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The grade on a breast report is a sum of three scores: how much of the tumour still forms tubes, how ugly its nuclei are, and how many cells are caught dividing. Each is scored 1 to 3, and the total of 3 to 9 becomes grade 1, 2 or 3. Grade says how the cancer behaves, not how far it has spread.
The method is the one Elston and Ellis described in 1991, a deliberately more objective revision of Bloom and Richardson's grade, and UK practice allows no other: the dataset in force says that grading systems other than this one should not be used. Three features are scored from 1 to 3. Tubule and acinar formation: score 1 if more than 75 percent of the tumour forms tubular structures with a clear central lumen, 2 if 10 to 75 percent, 3 if under 10 percent. Nuclear atypia and pleomorphism: score 1 for small regular nuclei up to about twice the diameter of a red blood cell, rising to 3 for obvious atypia. Mitotic count: counted in a defined field area and standardised to the microscope's field diameter, because the number of cells in a high-power field varies between microscopes. The three scores are added: 3, 4 or 5 is grade 1, 6 or 7 is grade 2, 8 or 9 is grade 3. Tubule formation is judged across the whole tumour; nuclei and mitoses are judged in the worst area, usually at the edge.
The grade earns its place on the report. In the Nottingham/Tenovus study, grade was assessed in 1,831 of more than 2,200 patients with primary operable breast cancer entered since 1973, and grade 1 tumours had significantly better survival than grade 2 and 3 (p less than 0.0001) (Elston 1991). Grading is required for every invasive carcinoma, including the rare special types and including adenoid cystic carcinoma, because prognosis varies by grade within a type. For audit it is mandatory to record the three component scores and not only the total.
Two cautions a reader should have. First, the grades are not meant to come out in equal thirds: the dataset gives the expected ratio of grades 1, 2 and 3 as about 2:3:5 in symptomatic breast cancer and about 3:5:2 in screen-detected breast cancer, and a unit whose distribution departs far from that is told to review its fixation and grading protocols. A grade 3 is therefore commoner in a cancer found because of a lump than in one found by screening. Second, the grade on the needle biopsy and the grade on the surgical specimen agree only about 70 percent of the time, and where they differ the surgical specimen is normally used for management; if a mixed tumour turns out to have a higher-grade component that the biopsy missed, the dataset asks for the receptor assays to be repeated as well.
Most cancers start in the ducts and drain first to the axillary nodes, which is why the armpit is checked and a sentinel node is sampled.
Same organ: Triple-negative breast cancer (TNBC), HR-positive / HER2-negative breast cancer, HER2-positive breast cancer, Male breast cancer, Ductal carcinoma in situ (DCIS), High-risk early HR-positive breast cancer, HR-positive metastatic breast cancer after CDK4/6 inhibitors, HER2-low and HER2-ultralow metastatic breast cancer, Early HER2-positive breast cancer, HER2-positive breast cancer with brain metastases, Early triple-negative breast cancer, Metastatic triple-negative breast cancer, Basal-like 1 triple-negative breast cancer (BL1), Basal-like 2 triple-negative breast cancer (BL2), Mesenchymal triple-negative breast cancer (M), Mesenchymal stem-like triple-negative breast cancer (MSL), Luminal androgen receptor triple-negative breast cancer (LAR), Immunomodulatory triple-negative breast cancer (IM), Metaplastic breast carcinoma, Carcinoma with medullary pattern (medullary breast cancer), Adenoid cystic carcinoma of the breast, Apocrine carcinoma of the breast, Secretory carcinoma of the breast, BRCA-associated triple-negative breast cancer, Inflammatory breast cancer, Paget disease of the nipple, Phyllodes tumour of the breast, Invasive lobular carcinoma of the breast, Invasive breast carcinoma of no special type (invasive ductal carcinoma), Tubular carcinoma of the breast, Mucinous carcinoma of the breast, Papillary carcinomas of the breast (encapsulated, solid and invasive papillary), Invasive cribriform carcinoma of the breast, Invasive micropapillary carcinoma of the breast, Neuroendocrine neoplasms of the breast, Lobular carcinoma in situ (LCIS)
Showing the organ this term concerns: Breast cancer (all types).
Shares Tumour size on a breast report, and why it differs from the scan, Nottingham Prognostic Index (NPI), and PREDICT, Grade, stage and receptor status: three different things on one breast report, Ductal carcinoma in situ (DCIS).
Shares Invasive breast carcinoma of no special type (invasive ductal carcinoma), The WHO classification of breast tumours, and what the 6th edition changed, Invasive lobular carcinoma of the breast, Ductal carcinoma in situ (DCIS).
Shares Grade versus stage, Tumour size on a breast report, and why it differs from the scan, Nottingham Prognostic Index (NPI), and PREDICT, Grade, stage and receptor status: three different things on one breast report.
Shares Grade, stage and receptor status: three different things on one breast report, Grade, HER2-positive breast cancer, Breast cancer (all types).
Shares Grade, stage and receptor status: three different things on one breast report, Grade, Breast cancer (all types), Triple-negative breast cancer (TNBC).
Shares Grade, stage and receptor status: three different things on one breast report, The WHO classification of breast tumours, and what the 6th edition changed, HER2-positive breast cancer, Breast cancer (all types).
Shares The WHO classification of breast tumours, and what the 6th edition changed, Invasive lobular carcinoma of the breast, Ductal carcinoma in situ (DCIS), Breast cancer (all types).
Shares Grade, stage and receptor status: three different things on one breast report, Ductal carcinoma in situ (DCIS), Breast cancer (all types), Triple-negative breast cancer (TNBC).