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06 Pathologic Examination C. The Diagnosis




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This article is from the The Biopsy Report: A Patient's Guide, by Ed Uthman uthman@neosoft.com with numerous contributions by others.

06 Pathologic Examination C. The Diagnosis

This is analogous to the "bottom line" of a financial report. The
purpose of the gross examination, the processing of the tissue, and
the microscopic examination is to build a logical argument toward a
terse assessment of what significance the biopsy has in regard to
the patient's health. Here is the diagnosis for the colon biopsy,
above:

Colon, sigmoid, endoscopic biopsy: tubular adenoma
(adenomatous polyp)

This format is widely used, but variations occur. The first term is
the organ or tissue involved ("colon"). The second term ("sigmoid")
specifies the site in the colon from which the biopsy was obtained.
The next term ("endoscopic biopsy") denotes the type of surgical
procedure used in obtaining the biopsy. Then follows the diagnosis
proper, in this case "tubular adenoma," a common benign tumor of the
large intestine and rectum, which increases the risk for developing
colorectal cancer in the future. In this particular case, an older
synonym for tubular adenoma, "adenomatous polyp," follows in
parentheses.

 

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