Testing Biopsy and Cytology Specimens for Cancer

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What can you do to learn more about your pathology results?

Pathology results have a key role in decisions made about treatment, and many patients want to learn more about their test results. Ask your doctors to explain your results in a way that you can understand. Focus on how the results influence your treatment options and help predict your outlook. Some pathologists will help you understand your pathology reports. But others believe that your oncologist, surgeon, primary care doctor, or other doctors are better able to explain the results because they know more about your overall medical situation. Also, doctors who already know you well are often best able to discuss the complex personal issues affected by your pathology results.

You may ask for copies of your pathology reports, and you may find it useful to keep a folder or notebook with your pathology, radiology, and other test results. If you see more doctors in the same hospital where your cancer was diagnosed, the new doctors will have access to the original pathology report and other medical records. If you see consulting doctors (such as for a second opinion) who practice at other facilities, it’s usually necessary to send copies of pathology reports and other medical records before your appointment. In most cases you can just sign a release form to have the copies sent, but it’s a good idea to keep an original copy for yourself that you can share with the new doctor in case a report is not available. You will always want to get back the original for those times you may need it again. Some cancer centers have a policy requiring that microscope slides of the patient’s cancer be reviewed by the pathologists at their own institution. Some pathology labs will give copies of microscope slides to you if you are going to visit another cancer center for a second opinion or consultation. Other labs mail the slides directly to the consulting cancer center’s pathology department. Again, you will probably have to sign forms to get this done.

If you or your doctors have any concerns about your pathology diagnosis, you can have your microscope slides reviewed by a consulting pathologist for a second opinion. Your oncologist or surgeon or the pathologist who first looked at your biopsy or cytology sample can often suggest a consultant with special qualifications in examining samples like yours. Or you can have your slides sent to the pathology department of a medical school or cancer center you have confidence in.

What information is included in a pathology report?

The pathology report of surgical specimens is often quite long and complex. It’s often divided into a number of subheadings.

Identifying information

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

Clinical information

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

For example, if a lymph node sample is being removed from a patient known to have cancer in another organ, the doctor will note the type of the original cancer. This information is often useful in guiding the pathologist’s selection of special studies that may be needed to find out whether any cancer in that lymph node is a metastasis (spread) from the original cancer or is a new cancer that started in the lymph node.

Gross description

The next part of the report is called the gross description. In medicine, “gross” means seen without a microscope. This is what the pathologist sees by simply looking at, measuring, and feeling the tissue sample.

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

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

For cytology specimens, 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 under the microscope. The appearance of the cancer cells, how they are arranged together, and the extent to which the cancer invades nearby tissues in the specimen are usually included in the microscopic description. For most cases of common cancers or for tissues that do not contain cancer, a microscopic description may not be included in the report. Results of any other studies done (histochemical stains, flow cytometry, etc.) may be noted in the microscopic description or in a separate section.


The most important part of the pathology report is the final diagnosis. This is the “bottom line” of the testing process, although this section may be at the bottom or the top of the page. The doctor relies on this final diagnosis to help decide on the best treatment options. If the diagnosis is cancer, this section will note the exact type of cancer and will usually include the cancer’s grade.


After the final diagnosis is made, the pathologist may want to add more information for the doctors taking care of the patient. The comment section is often used to clarify a concern or recommend further testing.


Last Medical Review: 01/29/2013
Last Revised: 03/07/2013