1. Specimen(s): From which organ(s) was/were the tissue sample(s) taken?
2. Pre-operative diagnosis: Testing is being done to confirm whether or not the patient has this type of cancer.
3. Gross description: This section describes what the tumor sample looks like to the naked eye: size, weight, and color. “In some cases, gross size is as important as the microscopic findings,” says Roswell Park Pathologist Charles LeVea, MD, PhD. “With breast cancer or lung cancer, for example, the size of the tumor helps determine the stage of the cancer. In other types of tumors, such as endometrial cancers, the microscopic depth of invasion helps determine the stage of the cancer.”
4. Diagnosis: This section reports what the microscope revealed about the tissue sample: Is it cancerous or not? If it is cancerous, how different from normal cells are the cancerous cells? The information provided will help the medical team predict how aggressive the cancer is and decide the best options for treatment.
Additional testing may be required to pinpoint a sub-type of cancer – for example, further testing of a breast tumor may indicate that a very specific type of treatment is needed. The results of additional testing are listed in a second report called an addendum.
The Diagnosis section will also indicate whether the outer edges of the tissue sample show evidence of cancer. If so, the sample has positive margins, and additional surgery may be needed to remove remaining cancerous tissue. A sample with no cancer cells at the outer edges has negative, clear, or free margins, which shows that all the cancer has been removed. In certain circumstances, the tumor may be close to a margin. This distance is measured and reported. The surgeon may use this information to decide whether additional surgery is needed.