READING YOUR PATHOLOGY REPORT

"A cancer pathology report is a kind of snapshot of the disease," says Charles Balch, M.D., professor of surgery at the Johns Hopkins Medical Institutions. While understanding that captured moment can help you cope with your disease, the language and format can be daunting, especially in the emotional tumult that often follows surgery. "I think it takes at least a week for a person to get over the shock and numbness [of learning they have cancer] and begin asking questions," he says. "The patient can ask for a copy of the pathology report right after surgery, and then when she sees the doctor for the follow-up visit or to have the stitches removed, she's ready to ask questions," says Kay H. Woodruff, M.D., president of the American Board of Pathology. Some pathologists are also willing to go over the report with you. "I'm rarely asked to do that, but when I have been, I've never said no," says Dr. Woodruff.

Other sources that will help you decipher the report are "The Biopsy Report: A Patient's Guide" by pathologist Edward O. Uthman, M.D. (available at www.cancerguide.org), which contains an excellent glossary of terms that you will read on your report, and "Understanding Your Cancer Pathology Report" by Dr. Woodruff on the College of American Pathologists' Web site (http://www.cap.org). When you get your pathology report, make copies and keep them with your other important medical records. And always take a copy with you when consulting other physicians.

What Is a Pathology Report?
A pathology report is a written description of the "gross" -- meaning, what can be seen with the naked eye -- and the microscopic appearance of organs and/or tissue removed from the body and the pathologist's interpretation of that information. A board-certified pathologist, a doctor who specializes in the microscopic examination of tissue, should do the examination. The pathology report contains a great deal of information, but from the point of view of the person with cancer, the essential elements to clearly understand are:

• What kind of cancer was found
• The grade of the cancer
• The tumor size
• Whether the cancer is invasive and how far it has spread in the region
• Other facters which may define how aggressive the cancer is

What Does It Tell You?
The first section of the report -- the diagnosis section -- is the most important to you since it is a straightforward listing of the pathologist's conclusions about what he or she saw in the tissue specimens. Sometimes a biopsy is done of other surrounding organs and a brief summary of the findings will be given here as well. The points made in the diagnosis should be well organized by number or letter, with each point specifying the name of the organ or structure removed. At the top of the report are the basic facts about you: your name, birth date, address, doctor, and the date the specimen was received by the pathologist. It's a good idea to check that these facts are accurate. Pathology reports vary from one institution to another, but most list the final pathologic findings just below a heading such as "Diagnosis" or "Final Pathologic Diagnosis."

Following the diagnosis section is a more detailed description of the tissue specimens. This may be called something like "Summary of Sections." Here, the pathologist describes where each specimen came from and other characteristics, such as its general appearance, size and perhaps weight. Any abnormalities found in the specimen, such as a tumor, will also be described. When a tumor is present, further tests may be done, and the results will also be included in the pathology report. If a woman has breast cancer, as in the example described below, her breast tumor cells will probably be examined for certain prognostic indicators, including type of cancer, grade, tumor size, and stage. The results of estrogen and progesterone receptor assays and a HER-2/neu test, if one is done, may be included as an addendum to the pathology report.

The names and titles of the pathologists who examined the tissue are listed at the bottom of the report.

The Diagnosis: A Sample Report
Let's look at the statements made by a pathologist in the diagnosis section of Lila H's pathology report. Forty-year-old Lila had her right breast removed when both a needle biopsy of a breast lump and a microscopic examination of fluid from the nipple of the same breast revealed cancer cells. The main categories in her diagnosis section were:

1. Right breast, mastectomy
2. Right axillary lymph nodes, regional dissection

This means the tissue the pathologist was examining included tissue from the right breast, which was removed by mastectomy; the lymph nodes from under her right arm, which were excised.

Under each category, more details are given. If a tumor or mass is removed, the description in the diagnostic section includes its size and where it was found. Later in the report, more details of what the tissue looked like to the naked eye may be given as well. Here is what was printed under the first point of Lila's diagnosis:

1. Right breast, mastectomy

a. Invasive ductal carcinoma, moderately differentiated, approximately 3.5 cm in greatest dimension, present in mid to medial breast
b. Extensive lymphatic invasion present, no blood-vascular invasion identified
c. Ductal carcinoma in situ, intermediate grade, with focal comedo necrosis, 3.4 cm in greatest dimension, present surrounding invasive carcinoma in mid to medial breast
d. Both invasive and in situ carcinomas are present focally at the posterior margin and within 0.1 cm to 0.3 cm of anterior margin

Each descriptive term conveys an important finding.

In "a," the pathologist notes that one tumor was "invasive" and the cell type was "ductal." Moderately differentiated refers to the appearance of the cells and places them in an intermediate grade. This tells you how fast the cancer is growing and how likely it is to spread. The size, measured in centimeters (not inches) is included and the location in the breast is noted.

In "b," the pathologist notes that cancer cells are extensively involving the lymph vessels within the breast tissues. There are no cancer cells seen within the blood vessels of the breast tissue.

Part "c": In addition to the invasive cancer, the pathologist sees the presence of non-invasive or in-situ cancer. In situ cancer is frequently found in association with invasive cancer. Again the grade is defined - in this case "intermediate.” The size and location of the in situ cancer are also noted.

The "d” section describes the surgical margin - in other words, the edge of the specimen. In this case, cancer cells are present at the posterior edge of the specimen in tiny amounts ("focally”) and are very close to the "front” edge of the specimen. Decisions about the need for additional surgery or radiation therapy may depend on the "surgical margin.”

Your Final Diagnosis
The pathology report is ground zero in your diagnosis, but it doesn't determine your final diagnosis. Your physician may order other tests, maybe even more surgery before any treatment decisions are made. Nevertheless, if you understandi this essential piece of your medical history, you'll be better able to discuss the options with your doctor.