Pathology Report

See the current version of the SEER Program Coding Manual under Reporting Guidelines for the complete coding instructions on the related pathology data items.

  • Section IV: Description of this Neoplasm
  • Section V: Stage of Disease at Diagnosis
  • Section VI: Stage Related Data Items

Types of Pathology Reports

  1. Cytology
    1. Breast fine needle aspiration (FNA) is a procedure where a small amount of breast tissue or fluid is removed from a suspicious area with a thin, hollow needle and checked for cancer cells.
      1. FNA is most commonly performed on suspicious lymph nodes in the axilla.
      2. This type of procedure is used to determine the diagnosis.
  2. Tissue
    1. Core Needle Biopsy
      1. Needle core biopsies for Breast cancers are very common in which a thread-like tissue sample of the tumor is removed.
      2. This type of procedure is most commonly done for a microscopic [histological] confirmation of breast cancer.
    2. Surgical Resection
      1. Procedure that is used to remove the cancer.
Data items found within pathology reports
Data Item Comments Text Field Source of coding instructions
Date of Diagnosis The pathology report is usually the date that the cancer is microscopically (histologically) confirmed; however, the date of diagnosis may be prior to the pathology report (e.g., diagnosed on imaging) # 2570 Text-Dx-Proc-Path SEER Program Coding Manual, under Reporting Guidelines, Section IV: Description of this Neoplasm
Primary Site

Breast has multiple subsites. Review the pathology report to see if you can determine the subsite

Note: If the pathology report(s) don’t provide the subsite, review the Mammogram, Ultrasound or other imaging to see if the subsite is documented

2580: Text-Dx-Primary Site Title AND

2570: Text-Dx-Proc Path

SEER Program Coding Manual, under Reporting Guidelines, Appendix C, Breast, Primary Site Coding Guidelines
Histology This is the ICD-O-3 Morphology code assigned

2590: Text-Dx-Histology Title
AND

2570 Text-Dx-Proc Path		 Solid Tumor Rules, under Reporting Guidelines, Breast
Behavior This reflects whether the tumor is benign, borderline, in situ, or invasive

2590: Text-Dx-Histology Title
AND

2570 Text-Dx-Proc Path		 Solid Tumor Rules, under Reporting Guidelines, Breast
Laterality The side of the body the tumor is found. This must be coded 1-4 or 9 for all breast cancers # 2570 Text-Dx-Proc-Path SEER Program Coding Manual, under Reporting Guidelines, Section IV: Description of this Neoplasm
Regional Nodes Positive Records the number regional lymph nodes found to contain metastasis # 2570 Text-Dx-Proc-Path SEER Program Coding Manual, under Reporting Guidelines, Section VII: First Course of Therapy
Regional Nodes Examined Records the number of regional lymph nodes that were removed and examine # 2570 Text-Dx-Proc-Path SEER Program Coding Manual, under Reporting Guidelines, Section VII: First Course of Therapy
Sentinel Lymph Nodes Positive Records the number of sentinel lymph nodes found to contain metastases # 2570 Text-Dx-Proc-Path SEER Program Coding Manual, under Reporting Guidelines, Section VII: First Course of Therapy
Sentinel Lymph Nodes Exam Records the total number of lymph nodes sampled during the sentinel node biopsy # 2570 Text-Dx-Proc-Path SEER Program Coding Manual, under Reporting Guidelines, Section VII: First Course of Therapy
Grade See Grade # 2570 Text-Dx-Proc-Path

SEER*RSA, Breast schema OR Schemas | SSDI Data | (naaccr.org)External Website Policy, Breast
Biomarkers

See Biomarkers

Note: These results may not be on the original pathology report. Many times they will on an addendum or a molecular pathology report		 # 2570 Text-Dx-Proc-Path

SEER*RSA, Breast schema OR Schemas | SSDI Data | (naaccr.org)External Website Policy, Breast
Genomic Testing

See Genomic testing

Note: These results may not be on the original pathology report. Many times they will on an addendum or a molecular pathology report		 # 2570 Text-Dx-Proc-Path

SEER*RSA, Breast schema OR Schemas | SSDI Data | (naaccr.org)External Website Policy, Breast

Updated: January 10, 2025