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The Sections of a Pathology Report (for cancer specimen)
The pathology report is usually divided into several sections:
Demographics: This information appears at the top of the report and identifies the patient and the physician. The patient's name, address, birth date, and date of procedure are usually included.
Anatomic Pathology Diagnosis: This is most important section of the report. It gives the pathologist's diagnosis and other clinical information that is necessary to determine treatment. The following are included in this section:
1. Histology: The type of cancer found and the arrangement of the cells.
2. Stage: The size of the cancer and the extent to which it has spread.
3. Grade: The nature of the cells and their aggressiveness.
Clinical History/Pre-Operative Diagnosis: The patient's initial diagnosis prior to the pathologist's diagnosis. For example, a breast lump was found, a suspicious nipple discharge was experienced, etc.
Specimen(s) Obtained: What was received by the pathologist following the procedure (cells, tissues) and when it was received.
Gross Description or "The Gross:" Characteristics of the specimen that the pathologist saw, measured and felt when examining the tissue with the naked eye (without a microscope).
Microscopic Description: What the tissues looked like to the pathologist upon examination under the microscope.
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