Step 3. The Gross Description
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.
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.
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.
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
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.
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.
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
remember that the gross description is a legal document, so the typed gross
descrip-tion should be proofread as carefully as the final diagnosis.