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How to Read a Pathology Report

Your physician will be notified immediately with any abnormal results. In nearly all cases, the results of your pathology report will be given to you by your clinician or surgeon and discussed with you in private, so your doctor will be there to help you understand the results. In general, though, there are a number of common sections that all Pathology Reports share and it may be useful for you as a patient to know how the information of a pathology report is organized.

Each report begins with the confidential patient information, followed by an exact list of the specific specimens received. For each specimen, the diagnosis is listed in bold. The diagnosis indicates the precise “site” of the specimen, that is, its location in the body, the procedure through which this particular specimen was obtained from the site, and the actual detailed diagnosis for the site, with additional comments if necessary. Among other relevant information, the diagnosis will indicate whether it is benign tissue or if disease has been detected at the site, and, if yes, it will indicate the disease patterns, type, pathologic stage, the differentiation, or its classifications, sometimes followed by another diagnosis summary or comments.

This diagnosis is followed by an elaborate macroscopic description of the specimen and how the tissue has been received. Section summaries indicate exactly how they correspond to the slides that have been the basis for the microscopic analysis. Sometimes an addendum will show the specific markers used in the immunohistochemical procedures. The signature at the end, usually inserted electronically, attests that final diagnosis has been formulated by the pathologist and that it corresponds to the specimen for which the report has been prepared.