How to read your surgical pathology report

Your pathology report

Your pathology report is a medical document prepared for you by your pathologist, a specialist medical doctor who works closely with the other doctors in your health care team. If you received a pathology report it means that a tissue sample from your body was sent to the laboratory for examination by a pathologist.

The examination of tissue plays a very important role in your medical care. The information found in your pathology report will help you and your doctor determine the direction of your care. Your pathologist will examine your tissue by eye and under a microscope. They will then provide you with a report describing what they see. Tissue sent for examination can range in size from a very small biopsy to an entire organ.

In pathology, every piece of tissue, regardless of its size, is called a specimen. All specimens are given a unique number so that it can be followed as it moves through the laboratory. Your name and other information about you are also attached to the specimen.

Patient identification

At the very top of your report, you will find information that identifies you as the patient whose tissue was sent to the laboratory for examination. Most hospitals now require at least three unique pieces of information about you in order to prevent your report from being sent to another patient by mistake.

The three pieces of information usually include your:

• Full name.
• Date of birth.
• Hospital number.

This section of your report should also include:

• The date your tissue was received in the laboratory.
• The name of your doctor who sent the tissue sample to the laboratory.
• The names of all other doctors who will receive a copy of the report.

You should contact the laboratory right away if any of the information in this section is incorrect or missing. Any incorrect information in this section may cause a delay in your care.

Clinical history

The doctor who has sent your tissue sample to the laboratory provides the information in the clinical history section. This section should include:

• Any symptoms you are experiencing.
• Your previous medical conditions.
• Why the tissue sample is being sent for examination.
• Any questions your doctor may have for the pathologist

A complete and accurate clinical history is very important because it helps your pathologist understand why the tissue sample was sent for examination. Let your doctor know if you think the information in the clinical history section of your report is incorrect or if important information is missing.

Specimen source  or specimen site

This section lists all the tissue samples that were sent to the laboratory for examination and gives each sample a number. In pathology, tissue samples are called specimens. Each specimen is given a name by the doctor who sent the tissue sample to the laboratory. The specimen name should include the location and side (right or left) of the body where the tissue sample was taken. The name may also include the name of the procedure used to remove the tissue sample.

Types of procedures include:

• Fine needle aspiration – A fine needle aspiration uses a very thin needle to remove a small tissue sample. The sample can be cells or fluid. These types of samples are called cytology specimens.
• Biopsy – A biopsy is a minor surgical procedure that removes a small tissue sample. The sample can be removed with a needle or a surgical scalpel. A biopsy may only remove some of the abnormal tissue. In necessary, the rest of the abnormal tissue can be removed later in a larger surgical procedure such as excision or resection.
• Excision – An excision is a surgical procedure that removes a small amount of tissue. The amount of tissue removed is larger than a biopsy. An excision usually removes all of the abnormal tissue with a very small amount of normal tissue. The small amount of normal tissue is called a margin.
• Resection – A resection is a larger surgical procedure that usually removes all of the abnormal tissue with some normal tissue. The normal tissue is called a margin. An entire organ may be removed in a resection.

Diagnosis

The diagnosis is the most important section of your pathology report. This section provides a summary or explanation for the changes seen in your tissue. Often, the explanation includes a name for the disease or condition that best explains your symptoms. If available, your pathologist may also review your other medical information including blood test results or imaging studies (x-rays, CT scans, MRI, etc .) before making a final diagnosis.

If more than one tissue sample was sent to the laboratory, the diagnosis section will usually list all the samples (each with a unique number). A diagnosis or description is usually provided for each sample.

Normal

Some tissue samples do not show any abnormal changes and may be diagnosed as normal. If your doctor indicated a specific disease of concern (such as cancer) and the tissue looks normal, the diagnosis will usually say the disease in question was not seen. “Negative” is a word pathologists use to say that something was not seen. For example, if no cancer was seen in the tissue sample, the diagnosis section may say “negative for malignancy”.

The descriptive diagnosis

In some situations, your pathologist will provide a descriptive diagnosis. This means that they describe what they see in the tissue sample without giving the name for a specific disease. This often includes words that are unfamiliar to people who are not medical doctors. To learn more about these words, visit our pathology dictionary.

The purpose of the diagnosis section is to summarize and clearly communicate the most important information about your case to you and the other members of your health care team. If your report includes a diagnosis of cancer, this section may include additional information that will help the other doctors on your team plan your treatment.

​Comments

The comments section may be used by your pathologist for the following reasons:

• To send additional important information about your diagnosis to you and the other members of your health care team.
  For example, your pathologist may use this section to explain your diagnosis and to provide reasons for reaching that diagnosis.
• To explain why a diagnosis could not be reached with the tissue sent for examination.
  For example, your pathologist may say that the tissue sample was too small or that the quality of the tissue made it very difficult to examine. In these situations, your pathologist may suggest that a new tissue sample should be sent to the laboratory for examination.
• Some pathologists may use this section to provide a microscopic description (see the section on Microscopic descriptions below).

Not all pathology reports will include a comments section.

Microscopic description

The microscopic description is a summary of what your pathologist saw when your tissue was examined under the microscope. The purpose of this section is to explain the changes seen in your tissue to other pathologists who may read your report in the future. This section will often include words that are unfamiliar to anyone who is not a pathologist.

This section may also include the results of tests such as special stains and immunohistochemistry. The results of these tests are often described as positive or negative.

Intraoperative consultation / Frozen section / Quick section

An intraoperative consultation is a special type of procedure that involves a surgeon sending a tissue sample to be examined by a pathologist while you are still in the operating room of the hospital. This may also be called a frozen section or quick section.

Intraoperative consultations can provide your surgeon with information to help them plan your medical care during or shortly after the surgery.

Unlike most tissue sent to the laboratory, tissue from an intraoperative consultation is quickly frozen, cut, stained, and examined under the microscope immediately. This allows your pathologist to provide the surgeon with information in ‘real-time’.

This tissue is not preserved, meaning many advanced tests, such as immunohistochemistry, cannot be performed at the time of the procedure. For this reason, an intraoperative consultation provides an initial diagnosis. The diagnosis may change after the tissue is sent to the laboratory and processed using more standard methods.

You will only find this section of your pathology report if your surgeon sent a sample of tissue to a pathologist during your surgery.

Synoptic report / Synoptic data

The synoptic report or synoptic data section will only be included in your pathology report if you were diagnosed with cancer. The purpose of this section is to summarize the most important information about your cancer diagnosis.

For example, the synoptic report will include:

• The type of cancer found.
• The location in the body where the tumour started.
• The size of the tumour.
• Information about how far the tumour has spread.
• The pathologic stage.
• Whether any of the lymph nodes sent for examination contained cancer cells.
• The tumour grade.
• The presence of cancer cells at the margin (edges) of the tissue removed by the surgeon.

This section is presented using checklists to organize the information listed above. Created by an international group of cancer doctors, these checklists are used by pathologists around the world.

In most cases, a synoptic report will be included in your pathology report only after most or all of the tumour has been removed from your body. A synoptic report is usually not included when a very small tissue sample (biopsy) is sent for examination.

Gross description

All pathology reports include a gross description. In pathology ‘gross’ refers to the way a tissue sample looks without using a microscope. The gross description is very important in the examination process. In some cases, your pathologist can make a diagnosis by looking at the tissue or reading the gross description.

The gross description will include:

• The type of tissue being examined.
• The size of the tissue.
• The presence of any markers (usually sutures or ink) left by the surgeon to help position the tissue.

The most important information in this section will include the identification of any abnormal tissue such as a tumour. The description may further include details of the tumour such as:

• Size.
• Colour.
• Shape.
• Relationship to the surrounding normal tissue.
• The number of abnormal areas.
• ‘Feel’ of the abnormal tissue.

In most Canadian and American hospitals, the gross description is prepared by a pathologist’s assistant, a specially trained laboratory professional who works with your pathologist.

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 or other specialized tests to your report.

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.

Ask your doctor any questions you have about your pathology report or treatment.

by Jason Wasserman MD PhD FRCPC (updated January 10, 2022)