Step 3. The Gross Description

Step 3. The Gross Description

Correlation between the macroscopic and microscopic findings is important when evaluating a specimen and rendering a diagnosis. Just as glass slides represent a permanent record of the histologic findings, the gross description re-presents a permanent record of the specimen’s macroscopic features. The goal of the gross de-scription is threefold. First, it serves as a descrip-tive report that enables the reader to reconstruct the specimen mentally and envision the location, extent, and appearance of the pathologic process. Second, it serves as a slide index, enabling the pathologist to correlate each slide to a precise lo-cation on the specimen. Third, it accounts for the distribution of the tissue, documenting how a specimen has been apportioned for various diag-nostic and research purposes.

To help reconstruct an image of a specimen, the gross description must be logical, factual, and succinct. A logical description is one that follows an orderly sequence. The first sentence should identify the patient and the specimen. It should tell the reader who the patient is, what the speci-men is, and what structures are present. The de-scription should then move from one individual component of the specimen to another in a method-ical progression. Proceed from overall to specific, from abnormal to normal, and from relevant to ancillary. The best way to avoid a description that is fragmented and chaotic is to dictate after the specimen has been dissected and examined. This approach allows one to gather all of the informa-tion, then integrate the gross findings into a nar-rative that is comprehensive and complete.

A factual description is one that records the objective characteristics of the specimen. With few exceptions, these characteristics include the size, weight, color, shape, and consistency of the specimen and any specific lesions. Among these, size is particularly important. For exam-ple, in resections of neoplasms, the size of the neoplasm is critical in staging the tumor, and the distance from the edge of the tumor to the surgical margin may help to determine the adequacy of excision and the need for adjuvant therapy. For excisions of parathyroid glands, the important distinction between a normal and proliferative gland is made on the basis of the gland’s weight.

Quite commonly, the gross description is so diluted by trivial details and technical minutiae that the important macroscopic features are not easily recognized by the reader. A concise dicta-tion is one that ignores this minutiae and records only information that serves to achieve the three goals of the gross description. A leaner descrip-tion can often be achieved by cutting the fat from two areas of the gross description. First, eliminate verbose descriptions of normal anat-omy. Descriptions of normal structures should be restricted to pertinent negative findings and to terse statements about size, color, consistency, and shape that help reconstruct the appearance of the specimen. Second, do not describe the mech-anics of the dissection. These technical details are already laid out in the dissection manual and do not belong in the gross dictation unless they clarify the histologic findings or unless your dis-section deviates from routine methods (e.g., in-flation of a lung with formalin).

Another important function of the gross de-scription is its role as a slide index (Appendix 1-B). The slide index places each histologic slide in its appropriate anatomic context. Consider, for example, the importance of knowing whether a section of a neoplasm was sampled from the center of a tumor or from the margin of surgical resection. Only the prosector knows for sure where and how the specimen was sampled, and it is the prosector’s responsibility to communicate this information in the gross description. This information should be summarized at the end of the gross description in the form of a slide index. The slide index should state the number of pieces submitted in each tissue block, the designations used to identify each tissue block, and the precise meanings of these designations. Tissue desig-nation should strive for simplicity, rationality, and standardization. The designations them-selves should use as few letters or numbers as possible, but the meanings of these designa-tions should be specific. For example, two sec-tions of tumor could be designated ‘‘TA’’ and ‘‘TB,’’ respectively. Remember that slides are fre-quently sent to other hospitals for consultation, and so these designations also need to be clear to someone not familiar with your institutional idiosyncrasies.

The gross description should also document the distribution of tissue for diagnostic and/or research purposes. Sometimes tissue may be sent for ancillary diagnostic studies including electron microscopy, cytogenetics, and flow cytometry. In some instances fresh tissue may be frozen and stored in a tissue bank so that it can be retrieved at a later time, or tissue may be requested by various laboratories for research purposes. Not only is it important to supervise (under the guidance of a pathologist) the distribution of these tissues, but it is also important to document in the gross de-scription where the tissue has been sent and for what purposes.

Other methods may be used to supplement the description of the macroscopic findings. Among them, photography plays an espe-cially versatile role. Indeed, recent advances in computer technology have expanded the role of photography as an adjunct to the gross dictation. Digital images of the gross specimen can be stored as electronic files, which can be readily retrieved for publication or research purposes or simply to clarify the gross description. Liberal photog-raphy is a practice that is to be encouraged as an effective supplement to the gross description.

Finally, remember that the gross description is a legal document, so the typed gross descrip-tion should be proofread as carefully as the final diagnosis.