Pathology Report 101
When tissue is removed from the body during a biopsy or surgery, it is studied closely. The results of the examination by a medical doctor known as a Pathologist are summarized in a document known as a Pathology Report. In fact, there may be several reports about the same tissue because some tests take longer than others.
As a general matter, a pathology report will be sent to the doctor who did the biopsy. That doctor will review the pathology report with you.
What Is Contained In A Pathology Report?
As a general matter, a pathology report includes information about the patient, a description of how cells look under the microscope, and a diagnosis.
More specifically, a pathology report may include the following information:
- Patient information: Name, birth date, biopsy date.
- Origin: Where the tissue samples came from.
- Clinical history: A short description about you, and how the sample was obtained.
- Gross description: A general description of the size, shape, and appearance of a specimen as it looks to the naked eye without magnification under a microscope. The origin of the tissue will also be noted.
- Microscopic description: How the sample looks under the microscope and how it compares with normal cells. (This section may be very technical).
- Tumor size: Measured in centimeters.
- Tumor margins: There are three possible findings when the biopsy sample is the entire tumor:
- Positive margins mean that cancer cells are found at the edge of the material removed.
- Negative, not involved, clear, or free margins mean that no cancer cells are found at the outer edge.
- Close margins are neither negative or positive.
- Photograph: An image of the biopsied section. It allows the pathologist to see which areas of the sample contained cancer and to describe the appearance of cancer cells.
- Diagnosis: Type of tumor/cancer, grade and stage (if known). These results indicate how abnormal the cells look under the microscope and how quickly the cancer is likely to grow and spread. Diagnosis may also include whether or not the cancer cells are sensitive to hormones.
- Other information: Usually notes about samples that have been sent for other tests or a second opinion.
- Pathologist's signature and name and address of the laboratory.
After identifying the tissue as cancerous, the pathologist may perform additional tests to get more information about the tumor that cannot be determined by looking at the tissue with routine stains, such as hematoxylin and eosin (also known as H&E), under a microscope. The pathology report will include the results of these tests.
How Long Does It Take To Get A Pathology Report?
There are several types of reports. A report on a frozen specimen may be made almost immediately after removal from the body.
A general report may be issued within a few days. A report of more extensive tests may take 10 days to two weeks.
If You Have Advanced Or An Unusual Cancer, Or It Has Spread
Although most cancers can be easily diagnosed, it is advisable to get a second opinion if the cancer has spread, is advanced, or is unusual.
A second opinion does not require another biopsy or physical examination.
- The second pathologist reexamines the same slides used by the first pathologist.
- You will need to obtain the slides and/or paraffin block from the pathologist who examined the sample or from the hospital where the biopsy or surgery was done.
You can ask for a second opinion just about the pathology report, or you can ask for it as part of getting a second opinion about a treatment recommendation.
- Second opinion about the pathology report
- Consider getting a second opinion from an academic center or a National Cancer Institute (NCI)-designated comprehensive cancer center. NCI designated centers can be found in the database available at www.cancer.gov/cancertopics/factsheet/NCI/cancer-centers .
- Also consider other facilities such as the Armed Forces Institute of Pathology (AFIP). It is advisable to contact the facility in advance to determine if this service is available, the cost, and shipping instructions. You can contact Armed Forces Institute of Pathology at: www.afip.org/
- Second opinion about treatment
NOTE: It is advisable to keep a copy of your medical records, including a copy of every pathology report. Experience shows that the amount of work involved in keeping your own copy is well worth the effort.