1. What is a pathology report?

   A pathology report is a document that contains the diagnosis determined by examining cells and tissues under a microscope. The report may also contain information about the size, shape, and appearance of a specimen as it looks to the naked eye. This information is known as the gross description.

   A pathologist is a doctor who does this examination and writes the pathology report. Pathology reports play an important role in cancer diagnosis and staging (describing the extent of cancer within the body, especially whether it has spread), which helps determine treatment options.

2. How is tissue obtained for examination by the pathologist?

   In most cases, a doctor needs to do a biopsy or surgery to remove cells or tissues for examination under a microscope.

   Some common ways a biopsy can be done are as follows:

   • A needle is used to withdraw tissue or fluid.
   • An endoscope (a thin, lighted tube) is used to look at areas inside the body and remove cells or tissues.
   • Surgery is used to remove part of the tumor or the entire tumor. If the entire tumor is removed, typically some normal tissue around the tumor is also removed.

   Tissue removed during a biopsy is sent to a pathology laboratory, where it is sliced into thin sections for viewing under a microscope. This is known as histologic (tissue) examination and is usually the best way to tell if cancer is present. The pathologist may also examine cytologic (cell) material. Cytologic material is present in urine, cerebrospinal fluid (the fluid around the brain and spinal cord), sputum (mucus from the lungs), peritoneal (abdominal cavity) fluid, pleural (chest cavity) fluid, cervical/vaginal smears, and in fluid removed during a biopsy.

3. How is tissue processed after a biopsy or surgery? What is a frozen section?

   The tissue removed during a biopsy or surgery must be cut into thin sections, placed on slides, and stained with dyes before it can be examined under a microscope. Two methods are used to make the tissue firm enough to cut into thin sections: frozen sections and paraffin-embedded (permanent) sections. All tissue samples are prepared as permanent sections, but sometimes frozen sections are also prepared.

   Permanent sections are prepared by placing the tissue in fixative (usually formalin) to preserve the tissue, processing it through additional solutions, and then placing it in paraffin wax. After the wax has hardened, the tissue is cut into very thin slices, which are placed on slides and stained. The process normally takes several days. A permanent section provides the best quality for examination by the pathologist and produces more accurate results than a frozen section (1).

   Frozen sections are prepared by freezing and slicing the tissue sample. They can be done in about 15 to 20 minutes while the patient is in the operating room (1). Frozen sections are done when an immediate answer is needed; for example, to determine whether the tissue is cancerous so as to guide the surgeon during the course of an operation.

4. How long after the tissue sample is taken will the pathology report be ready?

   The pathologist sends a pathology report to the doctor within 10 days after the biopsy or surgery is performed. Pathology reports are written in technical medical language. Patients may want to ask their doctors to give them a copy of the pathology report and to explain the report to them. Patients also may wish to keep a copy of their pathology report in their own records (1).

5. What information does a pathology report usually include?

   The pathology report may include the following information (1):

   • Patient information: Name, birth date, biopsy date.
   • Gross description: Color, weight, and size of tissue as seen by the naked eye.
   • Microscopic description: How the sample looks under the microscope and how it compares with normal cells.
   • Diagnosis: Type of tumor/cancer and grade (how abnormal the cells look under the microscope and how quickly the tumor is likely to grow and spread).
   • Tumor size: Measured in centimeters.
   • Tumor margins: There are three possible findings when the biopsy sample is the entire tumor:
     • Positive margins mean that cancer cells are found at the edge of the material removed.
     • Negative, not involved, clear, or free margins mean that no cancer cells are found at the outer edge.
     • Close margins are neither negative nor positive.
   • Other information: Usually notes about samples that have been sent for other tests or a second opinion.
   • Pathologist's signature and name and address of the laboratory.
   
   
6. What might the pathology report say about the physical and chemical characteristics of the tissue?

   After identifying the tissue as cancerous, the pathologist may perform additional tests to get more information about the tumor that cannot be determined by looking at the tissue with routine stains, such as hematoxylin and eosin (also known as H&E), under a microscope (2). The pathology report will include the results of these tests. For example, the pathology report may include information obtained from immunochemical stains (IHC). IHC uses antibodies to identify specific antigens on the surface of cancer cells. IHC can often be used to:

   • Determine where the cancer started.
   • Distinguish among different cancer types: for example, carcinoma, melanoma, and lymphoma.
   • Help diagnose and classify leukemias and lymphomas (3).

   The pathology report may also include the results of flow cytometry. Flow cytometry is a method of measuring properties of cells in a sample, including the number of cells, percentage of live cells, cell size and shape, and presence of tumor markers on the cell surface. (Tumor markers are substances produced by tumor cells or by other cells in the body in response to cancer or certain noncancerous conditions.) Flow cytometry can be used in the diagnosis, classification, and management of cancers such as acute leukemia, chronic lymphoproliferative disorders, and non-Hodgkin lymphoma (2).

   Finally, the pathology report may include the results of molecular diagnostic and cytogenetic studies. Such studies investigate the presence or absence of malignant cells, and genetic or molecular abnormalities in specimens.

7. What information about the genetics of the cells might be included in the pathology report?

   Cytogenetics uses tissue culture and specialized techniques to provide genetic information about cells, particularly genetic alterations. Some genetic alterations are markers or indicators of a specific cancer. For example, the Philadelphia chromosome is associated with chronic myelogenous leukemia (CML). Some alterations can provide information about prognosis, which helps the doctor make treatment recommendations (3). Some tests that might be performed on a tissue sample include:

   • Fluorescence in situ hybridization (FISH) determines the positions of particular genes. It can be used to identify chromosomal abnormalities and to map genes.
   • Polymerase chain reaction (PCR) is a method of making many copies of particular DNA sequences of relevance to the diagnosis.
   • Real-time PCR or quantitative PCR is a method of measuring how many copies of a particular DNA sequence are present.
   • Reverse-transcriptase polymerase chain reaction (RT-PCR) is a method of making many copies of a specific RNA sequence.
   • Southern blot hybridization detects specific DNA fragments.
   • Western blot hybridization identifies and analyzes proteins or peptides.

8. Can individuals get a second opinion about their pathology results?

   Although most cancers can be easily diagnosed, sometimes patients or their doctors may want to get a second opinion about the pathology results (1). Patients interested in getting a second opinion should talk with their doctor. They will need to obtain the slides and/or paraffin block from the pathologist who examined the sample or from the hospital where the biopsy or surgery was done.

   Some cancer centers and other facilities, such as the Armed Forces Institute of Pathology (AFIP), provide second opinions on pathology specimens. Patients should contact the facility in advance to determine if this service is available, the cost, and shipping instructions. Contact information for National Cancer Institute (NCI)-designated cancer centers can be found in the NCI-Designated Cancer Centers database available at http://www.cancer.gov/cancertopics/factsheet/NCI/cancer-centers on the Internet. Additional information about the AFIP is available on their Web site at http://www.afip.org/ on the Internet.

9. What research is being done to improve the diagnosis of cancer?

   NCI, a component of the National Institutes of Health, is sponsoring clinical trials that are designed to improve the accuracy and specificity of cancer diagnoses. Before any new method can be recommended for general use, doctors conduct clinical trials to find out whether it is safe and effective.

   People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available from the NCI's Cancer Information Service (CIS) (see below) at 1-800-4-CANCER and in the NCI fact sheet Clinical Trials: Questions and Answers, which is available at http://www.cancer.gov/cancertopics/factsheet/Information/clinical-trials on the Internet. This fact sheet includes information about types of clinical trials, who sponsors them, how they are conducted, how participants are protected, and who pays for the patient care costs associated with a clinical trial. Further information about clinical trials is available at http://www.cancer.gov/clinicaltrials on the NCI's Web site. The Web site offers detailed information about specific ongoing studies by linking to PDQ®, the NCI's comprehensive cancer information database. The CIS also provides information from PDQ.

Selected References

1. Morra M, Potts E. Choices. 4th ed. New York: HarperResource, 2003.
   
2. Borowitz M, Westra W, Cooley LD, et al. Pathology and laboratory medicine. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG, editors. Clinical Oncology. 3rd ed. London: Churchill Livingstone, 2004.
   
3. Connolly JL, Schnitt SJ, Wang HH, et al. Principles of cancer pathology. In: Bast RC Jr., Kufe DW, Pollock RE, et al., editors. Cancer Medicine. 6th ed. Hamilton, Ontario, Canada: BC Decker Inc., 2003.
   

Related NCI materials and Web pages:

• National Cancer Institute Fact Sheet 2.11, Clinical Trials: Questions and Answers ¹
  (http://www.cancer.gov/cancertopics/factsheet/Information/clinical-trials)
• National Cancer Institute Fact Sheet 5.9, Tumor Grade: Questions and Answers ²
  (http://www.cancer.gov/cancertopics/factsheet/Detection/tumor-grade)
• National Cancer Institute Fact Sheet 5.18, Tumor Markers: Questions and Answers ³
  (http://www.cancer.gov/cancertopics/factsheet/Detection/tumor-markers)
• National Cancer Institute Fact Sheet 5.27, Interpreting Laboratory Test Results ⁴
  (http://www.cancer.gov/cancertopics/factsheet/Detection/laboratory-tests)
• National Cancer Institute Fact Sheet 5.32, Staging: Questions and Answers ⁵
  (http://www.cancer.gov/cancertopics/factsheet/Detection/staging)
• National Cancer Institute Fact Sheet 7.47, How To Find a Doctor or Treatment Facility If You Have Cancer ⁶(http://www.cancer.gov/cancertopics/factsheet/Therapy/doctor-facility)
• National Cancer Institute-Designated Cancer Centers Database ⁷
  (http://www.cancer.gov/cancertopics/factsheet/NCI/cancer-centers)
• What You Need To Know About™ Cancer ⁸
  (http://www.cancer.gov/cancertopics/wyntk/overview)

For more help, contact:

NCI's Cancer Information Service
Telephone (toll-free): 1-800-4-CANCER (1-800-422-6237)
TTY (toll-free): 1-800-332-8615
LiveHelp^® online chat: https://cissecure.nci.nih.gov/livehelp/welcome.asp

Glossary Terms

Having to do with the abdomen, which is the part of the body between the chest and the hips that contains the pancreas, stomach, intestines, liver, gallbladder, and other organs.

Not normal. An abnormal lesion or growth may be cancer, premalignant (likely to become cancer), or benign (not cancer).

A rapidly progressing cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of white blood cells to be produced and enter the blood stream.

A protein made by plasma cells (a type of white blood cell) in response to an antigen (a substance that causes the body to make a specific immune response). Each antibody can bind to only one specific antigen. The purpose of this binding is to help destroy the antigen. Some antibodies destroy antigens directly. Others make it easier for white blood cells to destroy the antigen.

Any substance that causes the body to make a specific immune response.

The removal of cells or tissues for examination by a pathologist. The pathologist may study the tissue under a microscope or perform other tests on the cells or tissue. There are many different types of biopsy procedures. The most common types include: (1) incisional biopsy, in which only a sample of tissue is removed; (2) excisional biopsy, in which an entire lump or suspicious area is removed; and (3) needle biopsy, in which a sample of tissue or fluid is removed with a needle. When a wide needle is used, the procedure is called a core biopsy. When a thin needle is used, the procedure is called a fine-needle aspiration biopsy.

A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is a cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is a cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is a cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord. Also called malignancy.

The Cancer Information Service is the National Cancer Institute's link to the public, interpreting and explaining research findings in a clear and understandable manner, and providing personalized responses to specific questions about cancer. Access the CIS by calling 1-800-4-CANCER (1-800-422-6237), or by using the LiveHelp instant-messaging service at https://cissecure.nci.nih.gov/livehelp/welcome.asp. Also called CIS.

Cancer that begins in the skin or in tissues that line or cover internal organs.

The individual unit that makes up the tissues of the body. All living things are made up of one or more cells.

A measure of length in the metric system. There are 100 centimeters in a meter and 2½ centimeters in an inch.

The fluid that flows in and around the hollow spaces of the brain and spinal cord, and between two of the meninges (the thin layers of tissue that cover and protect the brain and spinal cord). Cerebrospinal fluid is made by tissue called the choroid plexus in the ventricles (hollow spaces) in the brain. Also called CSF.

Relating to the neck, or to the neck of any organ or structure. Cervical lymph nodes are located in the neck. Cervical cancer refers to cancer of the uterine cervix, which is the lower, narrow end (the “neck”) of the uterus.

A disease or condition that persists or progresses over a long period of time.

A slowly progressing disease in which too many white blood cells (not lymphocytes) are made in the bone marrow. Also called chronic granulocytic leukemia, chronic myeloid leukemia, and CML.

A type of research study that tests how well new medical approaches work in people. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease. Also called clinical study.

The study of chromosomes and chromosomal abnormalities.

The study of cells using a microscope.

The process of identifying a disease, such as cancer, from its signs and symptoms.

The molecules inside cells that carry genetic information and pass it from one generation to the next. Also called deoxyribonucleic acid.

A thin, tube-like instrument used to look at tissues inside the body. An endoscope has a light and a lens for viewing and may have a tool to remove tissue.

A method of measuring the number of cells in a sample, the percentage of live cells in a sample, and certain characteristics of cells, such as size, shape, and the presence of tumor markers on the cell surface. The cells are stained with a light-sensitive dye, placed in a fluid, and passed in a stream before a laser or other type of light. The measurements are based on how the light-sensitive dye reacts to the light.

A substance that flows smoothly and takes the shape of its container. Liquids and gases are fluids.

The functional and physical unit of heredity passed from parent to offspring. Genes are pieces of DNA, and most genes contain the information for making a specific protein.

Inherited; having to do with information that is passed from parents to offspring through genes in sperm and egg cells.

A description of a tumor based on how abnormal the cancer cells look under a microscope and how quickly the tumor is likely to grow and spread. Grading systems are different for each type of cancer.

Cancer that starts in blood-forming tissue such as the bone marrow and causes large numbers of blood cells to be produced and enter the bloodstream.

One of a pair of organs in the chest that supplies the body with oxygen, and removes carbon dioxide from the body.

Cancer that begins in cells of the immune system. There are two basic categories of lymphomas. One kind is Hodgkin lymphoma, which is marked by the presence of a type of cell called the Reed-Sternberg cell. The other category is non-Hodgkin lymphomas, which includes a large, diverse group of cancers of immune system cells. Non-Hodgkin lymphomas can be further divided into cancers that have an indolent (slow-growing) course and those that have an aggressive (fast-growing) course. These subtypes behave and respond to treatment differently. Both Hodgkin and non-Hodgkin lymphomas can occur in children and adults, and prognosis and treatment depend on the stage and the type of cancer.

A disease in which cells of the lymphatic system grow excessively. Lymphoproliferative disorders are often treated like cancer.

Cancerous. Malignant tumors can invade and destroy nearby tissue and spread to other parts of the body.

The edge or border of the tissue removed in cancer surgery. The margin is described as negative or clean when the pathologist finds no cancer cells at the edge of the tissue, suggesting that all of the cancer has been removed. The margin is described as positive or involved when the pathologist finds cancer cells at the edge of the tissue, suggesting that all of the cancer has not been removed.

A diagnostic indication that disease may develop.

A form of cancer that begins in melanocytes (cells that make the pigment melanin). It may begin in a mole (skin melanoma), but can also begin in other pigmented tissues, such as in the eye or in the intestines.

Too small to be seen without a microscope.

A thick, slippery fluid made by the membranes that line certain organs of the body, including the nose, mouth, throat, and vagina.

The National Cancer Institute, part of the National Institutes of Health of the United States Department of Health and Human Services, is the Federal Government's principal agency for cancer research. The National Cancer Institute conducts, coordinates, and funds cancer research, training, health information dissemination, and other programs with respect to the cause, diagnosis, prevention, and treatment of cancer. Access the National Cancer Institute Web site at http://www.cancer.gov. Also called NCI.

A federal agency in the U.S. that conducts biomedical research in its own laboratories; supports the research of non-Federal scientists in universities, medical schools, hospitals, and research institutions throughout the country and abroad; helps in the training of research investigators; and fosters communication of medical information. Access the National Institutes of Health Web site at http://www.nih.gov. Also called NIH.

A doctor who identifies diseases by studying cells and tissues under a microscope.

The description of cells and tissues made by a pathologist based on microscopic evidence, and sometimes used to make a diagnosis of a disease.

PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at http://www.cancer.gov/cancertopics/pdq. Also called Physician Data Query.

A molecule that contains two or more amino acids (the molecules that join together to form proteins). Peptides that contain many amino acids are called polypeptides or proteins.

Having to do with the parietal peritoneum (the tissue that lines the abdominal wall and pelvic cavity) and visceral peritoneum (the tissue that covers most of the organs in the abdomen, including the intestines).

An abnormality of chromosome 22 in which part of chromosome 9 is transferred to it. Bone marrow cells that contain the Philadelphia chromosome are often found in chronic myelogenous leukemia.

A thin layer of tissue that covers the lungs and lines the interior wall of the chest cavity. It protects and cushions the lungs. This tissue secretes a small amount of fluid that acts as a lubricant, allowing the lungs to move smoothly in the chest cavity while breathing.

A laboratory method used to make many copies of a specific DNA sequence. Also called PCR.

The likely outcome or course of a disease; the chance of recovery or recurrence.

A molecule made up of amino acids that are needed for the body to function properly. Proteins are the basis of body structures such as skin and hair and of substances such as enzymes, cytokines, and antibodies.

One of two types of nucleic acid made by cells. RNA contains information that has been copied from DNA (the other type of nucleic acid). Cells make several different forms of RNA, and each form has a specific job in the cell. Many forms of RNA have functions related to making proteins. RNA is also the genetic material of some viruses instead of DNA. RNA can be made in the laboratory and used in research studies. Also called ribonucleic acid.

When referring to a medical test, specificity refers to the percentage of people who test negative for a specific disease among a group of people who do not have the disease. No test is 100% specific because some people who do not have the disease will test positive for it (false positive).

A column of nerve tissue that runs from the base of the skull down the back. It is surrounded by three protective membranes, and is enclosed within the vertebrae (back bones). The spinal cord and the brain make up the central nervous system, and spinal cord nerves carry most messages between the brain and the rest of the body.

Mucus and other matter brought up from the lungs by coughing.

Performing exams and tests to learn the extent of the cancer within the body, especially whether the disease has spread from the original site to other parts of the body. It is important to know the stage of the disease in order to plan the best treatment.

A doctor who removes or repairs a part of the body by operating on the patient.

A procedure to remove or repair a part of the body or to find out whether disease is present. An operation.

A group or layer of cells that work together to perform a specific function.

An abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Tumors may be benign (not cancer), or malignant (cancer). Also called neoplasm.

A substance that may be found in tumor tissue or released from a tumor into the blood or other body fluids. A high level of a tumor marker may mean that a certain type of cancer is in the body. Examples of tumor markers include CA 125 (in ovarian cancer), CA 15-3 (in breast cancer), CEA (in ovarian, lung, breast, pancreas, and gastrointestinal tract cancers), and PSA (in prostate cancer).

Fluid containing water and waste products. Urine is made by the kidneys, stored in the bladder, and leaves the body through the urethra.

Having to do with the vagina (the birth canal).