Pathology Reports

Nicole Draper, MD

Information in a Surgical Pathology Report

– Patient information: Name, birth date, biopsy date.– Accession number: for example S13-1297– Gross description: Color, weight, and size of tissue as seen

by the naked eye. Lesions identified.– Microscopic description: How the tissue sections look

under the microscope and comparison with normal cells.– Diagnosis: May be general or very specific.– Tumor or lesion size: Measured in centimeters.– Margins:

• Positive : abnormal cells are found at the edge of the material removed.• Negative: no abnormal cells are found at the outer edge.• Close: usually within 1mm.

– Other information: Samples sent for other tests or a second opinion, TNM staging

http://www.jkjpathology.com/doctors/reports.htm

Sometimes importantinformation about theseverity of disease or prognostic factors are found in the comment or microscopic description.

Special stains, IHC or othertest modalities in additionto microscopic analysis of H&E stained slides

http://jmmultiplemyeloma.blogspot.com/2012/04/bone-marrow-surgical-pathology-report.html

The gross description caninform you how much tissue was evaluated.

Breast Cancer Reporting Guidlines• http://link.springer.com/article/10.1007%2FS1

2094-010-0478-8

Breast Cancer pTNMStandardized reporting makes finding desired information easier

http://blog.mtuitive.com/mTuitive-Blog/bid/243736/5-Quality-Measures-Pathology-Synoptic-Reporting-Captures

Skin Cancer

Negative margins are very important in skin cancers.Ink is typically used to definitively determine all margins.

Bone Tumor

IHC studies for antigen expression to determine likely origin of neoplastic cells

Brain Tumor

Molecular testing for mutations is becoming more important for diagnosis, prognosis and determining treatment options for many neoplasms.

Brain Tumor

Quick diagnosis by frozen sectionwhile the patient is still in the OR so surgeons can decide next step

Information in a Clinical Pathology Report

• Reference ranges of test values• Goal values for treatment• Specimen collection and handling needs• Limitations of a test• Interpretation of test results– Single tests– Multiple tests that are considered together to

make a diagnosis

TM Antibody Report

Negative antibody screen about 2 months ago

Positive antibody screen now after RBC transfusion 2 months ago

The “c” indicates a comment/interpretation of the test result

Coagulation Testing Interpretation

An overall interpretation of the combination of results of all of these single tests

LMW Heparin not therapeutic ornot drawn at the appropriate 4 hrs