The pathology report of surgical specimens is often quite long and complex. It’s often divided into a number of subheadings.
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 done, and the unique number of the specimen (which is assigned in the lab).
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 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 tests that may be needed to find out whether any cancer in that lymph node is a metastasis (spread) from the original cancer or a new cancer that started in the lymph node.
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, such as 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 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.
This is a description of what the pathologists see when they look in 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. 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.