Understanding patient information

Pathology reports usually start with information that identifies you as the intended recipient. While this section can seem unnecessarily long and administrative, it’s important to ensure the right patient gets the report and to help reduce the risk of errors.

You might see things in this section like:

• Your name and date of birth
• A specimen number or case number
• The date the sample was taken
• The name of the clinic, hospital, or provider involved

If you are looking for a simple place to start when reading your pathology report, check that this information is correct.

Specimen description

A specimen is the sample that was collected and sent to the lab, such as tissue from a biopsy, tissue removed during surgery, or cells from bodily fluid.

This section is often called gross description. “Gross” in this context means “seen with the naked eye.” This section often focuses on physical details, such as:

• The size, color, or texture of the sample
• Quantity of the sample
• How the sample was prepared for examination

These details are recorded before any analysis begins. It is part of a standard process that documents exactly what was received and how it was handled.

The language in this section can sound clinical, but it simply describes what was observed. It does not have conclusions or outcomes about your test. These observations help support accurate analysis later in the report and are routine in all pathology reports.

Diagnosis section

The diagnosis section is the pathologist’s summary of findings based on the specimen. It may combine what was seen with the naked eye, what was seen under the microscope, and any relevant clinical details provided with the sample.

In some reports, the diagnosis section is a brief paragraph summarizing the pathologist's findings based on the specimen. In others, especially for cancer diagnoses, it may appear as a structured checklist with many items.

Diagnoses are written using standard medical terminology so healthcare providers can clearly understand and share the findings with patients. Some diagnoses are brief, while others can be longer when needed to describe multiple features.

It is helpful to keep in mind that this section:

• Reflects findings from the sample only.
• Does not include imaging, symptoms, or results from a physical exam.
• Is not a complete picture of your situation on its own.

In some reports, the diagnosis section may also include information about nearby lymph nodes. Lymph nodes are small structures that help filter harmful substances in the body. When lymph nodes are examined as part of a biopsy or surgery, the report may note if cancer cells are present in them.

This analysis may also be covered in the description section of your pathology report. Findings about lymph nodes can help your healthcare team understand whether the cancer has spread beyond the original site and support decisions about treatment and care.

Tumor characteristics

Some pathology reports include a section describing tumor or cell characteristics. Whether your report includes this section will depend on why the test was performed and the type of sample your doctor took.

When included, this section may describe:

• How your cells look under a microscope.
• Patterns in how your cells are arranged.
• Structural features seen within the tissue.

Pathologists describe these features in detail to clearly communicate findings with your doctor and other healthcare providers. Some terms you might see are:

• Invasion: Whether cancer cells have spread into nearby tissue.
• Benign: Not cancer. Benign tumors may grow larger but do not spread to other parts of the body. Also called nonmalignant.
• Necrosis: Areas of dead cells within the tumor. This can occur when tumor cells grow quickly and outgrow their blood supply.

These terms help describe how the tumor is behaving, which can be important for understanding the condition and planning treatment. The descriptions are designed to be interpreted alongside the rest of your report.

A lot of the terms you’ll see will be standard medical terminology. To help decode this, the National Cancer Institute offers a searchable dictionary of cancer terms with plain language definitions for common cancer terms.

Margins

If you had surgery to remove a tumor or suspicious tissue, your report will typically include a section about margins. Margins refer to the edges of the tissue sample that were removed and examined. Pathologists may look to see whether abnormal cells reach the edge of the specimen.

You may see terms such as:

• Negative/clean margins: No cancer cells seen at the edge of the removed tissue.
• Positive/involved margins: Cancer cells seen at the edge of the removed tissue.
• Close margins: Cancer cells are not at the edge but are very near to it.

These findings help show whether all of the cancer may have been removed. For example, if cancer cells are found at or very close to the edge of the tissue, there may still be cancer cells remaining in the surrounding area.

These terms describe what was observed in the sample and may provide additional information your care team can use to decide next steps for your treatment plan. If you have any questions about your margin results, your doctor will be able to explain what these details mean for you.

Grade

In a pathology report, a pathologist will often use the word “grade” to describe how cells look under a microscope compared with typical, healthy cells. It focuses on their appearance rather than any conclusions or outcomes.

In general, cells that closely resemble healthy cells tend to grow and spread more slowly, while cells that appear more abnormal may behave more aggressively.

Grades are often expressed using numbers or short descriptions. For example, a lower number may be used when cells look more like healthy, organized cells, while a higher number may be used when cells look more abnormal. Cells that appear more abnormal may grow and behave differently, which is why they may need closer evaluation by your care team.

It is important to note that grading systems:

• Vary by condition and tissue type.
• May use numbers (like Grade 1 or Grade 3), categories, or descriptive terms, such as well-differentiated (more like normal cells) or undifferentiated (very different from normal cells).
• Are designed to standardize communication between your doctor and other healthcare providers.

Grade is one part of the overall picture. It does not determine treatment decisions on its own, but it is one of several factors your healthcare team considers—alongside other findings in your report and your wider clinical information—when planning care. Because the language in the grade section can feel abstract or numeric, it is often most helpful when explained by your doctor.

You may also see the word “stage” in discussions about cancer. While grade describes what the cancer cells look like under a microscope, stage refers to how large the cancer is and whether it has spread within the body. Both grade and stage help your healthcare team understand the condition and plan treatment.

Read What is cancer staging? to learn more about what cancer staging means, how it’s determined, and why different systems are used.

Notes or comments

Many reports include a notes or comments section, sometimes as an addendum. This section can provide additional context or information for your doctor.

It may:

• Add clarification about the sample.
• Note technical details about testing methods used.
• Flag considerations for other healthcare providers.
• Recommend additional tests that may be useful.
• Include results from additional tests on the sample, such as biomarker or molecular testing relevant to treatment planning.

Some of the terms included here, such as references to biomarker results (for example, “HER2 positive” or ER negative”) may be unfamiliar. In this context, “positive” and “negative” indicate whether a specific characteristic or marker was found in the sample (“positive”) or not (“negative”). These findings are used to help guide treatment decisions.

This section is often written primarily for your healthcare team, which is why the language can seem especially technical. If you have questions about this section, it’s a good idea to consult with your doctor.