What Information Is Included in a Pathology Report?

After analyzing and testing your biopsy or cytology samples, the pathologist will send your doctor a report that gives a diagnosis for each sample taken. The information in this report can then be used to help manage your care.

The pathology report is often quite long and complex. It’s often divided into several subheadings.

Identifying information

The general identifying information includes the person’s name, the medical record number issued by the hospital, the date when the biopsy or surgery was done, and the unique number of the sample (which is assigned in the lab).

Clinical information

The next part of the report often contains patient information that was provided by the doctor who removed the tissue sample. This may include a medical history and any special requests that were made to the pathologist.

For example, if a lymph node sample was removed from a person known to have cancer in another organ, the doctor will note the type of the original cancer. This can be useful in helping the pathologist choose which tests to do to find out if any cancer in that lymph node is the result of spread of the original cancer, or if it’s a new cancer that started in the lymph node.

Gross description

The gross description is what the pathologist sees by simply looking at, measuring, and feeling the tissue sample (as opposed to looking at it under a microscope).

For a small biopsy, this description is often a few sentences noting its size, color, and consistency. This section also records the number of tissue-containing cassettes submitted for processing.

Larger biopsy or tissue samples, such as a mastectomy for breast cancer, will have much longer descriptions, including the size of the entire sample, the size of the tumor, how close it is to the nearest surgical margin (edge) of the sample, how many lymph nodes were found in the underarm area, and the appearance of the non-cancer tissue. A summary of exactly where tissue was taken from is also included.

For cytology samples, the gross description is very short and usually notes the number of slides or smears made by the doctor. If the sample is a body fluid, its color and volume are noted.

Microscopic description

This is a description of what the pathologist sees when looking at the processed sample under a microscope. The appearance of the cancer cells, how they are arranged, and the extent to which the cancer invades nearby tissues are usually included in the microscopic description.

Results of any other studies done (histochemical stains, flow cytometry, etc.) may be noted in the microscopic description or in a separate section.

Some pathology reports may not have a microscopic description.

Diagnosis

The most important part of the pathology report is the final diagnosis. This is the “bottom line” of the tissue examination process, although this section is usually at the top of the page. If the diagnosis is cancer, this section will note the exact type of cancer and will usually include the cancer’s grade.

The treating doctor relies on this final diagnosis to help decide on the next steps, possibly including treatment options.

In some situations, a biopsy result might be inconclusive, which means that the pathologist can’t say for sure what the diagnosis is, based on the tests that were done. In such cases, the biopsy might need to be repeated, or other tests might be needed to be more certain of the diagnosis. If your biopsy result is inconclusive, talk to your doctor about what the next steps should be.

Comment

After the diagnosis, the pathologist may add more information for the doctor(s) taking care of the patient. The comment section is often used to clarify a concern or to recommend further testing.

Summary

Pathology reports for cancers should also contain a summary of the findings most relevant to making treatment decisions.

The College of American Pathologists (CAP) has guidelines that specify what information is most relevant for each type of cancer, and it provides templates of these “cancer protocols” to pathologists.

Addendum

Sometimes a pathologist is certain that a tissue sample is cancer based on the microscopic exam, but further testing (such as immunohistochemistry or a molecular test) is needed to determine the exact type of cancer, or to provide the treating doctor with more information to help determine the best treatment.

If the additional testing is going to take several more days, the pathologist might issue an initial report to let the patient and doctor know that the diagnosis is cancer and not some other disease. Then, once further testing is complete, an addendum section is added to the report, which includes the results of these tests.