Gross Description (Macroscopic): The gross description refers to the pathologist’s observations of the tissue sample using the naked eye. Procedure: The procedure describes how the tissue sample was removed. Specimen: The specimen section describes the origin of the tissue sample(s).Ĭlinical History: The clinical history section provides a brief description of the patient’s medical history relevant to the tissue sample that the pathologist is examining.Ĭlinical Diagnosis (Pre-Operative Diagnosis): The clinical diagnosis describes what the doctors are expecting before the pathologic diagnosis. You should check that this information is correct to ensure that you have the correct pathology report. The structure and information provided in your pathology report may vary, but the following sections are usually included.ĭemographics: This section includes the patient’s name and date of procedure. Your primary doctor should be able to address specific questions you have about your pathology report however, it is helpful to have a basic understanding of what the pathologist is looking for. Understanding your Pathology ReportĪlthough pathology reports are written by physicians for physicians, you may be able to decipher some of the medical jargon provided by the report. Your primary doctor should be able to address specific questions you have about your pathology report. Having a copy of your pathology report for your personal records is highly recommended. In addition, it is helpful to have a copy of the pathology report to refer to when you are researching your disease.īy having a basic understanding of what the pathologist is looking for and the structure of the report, you may better understand your pathology report. The primary doctor will use this report in conjunction with other relevant test results to make a final diagnosis and develop a treatment strategy.Īfter any biopsy or excision, you should request a copy of the pathology report for your records so that you have documentation of your pathologic diagnosis. The pathology report is a critical component of the diagnostic process. The pathologist then writes a pathology report summarizing his or her findings. Once a tissue sample is obtained, the pathologist will examine the tissue sample under the microscope in order to determine if it contains normal, pre-cancerous or cancerous cells. Next, the sample is stained so that the pathologist can see the cell structure under a microscope and determine whether the cells are exhibiting cancerous characteristics. Once a tissue sample is obtained, it is then “fixed”, meaning it is treated in a way that stops degradation and prevents the cells in the sample from changing characteristics. This procedure may also be called a bone marrow aspiration. Bone marrow biopsies are usually performed in the bones of the rear hip. The purpose of this procedure is to diagnose lymphoma and leukemia or determine whether certain types of cancer, such as breast or prostate, have spread to the bones. For example, throat cells may be sampled in this way.Ī physician may also perform a bone marrow biopsy, which uses a large needle to remove a sample of the bone marrow. It allows the physician to see the cells in question and then “scrape” the abnormal cells in order to get a sample. An endoscope is a lighted tube that can be guided into the body through an orifice, such as the mouth or anus, and is used to perform a biopsy. Fine needle aspiration involves guiding a thin needle into the cancer and gently sucking out cells for microscopic evaluation. The method used to gain a tissue sample depends on the type of mass and location in the body.Ī typical biopsy involves the surgical removal of a mass of abnormal cells. There are a variety of methods used to obtain samples, including a typical biopsy, fine needle aspiration, or a biopsy with the use of an endoscope. Most cancer patients will undergo a biopsy or other procedure to remove a sample of tissue for examination by a pathologist in order to diagnose their disease. Pathology tests involve evaluation of a small sample of cells under a microscope to determine whether they are cancerous by identifying structural abnormalities. A pathologist is a physician specializing in the diagnosis of disease based on examination of tissues and fluids removed from the body. Pathology is still the gold standard for the diagnosis of cancer, meaning it has been the most important diagnostic tool to date.
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