Pathology reports contain information about the patient, the tissue specimen being evaluated, and the final diagnosis.

Pathologists evaluate the tissue within a breast core biopsy or surgical specimen to diagnose the type of cancer, as well as evaluate the presence of various prognostic factors. Each patient’s cancer is unique, and each patient’s pathology report is unique to that patient. Oncologists, surgeons and radiation oncologists will use the information that the pathologists write in the pathology report to guide a patient’s individualized treatment plan.

Sample Pathology Report
Sample Breast Core Biopsy Report

The exact layout of pathology reports differs between different departments and hospitals, but all reports contain the same essential key information. This information includes: 

Patient Identifying Information   

This typically includes the patient name, date of birth, and medical record number, and it may contain other information such as age and race.

Physician Identifying Information   

This typically includes the physician name and contact information. The physician listed is typically the physician removing the tissue sample, such as the radiologist or the surgeon. Sometimes, more than one physician will be listed.

Specimen Case Number and Important Dates   

The specimen case number is a unique number assigned to that biopsy or resection sample taken from the patient, and it is typically in the format of “S-YEAR-NUMBER” such as “S2018-1234.” Important dates to note are the date the specimen is taken from the patient, and the date that it is received, accessioned (that is, assigned its unique case number), and processed in the pathology laboratory.

Clinical History   

In this section, the physician provides a brief clinical history of the patient to the pathologist evaluating the specimen. This may include the location of the breast lesion or past treatments received.

Body Site and Procedure   

The report will specify the location in the body from which the tissue was removed (such as, “right breast”) as well as the procedure performed (such as, “core needle biopsy” or “modified radical mastectomy”).

Diagnosis   

The final diagnosis is the most important part of the pathology report and it contains the pathologist’s diagnosis. The exact content of the diagnosis varies between whether the specimen is a core biopsy or a resection, as well as whether the diagnosis is benign or malignant.

Gross Description   

When a pathologist physically examines the tissue removed from the patient, it is called “grossing the specimen”, or “the gross examination.” This is in contrast to the microscopic examination performed later on the glass slides. In the “gross description” section, the pathologist will describe the physical characteristics of the tissue removed from the patient. This section will be very short for a core needle biopsy, but it can be quite long for a lumpectomy or mastectomy. The information in the gross description will include elements such as: the size dimensions of the tissue; the colors of ink used to orient the margins of the specimen; the size and location of any visible masses; the distance of the mass to the margins; and the number of sections submitted from the tissue.

Pathologist Identifying Information   

This includes the pathologist’s name and may include other contact information.  

The features that a pathologist will describe in your pathology report include: the type of cancer, tumor grade, the stage, and the margin status on a surgical excision (that is, is the tumor entirely removed in the specimen). Important components of the tumor stage are the tumor size and whether there is tumor in the lymph nodes.

Pathologists also perform additional special tests on invasive cancers to determine the biologic expression of prognostic and predictive markers; specifically the ER and PR expression of the tumor, and the HER2 status of the tumor. Finally, pathologists sometimes need to perform additional special tests (immunostains) to clarify whether a tumor is in situ or invasive, or whether a carcinoma is ductal or lobular. The results of these studies may also be listed in the pathology report.