Diagnosis

The diagnosis is the most important section of your pathology report. The diagnosis provides a summary or an explanation for the changes observed in your tissue sample. ​In medical terms, a diagnosis is the process of determining which disease or condition best explains your symptoms.

Whenever possible, your pathologist attempts to provide a single diagnosis that is recognized and understood by the other doctors in your medical team.

Examples of diagnoses include:

How to read the diagnosis section

The diagnosis section is usually organized by specimen number or name with each specimen receiving its own diagnostic explanation. In most hospitals, the diagnostic line also includes the type of specimen that was provided or the procedure that was performed. For example, if the entire thyroid gland was removed from a patient, the procedure is called a ‘thyroidectomy’ and this information may be included in the diagnostic line.

For example:

​”1. Thyroid gland, total thyroidectomy: Papillary thyroid carcinoma

The diagnosis in this case is ‘papillary thyroid carcinoma’ and the report will go on to provide additional important information about that diagnosis.

In some situations, however, if all the specimens show the same changes your pathologist may group all the specimens together and provide just one diagnosis. For example, if four separate brain biopsies were performed and submitted for examination and none of them demonstrated any evidence of cancer, the diagnosis may include:

​“1-4. Brain, biopsies – Reactive changes, negative for malignancy

Partial or incomplete diagnoses

In some cases, the changes present in the tissue submitted for examination do not completely meet the criteria for a specific diagnosis and your pathologist may choose to provide a more general diagnosis with additional information provided in the comments or microscopic description sections. For example, if a biopsy from a mass in a patient’s thigh clearly shows evidence of cancer composed of spindle-shaped cells, but there is not enough tissue to determine the type of cancer, the diagnosis line may read:

​“Right thigh, biopsy: Malignant spindle cell neoplasm, complete resection recommended (see comments)

​In this case, the pathologist has used the diagnosis section to inform your other doctors that a malignant tumour (a cancer) has been identified and that the tumour should be fully removed. The pathologist has also referred the doctor to the comments section where the case will be discussed in greater detail.
 

Descriptive diagnoses

In other situations, the changes seen in your tissue sample do fit into any specific diagnosis but are better summarized by simply describing the features observed under the microscope. For example, if a doctor performs a biopsy on a raised, red area on the inside of a patient’s cheek but the tissue only shows inflammation, the diagnosis may read:

“Left buccal mucosa, biopsy: Hyperplastic squamous mucosa with chronic inflammation, negative for malignancy

​While this type of diagnosis may seem foreign to anyone unfamiliar with the pathology or anatomy of the inside of the mouth, it is intended to convey the important pathological features of the case while highlighting the fact that there is no evidence of a malignant tumour (a cancer) in the tissue provided for examination.

Other important information included in the diagnosis section

The diagnosis section is designed to summarize and clearly communicate the most important information about your case to you – the patient – and to the other members of your health care team. If your report includes a diagnosis of cancer, the diagnosis section may include additional information that will help the other doctors on your team plan your treatment. For example, a patient diagnosed with squamous cell carcinoma of the cheek may include the following:

​1. Skin, right cheek, excision:
Squamous cell carcinoma, moderately differentiated.
Maximum tumour dimension is 3.0 cm.
Maximum depth of tumour invasion is 0.7 cm.
Positive for perineural invasion.
Negative for lymphovascular invasion.
All surgical margins are free of tumour; closest is 0.6 cm.
Pathologic stage: pT2NxMx.

If you have been diagnosed with cancer, this additional information can also be found in the synoptic report/data section of your report.

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