This article will help you read and understand your surgical pathology report by explaining the most common sections, words, and tests used in typical reports.
by Jason Wasserman MD PhD FRCPC, updated March 6, 2021
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.
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:
This section of your report should also include:
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.
The doctor who has sent your tissue sample to the laboratory provides the information in the clinical history section. This section should include:
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.
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:
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.
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”.
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.
The comments section may be used by your pathologist for the following reasons:
Not all pathology reports will include a comments section.
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.
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.
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:
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.
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 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:
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.
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.