A biopsy report is also known as a 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 specimen taken from your body. The biopsy report describes what the pathologist finds out about the specimen.
After the specimen is removed from the patient, it's put in a container with special type of liquid to preserve the sample. The pathologist or trained lab assistant reviews the specimen by the naked eye, 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 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
A biopsy report describes the findings of the specimen. It contains the following information:
Identifying 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 doctor 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, 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, followed by the diagnosis.
Comment. The section is used by the pathologist to address or clarify concerns of your healthcare provider or to recommend additional tests you may need.
Summary. The 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 of the large intestine and rectum was found.