How to Read Your Pathology Report
Surgical pathology reports vary somewhat regarding the information that they contain; however, each report will document the significant details that affect the management of your diagnosis. Typically, a surgical pathology report is divided into a minimum of four to five sections:
♦ Patient Identifiers and Clinical Information
♦ Specimen Section
♦ Gross Description
♦ Microscopic Description
Sometimes the report includes a comment section, which may note a specific scientific reference or journal article.
Patient Identifiers and Clinical
Each pathology report includes patient identifiers to ensure that the report is about you and your diagnosis. Your name, your birth date, and your hospital or medical record number, along with your pathologist’s signature and the name and address of the laboratory, will appear on your pathology report.
When your specimen is sent to the pathology laboratory, the container with your specimen also is labeled with your patient identifiers and matched to your medical record to ensure that the specimen is from you. After the lab processes your specimen and prepares the final pathology report, pathologists and other medical laboratory professionals check these identifiers repeatedly to ensure the report relates the correct information to your doctor for your care.
Each pathology department uses a numbering system to specifically label each person’s specimen. These numbers are called accession or surgical numbers and are used to help identify your specimen as it is processed by the pathology laboratory. All the microscope slides made from your specimen also will include your accession or surgical number and will correlate with your patient identifiers.
The diagnosis section represents the final medical diagnosis that is established after thorough examination of your specimen.
Sometimes your doctor may supply additional clinical information about you to help your pathologist when they examine your specimen. This may include your symptoms, medical conditions, or possible disorders your doctor would like your pathologist to look for or special studies your doctor would like performed on your specimen.
The specimen section refers to the anatomic location (place on the body) of the tissue or name of the organ. This section is important as an incorrect description or designation (such as to the right or left) can be detrimental with grave consequences. Pathologists and other medical laboratory professionals record this information carefully to ensure that the pathology report documents the appropriate designation.
The gross description section details what tissue the pathologist will examine under the microscope and describes how your specimen looks to the “naked eye.” It includes the size, color, number of tissue samples, and when appropriate, the weight of your specimen. Gross descriptions of a small biopsy specimen are typically short. However, a more complex specimen may require a more detailed description.
Usually, if there are multiple tissues or organs in your specimen, the pathologist will describe each and will take samples to examine under the microscope. Pathologists may sample different portions of even a single organ and include any area that looks abnormal or different from what is usually seen in a healthy organ. The pathologist will create a slide for each of these samples to be viewed under the microscope and will list each in your pathology report.
For each cancer, there are standardized criteria that vary depending on the location of the cancer and the type of cancer. The details are documented to stage the cancer, which directly affects your prognosis and subsequent treatment.
The microscopic description details how your specimen looks under the microscope and how it compares with normal cells. The section describes if the cancer has invaded nearby tissues. This microscopic description is then used, along with the gross description and your clinical history, to make the pathologic diagnosis.
The laboratory always performs a microscopic examination of a specimen. However, it does not always include a microscopic description on the pathology report. Pathologists who do not describe the microscopic features in the report may include findings that are outside of the norm or that would directly affect your care within the diagnosis section or as a comment.
The pathologist also uses the microscopic description to note small incidental findings that may not be important to your care but may interest other pathologists who may see the case. These findings could include the results of special studies or microscopic stains that the lab performed to help confirm the diagnosis or rule out a different diagnosis.
The diagnosis section represents the final medical diagnosis that is established after thorough examination of your specimen. Some diagnoses are very short, such as acute appendicitis. Other diagnoses can be quite lengthy, as they need to describe many aspects of the cancer that could affect your treatment and outcome.
In these cancer cases, there often will be additional information called cancer staging that is included in the diagnosis. This information describes what type of cancer is present, how the cancer looks (cancer grade), how far in the specimen the cancer has spread (cancer stage), and other aspects of the cancer, such as if the cancer is present in blood vessels. The diagnosis also will include whether the surgical margins (the edges or borders of a tumor) contain cancer. All this information helps determine if you will need additional treatments and helps predict your health over time.
Sometimes there are diseases that are subtle or difficult to diagnose or in which the disease process is considered controversial or unclear. Many pathologists tend to utilize the comment section to explain the intricacies when this type of issue arises. In addition, if the diagnosis is not clear, rare, or associated with new information or technology, the pathologist uses the comment section to list the possible diagnoses, recommendations for additional testing, or studies that may be helpful in finding the correct diagnosis.
In summary, the surgical pathology report represents a description, which includes the location of the specimen and what your specimen looks like both with the naked eye and under microscope examination. Your pathologist will integrate all the clinical information about you into the pathology report to make a pathologic diagnosis and will consult with your other doctors regarding your treatment and care.
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Reprinted by the permission of The College of American Pathologists, from MyBiopsy.org.
This article was published in Coping® with Cancer magazine, September/October 2011.