Pathology report

What is a pathology report?

A pathology report is created based on samples of tissue or a tumor taken from the body, which are analyzed under a microscope. A pathologist evaluates laboratory tests, cells, organs and tissues to help identify cancer and whether it has spread in the body.

Upon analysis, the pathologist determines:

• Status of the tissue as cancerous or noncancerous
• Features of the tumor that may help steer treatment options

Pathology reports, which may include descriptions and images, may also be used to help a care team determine treatment options. They’re typically sent to a doctor within 10 days after a biopsy or surgery.

What information is included in a pathology report?

Patient information

• Name and birth date
• Contact information for the pathologist and the testing laboratory
• Patient accession number to identify the corresponding lab sample
• List of other symptoms and medical conditions, if provided by care team

Sample or tumor information

• Specimen details, such as the type of procedure and source of biopsy (for example, “biopsy, left arm”) or surgery performed to obtain the specimen and the type of tissue
• Color, weight and size of the tissue sample or tumor as seen without the microscope
• Type of tumor/cancer and grade (how abnormal the cells appear under the microscope, and how quickly the tumor is likely to grow and spread)
• What the sample looks like under the microscope and how it compares with normal cells
• Data on whether or not cancer cells were found at the tumor margins, which would indicate if cancer cells were found along the outer edges of the tumor

Other information

• Additional comments—a pathologist may add notes explaining why something is inconclusive or recommending other diagnostic tests
• Information on samples sent for additional tests or a second opinion
• Summary of the most pertinent information
• Name of the pathologist, as well as the name and address of the laboratory where the report was completed

Words you may find on a pathology report

A pathology report is likely to include information and technical terms specific to the type of cancer involved, such as breast cancer or lung cancer. Below are terms that commonly appear on pathology reports.

Flow cytometry: This technique measures the properties of cells in a sample, including the number of cells, cell size and shape, percentage of live cells, and the presence of tumor markers on the cell surface. Flow cytometry information may be useful for certain cancer types, including non-Hodgkin lymphoma, acute leukemia and chronic lymphoproliferative disorders.

Grade: This is determined by how cancer cells look when compared with healthy cells. Information for tumor grading is guided using specific criteria applied to features seen in the tumor under the microscope. Grading may help during the prognosis and treatment process.

Immunohistochemical stain: This type of stain is performed in a lab that uses antibodies to detect antigens (foreign substances in the body) on the surface of cancer cells. An immunohistochemical stain may help indicate where the cancer started and identify cancer types, including lymphoma, carcinoma and melanoma.

In situ: This term is used to describe abnormal cells that remain where they started and aren’t currently spreading. “In situ” means “in place.”

Invasive: This is cancer that may have encroached into the adjacent or underlying deeper layer of the organ and may have spread to others parts of the body.

Lymph nodes: These tiny organs are part of the immune system, which helps the body fight disease. A pathology report indicates whether cancer has spread to nearby lymph nodes and other organs.

Mitotic rate: This notes how quickly cancer cells are dividing.

Stage: This predetermined set of information is used to indicate the size and location of the tumor, whether cancer cells have spread to lymph nodes near the tumor, and whether the tumor has spread to other areas of the body.

Tumor margin: These are the edges of the biopsy sample. A pathologist uses terms such as “positive” or “involved,” which indicate the presence of cancer cells in the margin, or “negative” or “clean,” which mean no cancer cells were found in the margin. Information about tumor margins may help determine appropriate treatment.

Tumor marker: This substance is found in blood, bone marrow, tissue or other body fluids. Tumor markers may be a sign of cancer or noncancerous conditions.

What pathology report results mean for a treatment plan

A care team uses pathology report results to determine a personalized treatment plan.

Patients may choose to get a second opinion on a diagnosis and treatment plan. If so, they’re advised to share a copy of the pathology report and other medical records and to ask in advance about any costs and shipping instructions.