A pathology report describes the findings in a tissue sample (biopsy or excision), which are always submitted to a pathologist after being removed from a patient. The tissue is sliced very thin and stained on a glass slide for a pathologist to examine under a microscope to determine if there is disease present, and if so, what kind.
“Pathology is the hub around which oncology rotates; it’s the center of patient management,” says Stuart J. Schnitt, MD, a pathologist at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC).
Oftentimes, the terminology of these reports can be difficult for patients to understand. In particular, be cautious about complicated abbreviations you do not understand, as their meaning may change with context. Google searches also often produce erroneous or misleading interpretations.
Your doctor will explain the results of your pathology report to you and can answer any questions you have.
What are the different components of a pathology report?
Patient and specimen identifiers
This information includes the patient’s name, birth date, and other personal information. It also details clinical history, the type of biopsy or procedure, and the type of tissue being analyzed.
Procedures often generate multiple specimens that are submitted together to the pathologist in separate containers. In these cases, a letter or number is assigned to identify these different samples submitted. The individual container labels are carefully recorded, including any specific designation (such as “cervical biopsy at 3 o’clock position”) that allows the pathologist to know where it is from.
“Gross” refers to what is apparent to the naked eye. This section is a detailed description of what the tissue looks like, including the size and appearance of the sample on the outside and cut surface. Abbreviations are especially common in this section; examples include “R” for right and “ESS” for entire specimen submitted. An index, or key, of samples prepared by the pathologist for microscopy is also included.
Procedures that generate multiple specimens are labeled accordingly so the clinician knows where each sample came from. “For example, with a colon biopsy, if only one specimen of several has cancer, the clinician needs to be able to relate that to an anatomical location in the patient,” explains DF/BWCC pathologist George L. Mutter, MD.
In the case of tumors, or localized lesions excised with adjacent tissues attached, visual inspection and measurement to nearest structures — like margins — may be included. These measurements as recorded in the Gross Description are only preliminary, as the pathologist does not yet have the definitive microscopic preparations (slides) required to verify where the actual tumor cells are in the specimen.
The final assessment of tumor extent and margins appears in the Diagnosis section, and may be a bit different from what was suspected grossly.
This is the “take-home message”: the most important section of a pathology report, according to Schnitt. It can be found at the beginning or the end of the report and serves as a concise summary of information from the entire pathology report. It is based on the gross description, microscopic examination, and sometimes special biomarker studies.
It is important to note that each specimen part has its own separate diagnosis. “Read the diagnosis for all parts,” advises Schnitt. “Patients may see in the report that a margin is positive but may not realize that an additional specimen taken from the same margin is negative — which means that the final margin is negative, not positive.”
Reports that include cancer in the specimen will classify the specific tumor type and any additional information, such as tumor distribution (stage), biomarker status, and molecular findings that may be useful in management. Some tumors will be assigned a grade — often numbered from 1 to 3, corresponding to well, moderately, or poorly differentiated — that describes how abnormal the cells look under the microscope. A higher number means the tumor cells are more abnormal.
Results of specialized marker studies are not typically ready at the time the pathology report is initially issued and are often reported separately.
The pathologist will note if the cancer has spread to nearby lymph nodes or organs if those are submitted for examination. If a lymph node or surgical margin contains cancer, it is labeled as “positive,” and if it does not, it is “negative.”
A recent addition to some pathology reports is “synoptic reporting.” This is an additional, standardized summary of cancer type and stage for surgical resection specimens. The content and format structure, including coded abbreviations, is customized to each tumor type by agreement amongst pathologists worldwide.
Mutter advises readers to “be prepared: these are medical records that are complicated, factual, the language and vocabulary may be very unfamiliar.”
Talk to your doctor if you have any questions about your pathology report. “Don’t take your report to the internet: your doctor is the best person to help you interpret your report,” Mutter says.