General Approach to Biopsy Reports

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STRUCTURE OF A REPORT

Surgical pathology reports for liver biopsies typically have a section for relevant clinical history, a diagnosis section, and a note or comment section. Some institutions also have a microscopic description. As a general guideline, an excellent pathology report includes a clear diagnosis as well as a concise note or comment that expands or refines the diagnosis when necessary. An excellent pathology report also directly addresses the clinical indication for the liver biopsy. As an illustration, a biopsy was performed for low titer antinuclear antibody (ANA) elevations and mild aspartate aminotransferase (AST) and alanine aminotransferase (ALT) elevations, and the clinical question is rule out autoimmune hepatitis. The biopsy shows mildly active fatty liver disease. The diagnosis of fatty liver disease will be conveyed in the diagnosis section, but the note or comment section should also indicate whether or not there is any evidence for autoimmune hepatitis, because that was the original clinical question.

Microscopic descriptions are included in the pathology report by some pathologists. Microscopic descriptions can add value to the report when used wisely. However, they are not necessary, and it is best to include all key pathology findings in the diagnosis or note or comment section. At times, microscopic descriptions can be somewhat tedious listings of all identifiable histologic findings. These exhaustive descriptions can have some value, particularly if recording information for possible future research studies or in training residents, but key pathology findings should not be buried in a microscopic section among long descriptions of minimal or trivial findings.

FORMAL GRADING AND STAGING SYSTEMS

It is important to accurately convey the amount of inflammation and fibrosis in a biopsy. The amount of fibrosis in chronic hepatitis C, for example, predicts liver-related morbidity and mortality.^1,2

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