Understanding your biopsy and pathology report

Start with the diagnosis and the sample

Check your name, the date and the body site first. Then find the diagnosis, impression or conclusion. Read any comment about further testing, and check whether the report is preliminary or final.

A pathologist is a doctor who examines cells and tissues to identify disease. The gross description records the appearance of the sample before microscopy; it does not mean that something is especially serious. The microscopic description explains what was seen under the microscope.

The type and size of the sample affect what can be answered. A small biopsy may establish the diagnosis without showing the whole tumour. A later operation can provide information that was simply not available before.

Cytology or FNAC

Cytology examines cells, including cells collected from fluid or by fine-needle aspiration cytology (FNAC). It may identify cancer, but sometimes more tissue is needed to classify it or run further tests.

Core or incisional biopsy

A needle core or a small piece of tissue is examined. It can often identify the cancer type and provide material for additional tests. It does not usually establish surgical margins.

Excision or resection

An operation removes a lesion or a larger part of an organ. The report may include tumour size, margins and any lymph nodes submitted. Not every operation includes lymph nodes.

Understanding uncertain wording

Words such as suspicious, atypical or inconclusive describe a finding or a limit to the evidence. They should not be converted into a diagnosis by looking up one word in isolation.

Malignant or positive for malignancy

Cancer has been identified in the sample. The next questions are which type it is and what additional information is needed.

Consistent with or favour

The findings support the diagnosis named. Read the whole conclusion and any qualifications; the degree of certainty depends on the setting.

Suspicious for

There is concern, but the sample does not establish a definite diagnosis. Ask what will resolve the uncertainty and when.

Atypical cells

The cells look abnormal. This can have several explanations, including non-cancerous changes or cancer. It is neither a confirmation nor an exclusion of cancer by itself.

Insufficient or non-diagnostic

The sample has not answered the clinical question. More tissue, a different test or specialist review may be needed.

No malignancy identified

No cancer was seen in the material examined. If the result does not fit the scan or examination, your team may recommend further assessment.

Cancer type, grade and stage are different

The type describes the kind of cancer. For example, adenocarcinoma arises from gland-forming cells, while lymphoma arises from lymphocytes, a type of white blood cell. The organ where a sample was taken is not always where the cancer began.

In situ describes abnormal cells confined to the layer where they developed. Invasive means cancer has grown into surrounding tissue. Invasive does not, by itself, mean that cancer has spread to distant organs.

Grade describes microscopic features that help estimate how a cancer may behave. Many cancers are graded from lower to higher grade, but the system depends on the cancer. Do not assume that a particular grade means the same thing in every organ.

Stage describes the extent of cancer in the body. A high grade is not the same as an advanced stage, and neither word alone tells you which treatments are available.

Margins, lymph nodes and other surgery findings

A margin is an edge of removed tissue. A negative or clear margin means no cancer was seen at the examined edge. An involved or positive margin means cancer reaches an edge. A close margin means cancer is near it; what distance is adequate depends on the cancer and the operation.

Clear margins are encouraging, but do not guarantee that no further treatment is needed. If a report uses R categories, R0 means no residual tumour, R1 microscopic residual tumour and R2 visible residual tumour. R2 is not simply another term for a microscopic positive margin.

“3 of 18 lymph nodes involved” means cancer was found in three of the eighteen nodes examined. Nearby lymph-node involvement does not automatically mean stage 4 cancer.

Lymphovascular invasion means cancer cells were seen in small lymphatic or blood vessels. Perineural invasion means cancer was seen involving the area around nerves. These findings can affect risk assessment, but neither alone proves distant spread.

What do T, N and M mean?

Many cancers use TNM: T describes the primary tumour, N the regional lymph nodes and M distant spread. T may depend on depth or structures involved, not just centimetres. The meaning of each number is specific to the cancer.

The prefix c usually indicates clinical staging using examination and tests; p indicates pathological staging based on tissue findings. A yp result describes pathology after treatment given before surgery. It should be interpreted with the original stage and response to treatment.

A pathology report may not contain every part of the stage. Your team combines it with scans and other information. Ask them to write down the overall stage and explain which findings establish it.

Stains and biomarkers: which results change treatment?

Immunohistochemistry (IHC) uses stains to identify proteins in cells. Some help identify the cancer; others help select treatment. A positive stain is not automatically bad news. It can sometimes identify a treatment option.

In breast cancer, oestrogen receptor (ER), progesterone receptor (PR) and HER2 results help guide treatment. Some HER2 findings need an additional gene test, such as in situ hybridisation (ISH). Interpretation depends on the test and the treatment being considered; do not choose a medicine from a score alone.

Ki-67 estimates the proportion of cells showing a marker of cell proliferation. Its importance varies between cancers. It contributes to grading some neuroendocrine tumours, but it is not a universal measure of prognosis or a treatment decision on its own.

Other tests may examine proteins, genes or DNA repair. Ask which tests are relevant to your diagnosis, whether enough tissue is available, and whether a result is needed before treatment begins.

Pending tests, addenda and a second opinion

An addendum is an additional report. Special stains, molecular tests or expert review may follow the initial diagnosis. Keep these documents together. A longer wait does not by itself mean that the result is worse; ask for an expected date and who will contact you.

For a pathology second opinion, the receiving laboratory may request glass slides, tissue blocks or digital images. Ask both laboratories about their process before arranging transport. Keep a record of what is transferred and follow their packaging and temperature instructions.

Another review can confirm or refine a diagnosis. It may use existing material without another biopsy, although sometimes more tissue is necessary. Your team can help prioritise tests so limited material is used thoughtfully.

Questions to take to your appointment

• What is the exact diagnosis, and which parts are confirmed?
• Does this result fit my scans and examination?
• Which findings affect my treatment, and which are descriptive details?
• Are any tests or addenda outstanding? When should we discuss them?
• Would specialist pathology review help, and where are my slides and blocks kept?
• What is the next step, and how soon does it need to happen?

Common questions

Related reading

• Histopathology and understanding your diagnosis
• Biomarker and molecular testing
• When a second opinion helps