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1. Macroscopic findings |
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examination report
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The pathologist starts his examination of the sent tissue with the
macroscopic description. This includes stating the original
localization of the removed organ, its size, consistency and colour, as
well as tissue- and tumour-specific descriptions.
A typical macroscopic report may be as follows:
Colonic polyp taken from the colon sigmoideum: pedunculated polyp
measuring 2 x 1.3 cm with a smooth surface, of soft consistency and
brownish-reddish colour. Tissue divided and embedded in toto.
In the first part of the description, the clinical information on the
original localization of the removed organ is repeated exactly. This is
followed by the exact macroscopic description of the investigation
material. This contains important information for the pathologist. In
many cases (surgical excisions), the dignity of the lesion can
already be assessed based on the macroscopic findings. This is of
utmost importance for a timely preparation the tissue, since in certain
malignant tumours particular, time-consuming additional analyses are
necessary in order to obtain an exact tumour diagnosis. Basically, the
shortened preparation period has two major advantages: financial ones
(shorter periods of hospitalization), higher degree of patient
contentment (by receiving definite results sooner). The additional
information – tissue divided and embedded in toto – is made for the
benefit of internal quality management in the histopathological
laboratory.
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2. Microscopic findings |
The microscopic report contains a morphological description of the
tissue prepared as 5 µm “histological” slides (in this case:
colonic polyp). It describes the tissue and its components, the cells.
A typical microscopic report may be as follows:
Polypous structure. Tubulo-villous growth pattern, mild epithelial
dysplasia. Minor infiltration of round cells, consisting of
lymphocytes, plasma cells and histiocytes. Margins free of epithelial
dysplasia. No atypical cells.
The microscopic report contains a large number of technical terms which
are not part of our everyday language. By using this terminology, the
pathologist can give a very detailed description of the alterations. It
helps in communicating with other pathologists, for example when a
second opinion is required, but is also part of the quality management. |
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3. Critical comment |
The critical comment contains the final diagnosis, obtained empirically
and by argument on the basis of the macroscopic and microscopic
investigation.
In our example, this will be:
Tubular adenoma with mild epithelial dysplasia in the colon sigmoideum.
Margins free of epithelial dysplasia. No indication of malignancy.
The critical comment contains the diagnosis and other relevant
information to the doctor in charge, whether the alterations are benign
or malignant and whether further surgical interventions will be
necessary.
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