The Biopsy Report
For many health problems, a diagnosis is made by removing a sample of tissue for study in the pathology laboratory. The biopsy report describes the findings of a specimen.
After the specimen is removed from the patient, it is processed as a histologic section or a smear.
- histologic sections
Histologic sections are very thin slices of the specimen that are stained and placed on a glass slide, and then covered with a thin piece of glass called a coverslip. Histologic sections are prepared in one of two ways:
- permanent sections - the specimen is put into a fluid called a fixative for several hours, depending on the specimen type; the fixed specimen is put into a machine which removes the water from the specimen, and replaces it with paraffin wax. The paraffin-impregnated specimen is embedded into a larger section of molten paraffin, and solidified by chilling. A machine called a microtome cuts thin sections of the paraffin block containing the biopsy specimen. The sections are then placed on a glass slide and dipped into a series of stains or dyes to change the color of the tissue. The color makes cells more distinctive when viewed under a microscope .
- frozen sections - the specimen can be examined shortly after it was removed from the patient. For example, surgical pathologists work closely with the surgeons during surgery for breast cancer. Often, a frozen section is used to determine how much of the breast tissue to remove.
Smears are done when the specimen is a liquid or there are small, solid chunks suspended in liquid, which are "smeared" onto a slide and 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 a specimen. It contains the following information:
- gross description
A gross description is the obvious examination of the specimen which 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 examination
A microscopic examination is a description of what the findings of the slides showed under a microscope; it is usually technical and not in simple language.
This is usually considered the "bottom line" and, 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. For example: colon, sigmoid, endoscopic biopsy, tubular adenoma. In other words, the patient had a biopsy of the sigmoid portion of the colon via endoscopy, and a benign tumor of the large intestine and rectum was found.
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