Main Guidelines for Pathology Report

A correct diagnosis inaccurately, inadequately, or incorrectly conveyed and acted upon can be as dangerous and harmful as a wrong diagnosis.  As a key component of the electronic medical record, pathology reports in highly personalized styles that are inconsistent and variable have degraded their rightful usability  for valuable insight into the patient and new discovery by data mining. Formulation of pathology report to accurately convey the diagnostic information requires more than general literacy. Unfortunately, this skill is largely neglected in our clinical training and in scholarly publications.  Although it is impossible and unwise to impose rigid formulae or styles for reporting diagnosis, some general guidelines should be followed.  This section introduces some of these guidelines and commonly-used diagnostic wording formats and styles although such attempts may inevitably seem subjectively prescriptive. It is hoped that the content in this section will help produce pathology reports that are clear in their intent, accurate without restriction on personal styles, and compatible with particular clinical settings.

Render complete diagnosis with key attributes

A good pathology diagnosis should include critical information to guide clinical management of the patient. Almost all pathology diagnoses encompass "qualitative" characteristics and "quantitative" attributes. The former indicate what it is -- e.g., "invasive mammary ductal carcinoma" or "acute ischemic colitis" whereas the later specifies how severe the pathological changes are. One disease (diagnostic entity) can vary greatly in its severity, extent of involvement and, as a result, its clinical outcome. Since quantitative attributes of a diagnostic entity often dictate its clinical management, it is important to include key quantitative attributes in the pathology report. Using the "Checklist" by CAP or structured reporting system by others to report resected malignant tumors are good examples. Such strategies should apply not only to neoplastic diseases but also to non-neoplastic (e.g., inflammatory and infectious) disease entities. Thus, a complete diagnosis should include information about both qualitative and quantitative aspects of a disease. Reporting prostatic adenocarcinoma in a needle core biopsy is a typical example and the recent recommendation by a panel of experts support this advocacy. For non-neoplastic lesions, the pathology report should also include five key elements: the key pathology diagnosis, severity, extent, etiology, and margins, if applicable. Many suggested reporting formats in this book follow this logic.

Report in response to specific clinical inquiry

Routine diagnostic pathology is largely a consultation service to other clinical disciplines. A good pathology report should address the specific clinical questions raised by our clinical colleagues, even when these inquiries may not seem relevant to the histologic findings. By doing so, confusions can be minimized, unnecessary phone calls can be avoided, and errors can be prevented. The most common reason for phone calls  from the clinician on a pathology report is not a wrong diagnosis but rather failure to address his/her clinical concerns. The clinical inquiry may be explicit (e.g., "liver mass, r/o mets v.s. HCC.") or implied (e.g., 76-year old man with reflux). If you only report "Mild reflux esophagitis with rare intraepithelial eosinophils" for an elderly patient with dysphagia, phone call from the clinician is likely asking questions such as "is there Barrett's ?", "did you see dysplasia?", "could you amend the report to indicate whether there is erosion?" etc. Of course, it is not always possible to predict precisely what the clinician will question, but a helping mind-set to address clinical concern guided by relevant differential diagnoses helps formulate effective and complete pathology reports.

Take key clinical findings / setting into consideration

Because of sampling issue and the non-specific nature of some changes, interpretation of morphologic abnormalities must be made with consideration of other clinical findings. For example, we frequently obtain small or superficial fragments of colonic mucosa with adenomatous changes that most often represent an adenoma and can be reported as such.  However, if the biopsy is from an "obstructive mass", an invasive carcinoma has to be suspected and simply reporting such findings as "adenoma" can be misleading with potential adverse consequence. Unfortunately, the key clinical findings are not always directly provided to the pathologist.  Obtaining the patient's history by review of the patient's medical record and/or discussion with the referring clinician is important in the practice of pathology.

The pathology report should also be tailored to the relevant clinical setting.  This means that the same diagnostic entity (disease) with similar histologic features may be reported differently depending upon the clinical situation. For example, “No glandular dysplasia or carcinoma” may not be necessary in reporting esophagitis in a 14-year old, but should be included in the report for an elderly patient with dysphagia.  A scant endometrial specimen in a 65-year old woman is considered adequate and “normal” but may not be adequate for evaluation of  an enlarged uterus.of a 42-year old with abnormal vaginal bleeding.

Be consistent in applying diagnostic criteria and wording in the report

Obviously, we must be consistent in applying diagnostic criteria to minimize inter- and intra-observer variability. If different diagnostic criteria or grading / staging schemas exist, it should be specified which one is used in the current report. Consistency in diagnostic wording is another important aspect of pathology reports. One of the main unnecessarily daunting challenges facing our clinical colleagues is to accurately decipher the key diagnostic information in a pathology report with diverse personal styles, divisional formats, subspecialty jargans, semantax etc.

Well-defined standard terminology and vocabulary are highly desirable in pathology reports. The importance of this becomes readily apparent when the case is referred to another institution for treatment, or when retrieval of a specific report from a large hospital medical record system (EMR) is necessary. Unless the terminology is commonly understood, errors in communication will inevitably occur. Consistency is also the foundation of standardization and data interoperability.

Pragmatic Recommendations

Convey the degree of diagnostic certainty / uncertainty:

Because of inevitable limitations such as specimen quality, lack of relevant clinical inflammation or unfamiliarity with the entity, etc., we render diagnoses with different degrees of certainty. This is well reflected by frequent presence of these terms such as "consistent with", "compatible with", "suspicious for", "suggestive of", "most likely", "probably". There is little disagreement that the degree of diagnostic certainty should be conveyed and documented in pathology report; however, there is no criteria as to the degrees of certainty conveyed by these different terms. The problem is further compounded by inter- and intra-observer variability in interpreting these ambiguous terms and accessing the degree of certainty to be conveyed.  In a commentary published in The American Journal of Pathology, Idowu and colleagues bring our attention to this important and long neglected issue in pathology practice. However, the question remains: if it's not possible to render absolute diagnosis in all cases - i.e., uncertainty cannot be eliminated, how do we convey the degree of uncertainty without using these "Ambiguous terminologies"? Although the sematic definition can be very abstract and subjectively contentious, ranking a set of these terms in the decreasing order of diagnostic certainty may help to understand, remember, and, most importantly, use them in a consistent fashion. In this Diagnosis Wording system, the degree of certainty is expressed in the decreasing order by a relatively small set of slanting adjectives loosely based on their definition in Oxford dictionary.  Recommended phrases used consistently in this system, in the order of decreasing certainty include: diagnostic of , consistent / compatible with, suspicious for, suggestive of .

Anything in existence has its entitled form of expression. Conceptually, anything that cannot be defined does not exist. If the uncertainty of a diagnosis exists, appropriate forms of linguistic presentation should be available. Thus, coming up with these terminologies to describe diagnostic certainty is the first step.  It is reasonable to believe that a better defined set of vocabularies, phrases and quantitative attributes to convey the degree of our certainty will emerge.

Recognize and indicate specimen adequacy:

Validity of morphologic diagnosis depends heavily on whether the specimen is truly representative of the targeted lesion. Tissue representativity has two related aspects:

1) Qualitative – whether morphologic features reflect those of the lesion, which is determined by the accuracy of the tissue sampling.  If tissue sampling fails to include the target lesion or area to be examined, then the pathology diagnosis based on histologic finding alone becomes misleading and has no clinical validity. For example, unremarkable lung parenchyma in a biopsy of a solid enhancing mass of the lung apparently is inconsistent with the clinical scenario even though the histologic diagnosis by itself is correct. Similar scenarios are common clinical occurrences -- cervical biopsy (for dysplasia) without transformation zone, esophageal biopsy (for Barrett’s / dysplasia) without squamous-glandular junction).

2) Quantitative – whether all morphologic features of the lesion are represented in the specimen, which is often determined by the amount of tissue sampled. For example, when mucosal biopsy of a colonic “mass” may only show some but not all features to meet diagnostic criteria of an invasive adenocarcinoma, should the “mass” be diagnosed as an adenoma, or adenocarcinoma?

Thus, it seems imperative to indicate the adequacy of tissue sample so that the validity of the morphologic diagnosis can be put in context. However, how specimen adequacy should be conveyed and documented in pathology report is still a quite opinionated subject. The main strategy recommended in this book is to take a factual approach, i.e., describe without justifying.

Address discrepancy

Discrepancy between histological findings and clinical observations is often a red-flag that should not be ignored. It frequently results from sampling errors. For example, small fragments of "adenoma" from an obstructing rectal mass almost always indicative of an underlying adenocarcinoma.  Histologically normal lung or liver tissue from "liver mass" or "lung mass" most likely results from missing the targeted mass during biopsy. Indicating such discrepancy in the report and recommending re-biopsy or other diagnostic modalities is warranted.

Discrepancy may also occur between current pathology interpretation and a previous diagnosis. Correlation of diagnosis in cervical biopsy with previous cytological interpretation is a well-known example.  

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Idowu, MO et al.: Equivocal or Ambiguous Terminologies in Pathology: Focus of Continuous Quality Improvement? American Journal of Surgical Pathology.  37 (11): 1722–1727, 2013,  doi: 10.1097/PAS.0b013e318297304f