Your breast cancer pathology report may be broken down into the following sections: demographics, gross description/specimen, clinical history/diagnosis, gross description, special tests/markers, microscopic description, prognostic report, summary and diagnosis. Know in advance that different labs and hospitals may use different words to describe the same thing.
Demographics. First, check the top of the report for your name, the date you had your operation and the type of operation you had. Make sure this information is accurate. This section may also include your doctor(s) name(s), medical record number and other identifying information.
Gross Description/Specimen. This section describes where the tissue samples came from. Tissue samples could be taken from the breast, from the lymph nodes under your arm (axilla), or both. In this section, you will find the description of the specimen or tissue sample based on what the naked eye can see. Included here will be the size and weight of the specimen and other visual observations made by the pathologist. Information about how the sample was handled, how it was sectioned and what materials were used in preparation for the microscopic examination is also included.
Clinical History. This is a short description of you and how the breast abnormality was found. It also describes the kind of surgery that was done.
Clinical Diagnosis. This is the diagnosis the doctors were expecting before your breast tissue sample was tested.
Gross Description. This section describes the tissue sample or samples. It talks about the size, weight, and color of each sample.
Special Tests or Markers. This section reports the results of tests for proteins, genes and how fast the cells are growing.
Microscopic Description. This section describes the way the cancer cells look under the microscope. This part of the report points out the features of the tumor or tissue sample. These features will lead to the specific diagnosis.
Prognostic Report. Results of the specific tests performed on the specimen are stated in this section.
Summary and Final Diagnosis.