Knowing what’s included in the basic contents of your pathology report can help you better understand your diagnosis and ask informed questions.

The report contains information that describes your diagnosis. Because some tests are only done for certain types of breast cancer, your report may not contain all of the information discussed here. The pathologist’s final diagnosis is the most important part of the report. It may include information about the tumor such as hormone receptor status, HER2 status, size, type and grade. If lymph nodes were removed during surgery and examined, their status may also be included. This information may be grouped together or in separate sections of the report. The pathology report will say whether the tumor is non-invasive or invasive. This tells you if the cancer is contained in the breast or if it has spread from the original site. The report will also list the size of the tumor, usually in centimeters or millimeters. The report may also note the tumor grade, which is often listed as grade 1, 2 or 3. Tumor grade is reported based on how the cancer cells look under a microscope. Grade 1 tumor cells look the most like normal tissue and usually grow slowly. Grade 3 tumor cells look very different from normal tissue and are fast-growing. Grade 2 falls somewhere between. In general, a lower grade tumor leads to a better prognosis. When breast cancer is surgically removed, during a surgical biopsy, lumpectomy or mastectomy, the surgeon removes the abnormal area, as well as the small border of normal breast tissue that surrounds it. This border is called a margin. The status of the margin helps show whether all of the cancer was removed. A negative margin means no cancer cells are seen at the edge of this tissue, and in most cases, no further surgery is needed. A positive margin means cancer cells are present at the edge, and more surgery may be needed. If lymph nodes are removed during surgery and tested, the report will include their results. Lymph node-negative means no cancer was found in the lymph nodes. Lymph node-positive means the lymph nodes do contain cancer cells. The stage of your breast cancer may not be included in the pathology report because staging is based on biopsy results along with other test results, which might not be available when the report is prepared. The pathology report will also include a patient information section that has basic identifying information including: Your name, medical record number, date of birth, age, sex, date of the biopsy and the name of the doctor who ordered the report. It’s a good idea to check this information to make sure you have the correct report.

The clinical history section describes the initial diagnosis before the biopsy and may include a brief summary of your symptoms. This section may also be labeled as clinical information, clinical diagnosis or pre-operative diagnosis. The report also notes the location of the tumor. If you’ve had breast cancer in the past, the pathologist may review this tissue to determine whether it’s a recurrence of a past tumor or a completely new breast cancer. Specimen information shows where in the breast the biopsy tissue was removed. It might say left or right breast, or it may give more detailed information. This section also includes the date the tissue was received in the pathology lab. The procedure description notes the type of biopsy that was used to remove the tissue sample and lymph nodes, if removed. It will say whether a needle biopsy or surgical biopsy was done, and whether a sentinel node biopsy or an axillary dissection was performed for the lymph nodes. The gross description records measurements and describes what the tissue looks like to the naked eye before it’s looked at under a microscope. It may include details such as size, weight, color, texture and other visual features. If there are multiple samples, each one has its own gross description section with a corresponding reference number to prevent confusion. Some reports might include IHC, or immunohistochemistry testing for molecular markers and proliferation rate tests, reported as Ki-67 or MIB1. These results don’t impact your prognosis or treatment, so they’re not included in every pathology report. If you see these test results in your report, it’s best to discuss them with your doctor. When the report is complete, the pathologist will sign and date it. The report will then be available for your doctor to review with you. For more information on pathology reports, visit the Diagnosis section on komen.org.