How to understand pathology reports

Author: Yang Hongping, General Hospital of Coal Shenma Medical Group

Reviewer: Chen Mingzhi, Chief Physician, General Hospital of Pingmei Shenma Medical Group

A pathology report is a highly professional and authoritative medical document, and is the "verdict" on the patient's disease. Pathology examination mainly refers to the removal of diseased tissues from the patient's body surface or body, and then making them into slices after processing such as sampling, dehydration, transparency, and wax immersion. The changes in their morphology and structure are observed under a microscope. It also includes further comprehensive analysis such as immunohistochemical staining, genetic testing, and special staining, and then a diagnosis is made and a pathology report is issued. Clinicians can judge the benign or malignant nature of the patient's disease based on the content of the pathology report, and take further treatment to give the patient a good prognosis.

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However, when patients receive the pathology report, they often don't know where to start.

Generally speaking, a pathology report includes the following 9 aspects.

1. Name of the medical institution.

2. Types of pathology reports (including routine pathology reports, routine pathology supplementary reports, frozen pathology reports, cytology pathology reports and molecular biology pathology reports).

3. Pathology number.

4. The patient’s basic information, including name, gender, age, department, bed number, inpatient number (outpatient number), sending unit, sending doctor, sending date, sending specimen type and clinical diagnosis.

5. What is seen with the naked eye, that is, the description of the gross observation of the specimens sent by the patients, is also the objective existence of the specimens sent by the patients that the pathologist sees with the naked eye when collecting the specimens. This aspect includes the name, type, location, size, number, shape, weight, color, cross-section condition, texture, presence or absence of capsule, relationship with surrounding tissues, and degree of infiltration of the specimens.

6. Attached images. Conventional pathology reports and frozen pathology reports are usually accompanied by 4 images, the top 2 images are gross images of the specimen, and the bottom 2 images are the most representative pathological images of the specimen under an optical microscope.

7. Pathological diagnosis. This is the most important part of the pathology report. It is necessary to indicate which organ the specimen comes from, how it is obtained (such as puncture, laparoscopy or surgical resection, etc.), and the type and nature of the lesion found after the test. The specimens obtained by surgical resection also include the scope of tumor invasion, whether lymph node metastasis occurs, and whether there is a vascular tumor thrombus. If the tumor lesion is atypical, it is necessary to add the content of differential diagnosis, and the differential diagnosis of tumors is usually achieved through immunohistochemical staining. Sometimes the pathological diagnosis also includes the pathologist's advice to the clinician.

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8. The date of the pathology report and the signatures of the initial doctor, the reporting doctor, and the reviewing doctor.

9. Notes on the pathology report. There are two main notes. One is that the pathology report is only valid when signed by the doctor himself and is only for clinical reference and not for other purposes. The other is that if there is any discrepancy with the clinical situation, please contact the pathology department in time (pathology department contact number).