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Is my pathology report complete without mention of microscopic section?

This Premium Q&A, reviewed and published, features a real conversation between an iCliniq user and a physician.

Patient's Query

Hello doctor,

I recently underwent hysteroscopy and D and C, and laparoscopic surgery due to postmenopausal vaginal bleeding and a transvaginal ultrasound that showed 1 cm of thickness, a uterine polyp, and an endometrioma on the right ovary. The path report had a gross-section and a diagnosis section, no microscopic section. The diagnosis on the polyp was an endometrial polyp. There is no mention of the endometrium. My doctor's office is saying there is no mention because the pathologist was not concerned about anything. This report seems incomplete to me. There was slightly more said about the ovary. Is this a complete report? Should I expect more of a description of the endometrium to be sure cancer is not present?

Hello,

Welcome to icliniq.com.

The full pathology report of any tissue includes a gross description, microscopic examination findings, and diagnosis. So, In this way, your report might be written. If cancer is present, then atypical malignant cells in microscopy are seen along with gross growth also. Your diagnosis is a polyp, which is a benign condition. Provide your report as an attachment for giving more comment on that.

Patient's Query

Hi doctor,

Thank you for the reply. This is the path report. The ultrasound showed both a polyp and 0.39 inches of endometrial thickness with a small cyst. I am concerned that the endometrium is not commented on.

Hello,

Welcome back to icliniq.com.

Here, in attached report (attachment removed to protect patient identity) pathologist has clearly mentioned that endometrial polyp is present. The submitted whole endometrial curettage specimen has been processed for histopathology examination. So I do not think any malignant cells present in that section as not mentioned by the pathologist. Here, microscopic examination findings are not mentioned in the report but anyway final diagnosis is mentioned. Usually, microscopic examination findings also should be written in histopathology report to make it complete. As far as the endometrial report is concerned, in curettage specimen, malignancy is not present as in diagnosis only polyp finding is present.

Medically reviewed byDr. K. Shobana
Published At May 30, 2018
Reviewed AtJuly 31, 2023

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