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A typical laboratory report is
divided into several sections.
This usually appears with the body site, surgical procedure, and final diagnosis. Examples of surgical procedures include biopsy, excision, and resection.
Example:
Right Breast, Lumptectomy:
Inifiltrating Ductal Carcinoma, Well Differentiated
This describes the actual appearance of the tissue specimen as viewed by the pathologists' eyes. A pathologist sometimes dictates a summary of sections where the site of each sample of tissue is indicated. Note that in some cases, orientation of the specimen is important if a later surgical procedure or additional treatment is planned. The pathologist often utilizes special inks or dyes to mark the margins. Note also that measurements and weights are given in metric terms. The pathologist may submit all of the tissue or if the tissue is very large, such as a uterus, representative sections may be submitted.
Example:
Received labelled with the patient's name and hospital number and designated "excisional biopsy of breast", is an excisional biopsy of tan-yellow soft tissue. The biopsy measures 5.5 x 5.0 x 3.9 cm. and weighs 18 grams. A short suture is designated by the surgeon as the superior margin and a long suture is designated the lateral margin. The superior margin is inked red, the lateral margin is inked green, the deep margin is inked black, the medial margin is inked yellow, and the inferior margin is inked blue. Serial cross sections reveal an ill-defined and infiltrative tumor measuring 2.7 cm. in maximal cross-sectional diameter. The tumor has a gritty tan-yellow surface with pin-point areas of hemorrhage. The surrounding breast tissue is composed of abundant and unremarkable yellow adipose tissue. All surgical margins are negative for tumor involvement with the tumor closely approaching the superior margin to within 0.7 cm.
Summary of Sections: Sections of tumor and adjacent superior surgical margin in cassette 1. Sections of inferior, medial, and lateral margins in cassettes 2, 3, and 4. Sections of the tumor in cassettes 6, 7, and 8. The remainder of the breast is submitted in cassettes 9 and 10. Totally submitted in 10 cassettes.
The microscopic description is the record of what the pathologist views under the microscope. It is here where the language becomes highly technical. Refer to each organ site section for commonly used terms and to your translated report from The Doctor's Doctor.
Example:
Microscopic sections reveal an infiltrating ductal carcinoma with pleomorphic glands infiltrating through the surrounding stroma and fat eliciting a desmoplastic stromal host response. There is good tubular differentiation and the glands are lined by cells showing a mild to moderate degree of atypia characterized by hyperchromatic nuclei with prominent nucleoli. The mitotic rate is estimated at 5 per 10 high power fields. All surgical margins are negative for malignancy. The surrounding breast tissue is composed of atrophic lobules and is otherwise unremarkable.
Some pathologists add a comment to the diagnosis. Others chose to integrate the information in the comment section with the diagnosis. Either way is acceptable. The comment section may include further clarifying information about the diagnosis or inform other physicians that other studies are pending. In this example, the tumor is graded and the reader is informed that additional studies for hormone receptors have been ordered. A comment about physician notification is also included.
Example:
This infiltrating ductal carcinoma is well differentiated by Scarff-Bloom-Richardson grading system. Tissue has been sent for immunohistochemical studies for estrogen and progesterone receptors. These results will be issued in an addendum. The results of this case were discussed with Dr. Berean on 5/1/95 at 0900.
Last Updated November 28, 2006
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