The pathology report is a legal document that transmits diagnostic information to the patient care provider in order to direct appropriate treatment and management. The treating physician must be able to understand the diagnosis or interpretation of the biopsy sample in order to discuss the findings with the patient and to determine patient-centered, personalized care for that patient. All pathology reports should therefore relate clear, consistent information with language that is uniformly understood by pathologists and clinicians. Having a standardized interpretation scheme provides a framework for pathologists from around the world to use for consistent, clear communication of cytological and ancillary testing results [1–4].

Report formats vary by laboratory information system. Some systems allow for pathologists to delete headings in the report and others do not. Most cytopathology reports include three sections: a section on specimen quality, a section for the interpretation category, and a section for the diagnosis. Indicating the quality of the sample and any associated limiting factors to interpretation provides important feedback information to the clinician who performed the biopsy as well as other treating physicians regarding the reliability of the sample for diagnosis. For example, an indeterminate interpretation of atypical or suspicious is better understood when prefaced by “evaluation limited by scant cellularity” or “evaluation limited by crush and air-drying artifact.” Satisfactory for evaluation indicates that the sample is sufficiently cellular and preserved for cytological evaluation and diagnosis.

The interpretation category simply provides a heading that more broadly classifies the lesion being diagnosed. An interpretation category provides clarity to interpretations that may be descriptive, and correlates with follow-up, at least to some degree. For example, a diagnosis of “atypical glandular cells suspicious for adenocarcinoma” is more likely not to be misinterpreted as diagnostic of adenocarcinoma when the heading is “suspicious”. Patients with unresectable disease must have a repeat procedure in order to qualify for neoadjuvant therapy, whereas patients with resectable appearing masses will go to surgery.