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