Most cancer patients will undergo a biopsy or other procedure to remove a sample of tissue for examination by a pathologist in order to diagnose their disease. A pathologist is a physician specializing in the diagnosis of disease based on examination of tissues and fluids removed from the body. Upon examination, the pathologist determines if the tissue sample contains normal, pre-cancerous or cancerous cells and then writes a report with his or her findings. The ensuing report is called a pathology report and is used by the primary doctor in conjunction with other relevant tests or X-rays to make a final diagnosis and determine a treatment strategy. By having a basic understanding of what the pathologist is looking for and the structure of the report, you may better understand your pathology report. Having a copy of your pathology report for your personal records is highly recommended. Your primary doctor should be able to address specific questions you have about your pathology report.
Request a Copy of the Pathology Report
After any biopsy or excision, you should request a copy of the pathology report for your records so that you have documentation of your pathologic diagnosis. In addition, it is helpful to have a copy of the pathology report to refer to when you are researching your disease.
Sections of Your Report
Although pathology reports are written by physicians for physicians, you may be able to decipher some of the medical jargon provided by the report. The structure and information provided in your pathology report may vary, but the following sections are usually included.
Demographics: This section includes the patient’s name and date of procedure. You should check that this information is correct to ensure that you have the correct pathology report.
Specimen: The specimen section describes the origin of the tissue sample(s).
Clinical History: The clinical history section provides a brief description of the patient’s medical history relevant to the tissue sample that the pathologist is examining.
Clinical Diagnosis (Pre-Operative Diagnosis): The clinical diagnosis describes what the doctors are expecting before the pathologic diagnosis.
Procedure: The procedure describes how the tissue sample was removed.
Gross Description (Macroscopic): The gross description includes the pathologist’s observations of the tissue sample using the naked eye. It may include size, weight, color or other distinguishing features of the tissue sample. If there is more than one sample, this section may designate a letter or number system to distinguish each sample.
Microscopic Description: In the microscopic description, the pathologist describes how the cells of the tissue sample appear under a microscope. Specific attributes that the pathologist may look for and describe may include cell structure, tumor margins, vascular invasion, depth of invasion and pathologic stage.
Cell Structure: Using a microscope, the pathologist examines the cell structure and microscopic attributes of the tissue sample and assigns a histologic grade to the tumor. The histologic grade helps the pathologist identify the type of tumor. The grade may be described numerically with the Scarff-Bloom-Richardson system (1-3) or as well-differentiated, moderately-differentiated or poorly differentiated.
• Grade 1 or well-differentiated: Cells appear normal and are not growing rapidly.
• Grade 2 or moderately-differentiated: Cells appear slightly different than normal.
• Grade 3 or poorly differentiated: Cells appear abnormal and tend to grow and spread more aggressively.
Tumor Margins: If cancerous cells are present at the edges of the sample tissue, then the margins are described as “positive” or “involved.” If cancerous cells are not present at the edges of the tissue, then the margins are described as “clear,” “negative” or “not involved.”
Vascular Invasion: Pathologists will also describe whether or not blood vessels are present within the tumor.
Depth of Invasion: The depth of invasion may not be applicable to all tumors, but is used to describe invasion of the tumor.
Pathologic Stage: The clinical stage is determined from the pathologic stage as well as other diagnostic tests such as X-rays. The pathologic stage, designated with a “p,” describes the extent of the tumor as determined from the pathology report only. The staging system most often used by pathologists is based on the American Joint Commission on Cancer’s (AJCC) TMN (tumor, metastasis, node invasion) system.
Special Tests or Markers: Depending on the tissue sample, the pathologist may conduct tests to further determine whether or not specific proteins or genes are present, as well as how fast cells are growing.
Diagnosis (Summary): The final diagnosis is the section where the pathologist concludes the information from the entire pathology report into a concise pathologic diagnosis. It includes the tumor type and cell of origin.
Pathologist Signature: The report is signed by the pathologist responsible for its contents.