Your surgeon may have told you what it meant, but understandably, you don't remember.

For your continued understanding, you may need more information.

Parts of a pathology report include

1) Demographics: Patient and physician identifying information, such as name, address, birth date, date of procedure.

2) Anatomical Pathology Diagnosis: The most important part of the report; what the pathologist's diagnosis is and all pertinent clinical information that will be needed for your treatment. This section contains the

Histology: Type of cancer and arrangement of the cells.
Grade: How abnormal the cells appear; how aggressive the cancer appears to be. Emphasized more recently in the pathology literature. One of the most popular grading systems is the modified
Scarff-Bloom-Richardson grading scale.
Stage: The size of the cancer and how far it has spread.

Histology: Type of cancer and arrangement of the cells.
Definitions from the National Comprehensive Cancer Network Treatment Guidelines for Patients.
Grade: How abnormal the cells appear; how aggressive the cancer appears to be. Emphasized more recently in the pathology literature. One of the most popular grading systems is the modified Scarff-Bloom-Richardson grading scale.
Definitions from the University of Utah Medical School.
Stage: The size of the cancer and how far it has spread.
Definitions from the National Comprehensive Cancer Network Treatment Guidelines for Patients.

3) Procedures/Addenda (ERA/PRA/DNA): Secondary measurements related to invasive breast cancer.

4) Clinical History/Pre-Operative Diagnosis: Initial diagnosis prior to the pathologist's diagnosis.

5) Procedure: How the cells were collected.

6) Specimen(s) Received: What was received by the pathologist following the procedure and when it was received.

7) Gross Description: Frequently referred to as "the gross." What the pathologist saw, measured and felt when examining the tissue with the naked eye without a microscope.

8) Microscopic Description: What the tissues looked like to the pathologist upon examination under the microscope.

To see a sample of a Traditional Pathology Report, click here.

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