Understanding your pathology report

By Jason Wasserman MD PhD FRCPC
December 10, 2024

A pathology report is a medical document that describes the examination of tissues, cells, or fluids taken during a medical procedure such as a biopsy, Pap test, or surgery. It includes details about the tests performed and often provides a diagnosis—a medical explanation for what was found. A pathologist, a doctor specialising in diagnosing diseases by studying these samples, writes this report.

What information is in a pathology report?

The information in a pathology report depends on the procedure and the sample. The layout and wording can vary between hospitals, but most reports include these sections:

• Patient identification: Your name, date of birth, gender, and sometimes your address appear at the top.
• Hospital or lab number: A unique number assigned to you to keep your records organized.
• Referring physician: The name of the doctor who ordered the test, such as your family doctor, surgeon, or oncologist.
• Clinical history: A brief note about why the test was done, such as specific symptoms or conditions the doctor asked the pathologist to look for.
• Specimen source: Describes where the sample was taken from and how it was collected, such as a biopsy or surgery.
• Diagnosis: This is the most important section, explaining the findings and whether a disease, condition, or abnormality was identified.

Additional sections in a pathology report

• Gross description: Describes the appearance of the sample without a microscope, including size, shape, colour, and any visible abnormalities.
• Microscopic examination: Explains what was seen under the microscope, including details about any abnormal cells or tissues.
• Comments: Provides extra details or clarifications, such as how and why a diagnosis was made or why further tests may be needed.
• Synoptic report: If you were diagnosed with cancer, this section summarizes key details, like the size and type of tumour, tumour grade, and whether it has spread.
• Addendum: Lists additional information added after the report was finalized, such as results from further tests.

What is the most important part of the pathology report?

The diagnosis section is the most important because it summarizes the findings and provides an explanation for your symptoms or condition. It may say the sample is normal, show changes related to treatment, or confirm a specific disease. If you have questions about this section, talk to your doctor. For more information about your diagnosis, visit our diagnosis library.

What should I do if I find a mistake in my pathology report?

If you notice a mistake, such as a misspelling of your name or an incorrect clinical history, let your doctor or the pathologist know. They can correct the report to ensure its accuracy.

Why is the pathology report important?

Your pathology report provides detailed information about your condition, helping you and your healthcare team decide on your diagnosis, treatment, and follow-up care. Understanding and discussing your report with your doctor is an important step in your care journey.

What is the role of the pathologist?

A pathologist is a specialized doctor who diagnoses diseases by studying tissue, cells, and bodily fluids under a microscope. They are a critical part of your healthcare team, working behind the scenes to help identify conditions such as cancer, infections, and inflammatory diseases. The pathologist writes the pathology report, which provides your doctor with the information needed to guide your care. They may also collaborate with other doctors, such as oncologists or surgeons, to recommend treatment options based on your diagnosis.

How is the tissue sample processed?

After a tissue sample is taken during a biopsy or surgery, it is sent to the pathology lab for processing. Here are the main steps:

1. Fixation: The sample is preserved in a special solution (usually formalin) to prevent decay.
2. Embedding: The tissue is embedded in paraffin wax to make it easier to cut into thin slices.
3. Sectioning: Thin slices of the tissue are cut and placed on glass slides.
4. Staining: The slides are stained with dyes (such as hematoxylin and eosin, or H&E) to highlight different tissue parts.
5. Microscopic examination: The pathologist examines the slides under a microscope to look for abnormalities.

Each step ensures the tissue is preserved and prepared for accurate examination.

What do special tests mean?

Sometimes, additional tests are performed on the tissue to provide more information. These include:

• Immunohistochemistry: Uses antibodies to detect specific proteins in the cells. It can help confirm the type of tumour or identify specific markers for treatment.
• Molecular testing: Tests such as next-generation sequencing look for genetic mutations or alterations in the tumour cells that may guide targeted therapy.

These tests are often critical in determining the best treatment plan for your condition.

How should I prepare for a discussion about my report?

Here are some tips to help you prepare:

1. Review your report: Read your pathology report and write down any questions you have.
2. Bring support: Consider bringing a family member or friend to your appointment. They can help you take notes or ask questions.
3. Ask for clarification: If medical terms are confusing, ask your doctor to explain them in more straightforward language.
4. Focus on key information: Pay attention to the diagnosis section and any further tests or treatment recommendations.

Taking an active role in understanding your report can help you feel more confident about your care.

Can I get a second opinion on my pathology report?

Yes, you can request a second opinion on your pathology report. A second opinion can be helpful if:

• The diagnosis is unclear or rare.
• The findings may impact your treatment plan significantly.
• You want reassurance about your diagnosis and treatment.

To request a second opinion, ask your doctor to send your pathology slides and report to another pathologist or hospital. Some patients also seek second opinions at specialized cancer centres. This process can provide peace of mind and ensure your diagnosis and treatment plan are as accurate as possible.

How to use MyPathologyReport.ca to learn more about your pathology report

MyPathologyReport.ca is a valuable resource designed to help you understand your pathology report. It offers clear, patient-friendly explanations of medical terms and common diagnoses found in pathology reports. Two key tools on the site can be especially helpful: the Diagnosis Library and the Pathology Dictionary.

• Diagnosis Library: This section provides detailed explanations of many common diagnoses you might find in your pathology report. Each article breaks down what the diagnosis means, how it’s made, and what it might mean for your care.
• Pathology Dictionary: This tool explains medical terms and phrases often used in pathology reports. You can use it to look up unfamiliar words or abbreviations, such as “margin” or “immunohistochemistry.” The dictionary offers simple definitions and examples to make your report easier to understand.

By using these resources, you can better understand your report and feel more confident discussing your diagnosis and treatment plan with your doctor. If you have additional questions, your healthcare team is always there to provide further guidance.