A pathology report is the document a pathologist writes after examining tissue or cells removed from your body. It is written mainly for your doctors, so it uses medical language and follows a format that can be hard to read at first. Most reports follow the same set of sections, and each section answers a different question.
This article walks through those sections in the order they usually appear and explains what each one tells you. Each section links to a more detailed article, so you can read from start to finish or jump straight to the part you need.
A pathology report is the official record of what the pathologist found in your sample. It names the diagnosis and describes the features that matter for your care. For cancer, those features often decide the stage and help guide treatment.
Pathology reports cover many kinds of samples, and their length varies. A small biopsy usually has a short report, while an organ removed during cancer surgery usually has a much longer report with a detailed cancer summary. Reports on cells rather than tissue, such as a Pap test, follow their own format, which we explain in our article on cytology reports.
Laboratories format reports differently, and not every report includes every section described here. Many laboratories put the final diagnosis near the top, because it is the part your doctor needs first.
The main sections are:
The top of a pathology report identifies you, your sample, and the people involved in your care. Before reading anything else, check that your name and date of birth are correct.
The dates help explain why a result took as long as it did. Our article on how long pathology results take describes the steps between collection and the final report.
The clinical history section summarizes what your doctor told the pathologist when the sample was sent. It may also be called “clinical information,” “clinical indication,” or “pertinent history.” It is usually short, such as “breast mass, rule out carcinoma” or “abnormal Pap test.”
This information matters because the same finding can mean different things in different situations. A pathologist examining a liver biopsy needs to know, for example, whether the person has a known cancer elsewhere. Clinical history helps the pathologist ask the right questions about the tissue.
Sometimes this section is brief or says “not provided.” That does not mean anything was missed. The pathologist can usually find the information in your medical record or by contacting your doctor.
The specimen section lists exactly what the laboratory received from your procedure. Each sample is described by its location in the body and the procedure used to remove it, such as “left breast, needle core biopsy” or “colon, right hemicolectomy.”
When more than one sample is sent, each one gets its own letter or number. A report might list “A. Breast, left, mastectomy” and “B. Lymph node, left axillary, sentinel.” The report uses the same letters throughout. Hence, the diagnosis for part A always refers to sample A. Extra pieces sent separately are often labeled “additional tissue” or “additional margin.”
The word specimen means the tissue or fluid sent to the laboratory. The procedure type tells you a great deal about what the report can answer. A biopsy samples a small area, while a resection removes a whole tumor or organ.
The final diagnosis is the most important section of a pathology report. It gives the pathologist’s conclusion about each sample, and it is the part your doctor acts on, so read it first.
Each diagnosis starts with the location and the procedure, followed by one or more diagnostic lines. Diagnoses are often written in capital letters and in short phrases rather than full sentences. When more than one sample was sent, each part has its own diagnosis.
A. BREAST, LEFT, 2 O’CLOCK, ULTRASOUND-GUIDED CORE BIOPSY:
– INVASIVE DUCTAL CARCINOMA, NOTTINGHAM GRADE 2.
– DUCTAL CARCINOMA IN SITU, INTERMEDIATE NUCLEAR GRADE.
B. LYMPH NODE, LEFT AXILLA, CORE BIOPSY:
– NEGATIVE FOR MALIGNANCY.
Most diagnostic lines fall into one of three kinds. Knowing which kind you are reading tells you where to look next.
When a sample has several lines, the most important finding is usually listed first. In the example above, the invasive cancer is listed before the in situ (noninvasive) cancer found next to it. Lines further down often describe minor or unrelated findings, which are included to make the report complete.
Words such as benign (not cancer) and malignant (cancer) appear in many diagnoses. Our article on the words used to describe benign and malignant results explains them in more detail.
Find your diagnosis in our Diagnosis Library.
If your final diagnosis names a specific disease, look it up in our Diagnosis Library. Each article explains that diagnosis and walks through the parts of a pathology report written for it so that you can read your own report alongside it.
Pathology reports use specific phrases to show how certain the pathologist is about a diagnosis. Pathologists choose these phrases carefully, and small wording differences can matter.
Phrases such as “diagnostic of” or a plain diagnosis with no qualifier mean the pathologist is confident. “Consistent with” and “compatible with” usually mean the findings fit the diagnosis, but the tissue alone cannot prove it. “Suggestive of,” “suspicious for,” and “cannot be excluded” express more uncertainty. Our article on how pathologists describe certainty explains each phrase.
“Correlate clinically,” or “clinical correlation is recommended,” means the pathologist wants your doctor to compare the findings with information outside the sample. That information might include your symptoms, your imaging, or other test results. It is a normal request and does not mean something is wrong.
“See comment” means the pathologist has written more about this diagnosis further down the report. Always read the comment when a diagnosis points to it, because it often explains why a particular word was chosen.
A synoptic report is a structured summary of the most important features of a cancer. It may be called a “cancer summary” or “tumor summary,” or it may say “per CAP protocol.” It appears as a list of items, each with its own answer on a separate line.
Synoptic reports follow published checklists, most often the College of American Pathologists (CAP) cancer protocols. Each protocol lists the information required for that cancer type. Most hospitals in North America and Europe now use these checklists to report cancers.
Synoptic reports are used whenever a cancer is removed by surgery. They are also common for biopsies of some cancers, notably breast and prostate cancer. The items in a synoptic report usually include:
Some answers may say “not applicable” or “cannot be determined.” These answers are expected, because the checklist must be completed even when an item does not apply. Biomarker results, such as estrogen receptor or HER2, are often reported in a separate biomarker template that may be added later. Our Cancer Report Guides walk through the synoptic report for several common cancers, one line at a time.
The comment section is where the pathologist explains the diagnosis in their own words. It may also be called a “note.” It usually appears just below the diagnosis or at the end of the report.
Pathologists use the comment to explain uncertainty and to describe the tests that support the diagnosis. They also use it to suggest a repeat biopsy or further testing. A comment might say, “In this limited biopsy, the grade may be underestimated.” Another might say, “The case was reviewed by a second pathologist, who agrees.”
The comment is often the most useful part of the report after the diagnosis itself. It is written for your doctor, so ask them to explain any comment you do not understand.
The microscopic description explains what the pathologist saw when examining your tissue under the microscope. It describes the cells and how they are arranged, using technical terms that support the diagnosis. Not every report includes it, and many laboratories leave it out when the diagnosis is straightforward.
This section is often the hardest part of the report to read, and you rarely need it to understand your diagnosis. Our article on how to read the microscopic description explains this section in detail.
The gross description describes what the tissue looked like to the naked eye before it was examined under the microscope. It is written when the sample first arrives, often by a pathologist’s assistant, a specially trained professional who works under the pathologist’s supervision. In this setting, the word “gross” means “visible without a microscope.”
For a small biopsy, the gross description may be one line, such as “three tan cores of tissue, each 1.5 cm in length.” For a large surgical specimen, it may be several paragraphs. It describes the organ size, any tumor seen, and how close the tumor is to the cut edges.
The gross description often ends with a list of which tissue pieces were placed in which cassettes. A line such as “A1 to A4, tumor” means four blocks of tumor tissue were made. This list is mainly for the laboratory, but it shows how the tissue was sampled.
The gross description records what could be seen before the microscope, so it does not always match the final findings. For example, a pathologist’s assistant might count 20 lymph nodes in the fat around a tumor. Under the microscope, the pathologist may confirm only 17, because some of the nodules turn out to be fat or blood vessels. In that case, the microscopic count is correct, and it is the number used in the final diagnosis and the synoptic report. Tumor size works the same way, and the final size is confirmed under the microscope.
Looking up a word in your report?
Our Pathology Dictionary explains more than 600 individual terms used in pathology reports, from “adipose tissue” to “dysplasia.” It is the best place to look up a single word or phrase you do not recognize.
Additional tests are performed on the tissue when the routine slides cannot fully answer the question. The results may appear in the diagnosis, in the comment, or in their own section, and they may also arrive later in an addendum.
Some tests are reported under a separate accession number. A line such as “see corresponding flow cytometric analysis” points to another report that should be read alongside this one. If your report says that results are still pending, our article on pending or additional testing explains what to expect.
Biomarker and genetic test results
Our Biomarkers and Genetic Tests section explains results such as estrogen receptor, HER2, and next-generation sequencing. It explains what each result means and how it guides treatment.
An intraoperative consultation is a quick diagnosis made while you are still in the operating room. The surgeon sends tissue to the pathologist, who answers within minutes. That answer can help the surgeon decide how to proceed, and the most common method is a frozen section.
The report records the answer given during surgery, often under a heading such as “intraoperative diagnosis” or “frozen section diagnosis.” The final diagnosis is made later, after the tissue has been fully processed, and it can occasionally differ from the intraoperative answer. In one study of more than 3,600 frozen sections, about 3% differed from the final diagnosis. Another 3% were deferred to the final report, which is always the diagnosis that counts.
We will soon publish a full article on intraoperative consultations that explains when they are used and how to read the results in your report.
A pathology report can be updated after it is first issued. The type of update tells you how much has changed.
Addenda are common and are a normal part of the process, while amendments are less common. When a diagnosis is amended, the pathologist usually contacts your doctor directly.
Every final pathology report is signed by the pathologist responsible for the diagnosis. The signature is usually electronic and appears at the end of the report with the date and time it was signed. A report is not final until it has been signed.
In teaching hospitals, the report may also list a resident, a doctor in training who worked on the case under the pathologist’s supervision. The signing pathologist is still responsible for every word in the report. Some reports also note that a second pathologist reviewed the case, which is a routine quality check for many new cancer diagnoses.
After you read your pathology report, the next step is to talk with the doctor who ordered the test. They know your full history and can explain what the diagnosis means for your care and what happens next. Writing down your questions before the appointment can help you get the most from it.
Our article on what happens after your pathology report describes the usual next steps. If your report is missing from your patient portal, our article on getting your results explains who to contact. For help with the terms in your report, you can look them up in our Pathology Dictionary or ask Osler, our pathology assistant.
Some reports you receive may describe imaging tests, such as a CT scan or MRI, rather than tissue. Our article on pathology reports and imaging reports explains how to tell them apart.