A breakdown of your pathology report

I’m a pathologist and the main way I communicate to the outside world — to your doctor and ultimately to you, the patient is via the pathology report. But the short missives I send from behind the microscope lack any excitement and can fall short of full communication.

Here’s the usual story:

Skin left scapula, biopsy

Nodular basal cell carcinoma

Negative for perineural invasion

Margin status: Positive

Doesn’t sound real interesting, does it?

How about a more exciting story? I occasionally write intense dramas like this one:

Brain, left parietal lobe, biopsy

Infiltrative astrocytoma, grade IV (glioblastoma)

Trust me. This diagnosis has pathologists on the edge of their collective seats and is the start of a compelling and sad story for the patient. Part of what I hope to share with you in this blog is to let you know just how compelling and exciting stories such as these are.

For now, let’s start with the basics. You need to get to the major plot line of the pathology report — the final diagnosis.

The most important information in a pathology report, why the biopsy, tissue, or organ was removed in the first place, is the diagnosis. This is usually called a final diagnosis. Or in some places, they might get fancy and call it an interpretation. Despite the importance of this information, it is not listed in a standardized manner. It might be on top of the report in the middle or even at the end. I’ve reviewed thousands of reports from hospitals and clinics around the country and have seen tremendous variation in the appearance of pathology reports. I have spent many frustrating minutes flipping through reports to find the diagnosis, especially if there has been specialized testing added, and I am trained to do this!

Once you’ve found it, all diagnosis lines have a standardized format: type of tissue, body site, type of procedure.

Type of tissue — what is it?

Type of tissue examples: skin, bone, brain, breast, liver, colon.

Body site — where is it from? (This includes the very important right or left side.)

Type of body site examples (the more specific, the better): right breast, left forearm, right proximal dorsal third toe, right hepatic lobe, sigmoid colon.

Type of procedure — what was done to you?

Examples of type of procedure: biopsy, excision, resection, tonsillectomy, mastectomy, colectomy, appendectomy.

After this line, the final diagnosis tells you what it is. It should be the answer to the question you, and your doctor is asking: What is this? Is this cancer? Why do I have this problem? Occasionally, it is really just a diagnosis to document the specimen, and your condition or state.

A simple example is a diagnosis for a vasectomy:

Vas deferens, right and left, removal:

Complete cross-sections of vas deferens identified, both specimens

Negative for malignancy

Now, if this patient later goes on to father a child, this diagnosis may not seem so simple! So everything must be carefully documented. You’ll note: people don’t have a vasectomy for cancer treatment, and yet I’ve written that important line “negative for malignancy” as a near reflex, important to document. That is called a pertinent negative.

Here’s the most common malignancy there is, my first example above:

Skin, left scapula, biopsy:

Nodular basal cell carcinoma

Negative for perineural invasion

Margin status: positive

This tumor arose in the skin, on the left shoulder blade and was removed with a biopsy in the clinic. It is thought to arise from the basal layer of the epidermis, and it touches the deep portion of the biopsy. If it had invaded into nerves, which it rarely can do, the dermatologist may first opt to give the patient radiation before additional removal. It is a simple diagnosis and also easily treated.

A simple diagnosis, not easily treated, is my second example:

Brain, left parietal lobe, biopsy:

Infiltrative astrocytoma, grade IV (glioblastoma)

This tumor arose slowly within the brain. Although the type of procedure — biopsy — is the same as the skin, it represents a much more difficult procedure. While not written here, this diagnosis was written after the pathologist consulted with radiology reports, to confirm the proper setting. Like basal cell carcinoma, an infiltrative astrocytoma is a well-understood old tumor, usually diagnosed with on a simple, routine stain. Yet receiving this diagnosis caps off a series of life-changing events for the patient and their family.

Obviously, there are millions of examples of relevant pathology reports. This post is intended to give you a key to start reading your report by at least knowing where to start. Once you know the final diagnosis, you can begin to decipher your report.

You can also view a document from the College of American Pathologists: How to read your pathology report.

Jena Martin is a pathologist.

Image credit: Shutterstock.com

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