What is a pathology report?
A pathology report is a document that contains the diagnosis determined by examining cells and tissues under a microscope. The report may also contain information about the size, shape, and appearance of a specimen as it looks to the naked eye. This information is known as the gross description.
A pathologist is a doctor who does this examination and writes the pathology report. Pathology reports play an important role in cancer diagnosis and staging (describing the extent of cancer within the body, especially whether it has spread), which helps determine treatment options.
How is tissue obtained for examination by the pathologist?
In most cases, a doctor needs to do a biopsy or surgery to remove cells or tissues for examination under a microscope.
Some common ways a biopsy can be done are as follows:
- A needle is used to withdraw tissue or fluid.
- An endoscope (a thin, lighted tube) is used to look at areas inside the body and remove cells or tissues.
- Surgery is used to remove part of the tumor or the entire tumor. If the entire tumor is removed, typically some normal tissue around the tumor is also removed.
Tissue removed during a biopsy is sent to a pathology laboratory, where it is sliced into thin sections for viewing under a microscope. This is known as histologic (tissue) examination and is usually the best way to tell if cancer is present. The pathologist may also examine cytologic (cell) material. Cytologic material is present in urine, cerebrospinal fluid (the fluid around the brain and spinal cord), sputum (mucus from the lungs), peritoneal (abdominal cavity) fluid, pleural (chest cavity) fluid, cervical/vaginal smears, and in fluid removed during a biopsy.
What information does a pathology report usually include?
The pathology report may include the following information:
- Patient information: Name, birth date, biopsy date
- Gross description: Color, weight, and size of tissue as seen by the naked eye
- Microscopic description: How the sample looks under the microscope and how it compares with normal cells
- Diagnosis: Type of tumor/cancer and grade (how abnormal the cells look under the microscope and how quickly the tumor is likely to grow and spread)
- Tumor size: Measured in centimeters
- Tumor margins: There are three possible findings when the biopsy sample is the entire tumor:
- Positive margins mean that cancer cells are found at the edge of the material removed
- Negative, not involved, clear, or free margins mean that no cancer cells are found at the outer edge
- Close margins are neither negative nor positive
- Other information: Usually notes about samples that have been sent for other tests or a second opinion
- Pathologist’s signature and name and address of the laboratory