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Understanding Your Pathology Report for Breast Care at UPMC in Central Pa.

When tissue is removed from the body through a biopsy or cancer surgery, a pathology report is written. This report provides the results of the tests that were done on your tissue. You and the UPMC Breast Care Center team will use the findings in this report to plan your treatment.

UPMC Breast Care Center in Central Pa. understands that you may have never read a pathology report. We know that terms used in the report may be unfamiliar or the numbers may not make sense. The purpose of this section is to help you understand your pathology report so that you can make the best decisions about your care.

Your pathology report will include personal information, such as your name, date of birth and address. You will also see information about where your tissue sample was taken from. The report will also discuss how your breast abnormality was found, by mammogram for example.

Next, the report will discuss the diagnosis that the doctors were expecting before your tissue sample was tested. Your report will also describe the size, weight and color of the pieces of tissue that were removed.

The following two parts of the report discuss what was found in each test of your tissue. These parts are the:

  • Microscopic description
  • Special tests or markers

The final part of your pathology report provides a short description of all the important findings in the tissue that was examined. This is the summary or final diagnosis.

Microscopic Description

Within this section, you will find answers to specific questions about your breast abnormality including:

  • Is it cancer?
  • If it is cancer, is it invasive?
  • How different are the cancer cells from normal cells?
  • How fast are the cancer cells growing?
  • How big is the cancer?
  • Has the whole cancer been removed?
  • Are there cancer cells in your lymph channels or blood vessels?
  • Are there cancer cells in your lymph nodes? If so, how many lymph nodes are involved?

To answer these questions, the pathologist will study what your cancer cells look under the microscope. The pathologist will also study the relationship of your cancer cells to the normal surrounding tissue.

Is it a cancer?

A breast abnormality isn’t always cancer. Sometimes, it is simply a collection of normal cells. In other cases, it is made up of cells that fall somewhere between normal and cancerous. These are called atypical cells.

To determine if the abnormality is cancer, the pathologist will look at how the cancer cells grow and travel. Cancer cells grow in an uncontrolled way. They may grow into the tissue nearby or travel to other areas of the body.

Is it invasive?

If the cancer stays within the milk ducts or milk lobules in the breast and does not affect surrounding tissue, then it is non-invasive. These cancers may also be called “in situ” or pre-cancers.

If the cancer has grown into surrounding tissue, or spread to other parts of the body through the blood or lymph system, then it is invasive. Cancer cells that spread to other parts of the body are called metastatic breast cancer.

During a biopsy, tissue samples are taken from the abnormality and surrounding tissue. The pathologist will study these samples for cancer cells to determine if your cancer is invasive or non-invasive.

Here are some of the ways that your cancer cells may be described in the pathology report:

  • DCIS (Ductal Carcinoma In Situ)
  • LCIS (Lobular Carcinoma In Situ)
  • IDC (Invasive Ductal Carcinoma)
  • ILC (Invasive Lobular Carcinoma)

How different are the cancer cells from normal cells?

Cancer cells are given a “grade” based upon how different they look when compared to normal breast cells. These grades are:

  • Grade 1 (low grade or well differentiated)
    • Look a little different from normal cells
    • Usually slow growing
  • Grade 2 (intermediate/moderate grade or moderately different)
    • Do not look like normal cells
    • Faster growing than normal
  • Grade 3 (high grade or poorly differentiated)
    • Look very different from normal cells
    • Fast growing

How fast are the cancer cells growing?

Pathologists will conduct tests to determine the number of cells in your tumor that are growing. They will also look at the rate at which the cells are growing. This will help them determine if your cancer is more aggressive.

The first test looks for a protein called Ki-67. This protein increases as cells prepare to divide into new cells. The more cells that are positive for Ki-67 the faster the cells are growing and dividing. A result of less than 10 percent is considered low, 10 to 20 percent is considered intermediate/borderline and more than 20 percent is high.

A second test called S-phase fraction will determine what percentage of cells in the tissue are in the process of copying their DNA. S-phase is short for “synthesis phase.” This process occurs just before a cell divides. A result of less than 6 percent is considered low, 6 to 10 percent is considered intermediate/borderline and more than 10 percent is high.

How big is the cancer?

Size is one of the characteristics that are used to determine the stage and treatment of your cancer. Doctors measure cancers in centimeters.

Has the whole cancer been removed?

When cancer is removed, the surgeon also takes a portion of the surrounding tissue. This surrounding tissue is called the margin of resection. A pathologist will examine this margin to make sure that it is clear of cancer cells. This will determine if the whole cancer has been removed.

Your pathology report will describe the margin as one of the following:

  • Negative (or clean)
    • No cancer cells in the margin
    • Additional surgery is not needed
  • Positive
    • Cancer cells are present at the edge of the margin
    • Additional surgery is needed to remove remaining cells
  • Close
    • Cancer cells are close to the edge of the margin
    • Additional surgery may be needed

Are there cancer cells in your lymph channels or blood vessels?

Fluid and blood from your breast tissue is drained from the breast through blood vessels and lymph channels. If cancer cells are found in these vessels or channels, there is an increased risk that your cancer will return. Your pathology report will say “present” if cancer cells are found. If there are no cancer cells in these areas, your report will say absent.

Are there cancer cells in your lymph nodes?

There are several lymph nodes located around the perimeter of your breast. The lymph nodes are small structures that filter harmful waste out of lymph fluid before it enters the blood stream. The lymph nodes contain immune cells that can help fight infection and destroy germs.

When cancer cells are found in the lymph nodes there is an increased risk that the cancer will spread. In this case your report will say positive. If there are no cells in the lymph nodes, then your results will be negative.

How many lymph nodes are involved?

Your treatment will vary depending upon how many lymph nodes contain cancer cells and how much cancer is in each node. The following terms are used when referring to the amount of cancer in each node:

  • Microscopic
    • Only a few cancer cells are in the node
    • A microscope is needed to see the cells
  • Gross
    • A lot of cancer is present
    • Can be seen or felt without a microscope
  • Extracapsular extension
    • Cancer is located outside the wall of the node

Special Tests or Markers

This portion of your pathology report focuses on the proteins and genes contained within the cancer. It also looks more closely at the rate at which cancer cells are growing. Within this section the following questions will be answered:

Do the cancer cells have hormone receptors?

Hormone receptors are located within cells. They “listen” for signals from hormones that tell the cell to grow. Some receptors respond to the hormone estrogen. Others respond to progesterone.

When a cancer contains a hormone receptor that responds to estrogen it is called ER-positive. When a cancer contains a hormone that responds to progesterone it is PR-positive.

A breast cancer that is ER-positive, PR-positive, or both is typically treated with endocrine therapy. This may also be known as hormone therapy.

Within this portion of the pathology report you will see your results listed in one of the following ways:

The number of cells that have receptors out of 100 cells tested. This will be given as a percentage.

  • An Allred score between 0 and 8. This system measures both the percentage of positive cells and how well the receptors show up. This is called intensity. The higher the score, the more receptors there were and the easier they were to see.
  • The word positive or negative. Even if your report says negative, you may respond to endocrine therapy if you have a low number of hormone receptors.

Does the cancer have genes that affect how the cancer might be treated?

Genes make the proteins that cells need to work properly. This is called a genetic recipe. Some genes can influence the behavior of a breast cancer, including how it responds to treatment.

Pathologists will test cancer cells to see which genes and proteins are normal or abnormal. If the genetic recipe contains a mistake it is called a “genetic mutation” or genetic abnormality.” The report will say “gene amplification” if the genetic recipe repeats the same instruction over and over. This causes the gene to make too many copies of itself.

If the genetic recipe calls for too much protein to be made this is referred to as an “overexpression” of that protein.

One protein that pathologists look for specifically is called HER2.

The HER2 protein is a receptor that controls how a breast cell grows, divides and repairs itself. It is made by the HER2 gene and is a receptor on breast cells. The HER2 protein controls how a breast cell grows, divides and repairs itself.

Sometimes, the HER2 gene becomes abnormal and makes too many copies of itself. This “amplification” of the HER2 gene occurs in about 25% of breast cancers. Amplified HER2 genes call for too much HER2 protein to be made. This causes the breast cells to grow and divide uncontrollably. This can lead to breast cancer.

A pathology report will describe the cancer as HER2-positive when it has either amplified HER2 genes or overexpressed HER2 protein. These HER2-positive breast cancers grow faster and are more likely to come back. Fortunately, they respond to targeted treatments that work against HER2-positive cells.

There are four tests for HER2:

  • IHC test (ImmunoHistoChemistry)
    • Shows if there is too much HER2-receptor protein in the cancer cells
    • Results can be 0 (negative), 1+ (also negative), 2+ (borderline) or 3+ (positive)
  • FISH test (Fluorescence In Situ Hybridization)
    • Shows if there are too many copies of the HER2 gene in the cancer cells
    • Results can be positive (extra HER2 gene copies) or negative (normal number of HER2 gene copies)
  • SPoT-Light HER2 CISH test (Subtraction Probe Technology Chromogenic In Situ Hybridization)
    • Shows whether there are too many copies of the HER2 gene in the cancer cells
    • Results can be positive (extra copies) or negative (normal number of copies)
  • Inform HER2 Dual ISH test (In Situ Hybridization)
    • Shows whether there are too many copies of the HER2 gene in the cancer cells
    • Results can be positive (extra copies) or negative (normal number of copies)

NOTE: It is important to find out which test for HER2 that you had.

Targeted therapy for HER2-positive breast cancers is only effective when the results are:

  • IHC 3+
  • FISH positive
  • SPoT-Light HER2 CISH positive
  • Inform HER2 Dual ISH positive

An IHC +2 result is called borderline. If you have this result you should ask to also have the tissue tested with the FISH test.

Summary or Final Diagnosis

Within this section of the pathology report you will find the “bottom line” results. If cancer has been diagnosed, this section will include the following:

  • The type of cancer
  • The tumor grade
  • Lymph node status
  • Margin status
  • Stage of your cancer
  • Results of tests for hormone receptors and HER2, or other genes

These findings will help you and your UPMC Breast Care Center team develop a treatment plan that offers the best possible outcome for your cancer.

Glossary

The following list of terms from breastcancer.org will help you better understand some of the language used within your pathology report.

Providers

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Locations

UPMC Pinnacle Breast Care Center
Part of PinnacleHealth Breast Care Center
11 Sprint Drive
Suite C
Carlisle, PA 17015

Phone: 717-960-3360
Fax: 717-706-6709

PinnacleHealth Breast Care Center
Located at UPMC Hillman Cancer Center at the Rocco and Nancy Ortenzio Cancer Pavilion
2035 Technology Parkway
Suite 200
Mechanicsburg, PA 17050

Phone: 717-988-1450
Fax: 717-221-5544

PinnacleHealth Breast Care Center
Located at Medical Sciences Pavilion
4300 Londonderry Road
Suite 202
Harrisburg, PA 17109

Phone: 717-545-5000
Fax: 717-545-5002

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