By Jason Wasserman MD PhD FRCPC
June 28, 2024
A pathology report is a medical document that describes the examination of tissues, cells, or bodily fluids removed from the body during a medical procedure such as a biopsy, Pap test, or surgery. It summarises any tests performed and, whenever possible, a diagnosis (in medicine, diagnosis means identifying the nature of a disease or condition and distinguishing it from similar conditions). The report is created for you by a pathologist or a medical doctor specialising in diagnosing disease by examining tissues, cells, or bodily fluids.
What information is found in a pathology report?
All pathology reports are different, and the type and amount of information in your report will depend on the procedure performed. It is important to note that the words used in a pathology report and the order of the sections will vary greatly from hospital to hospital.
All pathology reports should include the following information:
Patient identification
Your personal information should be found near the top of the report. This information includes your full name, date of birth, and gender. Some reports will also include your home address.
Hospital or laboratory number
This is a unique number assigned to you by the hospital or laboratory. Some reports may use a government-issued number. This number is used to keep all your information together.
Referring physician
The name of the doctor who ordered the test should be listed on your report. This may be your family doctor, surgeon, or oncologist. In some situations, it is the radiologist’s name if the procedure was performed using ultrasound, CT, or MRI guidance.
Clinical history
This is a short description of why the procedure is being performed. This is also where your doctor may ask the pathologist to look for specific changes or conditions. For example, if you have been experiencing abdominal pain and bloating after eating for several months, your doctor may decide to perform biopsies of your stomach and small intestine to look for changes that could be causing these symptoms. The clinical history provided with the biopsies may say, “Abdominal pain and bloating x months. Please assess for gastritis or H. pylori”. In this example, the doctor told the pathologist about the symptoms that led to the procedure and asked the pathologist to look for a condition called gastritis (inflammation of the stomach) and a bacteria called Helicobacter pylori, which commonly infects the stomach.
Specimen source
In pathology, the word specimen describes all types of tissues, cells, and fluids removed from the body for examination by a pathologist. The specimen source (or site) should describe the location of the body where the tissue was taken. This section may also say the type of procedure that was performed. For example, it may say fine needle aspiration biopsy (FNAB), excision, or resection. When multiple tissue samples are taken, each should be listed separately.
Diagnosis
This is the most important part of your pathology report. The diagnosis section provides a summary or explanation for the changes seen in the tissue sample. The word diagnosis is defined as the process of determining the nature of a disease and distinguishing it from other conditions. However, the diagnosis section will not always describe a disease or provide the name of a specific condition. In some situations, the diagnosis section reports that the tissue sample is normal or that no changes are seen in the sample that explain the symptoms. In other situations, the diagnosis section reports changes related to prior treatment, such as chemotherapy, radiation therapy, or other medications. Occasionally, changes will be seen in the tissue sample that is abnormal but not specific to a single disease or condition. In this situation, your pathologist may use the diagnosis section to describe the changes seen without giving a final diagnosis. If more than one specimen was submitted for examination, the diagnosis section may list all specimens examined and provide a diagnosis for each.
Visit our diagnosis library to learn more about your diagnosis.
Other information that may be found in your pathology report
Gross description
In pathology, ‘gross’ refers to how the tissue looks without a microscope or with the naked eye. When the laboratory receives a tissue sample, it undergoes a gross examination before some (or all) of the tissue is sent to a pathologist for examination under the microscope. The gross examination of tissue is a very important part of the diagnostic process, and in some cases, a pathologist can make a diagnosis simply by looking at the tissue or reading the gross description.
In many hospitals, a pathologist’s assistant (PA), a medical professional trained to examine human tissue, performs the gross examination of a tissue sample. The PA documents their findings in the gross description section of the pathology report.
The gross description should include information such as the type of tissue received, the size of the tissue (usually measured in three dimensions), and the presence of any markers (usually sutures or ink) left by the surgeon to help orient the tissue. Any abnormal tissue, such as a tumour, should also be clearly described. This description may include the abnormal tissue’s size, colour, and shape and its relationship to the surrounding normal tissue. The distance between the abnormal tissue and the cut edge of the tissue or margin should also be measured.
At the end of the gross examination, tissue is sent for microscopic examination. “In toto” means that all the tissue received was submitted for microscopic examination. Representative sections or selected tissue areas are sampled and sent for microscopic examination for larger specimens. All sampled tissues are placed in labelled blocks or cassettes, which help your pathologist identify them later. Each block becomes a slide which the pathologist examines under the microscope. All tissue blocks should be listed at the end of your pathology report.
Intraoperative consultation (also known as a frozen section or quick section)
An intraoperative consultation is a pathologist’s rapid examination of tissue, typically while a medical procedure such as surgery occurs. The purpose of an intraoperative consultation is to provide your doctor with information that will help with decision-making during the procedure. Another name for an intraoperative consultation is the frozen section because the examination often involves freezing tissue, which is then examined under the microscope.
Microscopic examination
The microscopic description summarises what your pathologist saw when your tissue was examined under the microscope. This section aims to explain the changes in your tissue to other pathologists who may read your report in the future. This section commonly includes words that are unfamiliar to anyone who is not a pathologist (for help with these words, we suggest checking out our pathology dictionary for patients). This section may also include the results of tests such as special stains and immunohistochemistry. Not all pathology reports will include a microscopic description.
Comments
This section may provide a more detailed explanation of the changes seen in the tissue sample or explain what features led to the diagnosis. For challenging cases, the comments section may also be used to explain why a diagnosis could not be reached or why multiple diseases or conditions need to be considered as possibilities. Your pathologist may also use this section to make recommendations, such as performing another biopsy or taking a larger tissue sample. If additional tests have been ordered, they will also be described here.
Synoptic report
A synoptic report is a special section that will only be included in your pathology report if you were diagnosed with cancer. The synoptic report summarises the information your doctor will need to plan your treatment. A synoptic report section is usually only included in your pathology report after most or all of the tumour has been removed from your body. Therefore, a synoptic report section is usually not included in reports for small procedures such as biopsies.
The synoptic report section typically includes the following types of information:
- The name and type of cancer found in the tissue sample.
- The location of the tumour.
- The size of the tumour.
- The tumour grade.
- The assessment of margins.
- The examination of lymph nodes for metastatic disease.
- The pathological stage of the disease (pTNM).
- The results of any immunohistochemical or molecular studies that may have been performed.
Addendum
The addendum section includes any additional information added to your report after it was completed and sent by your pathologist to you and the other doctors in your health care team. This section is often used to add the results of additional tests that were performed, such as immunohistochemistry, fluorescence in situ hybridization (FISH), or next-generation sequencing (NGS). The results of an internal or external consultation or review of your case may also be included in this section. An addendum should only be used to describe additional information which supports the original diagnosis. New information that results in a change of diagnosis should be reported as something called an amendment.
What is the most important part of my pathology report?
The diagnosis section is the most important part of your pathology report because it explains or summarises the changes seen in your tissue sample. The diagnosis section will say if a disease or condition was found or if the tissue sample was normal. Talk with your doctor about the information in your report’s diagnosis section. To help understand your diagnosis, check out our diagnosis library.
What should I do if I find a mistake in my pathology report?
If you find a mistake in your pathology report, for example, if your name is spelt wrong or if the clinical history provided is incorrect, you should contact your doctor to have the report corrected. Alternatively, you can contact the pathologist who issued the report.
Other helpful resources
About this article
Doctors wrote this article to help you read and understand your pathology report. It explains the typical sections found in most types of pathology reports and the kind of information found in each section. Contact us if you have questions about this article or your pathology report.
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