How to read a pathology report

A pathology report is a medical document created by a pathologist, who is a doctor specializing in diagnosing diseases through the examination of tissues, cells, and body fluids. This report details the findings from a specimen taken from your body and analyzed under a microscope or tested in a laboratory. The information in your pathology report helps your healthcare team confirm your diagnosis, understand the extent of the disease, and plan the most appropriate treatment.

Are there different types of pathology reports?

Yes. The type of pathology report depends on the kind of specimen examined and the purpose of the test.

Common types include:

• Surgical pathology reports – These describe findings from tissue removed during surgery or biopsy. Surgical pathology includes subspecialties such as gastrointestinal pathology, dermatopathology (skin), neuropathology (brain and nervous system), gynecologic pathology (female reproductive organs), and urologic pathology (urinary tract and male reproductive organs).

• Cytology reports – These are prepared for tests where isolated cells and fluids are removed from the body rather than whole pieces of tissue. Examples include fine needle aspiration (FNA) biopsies, where a thin needle is used to remove cells from a lump or organ, and Pap tests, where cells are collected from the cervix or anal canal to screen for precancerous changes.

• Autopsy reports – These provide a detailed review of the body after death. Medical autopsies are performed in hospitals to understand disease processes and improve patient care. Forensic autopsies are conducted in legal or criminal investigations to determine the cause and manner of death, often under the jurisdiction of a coroner or medical examiner.

• Molecular pathology reports – These present results from tests that look for genetic changes, biomarkers, or other molecular features of a disease.

What kind of information is found in a typical pathology report?

While the format may differ between hospitals, most pathology reports include:

• Patient and specimen information – Your identifying details and information about the specimen’s location and collection date.

• Clinical history – Why the test was ordered and relevant medical background.

• Diagnosis – A concise summary of the key findings and the confirmed diagnosis.
• Microscopic description – What the pathologist observes under the microscope, including cell appearance and tissue structure.

• Special tests and results – Findings from additional testing such as immunohistochemistry, molecular testing, or cultures.

• Synoptic report – In cancer cases, many reports include a structured, checklist-style section that summarizes important features, such as tumor size, grade, margins, lymph node status, and biomarker results. Synoptic reports ensure that all essential information is recorded in a consistent format.

• Comments – Additional notes that provide clarification, context, or recommendations for further testing.

• Gross description – How the specimen looks to the naked eye, including size, shape, color, and texture.

How to read your pathology report

Look at the “Diagnosis” section first.

This is the most important section of your report. It contains the confirmed diagnosis and often the exact name of the disease or condition. In cancer cases, it may include details such as the type of tumor and whether it is benign (non-cancerous) or malignant (cancerous). If there is more than one specimen, separate diagnoses may be provided for each one.

Review any special test results.

Special tests, such as immunohistochemistry or next-generation sequencing, may be performed to provide additional information about the diagnosis or to guide treatment decisions. These results may indicate the presence of specific proteins, genetic changes, or other markers important for prognosis and treatment planning.

Understand the microscopic description.

The microscopic description details what the pathologist saw under the microscope, including the size, shape, and arrangement of cells, the tissue structure, and any signs of inflammation or abnormal growth. This section often contains technical terms, so ask your doctor to explain anything unclear. While it’s valuable for understanding the reasoning behind the diagnosis, the final diagnosis is what guides treatment.

Look for other important features such as grade, stage, margins, and lymph node status.

For cancers and some precancerous conditions, the report may include:

• Grade: How closely the tumor cells resemble normal cells. Low-grade tumors resemble normal tissue and tend to grow more slowly, whereas high-grade tumors appear highly abnormal and may behave more aggressively.

• Stage: How far the cancer has spread, based on tumor size, lymph node involvement, and whether it has spread to other parts of the body. Some staging details may be mentioned in the pathology report, while the full stage is determined by combining information from surgery, radiology, and pathology.

• Margins: Whether the abnormal tissue or tumor was removed entirely. “Negative margins” mean no tumor cells are seen at the edge of the removed tissue. “Positive margins” mean tumor cells are present at the edge, suggesting that some cancer may remain.

• Lymph node status: Whether cancer has spread to nearby lymph nodes and how many were affected.

Don’t be afraid to ask for help.

Your pathology report is written for medical professionals and will use technical language. Your doctor can guide you through each section, explain how the findings fit together, and discuss their implications for your diagnosis and treatment.

How is the tissue sample processed?

After a tissue sample is taken during a biopsy or surgery, it is sent to the pathology lab for processing. Here are the main steps:

1. Fixation: The sample is preserved in a special solution (usually formalin) to prevent decay.
2. Embedding: The tissue is embedded in paraffin wax to make it easier to cut into thin slices.
3. Sectioning: Thin slices of the tissue are cut and placed on glass slides.
4. Staining: The slides are stained with dyes (such as hematoxylin and eosin, or H&E) to highlight different tissue parts.
5. Microscopic examination: The pathologist examines the slides under a microscope to look for abnormalities.

Each step ensures the tissue is preserved and prepared for accurate examination.

How long should it take to get a pathology report?

For most small biopsies, results are usually available within 1 to 3 business days. More complex specimens, or cases that require special stains, molecular testing, or review by another specialist, may take a week or more. Your doctor will typically share the results as soon as they are ready.

How do I get a copy of my pathology report?

You can request a copy from your doctor, the hospital’s medical records department, or through your hospital’s secure online patient portal. Because pathology reports contain technical medical language, it’s helpful to review your results with your doctor so they can explain what the terms mean in your situation.

Can a pathology report change after it’s issued?

Yes. A report may be updated if additional testing is performed after the initial diagnosis or if another pathologist provides a second opinion. In these cases, an amended or addendum report will be issued, and your doctor should explain the changes to you.

Why is the pathology report important?

The pathology report is often the foundation of your diagnosis and treatment plan. In cancer care, it contains details that determine tumor type, grade, and stage—information essential for selecting the proper treatment. Understanding your pathology report helps you take an active role in decisions about your care.

Questions to ask your doctor

• What does my pathology report say about my diagnosis?

• Were all the necessary tests completed?

• Does my report include a synoptic summary?

• How will these results affect my treatment plan?

• Should I get a second opinion on my report?