Your pathology report
This article was last reviewed and updated on September 9, 2018.
by Jason Wasserman, MD PhD FRCPC
Your pathology report is a medical document prepared for you by a pathologist.
If you received a pathology report, that means that your tissue sample was sent to the laboratory and examined by a pathologist. The results of that examination are described in your report. Your report has also been sent to the other members of your medical team.
Your pathology report includes information about the type of tissue sent for examination, the appearance of the tissue when it was examined under the microscope, and the results of any additional tests that were performed on your tissue sample. The most important part of your report is the diagnosis.
Pathology reports are organized into sections to make them easier to read. Your report may not include all the sections on the list below and the names of the sections will vary between hospitals.
Patient identification - This section identifies you as the patient described in the report. Most hospitals use three unique personal identifiers such as your name, date of birth, and hospital card number.
Specimen source - This section lists each sample of tissue that was sent to pathology for examination and where each sample came from on your body.
Clinical history - This section includes information about you and any additional information about why your tissue sample was sent to pathology for examination.
Diagnosis - This section provides a summary or explanation for the observations made by your pathologist when they examined your tissue.
Comments - Your pathologist may use this section to provide additional information about your case or to describe what was observed when your tissue was examined,
Microscopic description - Your pathologist may use this section to describe what they saw when your tissue was examined through the microscope including the results of any additional tests that were performed.
Gross description - This section provides a summary of the number of tissue samples received by pathology, the size, shape, and color of each sample, any abnormal looking tissue seen, and the number of slides made from each sample of tissue.
Some pathology reports may include other special sections such as:
Intraoperative consultation/frozen section - this section includes information about any tissue that was sent by your doctor to a pathologist for examination while you were still in the operating room.
Synoptic data - this section is a summary of the most important pathological information about any cancer (malignant tumour) that was removed from your body.
Addendum - this section is used to update your report with any additional information that only became available after your report was completed and sent to your medical team.
Where should I start?
If you are reading your pathology report for the first time, the most important information will be found in the diagnosis section.