Understanding Your Pathology Report

The general identifying information includes:

• Your name
• Medical record number issued by the hospital
• Date when the biopsy or surgery was done
• Unique number of the sample, which is assigned in the lab
• Contact information for the pathologist, ordering provider, and the lab where the sample was tested

The next part of the report often contains information that was provided by the doctor who removed the tissue sample and/or the ordering provider. This may include:

• Your medical history
• Reason for the biopsy/surgery
• Any special requests that were made to the pathologist.

For example, if a lymph node sample was removed from a person with cancer in another organ, the doctor will note the original cancer type. The pathologist will order tests to learn if cancer in that lymph node is cancer that has spread or if it’s a new cancer that started in the lymph node.

The most important part of the pathology report is the final diagnosis. 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 and stage
• Lymph node status
• Margin status

Your cancer care team relies on this final diagnosis to help decide on the next steps of your care plan.

Sometimes, a biopsy result might be inconclusive, which means that the pathologist can’t provide a diagnosis based on the tests that were done. In such cases, the biopsy might need to be repeated, or other tests might be needed. If your biopsy result is inconclusive, talk to your cancer care team about what the next steps should be.

The pathologist provides a gross description by simply looking at, measuring, and feeling the tissue sample.

For a small biopsy, this description is often a few sentences noting the:

• Size
• Color
• Consistency
• Number of tissue-containing cassettes submitted for processing.

Larger biopsy or tissue samples will have much longer descriptions. For example, a mastectomy for breast cancer would include:

• Size of the entire sample
• Size of the tumor
• How many lymph nodes were found in the underarm area
• Appearance of the noncancerous tissue
• Summary of exactly where tissue was taken from.

When needed, the weight and number of samples are also included.

In some cases, multiple biopsies or tissue samples may be submitted and will be described individually, including how they were labeled and placed in cassettes.

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

This is a description of what the pathologist sees when looking at the processed sample under a microscope. It usually includes:

• Grade, or the appearance of the cancer cells
• Cell features, or how cancer cells are arranged or behave
• Invasion, or the extent to which the cancer invades nearby tissues
• Tumor margins, or if cancer cells are present at the edges of the sample
• Lymph node status, or if the lymph nodes were positive for cancer

Results of any other studies done, such as histochemical stains, flow cytometry, or biomarkers, may be noted in the microscopic description or in a separate section.

Some pathology reports may not have this section.

Pathology reports for cancers should 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.

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.

This section may also include:

• Images
• References
• Other molecular studies

Sometimes, a pathologist is certain that a tissue sample is cancer based on the microscopic exam, but further testing 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 stating the cancer diagnosis. Then, once further testing is complete, an addendum section is added to the report, which includes the results of these tests.