Personalized Cancer Treatment

Your Pathology Report

Your treatment options are based on the results of biomarker testing as well as what the pathologist finds when evaluating a sample of your tumor taken during a biopsy or during surgery. A pathologist looks at the specimen both with and without a microscope to describe exactly how the tumor looks. The doctor will also perform various tests on it, such as an exam to look for specific markers on the cells. Once all tests are complete, the pathologist prepares and signs a detailed pathology report.

Pathology reports vary somewhat from hospital to hospital, but each report contains important details that will help your doctors accurately diagnose and manage your cancer (Table 1). Your doctor and treatment team use the information in the 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 the report includes details that help identify you, details about the specimen, and the stage of disease. As more is learned about tumors, additional information is being included on some pathology reports.

Patient Identifiers

To ensure that the pathology report is about you, each report includes details that identify you as the patient, such as your name, birth date and hospital or medical record number. Your patient identifiers are also noted on the container of any specimen that is sent to the laboratory and will be matched to your medical record. The pathology department assigns a number to your specimens and slides that match your patient identifier. The report also contains the name of the pathologist and the name and address of the laboratory.

Specimen Details

Gross Description

The gross description is what the tissue from the tumor looks like when it is examined without a microscope. 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. When the specimen is the entire tumor, the pathologist records its size in weight as well as length (at its longest point). Length is recorded in centimeters (cm); one inch equals 2.54 cm.

Microscopic Description

The microscopic description refers to what the cells of the tumor look like when viewed under a microscope. The pathologist reports the size and shape of the cells as well as how frequently the cells are dividing (also known as the mitotic rate). The pathologist assigns a histologic grade to the cancer based on how the appearance of the cancer cells compare with that of normal cells from the same place in the body. This 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. 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 (Table 1). Grading may vary from hospital to hospital. Talk with your doctor about the tumor grade for your cancer and how it relates to your diagnosis and treatment. The margins (edges) of the tumor are also evaluated for the presence of cancer cells (Table 1).

Table 1. Some important parts of a pathology report

Descriptor What is described or measured What finding means
Cellular features
Size and shape

Number of cells dividing (mitotic rate)
Cancer cells are often larger or smaller than normal cells, and their shapes may vary from one another and appear distorted.

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.
Extent of invasion The structures that are affected by the tumor Extent of invasion is often a factor in staging and a consideration when selecting treatment, including determining whether a tumor is operable.
Histologic grade How closely the tumor cells resemble normal cells; reported as well-differentiated (G1), moderately differentiated (G2), poorly differentiated (G3) or undifferentiated (G4) The more the cancer cells look like normal cells (lower grade), the better the prognosis; the higher the grade, the more aggressive the tumor.
Histology The histologic type (the specific subtype of cancer according to how the cells look under the microscope) Treatments and prognosis vary according to histologic type.
Location The exact part of the body from where the tumor (or specimen) was removed  
Lymph node status Presence or absence of cancer cells in the nearby lymph nodes Negative lymph node status is generally associated with less extensive cancer and a better prognosis; lymph node status is another primary factor in staging.
Molecular testing Presence or absence of genetic alterations Tumors with specific alterations may be more or less likely to respond to certain targeted therapies.
Size Length (in longest direction) and width of the tumor Prognosis is likely to be better for smaller tumors; size is usually a primary factor in staging.
Stage Status of the cancer with regard to the TNM classification system The prognosis is usually better for early-stage disease than for later-stage disease (see Table 2).
Surgical margins Presence (positive) or absence (negative) of cancer cells in the normal tissue at the edges of the tumor More treatment may be needed if the margins are close or positive.

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, but most systems use the following criteria to determine the stage of cancer:

  • Site of the primary tumor (where the cancer originates)
  • Size and number of tumors
  • Whether the cancer has spread to lymph nodes
  • Cell type and tumor grade
  • Presence or absence of cancer metastasis (spread to other locations in the body)

Staging the cancer is important to help the doctor plan the best treatment, to identify clinical trials that may be right for you, and to provide a base for understanding among health care providers and researchers.

The TNM staging system is a widely used staging system 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 2). 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 version of this system.

Additional procedures

Sometimes the pathologist needs to use other procedures to learn more about the tumor. As testing for genetic alterations 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 2. Tumor, Node, Metastasis (TNM) classification system for staging most cancers

Primary tumor (T)
T1, T2, T3, T4
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
Regional lymph nodes (N)
N1, N2, N3
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
Distant metastasis (M)(LCIS)
Metastasis cannot be evaluated
No metastasis found
Distant metastasis present

Diagnosis and comments

The pathologist evaluates the information from the examination and testing of specimens, along with the results of imaging studies, blood tests, clinical exams and your medical history in order to make a diagnosis. This diagnosis may be found either at the beginning or the end of the report. The pathologist may also add comments about the disease process or make suggestions for further studies. If you have any questions about your 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 decide you want a second opinion, talk with your doctor first. Many facilities provide second opinions on pathology specimens.

Questions to ask your doctor

  • May I have a copy of my pathology report?
  • What is the exact type of cancer that I have?
  • What is the stage of cancer and what does that mean in my case?
  • Has the cancer spread to my lymph nodes or other organs?
  • Is there testing for genetic mutations that would be helpful?
  • Will I need more tests before we decide which treatment to use?
  • What is my prognosis?

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