What is a Traditional Pathology Report?
What is a Pathology Report?
The pathologist is a physician who specializes in identifying diseases by studying cells and tissues under a microscope. The pathologist who completed your report studied cells and tissue taken during your surgery.
The pathologist determines if the cells are cancerous (malignant), precancerous (premalignant: at high risk of becoming cancerous) or benign (harmless).
The pathologist then wrote a report for your surgeon detailing the findings of this study. Your surgeon and other physicians involved in your care, will use this report to assist in developing plans for your treatment.
Most pathology reports have your name listed either at the top or bottom of the report. This is followed by specific information that is standard in surgical pathology reports.
- Anatomic Pathology Diagnosis
- Clinical History/Pre-Operative Diagnosis
- Specimen(s) Received
- Gross Description
- Microscopic Description
Understanding Your Report
Although the information is precise and clear, the pathology report is written in a language for your surgeon or physician. For example, your report may state that “in situ” disease is present, but no “invasion.” What does that mean to you? Your surgeon may have told you what it meant, but understandably, you don’t remember.
For your continued understanding, you may need more information.
Parts of a pathology report include
1.) Demographics: Identifying information for the patient, such as name, address, birth date, date of procedure, and the physician.
2.) Anatomical Pathology Diagnosis: The most important part of the report; what the pathologist’s diagnosis is and all pertinent clinical information that will be needed for your treatment. This section contains the
- Histology: The type of cancer and arrangement of the cells.
- Grade: A description of the tumor based on how abnormal the cancer cells look under a microscope and how quickly the tumor is likely to grow and spread. Grading systems are different for each type of cancer. One of the most popular grading systems for breast cancer is the modified Scarff-Bloom-Richardson grading scale.
“Tumor Grade: Questions and Answers” from the National Cancer Institute.
Stage: The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer and whether the cancer has spread from the original site to other parts of the body.
“Staging: Questions and Answers” from the National Cancer Institute.
3.) Procedures/Addenda (ERA/PRA/DNA): Secondary measurements related to invasive breast cancer.
4.) Clinical History/Pre-Operative Diagnosis: The initial diagnosis prior to the pathologist’s diagnosis.
5.) Procedure: How the cells were collected.
6.) Specimen(s) Received: What the pathologist received following the procedure and when it was received.
7.) Gross Description: Frequently referred to as “the gross.” What the pathologist saw, measured and felt when examining the tissue with the naked eye without a microscope.
8.) Microscopic Description: What the tissue looked like to the pathologist when examined under the microscope.
To see a sample of a Traditional Pathology Report, Click here