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Learn about some of the medical terms in a pathology report that shows breast cancer.

Types of breast biopsies

A biopsy is a procedure that removes small pieces of tissue so they can be examined under a microscope or tested. A breast biopsy can be done by: 

• Needle biopsy, where a hollow needle is used to remove samples from an abnormal area in your breast.
• Incisional biopsy, a type of surgical biopsy in which only part of an abnormal area is removed.
• Excisional biopsy, a type of surgical biopsy that removes the entire abnormal area, often with some of the surrounding normal tissue. It is much like a lumpectomy, a type of?breast-conserving surgery.

After biopsy samples are collected from your breast, they are studied by a pathologist, a doctor who specializes in diagnosing and classifying disease. After testing the samples, the pathologist creates a pathology report on what was found. Your doctors can use this report to help manage your care.

Breast anatomy

The normal breast contains milk ducts (tiny tubes) that end in groups of sacs called lobules (where milk is made). Ducts, lobules, and many other organs in the body are lined by a layer of tissue called epithelium.

What is a carcinoma or adenocarcinoma?

Carcinoma is a term used to describe a cancer that begins in the lining layer (epithelium). Nearly all breast cancers are carcinomas. Most of these are a type of carcinoma that starts in glandular tissue, which is called an?adenocarcinoma.

In-situ carcinoma

In-situ carcinoma, also known as carcinoma in situ or CIS, means that abnormal cells are growing in the lining (epithelium) of the ducts or lobules but they aren’t invading into deeper tissue layers.

Infiltrating or invasive carcinoma

If the carcinoma cells have grown (invaded) deeper than the epithelium, this is called an?invasive?or?infiltrating carcinoma. This is a true cancer, meaning that the tumor cells can grow outside the breast or spread (metastasize) to other parts of the body.

Types of invasive carcinomas

The main types of invasive breast carcinomas are:

• Invasive ductal carcinoma (IDC) or invasive mammary carcinoma of no special type
• Invasive lobular carcinoma (ILC)
• Mixed ductal and lobular carcinoma or carcinoma with ductal and lobular features

Invasive ductal carcinoma is the most common type of breast cancer.

In general, these cancers are treated similarly, although there might be some slight differences. These differences might become more pronounced in the future, as some drugs now being studied might be more useful for invasive lobular cancers.

Types of IDC

Different types of IDC?can be identified under the microscope:

• Tubular, mucinous, and cribriform carcinomas are types of well-differentiated IDC that tend to have a better prognosis (outlook) than the more common type of IDC (invasive mammary carcinoma of no special type).
• Micropapillary carcinoma?tends to grow and spread more quickly.

In some situations, different treatments might be recommended for these types of breast cancer.

Since some breast cancers are made up of more than 1 type, the entire tumor must be removed by?lumpectomy?or?mastectomy in order to know what types your tumor contains.

Vascular, lymphovascular, or angiolymphatic invasion

If cancer cells are seen in small blood vessels or lymph vessels (lymphatics) within the tumor, it is called?vascular,?angiolymphatic, or?lymphovascular invasion.

When cancer is growing in these vessels, there is an increased risk that it has spread outside the breast.

Even if this type of invasion is there, it doesn’t always mean that your cancer has spread.

Breast cancer grade

Certain features of the cancer can help predict how likely it is to grow and spread. These features include:

• Gland formation, which describes how closely the arrangement of cells looks like normal milk glands.
• Nuclear grade, which describes how much the nuclei of the cells (where the DNA is) look like those of normal breast cells.
• Mitotic count, which describes how many of the cancer cells are in the process of dividing to make new cells.

Taken together, these features determine the grade of the cancer. The grade can be described in different ways.

Differentiation

The cancer grade is sometimes described using differentiation, or how closely the cancer cells and their arrangements look like those of normal, mature breast cells.

• Well-differentiated carcinomas?have relatively normal-looking cells that are growing in patterns that are close to normal. These cancers tend to grow and spread slowly and to have a better prognosis.
• Moderately differentiated carcinomas?have cells and growth patterns that look a little more abnormal.
• Poorly differentiated carcinomas?lack normal features. They tend to grow and spread faster.

Histologic grade

The cancer grade can also be described using a histologic grade, also called the Nottingham grade, or Elston grade. The 3 features above are each given a score from 1 to 3, and their sum is used to assign the grade.

Sum	Grade	Differentiation
3 to 5	1	Well-differentiated
6 or 7	2	Moderately differentiated
8 or 9	3	Poorly differentiated

 

Estrogen receptor (ER) and progesterone receptor (PR) status

If breast cancer is found on the biopsy, the cells will be tested for hormone receptors.

Receptors are proteins on cells that can attach to certain substances, such as hormones that circulate in the blood and breast tissue. Normal breast cells and some breast cancer cells have receptors that attach to the hormones estrogen and progesterone. These hormones often fuel the growth of the cancer cells.

On your pathology report

Cancer cells might contain neither, one, or both of these receptors.

• ER-positive or ER+ means it has estrogen receptors (ER).
• PR-positive or PR+ means it has progesterone receptors (PR).

Results for ER and PR are reported separately, and they might be reported in different ways:

• Negative, weakly positive, or positive
• Percent positive
• Percent positive and whether the staining is weak, moderate, or strong

Cancers that are ER-positive or PR-positive (or both) are considered to be hormone receptor-positive (HR+). HR+ cancers tend to have a better prognosis and are much more likely to respond to?hormone therapy?than cancers without these receptors. Ask your doctor how these results might affect your treatment.

HER2 (HER2/neu) status

HER2-positive breast cancers have too many copies of the?HER2?gene, which instructs the cells to make too much of the HER2 or HER2/neu protein. This helps them grow.

These cancers tend to grow and spread more quickly than other breast cancers, but they are also more likely to respond to drugs that target the HER2 protein.

Tests for HER2

Testing for HER2 can be done in several ways. Immunohistochemistry is often used first. This might be followed by the FISH test to further classify the tumor type.

Possible test results

After testing for HER2 status, several different results might appear on a pathology report. Ask your doctor how the results of these tests might affect your treatment.

Stage (extent) of breast cancer

The?stage?of a breast cancer is based on the size of the tumor and if the cancer has spread, as well as certain other characteristics such as the tumor grade.

The staging system most often used for breast cancer is the 黑料大湿Posts Joint Committee on Cancer (AJCC) TNM system, which relies mainly on 3 key pieces of information:

• The?T category?is based on the size of the tumor and whether it has reached the skin over the breast or the chest wall under the breast.
• The?N category?indicates if the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are affected.
• The M category stands for metastasis (spread to distant parts of the body). It is usually based on the results of exams and imaging tests, so it’s not normally part of a pathology report from a breast biopsy or surgery.

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced.

Once the T, N, and M categories, the tumor grade, estrogen receptor (ER) and progesterone receptor (PR) status, and HER2 status have been determined, this information is combined to give the cancer an overall stage. Non-invasive cancer (ductal carcinoma in situ, or DCIS) is listed as stage 0.

For more information, see?Stages of Breast Cancer and Cancer Staging. Talk with your doctor about the stage of your cancer and what it might mean for you.

Lymph node tests

If breast cancer spreads, it often goes to the lymph nodes under the arm (axillary lymph nodes) first. Lymph node spread affects the stage of the cancer as well as a person’s prognosis.

Other terms that might be on a pathology report

You might see other medical terms on your pathology report. Many of these are benign changes. Usually, they are not important when seen on a biopsy where there is breast cancer.

Benign (noncancerous) changes

Benign changes that might be noted on a pathology report include:

• Usual ductal hyperplasia (UDH)
• Adenosis or sclerosing adenosis
• Radial scar or complex sclerosing lesion
• Papilloma or papillomatosis
• Apocrine metaplasia
• Columnar cell change
• Collagenous spherulosis
• Duct ectasia
• Fibrocystic changes or cysts
• Flat epithelial atypia (FEA)
• Columnar alteration with prominent apical snouts and secretions (CAPSS)

These are not important when seen on a biopsy result that also shows invasive breast cancer.

Atypical or precancer changes

Types of atypical or precancer breast changes include:

• Atypical ductal hyperplasia (ADH)
• Atypical lobular hyperplasia (ALH)
• Ductal carcinoma in situ (DCIS) or intraductal carcinoma
• Lobular carcinoma in situ (LCIS) or in-situ lobular carcinoma

These might need to be removed completely as a part of treatment.

If found on an excisional biopsy, at or near a margin, more breast tissue might need to be removed, even if all of the invasive cancer was taken out.

If they are found in a needle biopsy that also shows invasive cancer, they typically are not important.

For more on these conditions, see:

Microcalcifications or calcifications

Microcalcifications or calcifications are small calcium deposits that can be found in both noncancerous and cancerous breast lesions. They can be seen both on mammograms and under a microscope.

Because certain calcifications can be found in areas containing cancer, their presence on a mammogram might lead to a biopsy of the area. Once the biopsy is done, the pathologist looks at the removed tissue to be sure that it contains calcifications. If the calcifications are there, the doctor knows that the biopsy sampled the correct area (the abnormal area on the mammogram).

Margins or ink

When an entire tumor and some surrounding normal breast tissue is removed, the margins (edges) of the specimen are coated with ink. This helps the pathologist tell whether the abnormal area was removed completely when looking at it under a microscope. If cancer cells are touching the ink, called?positive margins, it can mean that some cancer cells were left behind and more surgery or other treatments might be needed. Sometimes, though, the surgeon has already removed more tissue during surgery to help make sure that this isn’t needed.

Sometimes, all the invasive cancer is removed, but there might be precancer or another serious condition at or near the margin, such as?ductal carcinoma in situ (DCIS).

If your pathology report shows positive margins, your doctor will talk to you about what treatment is best.

Other lab tests that might be done

Other lab tests might be done to get more information about your breast biopsy.