The Biopsy Report

What is a biopsy report?

A biopsy report is also known as a histopathology report or a surgical pathology report. For many health problems, a diagnosis is made by removing a piece of tissue for study in the pathology lab. The piece of tissue may be called the sample or specimen. A pathologist looks at the specimen. A pathologist is a doctor who specializes in diagnosing what type of disease is found in tissue samples or specimens taken from your body. The biopsy report describes what the pathologist finds out about the specimen. Biopsy report information may differ somewhat, but all reports contain important details that your healthcare provider needs to diagnose and manage your condition or disease.

What happens to the specimen after the biopsy is done?

After the specimen is removed from the patient, it's put in a container with a special type of liquid to preserve the sample. The pathologist or trained lab assistant reviews the specimen by the naked eye. This means without using a microscope. The pathologist looks at, measures, feels, or takes pictures of the specimen. This type of exam helps the pathologist determine which part of the specimen is the most important. That part will be looked at under a microscope to help diagnose a disease or condition.

Next, the pathologist or a trained lab assistant gets the specimen ready to look at under a microscope. Specimens are processed based on the type of sample sent to the pathology lab. They can be prepared as a histologic section or a smear, as described below.

• Histologic sections are very thin slices of the specimen that are stained, placed on a glass slide, and then covered with a thin piece of glass called a coverslip.

• Smears are done when the specimen is a liquid or there are small, solid chunks suspended in a liquid. These are "smeared" onto a slide. They are then allowed to dry or are fixed. The fixed smears are stained, covered with a coverslip, and then examined under a microscope

Routine processing and histology can take one day or more. Sometimes information about a tissue sample is needed during surgery to make immediate decisions. A pathology consult can be done during surgery if the surgeon can't wait for routine processing and histology. This is often called a frozen section exam and usually takes 10 to 20 minutes.

What is the purpose of a biopsy?

A biopsy report describes the findings of the specimen. Most reports contain the following information:

• Identification and clinical information. This information includes your name, medical record number, date of the procedure, and the unique identifier of the specimen. The clinical information is your medical information and the special request from the healthcare provider who provided the sample.

• Gross description. A gross description describes how it looks to the naked eye and where the biopsy was taken from. It may include a description of the color, size, weight, and texture of the specimen.

• Microscopic exam. A microscopic exam is a description of what the findings of the slides showed under a microscope. It's usually technical and not in simple language.

• Diagnosis. This is usually considered the "bottom line." Although the format varies, often the diagnosis is expressed as: organ or tissue, site from which the biopsy was obtained, type of surgical procedure used to obtain the biopsy, and then diagnosis.

• Comment. This section is used by the pathologist to address or clarify concerns of your healthcare provider or to recommend additional tests you may need.

• Summary (also called a synoptic report). This section consists of a summary of the pathologist's findings. For example: colon, sigmoid, endoscopic biopsy, tubular adenoma. In other words, you had a biopsy of the sigmoid portion of the colon by endoscopy, and a benign tumor was found.

• The name of the pathologist and the name and address of the pathology lab is included in the report.