Understanding your medical notes
Pathology report explained: how to read yours in plain English
A pathology report describes what a specialist doctor — a pathologist — found when examining tissue, cells or fluid taken from your body. It's one of the most technical documents a patient ever receives, and it follows a fixed structure that makes sense once you know it. This guide walks through that structure section by section.
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Explain my pathology report → Your text isn't stored. Available on web, iOS & Android.What is a pathology report?
Whenever a sample is taken from your body — during a biopsy, an endoscopy, an operation, or a screening test like cervical screening — it usually goes to a pathology laboratory. There, it's examined by eye and under a microscope, sometimes with extra laboratory tests. The pathology report (you may also see "histology" or "histopathology" report for tissue, or "cytology" for cells) is the pathologist's written account of that examination, addressed to the doctor who sent the sample.
What a pathology report usually contains
Exact headings vary between laboratories, but most reports include some or all of these sections:
- Specimen and clinical details — what was sampled, from where, and the clinical question the pathologist was asked ("clinical history" or "clinical details").
- Macroscopic (gross) description — what the sample looked like to the naked eye: size, colour, texture. Routine and descriptive; often the least important part for you to understand.
- Microscopic description — what the cells and tissue looked like under the microscope. This is where the densest terminology lives: words like "atypia" (cells looking unusual), "hyperplasia" (increased cell numbers) or "in situ" (contained within its original layer).
- Diagnosis or conclusion — the pathologist's overall interpretation, usually at the end. This is the section your clinicians act on.
- Margins — for surgically removed tissue, whether the abnormal area reaches the edges of what was removed, often with a distance in millimetres.
- Biomarkers and additional tests — results of extra tests such as immunohistochemistry (IHC) or molecular studies, which may arrive in a supplementary report marked "to follow".
Reports may also carry laboratory codes (such as SNOMED codes) — these are for records systems, not messages about your health.
Terms you may see, in plain English
| Term | What it refers to |
|---|---|
| Histology | The study of tissue under the microscope |
| Cytology | The study of individual cells (e.g. from a smear or fluid) |
| Benign | Not cancer |
| Malignant | Cancerous |
| Atypia | Cells that look different from usual under the microscope |
| Hyperplasia | An increased number of cells in a tissue |
| In situ | Abnormal cells contained within the layer where they started |
| Differentiation | How closely cells resemble the normal tissue they came from |
| Margins | The edges of surgically removed tissue |
| IHC | Immunohistochemistry — a staining test for markers on cells |
| NAD | No abnormality detected |
What any of these mean in your case depends on context only your care team has — the same word can carry very different implications in different reports.
See the difference
Original report wording
"Skin, left forearm, punch biopsy: sections show a compound naevus with no evidence of atypia. Completely excised."
Plain-English version
"A small skin sample from the left forearm shows a common type of mole. The report does not describe any unusual-looking cells, and it states the mole was fully removed."
Illustrative example only — not based on a real patient.
Reading your own pathology report?
Paste it into Patiently AI and get each section explained in plain English — the exact terms in your report, decoded in context, with questions worth asking your care team.
Try it with your own report → Paste, upload, or photograph your pathology report.Questions you may want to ask about your pathology report
- What is the main finding in the conclusion section?
- Was the sample sufficient, or might anything need repeating?
- What do the margins mean in my case?
- Are any further tests planned or pending, and what are they looking for?
- What happens next, and who will contact me?
These are prompts for a conversation with your care team, not medical advice — Patiently AI drafts a personalised set from your own report.
Frequently asked questions
What is a pathology report?
It's the document a pathologist writes after examining tissue, cells or fluid removed from your body — during a biopsy, an operation, or a screening test. It describes what the sample looked like, what was seen under the microscope, and the conclusion the pathologist reached.
Which part of a pathology report matters most?
The diagnosis or conclusion section — usually at the end, sometimes headed "Diagnosis", "Conclusion" or "Summary". The macroscopic and microscopic sections describe the evidence; the conclusion states what the pathologist made of it. If you read one section, read that one — with your clinician, who can put it in context.
What do "margins" mean in a pathology report?
When tissue is surgically removed, the margins are its edges. The report often states whether the abnormal area reaches the edge and how close it comes, in millimetres — this helps the surgical team judge whether the whole abnormal area was removed. What a particular margin measurement means for your care is a question for your surgical team.
Why does my pathology report say further tests are pending?
Some samples get additional laboratory tests after the first examination — for example immunohistochemistry (IHC) or molecular tests, which look at markers on or in the cells. When a report says results are "to follow" or "pending", a supplementary report usually comes later. Your clinician can tell you what is being tested and when to expect it.
Can Patiently AI explain my pathology report?
Yes. Paste the report — or upload a photo, PDF or Word file — and Patiently AI explains what it says in plain English, decodes terms like atypia, in situ and margins, and suggests questions to ask. It's free, needs no account, and removes identifying details on your device before processing. It explains the language; it doesn't diagnose or judge severity.