PERSONALIZED CANCER TREATMENT
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Personalized Cancer Treatment
Your Pathology Report
 Your treatment options are based on the results of biomarker testing, as well as the results of pathologic evaluation. The pathologic evaluation is an examination of the tumor tissue taken during a biopsy or during surgical removal of the tumor. A pathologist looks at the specimen both with and without a microscope to describe the exact appearance, color, shape, and size of the specimen, as well as the details of the cellular structure. After examining the specimen and performing various tests on it, such as looking for specific markers on the cells, the pathologist prepares and signs the detailed report.
Pathology reports vary somewhat from hospital to hospital, but each report documents important details that aid in the diagnosis and management of your cancer. Your doctor and treatment team use the information in the pathology report to guide decision-making about a treatment plan designed especially for you.
Understanding your pathology report can be confusing because it contains highly technical medical information. The basic information on a pathology report includes patient identifiers, details about the specimen and the stage of disease. As more is learned about the molecular make-up of tumors, additional information is being included on some pathology reports.
Patient Identifiers
To ensure that the pathology report is about you, each report has your patient identifiers: your name, birth date and hospital or medical record number. The report also will indicate your pathologist’s name and the name and address of the laboratory. Your patient identifiers are also put on the container of any specimen that is sent to the laboratory and will be matched to your medical record to ensure that the specimen is yours. The pathology department assigns a number to your specimens and slides that match your patient identifier to track the specimens in the laboratory.
Specimen Details
Gross Description
Tissue from the tumor is first described by the pathologist as seen without a microscope (gross description). The pathologist notes the type of biopsy or surgery performed; the type of tissue taken; the location from which the tissue was taken; and its shape, size and color. Multiple specimens may be taken and prepared for study. If a tumor is removed, its size is recorded in weight as well as length (at its longest point). Length is recorded in centimeters (cm); 1 inch is equal to 2.54 cm.
Microscopic Description
Laboratory technicians specially prepare tissue specimens for examination with a microscope by applying a preservative and/or other solutions. The sample is then put in paraffin wax and after the wax hardens, the specimen is sliced into very thin sections. These sections are then stained to make the details of the cells stand out, and the prepared specimens are placed on glass slides for examination under a microscope. This process produces permanent samples, and the careful examination of the prepared slides may take several days.
Sometimes immediate results are needed during an operation because more tissue may need to be removed if the sample contains cancer cells. For example, if cancer cells are found in samples of lymph nodes near the tumor, those lymph nodes need to be removed; but if no cancer is found, the lymph nodes can stay. When immediate results are needed, a “frozen section” can be prepared in the laboratory by rapidly freezing the tissue sample, making thin slices of it, staining the sample, and looking at it under a microscope. The process takes 15-20 minutes, and the sample is of only short- term use. Although the details of a frozen section are usually not as clear as those of a permanent slide, they are good enough to provide information for the surgeon during the operation.
Cellular Features
The microscopic examination gives details of how the cells of the tumor look compared with normal cells under the microscope. The features the pathologist evaluates include:
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SIZE AND SHAPE OF THE CELLS. Cancer cells are often larger or smaller than normal cells, and their shapes may vary from one another and appear distorted.
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SIZE AND SHAPE OF THE CELL NUCLEUS. The nucleus (or center) is also often abnormal and may contain a large amount of DNA.
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NUMBER OF CELLS.
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FREQUENCY OF DIVIDING CELLS THAT ARE SEEN (THE MITOTIC RATE). A large number of dividing cells means rapid growth, which is typical of aggressive cancer cells. Few dividing cells are more likely to indicate a better prognosis.
The margins (edges) of the tumor are evaluated for the presence of cancer cells. The margins are designated as positive if cancer cells are found at the edges of the tissue sample; negative, free or clear if no cancer cells are found at the outer edges, and close margins if neither positive or negative margins are identified.
Grade
The pathologist assigns a grade to the cancer based on how the cancer cells compare with normal cells. The histologic grade (also called differentiation) refers to how closely the tumor cells resemble normal cells of the same tissue type. Cells that look more like healthy cells are described as low-grade or well-differentiated. Cancer cells that look less like healthy cells are called high-grade or poorly differentiated or undifferentiated. The nuclear grade refers to the size and shape of the nucleus of the cancer cells and the percentage of the cells that are dividing. Many features of the cells are considered in determining the grade, and different grading criteria are used for different cancers. Tumor grading for many other cancers is based on degrees of severity from 1 to 4.
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GX Undetermined, grade cannot be assessed
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G1 Well-differentiated (low grade)
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G2 Moderately differentiated (intermediate grade)
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G3 Poorly differentiated (high grade)
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G4 Undifferentiated (high grade)
Grading for breast cancer is generally based on Grades 1 to 3, but grading may vary from hospital to hospital as refinements of the system are considered. Talk with your doctor about the tumor grade for your cancer and how it relates to your diagnosis and treatment.
Stage of Disease
The cancer stage describes the severity or extent of a person’s cancer. Staging systems vary according to the cancer they describe. Most staging systems use the following criteria to determine the stage of cancer:
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Site of the primary tumor (where the cancer originates)
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Size and number of tumors
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Whether the cancer has spread to lymph nodes
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Cell type and tumor grade
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Presence or absence of metastasis (spread to other locations in the body)
Staging the cancer is important to help the doctor plan suitable treatment and estimate a prognosis, to identify clinical trials that may be right for the person, and to provide a base for understanding among health care providers and researchers.
The TNM staging system is a widely used staging system that is used in many medical facilities. The system is based on the extent of the tumor (T), extent of spread to nearby lymph nodes (N), and the presence of distant metastasis (M) (Table 1). Numbers are assigned to each letter to indicate the size of the primary tumor and the amount of cancer spread. Once the TNM values have been assigned, they are combined to provide an overall stage that receives a Roman numeral from I to IV, with IV being the most advanced stage. Other factors, such as cell type, grade, and tumor marker levels may also be considered in assigning the stage. The TNM staging is not used for all cancers and each cancer type has its own versions of this system.
Additional Procedures
Sometimes the pathologist needs to use other procedures to learn more about the tumor. As testing for genetic mutations and other biomarkers becomes more common, the pathology report will include the results of this testing. Testing for protein biomarkers in tumors is often done by a test called immunohistochemistry (IHC) analysis, and the results are given as 0 (no expression of the protein), 1+, 2+, and 3+ (high expression of the protein). Depending on the type of cancer, other information may also be included, such as the molecular subtype of the tumor.
Table 1. Tumor, Node, Metastasis System for Staging Most Cancers
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Primary Tumor (T) |
TX
T0
Tis
T1, T2, T3, T4
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The tumor cannot be measured.
No evidence of primary tumor.
Carcinoma in situ (abnormal cells are present in superficial layer of tissue; sometimes called preinvasive cancer).
Size and/or extent of the primary tumor; the larger the number, the farther the cancer has grown into nearby tissues.
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Regional Lymph Nodes (N) |
NX
N0
N1, N2, N3
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The nearby lymph nodes cannot be evaluated.
The nearby lymph nodes do not contain cancer.
Size, location, and/or number of lymph nodes in which cancer cells are found; the higher the number assigned, the more lymph nodes involved.
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Distant Metastasis (M)(LCIS) |
MX
M0
M1
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Metastasis cannot be evaluated.
No metastasis found.
Distant metastasis present.
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Diagnosis and Comments
The pathologist evaluates the information from his or her examination and testing of specimens, along with the results of imaging studies, blood tests, clinical examinations, and medical history in order to make a diagnosis, which may be found either at the beginning or at the end of the report. The pathologist also may add comments about the disease process or make suggestions for further studies. If you have any questions about the pathology report, talk with your doctor or the pathologist. Sometimes a doctor or a patient will want a second opinion about the pathology results. Because the slides and tissue sample are permanently preserved, they can be used by another pathologist. If you should desire a second opinion, talk with your doctor first. Many facilities provide second opinions on pathology specimens.
Questions You May Want to Ask Your Doctor
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May I have a copy of my pathology report?
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What is the exact type of cancer that I have?
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What is the stage of cancer and what does that mean in my case?
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Has the cancer spread to my lymph nodes or other organs?
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Is there testing for genetic mutations that would be helpful?
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Will I need more tests before we decide which treatment to use?
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What is my prognosis?
Additional Sources of Information
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