breastcancerorg pathology report guide 2013

8/20/2019 Breastcancerorg Pathology Report Guide 2013

1/27

Breastcancer.org is a

nonprofit organization

dedicated to providing

education and informationon breast health and

breast cancer.

Developed for

you by

Your Guideto the

Breast CancerPathology Report


2/27

The pathology report is used by

your doctor to determine whichtreatments are right for you.

Your Guideto theBreast CancerPathology Report

A report is written each time tissue is

removed from the body to check for

cancer. These are called pathology

reports. Each report has the results

of the studies done on the removedtissue. The information in these

reports will help you and your

doctors decide on the best treatment

for you.

Reading your pathology report can

be scary and confusing. Different labs

may use different words to describe

the same thing. On page 34, you’ll

find an easy-to-understand word list.

We hope we can help you make sense

of this information so you can get the

best care possible.


3/27

TABLE OF CONTENTS

Wait for the Whole Picture

• Waiting for test results ............................2

• Get all the information you need .............3

• Parts of your pathology report .................4

Reading Your Pathology Report

• The pathology report answers

questions about a breast abnormality ......6

• Is the breast abnormality a cancer? ........6

• Is the breast cancer invasive? ..................7

• How different are the cancer cells

from normal cells?...................................9

• How fast are the cancer cells

growing? ................................................10

• How big is the cancer? .........................12

• Has the whole cancer

been removed? ......................................13

• Are there cancer cells in your lymph

channels or blood vessels? ...................15

• Are there breast cancer cells in

your lymph nodes? ................................16

• How many lymph nodes

are involved?..........................................17

• How much cancer is in each

lymph node? ..........................................17

• Do the cancer cells have

hormone receptors? ..............................18

• Does the cancer have genes that

affect how the cancer might

be treated?.............................................20

• Genetic testing that is not part of

your pathology report .............................25• What stage is the breast cancer? .........28

— Stage 0 ..............................................28

— Stage I ...............................................29

— Stage II ..............................................30

— Stage III ............................................31

— Stage IV ............................................33

Word List .................................................34

Key Questions .........................................44

Pathology Report Checklist ...................45

Notes .......................................................46


4/27

Waiting for test results

When you have all of the test results,you and your doctor can make the

right decisions for you. The analysis of

the removed tissue can lead to several

different reports. Some tests take longer

than others. Not all tests are done by

the same lab. Most information comes

within 1 to 2 weeks after surgery, and

you will usually have all the results

within a few weeks. Your doctor can letyou know when the results come in. If

you don’t hear from your doctor, call

the office.

EXPERT TIP: Marisa Weiss, M.D.,breast cancer doctor

“The information in your pathology reportoften comes in bits and pieces. Just aftersurgery, the cancer cells are first looked atunder the microscope. Results from additionalstudies that require special techniques maytake longer. So you may have one, two, or

WAIT FOR THEWHOLE PICTURE

2

Get all the information you need

When you have all the test informationyou need, you and your doctor can

make a final decision about your

treatment. Don’t focus too much on any

one piece of information by itself. Try to

look at the whole picture as you think

about your options.

Different labs and hospitals may

use different words to describe thesame thing. If there are words in your

pathology report that are not explained

in this booklet, don’t be afraid to ask

your doctor what they mean.

three lab reports from one surgery. Together,the lab reports make up your pathologyreport. Try to keep all your reports in oneplace, so that when you go for your treatmentevaluations, the doctors will have all theinformation they need.”

3

For more information, go to:

www.breastcancer.org


5/27

Parts of your pathology report

Personal information. Make sure it’syour correct name and date of operationat the top of the report.

Specimen. This section describes wherethe tissue samples came from. Tissuesamples could be taken from the breast,from the lymph nodes under your arm(axilla), or both.

Clinical history. This is a short

description of you and how the breastabnormality was found. It also describesthe kind of surgery that was done.

Clinical diagnosis. This is the diagnosisthe doctors were expecting before yourtissue sample was tested.

WAIT FOR THEWHOLE PICTURE (continued)

4

4

Gross description. This section describesthe pieces of tissue removed. It talksabout the size, weight, and color ofeach piece.

Microscopic description. This sectiondescribes the way the cancer cells lookunder the microscope, their relationshipto the normal surrounding tissue, andthe size of the cancer.

Special tests or markers. This sectionreports the results of tests for proteins,genes, and cell growth rate.

Summary or final diagnosis. This sectionis the short description of all the importantfindings in all of the tissue examined.



5

5


6/27

The pathology report answers questions

about a breast abnormalityBreast tissue can develop abnormalitiesthat are sometimes cancerous. Usuallybreast cancer begins either in the cellsof the lobules, which are milk-producingglands, or the ducts, the passages thatdrain milk from the lobules to the nipple.Breast cancers have many characteristicsthat help determine the best treatment.

Is the breast abnormality a cancer? A lump or spot in the breast can be madeof normal cells or cancer cells. There canalso be cells that fall somewhere betweennormal and cancerous (“atypical” cells).

Cancer cells are cells that grow in anuncontrolled way. They may stay in theplace where they started to grow, or they

READING YOURPATHOLOGY REPORT

This is what normal cellsinside a milk duct look

like under a microscope.

This is what the insideof a breast looks like.

rib cage

chest wall

muscle

fat

duct

lobule

nipple

6

may grow into the normal tissue around

them. Cancer cells may also spreadbeyond the breast.

The abnormal lump or spot may be foundusing mammography or other testingmethods. A procedure called a biopsyremoves a piece of tissue from the lump orspot to find out if cancer cells are present.

The pathology report will tell you whatkinds of cells are present.

Is the breast cancer invasive?If breast cancer is found, it’s importantto know whether the cancer has spreadoutside the milk ducts or lobules of thebreast where it started.

Non-invasive cancers stay within the milkducts or milk lobules in the breast. Theydo not grow into or invade normal tissueswithin or beyond the breast. Non-invasivecancers are sometimes called in situ orpre-cancers.

If the cancer has grown into normaltissues, it is called invasive. Most breastcancers are invasive. Sometimes cancercells spread to other parts of the bodythrough the blood or lymph system. Whencancer cells spread to other parts of thebody, it is called metastatic breast cancer.

In some cases, a breast cancer may be

both invasive and non-invasive.

invasivecells

non-invasive

cells

7

The real sizeof a normal

duct or lobuleis smallerthan this

.


7/27

You may see these descriptions of thetype of cancer cells in your report:

DCIS (Ductal Carcinoma In Situ). Thisis a cancer that is non-invasive. It staysinside the milk ducts.

NOTE: There are subtypes of DCIS. You’llfind their names in the word list that beginson page 34 of this booklet.

LCIS (Lobular Carcinoma In Situ). Thisis a tumor that is an overgrowth of cellsthat stay inside the milk-making part

of the breast (called lobules). LCIS isnot a true cancer. It’s a warning signof an increased risk for developing aninvasive cancer in the future in eitherbreast.

IDC (Invasive Ductal Carcinoma). This isa cancer that begins in the milk duct buthas grown into the surrounding normaltissue inside the breast. This is the mostcommon kind of breast cancer.

ILC (Invasive Lobular Carcinoma). Thisis a cancer that starts inside the milk-making glands (called lobules), butgrows into the surrounding normaltissue inside the breast.

NOTE: There are other, less common typesof invasive breast cancer. You’ll find theirnames in the word list beginning on page34 of this booklet.

MY REPORT SAYS:

The type of cancer I have is ______________

_______________________________________ .

READING YOURPATHOLOGY REPORT (continued)

8

How different are the cancer cells

from normal cells?Grade is how different the cancer cellsare from normal cells. Experts comparethe appearance of the cancer cells tonormal breast cells. Based on thesecomparisons, they give a grade to thecancer. Grade is different from stage (see page 28 for information aboutstage).

There are three cancer grades:Grade 1 (low grade or welldifferentiated). Grade 1 cancer cells looka little bit different from normal cells.They are usually slow-growing.

Grade 2 (intermediate/moderate gradeor moderately differentiated). Grade 2cancer cells do not look like normal cells.They are growing a little faster thannormal.

Grade 3 (high grade or poorlydifferentiated). Grade 3 cancer cells lookvery different from normal cells. They arefast-growing.

The cancer is: (check one )

Grade 1 Grade 2 Grade 3



9


8/27


How fast are the cancer cells

growing?Your pathology report may includeinformation about the rate of cellgrowth—the proportion of cancer cellswithin the tumor that are growing anddividing to form new cancer cells. Ahigher percentage suggests a faster-growing, more aggressive cancer, ratherthan a slower, less aggressive cancer.

Tests that can measure the rate of cellgrowth include:

• Ki-67. Ki-67 is a protein in cells thatincreases as they prepare to divideinto new cells. A staining process canmeasure the percentage of tumorcells that are positive for Ki-67. Themore positive cells there are, the morequickly they are dividing and formingnew cells.

In breast cancer, a result of less than10% is considered low, 10-20% isintermediate/borderline, and morethan 20% is considered high.

If you have an Oncotype DX testdone on the cancer to estimate yourrecurrence risk, checking Ki-67 levels isincluded as part of the testing.

• S-phase fraction. The S-phase fractionnumber tells you what percentageof cells in the tissue sample are in

the process of copying their geneticinformation (DNA). This S-phase, shortfor “synthesis phase,” happens justbefore a cell divides into two new cells.

In breast cancer, a result of less than6% is considered low, 6-10% isintermediate/borderline, and morethan 10% is considered high.



The rate of cancer growth is: (check one )

Low Intermediate/borderline High

MY REPORT SAYS:

Test used: (check one )

Ki-67 test S-phase fraction test

10 11


9/27

How big is the cancer?

Doctors measure cancers in centimeters(cm). The size of the cancer is one of thefactors that determines the stage andtreatment of the breast cancer.

Size doesn’t tell the whole story. All ofthe cancer’s characteristics are important.A small cancer can be very fast-growingwhile a larger cancer may be slow-growing,or it could be the other way around.

The size of the cancer is _______ centimeters.

MY REPORT SAYS:

12

5 cm

= 2 inches

3 cm

1 cmTumor size:


Has the whole cancer been removed?

When surgery is done to remove thewhole cancer, the surgeon tries to takeout all of the cancer with an extra area,or margin, of normal tissue around it.This is to be sure that all of the canceris removed.

The outer edge of the tissue removedis called the margin of resection. It islooked at very carefully to see if it is

clear of cancer cells.The pathologist also measures thedistance between the cancer cells andthe margin.



13


10/27

Margins around a cancer are describedin three ways:

Negative. No cancer cells can be seenat the outer edge. Usually, no moresurgery is needed.

Positive. Cancer cells come right outto the edge of the tissue. More surgeryis usually needed to remove anyremaining cancer cells.

Close. Cancer cells are close to the edge

of the tissue, but not right at the edge.More surgery may be needed.

NOTE: What is called negative (or clean orclear) margins can be different from hospitalto hospital. In some hospitals, doctors wantat least 2 millimeters (mm) of normal tissuebetween the edge of the cancer and theouter edge of the tissue. In other places, just one healthy cell is called a negativemargin.

The margins are: (check one )

Negative Positive Close

MY REPORT SAYS:

the edge

cancer

cells

normaltissue the edge

cancer

cells

normaltissue

Negative Positive

14


Are there cancer cells in your lymph

channels or blood vessels?The breast has a network of lymphchannels and blood vessels that drainfluid and blood from your breast tissueback into your body’s circulation. Thesepathways remove used blood and wasteproducts.

There is an increased risk of cancercoming back when cancer cells are found

in the fluid channels of the breast. Inthese cases, your doctor may customizeyour treatment to reduce this risk.

If lymphatic or blood vessel (vascular)invasion is found, your pathology reportwill say present. If there is no invasion,the report will say absent.

NOTE: Lymphatic or vascular invasion isdifferent from lymph node involvement.

Lymphatic or vascular invasion is: (check one )

Present Absent

normal duct cells

wall of milk duct

cancer cells

lymphatic channel

blood vessel

breast tissue

This is a picture of cancer cells that havespread through the wall of the milk ductand into the nearby lymph channels.

15

1 inch

2 mm

1 cm


11/27

Are there breast cancer cells

in your lymph nodes?Your doctor will examine your lymphnodes to see if they contain cancer.Having cancer cells in the lymph nodesunder your arm is associated with anincreased risk of the cancer spreading.

Lymph nodes are filters along the lymphfluid channels. Lymph fluid leaves thebreast and eventually goes back into the

bloodstream. The lymph nodes try tocatch and trap cancer cells before theyreach other parts of the body.

When lymph nodes are free, or clear,of cancer, the test results are callednegative. If lymph nodes have somecancer cells in them, they are calledpositive.

Lymph node areas adjacent to breast area

MY REPORT SAYS:

The lymph nodes are: (check one )

Positive Negative

16

How many lymph nodes

are involved?The more lymph nodes that containcancer cells, the more serious thecancer might be. So doctors use thenumber of involved lymph nodes tohelp make treatment decisions.

Doctors also look at the amount ofcancer in the lymph nodes.

How much cancer is in eachlymph node?

You may see these words describinghow much cancer is in each lymph node:

Microscopic. Only a few cancer cells arein the node. A microscope is needed tofind them.

Gross. There is a lot of cancer in thenode. You can see or feel the cancer

without a microscope.

Extracapsular extension. Cancer hasspread outside the wall of the node.

For more information, go to:www.breastcancer.org

If positive:

The number of involved nodes is _________ .

17


A Pectoralis majormuscle

B Axillary lymphnodes: level I

C Axillary lymphnodes: level II

D Axillary lymphnodes: level III

E Supraclavicularlymph nodes

F Internal mammary

lymph nodes


12/27

Do the cancer cells have

hormone receptors? Hormone receptors are like ears on andin breast cells that listen to signals fromhormones. These hormone signals tellbreast cells that have the receptors togrow.

A cancer is called ER-positive if it hasreceptors for the hormone estrogen. It’scalled PR-positive if it has receptors for

the hormone progesterone. Breast cellsthat do not have receptors are negativefor these hormones.

Breast cancers that are ER-positive,PR-positive, or both tend to respond tohormonal therapy. Hormonal therapyis medicine that reduces the amountof estrogen in your body or that blocksestrogen from the receptors.

If the cancer has no hormone receptors,there are still treatments available.

Hormone receptors are proteins. Like allproteins, their production is controlledby genes. To learn more about tests forvarious genes, please see page 20.

You will see the results of your hormonereceptor test written in one of thesethree ways:

MY REPORT SAYS:Hormone receptors are:

ER-positive ____% (0%-100%) ER-negative

or circle: Allred score: 0 1 2 3 4 5 6 7 8

PR-positive ____% (0%-100%) PR-negative

or circle: Allred score: 0 1 2 3 4 5 6 7 8

18


1. The number of cells that havereceptors out of 100 cells tested. You will see a number between 0%(none have receptors) and 100% (allhave receptors).

2. An Allred score between 0 and 8. This scoring system is named for thedoctor who developed it. The systemlooks at what percentage of cellstest positive for hormone receptors,along with how well the receptorsshow up after staining (this is called“intensity”). This information is thencombined to score the sample ona scale from 0 to 8. The higher thescore, the more receptors were foundand the easier they were to see in thesample.

3. The word “positive” or “negative.”

NOTE: Even if your report just says“positive” or “negative,” ask your doctor

or lab to give you the number of cells(percentage) that have receptors. Thisis important because sometimes a lownumber may be called negative. But evencancers with low numbers of hormonereceptors may respond to hormonaltherapy. And a high positive number isimportant to know because it predicts aparticularly good response to hormonaltherapy.


19


13/27

Does the cancer have genes that

affect how the cancer might betreated?

Genes contain the recipes for thevarious proteins a cell needs to stayhealthy and function normally. Somegenes and the proteins they makecan influence how a breast cancerbehaves and how it might respond toa specific treatment. Cancer cells froma tissue sample can be tested to seewhich genes are normal and which areabnormal. The proteins they make canalso be tested.

If the genetic recipe contains a mistake,the report will say “genetic mutation” or “genetic abnormality.” An exampleis one of the inherited breast cancergene abnormalities, called BRCA1 orBRCA2. Testing for BRCA1 and BRCA2

is not part of the standard pathologyworkup. (Please see page 25 for moreinformation on these abnormalities.)

If the genetic recipe repeats the sameinstruction over and over again, thereport will say “gene amplification.” Genetic amplification happens whena genetic recipe’s repeated instructioncauses the gene to make too manycopies of itself.

If the genetic recipe mistake(abnormality) or repeated instruction(amplification) calls for too much proteinto be made, the report will say that thereis overexpression of that protein.

20


HER2 status. Your pathology reportusually includes the cancer’s HER2status. The HER2 gene is responsible formaking HER2 proteins. These proteinsare receptors on breast cells. Undernormal circumstances, HER2 receptorshelp control how a breast cell grows,divides, and repairs itself. But in about25% of breast cancers, the HER2 genecan become abnormal and make toomany copies of itself (amplification ofthe HER2 gene). Amplified HER2 genescommand breast cells to make toomany receptors (overexpression of theHER2 protein). When this happens, theoverexpressed HER2 receptors shout at(rather than talk to) the breast cells togrow and divide in an uncontrolled way.This can lead to the development ofbreast cancer.

Breast cancers that have amplified HER2

genes or that overexpress the HER2protein are described in the pathologyreport as being HER2-positive. HER2-positive breast cancers tend to growfaster and are more likely to spread andcome back when compared with HER2-negative breast cancers. But HER2-positive breast cancers can respond totargeted treatments that are designed towork against HER2-positive cancer cells.



21


14/27

There are four tests for HER2:

1. IHC test (ImmunoHistoChemistry): • The IHC test shows whether there istoo much HER2-receptor protein inthe cancer cells.

• The results of the IHC test can be0 (negative), 1+ (also negative), 2+(borderline), or 3+ (positive; theHER2 protein is overexpressed).

2. FISH test (Fluorescence In SituHybridization):

• The FISH test shows whether thereare too many copies of the HER2gene in the cancer cells.

• The results of the FISH test can bepositive (extra HER2 gene copies—amplified) or negative (normalnumber of HER2 gene copies—notamplified).

3. SPoT-Light HER2 CISH test

(Subtraction ProbeTechnologyChromogenic In Situ Hybridization):

• The SPoT-Light test shows whetherthere are too many copies of theHER2 gene in the cancer cells.

• The results of the SPoT-Light testcan be positive (extra copies—amplified) or negative (normalnumber of copies—not amplified).

MY REPORT SAYS:

HER2 status is: (check one)

Positive Negative Borderline

22


Test used: (check one) IHC FISH

SPoT-Light HER2 CISH Inform HER2 Dual ISH

23


4. Inform HER2 Dual ISH test (In SituHybridization):

• The Inform HER2 Dual ISH testshows whether there are too manycopies of the HER2 gene in thecancer cells.

• The results of the Inform HER2Dual ISH test can be positive (extracopies—amplified) or negative(normal number of copies—notamplified).

Find out which test for HER2 you had.This is important. Only cancers that testIHC 3+, FISH positive, SPoT-Light HER2CISH positive, or Inform HER2 Dual ISHpositive respond to therapy that worksagainst HER2-positive breast cancers.An IHC 2+ test result is called borderline.

Research has shown that some HER2status test results may be wrong.This is probably because different

labs have different classification rules.Each pathologist also may use slightlydifferent criteria. This usually happenswhen test results are borderline (IHC2+). If you have a 2+ result, you canand should ask to also have the tissuetested with the FISH test. If your resultsare negative, you may want to ask yourdoctor if another HER2 test makes sensefor you.


15/27

EGFR status. The EGFR gene, much likethe HER2 gene, can be overexpressed insome breast cancer cells and influencehow the cancer cells behave. Yourpathology report may also containinformation about EGFR overexpression.

Genomic assays. Unlike individualgene testing, such as testing for HER2,genomic assays analyze the activity ofa group of normal and abnormal genesthat can increase the risk of breastcancer coming back after treatment. This

analysis can help decide if a person islikely to benefit from chemotherapy toreduce the risk of the cancer comingback. A number of genomic assays forbreast cancer are currently available,including Oncotype DX, MammaPrint,and Mammostrat.

If the breast cancer is early-stage andhormone-receptor-positive, you andyour doctor may decide that a genomicassay is appropriate for your situation.The results of your genomic assay arereported separately from yourpathology report. The test results willindicate the likelihood of the cancercoming back based on the overallpattern of gene activity found in thebreast cancer cells. Your doctor can usethis information to help decide whetherchemotherapy to reduce the risk ofbreast cancer coming back makes sensein your overall treatment plan.

The Oncotype DX test also is used toestimate recurrence risk of DCIS and/ or the risk of a new invasive cancerdeveloping in the same breast, andhow likely a person is to benefit fromradiation therapy after DCIS surgery.


24

Genetic testing that is not a part of

your pathology reportInherited cases of breast cancer arelikely associated with abnormal genes.Two of the most common are abnormalversions of BRCA1 (BReast CAncer gene1) and BRCA2 (BReast CAncer gene 2).According to the National CancerInstitute, women with an abnormalBRCA1 or BRCA2 gene have about a60% risk of being diagnosed with breast

cancer during their lifetimes (comparedto about 12% for women overall). Theirrisk of ovarian cancer is also increased.Abnormal BRCA1 or BRCA2 genes arefound in 5% to 10% of all breast cancercases in the United States.

Changes in other genes are alsoassociated with breast cancer, thoughthey are less common and don’t seemto increase risk as much as abnormal

BRCA1 and BRCA2 genes. Althoughabnormal BRCA1 and BRCA2 genes areconsidered rare, the following genesare considered rarer and haven’t beenstudied as much as the BRCA genes:

• ATM gene. Inheriting one abnormalATM gene has been linked to anincreased rate of breast cancer in somefamilies because the abnormal genestops the cells from repairing damaged

DNA.

25




16/27

• p53 gene. Inheriting an abnormalp53 gene (also called the TP53 gene)causes Li-Fraumeni syndrome, adisorder that causes people to developsoft tissue cancers at a young age.

• CHEK2 gene. Li-Fraumeni syndromealso can be caused by an abnormalCHEK2 gene; even when it doesn’tcause Li-Fraumeni syndrome, anabnormal CHEK2 gene can doublebreast cancer risk.

• PTEN gene. An abnormal PTEN genecauses Cowden syndrome, a raredisorder that causes a higher risk ofboth benign and cancerous breasttumors, as well as growths in thedigestive tract, thyroid, uterus, andovaries.

• CDH1 gene. Women with an abnormalCDH1 gene have a higher risk ofinvasive lobular breast cancer.


26

Finding out whether you have aninherited abnormal gene requiresspecial tests, and the results areseparate from the results in yourpathology report. If your doctor isconcerned that you and your immediaterelatives may have inherited abnormalBRCA1 or BRCA2 gene, he or shemay recommend that you and otherfamily members be tested. BRCA1 andBRCA2 tests are done using a bloodor saliva sample, not a tissue sample.

Your doctor or genetic counselor alsomay order testing for an abnormalATM, p53, CHEK2, PTEN, or CDH1 geneif it’s determined from your personalor family history that these tests areneeded.


27


17/27

What stage is the breast cancer?

Cancer stage is based on the size of thecancer, whether the cancer is invasiveor non-invasive, whether lymph nodesare involved, and whether the cancerhas spread to other places beyond thebreast. Many of the cancer traits youreviewed in this booklet are not includedin staging.

The purpose of the staging system is to

help organize the different factors andsome of the personality features of thecancer into categories in order to:

• best understand your prognosis (themost likely outcome of the disease)

• guide treatment decisions (togetherwith other parts of your pathologyreport)

• provide a common way to describethe breast cancer so that results of

your treatment can be compared andunderstood

Stage 0

Stage 0 is used to describe non-invasivebreast cancers, such as ductal carcinomain situ (DCIS). In stage 0, there is noevidence of cancer cells or non-cancerousabnormal cells breaking out of the part

of the breast in which they started, orgetting through to or invading neighboringnormal tissue.

28

Stage I

Stage I is divided into subcategoriesknown as IA and IB.

Stage IA describes invasive breastcancer (cancer cells are breakingthrough to or invading normalsurrounding breast tissue) in which:

• the tumor measures up to 2 centimetersAND

• the cancer has not spread outside thebreast; no lymph nodes are involved

Stage IB describes invasive breastcancer in which:

• there is no tumor in the breast; instead,small groups of cancer cells—largerthan 0.2 millimeter but not larger than2 millimeters—are found in the lymphnodes OR

• there is a tumor in the breast thatis no larger than 2 centimeters, andthere are small groups of cancercells—larger than 0.2 millimeter butnot larger than 2 millimeters—in thelymph nodes

Microscopic invasion is also possiblein stage I breast cancer. In microscopicinvasion, the cancer cells have only justbegun to invade the tissue outside thelining of the duct or lobule. To qualifyas microscopic invasion, the cells thathave begun to invade the tissue cannot

measure more than 1 millimeter.

29





18/27

Stage II

Stage II is divided into subcategoriesknown as IIA and IIB.

Stage IIA describes invasive breastcancer in which:

• no tumor can be found in the breast,but cancer (larger than 2 millimeters)is found in 1 to 3 axillary lymph nodes(the lymph nodes under the arm) or inthe lymph nodes near the breastbone

(found during a sentinel node biopsy)OR

• the tumor measures 2 centimeters orsmaller and has spread to the axillarylymph nodes OR

• the tumor is larger than 2 centimetersbut not larger than 5 centimeters andhas not spread to the axillary lymphnodes

Stage IIB describes invasive breastcancer in which:

• the tumor is larger than 2 centimetersbut no larger than 5 centimeters; smallgroups of breast cancer cells—largerthan 0.2 millimeter but not larger than2 millimeters—are found in the lymphnodes OR

• the tumor is larger than 2 centimetersbut no larger than 5 centimeters;

cancer has spread to 1 to 3 axillarylymph nodes or to lymph nodes nearthe breastbone that were found duringa sentinel node biopsy OR

• the tumor is larger than 5 centimetersbut has not spread to the axillarylymph nodes

30

Stage III

Stage III is divided into subcategoriesknown as IIIA, IIIB, and IIIC.

Stage IIIA describes invasive breastcancer in which either:

• no tumor is found in the breast or thetumor may be any size; cancer is foundin 4 to 9 axillary lymph nodes or inthe lymph nodes near the breastbone(found during imaging tests or a

physical exam) OR • the tumor is larger than 5 centimeters;

small groups of breast cancer cells(larger than 0.2 millimeter but notlarger than 2 millimeters) are found inthe lymph nodes OR

• the tumor is larger than 5 centimeters;cancer has spread to 1 to 3 axillarylymph nodes or to the lymph nodesnear the breastbone (found during a

sentinel lymph node biopsy)

Stage IIIB describes invasive breastcancer in which:

• the tumor may be any size and hasspread to the chest wall and/or skin ofthe breast and caused swelling or anulcer AND

• may have spread to up to 9 axillarylymph nodes OR

• may have spread to lymph nodes nearthe breastbone

31



19/27

Stage III (continued)

Inflammatory breast cancer isconsidered at least stage IIIB. Typicalfeatures of inflammatory breast cancerinclude the following:

• a substantial portion of the breast skinis reddened

• the breast feels warm and may beswollen

• cancer cells have spread to the lymphnodes and may be found in the skin

Stage IIIC describes invasive breastcancer in which:

• the cancer has spread to 10 or moreaxillary lymph nodes OR

• the cancer has spread to lymph nodesabove or below the collarbone OR

• the cancer has spread to axillary lymphnodes or to lymph nodes near the

breastbone

MY REPORT SAYS:

The cancer is stage: (check one)

Stage 0 Stage IA Stage IB

32

Stage IV

Stage IV describes invasive breastcancer in which:

• the cancer has spread beyond thebreast and nearby lymph nodes toother organs of the body, such as thelungs, distant lymph nodes or skin,bones, liver, or brain

The words used to describe stage IVbreast cancer are “advanced” and

“metastatic.” Cancer may be stage IV atfirst diagnosis, or it can be a recurrenceof a previous breast cancer that hasspread to other parts of the body.

Stage IIA Stage IIB Stage IIIA

Stage IIIB Stage IIIC Stage IV



33



20/27

Abnormal cells: Cells that do not look oract like the healthy cells of the body.

Aggressive cancer cells: Cells that arefast-growing and have a tendency tospread beyond the area where theystarted.

Atypical ductal hyperplasia: Abnormalcells that have accumulated in a breastduct. The cells have increased in numberand fill almost the entire duct. The cellscan keep changing until they becomeDCIS. Atypical ductal hyperplasia canincrease the risk of a future breastcancer.

Atypical lobular hyperplasia: Abnormalcells that have accumulated in abreast lobule. The cells have increasedin number and fill almost the entirelobule. It’s possible for the cells tokeep changing until they becomeLCIS. Atypical lobular hyperplasia canincrease the risk of a future breastcancer.

Axillary lymph nodes: Lymph nodesunder your arms.

Basal-like breast cancer: Basal-likeis one of the four main molecularsubtypes of breast cancer. Basal-likebreast cancer is hormone-receptor-negative and HER2-negative. Also calledtriple-negative breast cancer.

Benign: Not cancerous or precancerous.Biopsy: An operation to remove tissueto check whether it’s cancer or not.

BRCA1: An abnormal gene, known asBReast CAncer gene 1, associated with ahigher risk of developing breast cancer.

WORD LIST

34

BRCA2: An abnormal gene, known asBReast CAncer gene 2, associated with ahigher risk of developing breast cancer.

Clean margins: Removed breast tissuearound the tumor in which the outeredge is free of cancer cells. Also called“negative margins.”

Close margins: Removed breast tissuearound the tumor in which cancer cellscome near the outer edge.

Colloid (mucinous) carcinoma of the

breast: A rare type of invasive breastcancer that contains small pools ofmucous material.

Comedo DCIS: A type of non-invasivecancer that tends to grow quickly.Comedo refers to areas of dead cancercells that build up inside the tumor—asign that the cancer cells are growingso quickly that some of the cells are notgetting enough nourishment.

Comedonecrosis: Clumps of deadcancer cells, often seen in high-gradeDCIS. The cells are so crowded thatsome of them do not get enoughnourishment and die.

Cribriform carcinoma of the breast: Aless common type of invasive breastcancer that invades the connectivetissues of the breast and features holesbetween the cancer cells (like the holes

in Swiss cheese).Cribriform DCIS: A type of non-invasivebreast cancer that usually grows slowly.Cribriform DCIS features gaps betweencancer cells in the affected ducts (likethe pattern of holes in Swiss cheese).

35


21/27

Ductal Carcinoma In Situ (DCIS): Anuncontrolled growth of breast cellswithin the milk duct without invasioninto the normal surrounding breasttissue.

EGFR gene: A gene that controls howquickly cells divide. Also called HER1.

EGFR-negative: A breast cancer with anormal number of the EGFR gene.

EGRF-positive: A breast cancer with toomany copies of the EGFR gene.

ER-negative: A cancer that does nothave estrogen receptors.

ER-positive: A cancer that has estrogenreceptors.

Estrogen: The major female sexhormone. Estrogen can cause somecancers to grow.

Extracapsular extension: When cancerhas spread outside the wall of a lymphnode.

Fibrocystic changes: Benign changesin the breast, such as large amounts ofrubbery, firm (“fibrous”) tissue or fluid-filled cysts.

FISH (Fluorescence In Situ Hybridization)test: A test for multiple genes, includingthe HER2 gene.

Gene: The code material for a cell tomake a single protein. Proteins performdifferent functions for the cell including

growth and repair.Genomic assay: A test that analyzes theactivity of a group of genes.

Grade: How different the cancer cellslook from normal cells as well as howquickly the cells are growing.

WORD LIST (continued)

36

Gross lymph node involvement: Asituation in which many cancer cells arefound in a lymph node.

HER2 (Human Epidermal growth factorReceptor 2): A gene that helps controlthe growth and repair of cells.

HER2-enriched: HER2-enriched is oneof the four main molecular subtypesof breast cancer. HER2-enriched breastcancer is hormone-receptor-negativeand HER2-positive.

HER2 gene amplification: A situationthat arises when a HER2 gene doesn’twork correctly and makes too manycopies of itself.

HER2-negative: A breast cancer witha normal number of HER2 genes andprotein receptors.

HER2-positive: A breast cancer withHER2 gene amplification or HER2protein overexpression. HER2-positive

breast cancers tend to grow faster andare more likely to spread and comeback compared to HER2-negative breastcancers.

HER2 protein overexpression: When theHER2 gene makes too many copies ofitself, and those extra HER2 genes tellbreast cells to make too many HER2receptors.

HER2 receptors: Proteins made by the

HER2 gene that receive signals thatstimulate cells to grow and multiply.

Hormone receptors: Proteins on andin cells that respond to signals fromhormones.

37


22/27

IHC (ImmunoHistoChemistry) test: Atest used to measure proteins, includingthe HER2 protein.

In situ: A cancer within the part of thebreast where it started, such as in theducts, without signs of spread.

Infiltrating: A cancer that has spreadbeyond the place where it started. Alsocalled “invasive.”

Inflammatory Breast Cancer (IBC): Arare and aggressive form of breastcancer that starts with reddening,

swelling, and warmth of the breast, withsymptoms worsening within days orhours. IBC is considered at least stageIIIB.

Inform HER2 Dual ISH test: A test usedto figure out whether breast cancer cellsare HER2-positive.

Invasive: A cancer that has spreadbeyond the place where it started. Alsocalled “infiltrating.”

Invasive Ductal Carcinoma (IDC): Acancer that started in the milk duct buthas grown into the normal breast tissuearound it.

Invasive Lobular Carcinoma (ILC): Acancer that started in the milk lobulesand has grown into the normal breasttissue around it.

Ki-67 test: A test that shows how fastcancer is growing.

Lobular Carcinoma In Situ (LCIS): Cellsthat are not normal but stay insidethe milk-making parts of the breast(lobules). LCIS isn’t a true cancer, buta warning sign of an increased risk fordeveloping an invasive cancer in thefuture in either breast.


38

Local recurrence: A breast cancer thatcomes back in the breast area where itwas originally diagnosed.

Locoregional recurrence: A breastcancer that comes back in the lymphnodes in the armpit or collarbone areanear where the cancer was originallydiagnosed. Sometimes referred to as“regional” recurrence.

Luminal A breast cancer: Luminal Abreast cancer is one of the four mainmolecular subtypes of breast cancer.Luminal A breast cancer is hormone-receptor-positive (either estrogen- and/ or progesterone-positive) and HER2-negative.

Luminal B breast cancer: Luminal Bbreast cancer is one of the four mainmolecular subtypes of breast cancer.Luminal B breast cancer is hormone-receptor-positive (either estrogen- and/ or progesterone-receptor-positive) andHER2-positive.

Lymph channels: Vessels that drainclear, cell-cleansing fluid (“lymph”)away from tissues.

Lymph nodes: Filters along the lymphfluid channels; they can catch and trapcancer cells before they reach otherparts of the body.

Lymph system: A network of vessels

and nodes that creates and drains clear,cell-cleansing fluid (“lymph”) from thebody. The lymph system is an importantpart of the body’s immune system.

Lymphatic invasion: When cancer cellsare found in the lymph channels.

39


23/27

MammaPrint: A test that analyzes 70genes from an early-stage breast cancertissue sample to find out whether breastcancer has a low or high risk of comingback within 10 years after diagnosis.

Mammostrat: A test that measuresthe levels of five genes in early-stage,hormone-receptor-positive breastcancer cells. A risk index score is thencalculated; the higher the score, themore likely the cancer is to come back(recur).

Margin: The layer of healthy breasttissue around the cancer that wasremoved during surgery.

Medullary carcinoma of the breast: Arare type of invasive cancer that usuallypresents with a soft, fleshy tumor thatresembles a part of the brain called themedulla. Medullary carcinoma of thebreast is usually hormone-receptor-negative and HER2-negative.

Menopause: The time when a womancompletely stops getting her period(menstruating).

Metastatic: Breast cancer that hasspread to other parts of the body, suchas the bones or brain.

Microscopic invasion: A situation inwhich cancer cells have just started toinvade the tissue outside the lining of a

duct or lobule.Microscopic lymph node involvement: When only a small number of cancercells are found in a lymph node.

Milk ducts: Tiny tubes in the breast thatcarry milk from the lobules to the nipple.


40

Milk lobules: Milk-making glands in thebreast.

Moderately differentiated: Cancer cellsthat don’t look like normal cells. Theygrow a little faster than normal. Alsocalled “grade 2.”

Mucinous (colloid) carcinoma of thebreast: A rare type of invasive cancer thatcontains small pools of mucous material.

Negative margins: Removed breasttissue around the tumor in which the

outer edge is free of cancer cells. Alsocalled “clean margins.”

Non-invasive: A cancer that stays insidethe part of the breast where it started.

Oncotype DX: A test that providesinformation on how likely the breastcancer is to return and whether you arelikely to benefit from chemotherapy.Oncotype DX can also determinewhether someone with DCIS can benefitfrom radiation therapy.

Papillary carcinoma of the breast: Arare type of invasive breast cancerthat is made up of small, finger-likeprojections.

Papillary DCIS: A type of non-invasivebreast cancer that does not spread andtends to grow slowly. Papillary DCISfeatures cancer cells arranged in afinger-like pattern within the ducts.

Pathologist: A doctor who looks attissue under a microscope to see if it’snormal or affected by disease.

Pathology report: The written resultsof each test done on tissue after it hasbeen removed from the body duringbiopsy, lumpectomy, or mastectomy.

41


24/27

Perimenopause: The 1- to 3-year periodof hormonal flux before periods stopcompletely.

Poorly differentiated: Cancer cells thatlook very different from normal cells.They are fast-growing. Also called“grade 3.”

Positive margins: A situation in whichcancer cells come up to the outer edgeof the breast tissue that was removedduring surgery. This suggests that morecancer cells were left behind in thebody.

PR-negative: A cancer that does nothave progesterone receptors.

PR-positive: A cancer that hasprogesterone receptors.

Pre-cancerous: An overgrowth ofabnormal cells that shows no signsof invasion. Pre-cancerous cells are awarning sign of possibly developing

cancer in the future.Progesterone: A female sex hormone.Progesterone can cause some cancersto grow.

Prognosis: The most likely outcome ofa disease.

Recurrence: When a cancer comes back.

Regional recurrence: A breast cancerthat comes back in the lymph nodesin the armpit or collarbone area nearwhere the cancer was originallydiagnosed. Sometimes referred to as“locoregional”recurrence.

S-phase fraction test: A test that showshow fast a cancer is growing.

Sclerosing adenosis: A benign breastcondition in which enlarged lobulesform breast lumps.

Sentinel lymph node: The first lymphnode or nodes to which cancer cells arelikely to spread from a tumor.

Solid DCIS: A type of non-invasivebreast cancer; it tends to grow slowly.Solid DCIS cancer cells completely fillthe affected breast ducts.

SPoT-Light HER2 CISH test: A test used

to count the number of copies of theHER2 gene.

Staging: A system doctors use toclassify a breast cancer according tohow advanced it is.

Triple-negative breast cancer: Breastcancer that tests negative for estrogenreceptors, progesterone receptors, andHER2. Triple-negative breast cancertends to be more aggressive than other

types of breast cancer.Tubular carcinoma of the breast: A raretype of invasive breast cancer that ismade up of tube-shaped cells and tendsto grow slowly.

Vascular invasion: When cancer cells arefound in the blood vessels.

Well differentiated: Cancer cells thatlook a little bit different from normalcells. They are usually slow-growing.

Also called “grade 1.”

42 43





25/27

With your doctor’s help, it’s importantthat you understand the answers to the

questions below:

1. Is this breast cancer invasive,non-invasive, or both invasive andnon-invasive?

2. Is this a slow-growing or a fast-growingbreast cancer?

3. Are the margins negative, close, orpositive?

4. Are there any cancer cells present inlymph channels or blood vessels?

5. What do the hormone receptor testsshow? Can I take a medicine that lowersor blocks the effects of estrogen?

6. Which of these HER2 tests wasperformed on the tissue?

• IHC (ImmunoHistoChemistry) test

• FISH (Fluorescence In Situ Hybridization) test

• SPoT-Light HER2 CISH (SubtractionProbe Technology Chromogenic In SituHybridization) test

• Inform HER2 Dual ISH (Inform Dual InSitu Hybridization) test

7. Is the HER2 test positive, negative, orborderline?

8. Are any lymph nodes involvedwith this cancer? If so, how many?

9. What other lab tests were done on thecancer tissue? What did they show?

10. Is any further surgery recommendedbased on these results?

11. Which treatments are most likely to workfor this specific cancer?

KEY QUESTIONS

44

This checklist can help you keep theimportant results from all your pathology

reports together in one place. With yourdoctor’s help, fill in the answers below.sThen take this booklet with you when youvisit your other doctors, so they have theinformation they need.

My pathology reports show the following cancerfeatures:

1. Invasive or non-invasive: invasive non-invasive both invasive and non-invasive

2. Size: _______ centimeters (cm)

3. Grade: grade 1 grade 2 grade 34. Lymphatic or vascular involvement:

present absent

5. Margins of resection: negative close positive

6. Hormone receptors: estrogen receptors:

positive _______% (0%-100%) negative or circle: Allred score 0 1 2 3 4 5 6 7 8

progesterone receptors: positive _______% (0%-100%) negativeor circle: Allred score 0 1 2 3 4 5 6 7 8

7. HER2 status based on one or more of thesetests: IHC (ImmunoHistoChemistry) test: positive negative borderline

FISH (Fluorescence In Situ Hybridization) test: positive (amplified) negative (not amplified)

SPoT-Light HER2 CISH (Subtraction ProbeTechnology Chromogenic In Situ Hybridization)test: positive (amplified) negative (not amplified)

Inform HER2 Dual ISH (Inform Dual In Situ Hybridization) test:

positive (amplified) negative (not amplified)8. Lymph node status: positive (cancer found in lymph node[s])

number of lymph nodes involved: _______ negative (no cancer in lymph nodes)

9. Oncotype DX, MammaPrint, or Mammostrattest results: Recurrence score: _______

10-year recurrence risk: _______

PATHOLOGYREPORT CHECKLIST

45


26/27

NOTES

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________



46


27/27

This booklet was madepossible by an unrestricted

Breastcancer.org is the number one online

resource for breast cancer information

and support, providing over 6,000

pages of expert-reviewed information

on all aspects of breast cancer—from

diagnosis through treatment and beyond.

Breastcancer.org also hosts a vibrant peer

support community with over 120,000registered members.

Breastcancer.org reaches millions of

people around the world. Our mission is

to help people affected by breast cancermake sense of complex medical and

personal information so they can make

the best decisions for their lives. Our goal

is to empower everyone to face breast

cancer with knowledge, clarity,

and confidence.

Visit us online at www.breastcancer.org.

breastcancerorg pathology report guide 2013

Documents