1. Pathology Reports
Nicole Draper, MD

2. Information in a Surgical Pathology Report
Patient information: Name, birth date, biopsy date.
Accession number: for example S
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

4. Special stains, IHC or other
test modalities in addition
to microscopic analysis of
H&E stained slides
Sometimes important
information about the
severity of disease or
prognostic factors are found
in the comment or
microscopic description.

5. The gross description can inform you how much tissue was evaluated.

6. Breast Cancer Reporting Guidlines

7. Standardized reporting makes finding desired information easier
Breast Cancer pTNM
Standardized reporting makes finding desired information easier

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

9. Bone Tumor
IHC studies for antigen expression to determine likely origin of neoplastic cells

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

11. Brain Tumor Quick diagnosis by frozen section
while the patient is still in the OR
so surgeons can decide next step

12. 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

13. 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

14. Coagulation Testing Interpretation
An overall interpretation of the combination of results of all of these single tests
LMW Heparin not therapeutic or
not drawn at the appropriate 4 hrs