Gross examination of surgical specimens
ILOs:
Types of tissue biopsies
Items to be described in gross examination
Value of gross examination in surgical specimens
Examples of specimens with gross examination
Introduction:
Gross examination is the process by which pathology specimens are inspected with bare
eye to obtain diagnostic information, while being processed for further microscopic
examination.
Gross examination of surgical specimens is typically performed by a pathologist, or a
pathologist assistant working within a pathology practice. Individuals trained in these
fields are often able to gather diagnostically critical information in this stage of
processing, including the stage and margin status of surgically removed tumors.
Gross examination of a kidney with a renal oncocytoma (left of image)
Types of tissue biopsy:
Used when the patient cannot feel a tumor
or when the area is deeper inside the body
During this procedure, a doctor guides the
Image-guided needle to the location with the help of an
biopsy imaging technique
Can be done using a fine needle, core, or
vacuum-assisted biopsy and assisted with
CT, MRI or fluoroscopy
It is done by using a very thin, hollow needle
Fine needle attached to a syringe
aspiration Used to collect a small amount of tissue from
biopsy the suspicious area to examine
This type of biopsy uses a larger needle to
remove a larger tissue sample
Core needle It is similar to fine needle biopsy and is also
biopsy minimally invasive
This type of biopsy uses a suction device to
Vacuum- collect a tissue sample through a specially
assisted designed needle
biopsy
These two procedures are similar and doctors use them at same
Bone marrow time to examine bone marrow
aspiration and Bone marrow has a solid part and a liquid one
biopsy o A bone marrow aspiration removes a sample of the fluid
with a needle
o A bone marrow biopsy removes
a small amount
of solid tissue using a needle
Doctors use these procedures to
find out if a person has a blood disorder
or blood cancer
(leukemia, lymphoma, or multiple
myeloma)
A common site for a bone marrow
aspiration and biopsy is the pelvic bone
Endoscopic biopsy
Punch biopsy
Other types Shave biopsy
Excisional biopsy
Laparoscopic biopsy
Liquid biopsy
Items to be described in gross examination:
The gross description may include:
Description of how specimen is received and labeled:
o Formalin vs Other fixative vs No fixative “fresh”
o Patient’s name – medical record number – tissue site
and type
o If designation is not present on the container label,
indicate as such
Identify specimen components and/or parts:
o Organ and tissue type and, if applicable, each part
o Call an organ by its name unless it is not recognizable as such
o Include procedure if applicable
o Indicate clinician’s ink, specimen orientation by suture or ink
Take the measurements and weights:
o Measure specimens in metric units in 3 dimensions (2 if cylindrical or flat),
from largest to smallest dimension unless specifying which dimension
o Weight in metric units: Uterus – Endocrine – Breast reduction – Spleen –
Kidney – Liver – Lung – Heart – Prostate – Testis – Pituitary – Brain –
Ovarian tumor – Others (if requested by surgeon)
o For cystic lesions weigh before emptying the contents
Special studies or procedures:
o Specify study by microbiology, flow cytometry, electron microscopy,
cytogenetics, molecular studies, frozen tissue bank, photography, touch
preps, decalcification
Ink colour code:
o Indicate the ink location (where you have applied it) and the colour
o It is highly desirable to consistently ink the specimen in terms of colour in
relation to specimen orientation
Below is a recommended colour scheme:
Blue Green Black Red Orange
Superior Inferior Posterior/Deep Medial Anterior Lateral
If 2 or 3 colours are needed Orange, Black and Blue are preferred
Description:
o Shape and configuration: round, spherical, ovoid, elliptical, cylindrical,
rectangular, irregular, polypoid, exophytic, endophytic, gyriform, ulcerated,
heaped-up, raised, flat, linear, whorled, bulging, multiloculated, cystic,
vesicular, globular etc.
It is acceptable to say “of the usual shape” when dealing with an entire
organ
o Color: red, tan-brown, red-purple to brown-black, transparent, hemorrhagic
etc.
o Texture: : smooth, rough, soft,
firm, bony, mucoid, friable,
rubbery, necrotic, fluid,
consolidated, dry etc.
o Odor: only if obvious (don’t
routinely sniff specimens,
especially if in formalin): rancid,
burnt etc.
o Indicate frozen section tissue
(FS1A or FSA1)
o State if entirely submitted or
representatively submitted
o Gross only specimens: mention
identifying inscriptions
Section code:
o Label each cassette with a number or letter, or combination of both
depending on the lab's designation system
o Indicate the content of each cassette, esp. if it is a resection margin or
frozen section remnant
o Specify how many pieces of specimen in each cassette
o Summarize the total number of cassettes / blocks
o Indicate special studies and designate those cassettes
1A 1B 1C B1
Proximal Distal resection Mass lesion Lymph node
resection margin For DiPAS stain Bisected
margin 2 pieces +10 unstained for Frozen section
1 piece immunohistochemistry remnant
Total 4 blocks, 4 H & E, 1 DiPAS, and 1 CK20, 1 CK7, 1 ErBP4, 1 Calretinin
Larger biopsy or tissue specimens, such as a mastectomy for breast cancer, will
have much longer descriptions including:
o the size of the entire piece of tissue
o size of the cancer
o how close the cancer is to the nearest surgical margin (edge) of the
specimen
o how many lymph nodes were found in the underarm area
o the appearance of the non-cancer tissue
For cytology specimens, the gross description is very short and usually notes the
number of slides or smears made by the doctor. If the sample is a body fluid, its
color and volume are noted
Value of gross examination in diagnosis of surgical specimens:
Gross examination of pathological tissue specimens forms an important part in reaching
at a correct diagnosis and is crucial to understand the nature and extent of disease in
both a structural sense and a specific clinical context
Accurate gross description and observation of the pathology specimen can give many
clues to aid in the final diagnosis and it can be achieved in as many as 90% of specimens
on the basis of gross examination alone For example: Accurate diagnosis can often be
made based on the classic gross appearance of a lung lesion. On the other hand,
inaccurate diagnosis or wrong tumor staging is unavoidable if lesions are missed,
unrecognized, or inadequately sampled . Different grossing techniques should be used for
grossing neoplastic and nonneoplastic lung specimens
In the remaining 10 % the skilled pathologist can be close to the diagnosis or can, at least,
construct an accurate differential diagnosis that can provide guidance for subsequent
studies
Sadly the numbers of pathologists with skills in macroscopic "gross" pathology is rapidly
declining, with concomitant loss in the quality of gross examinations, lower accuracy and
elegance of specimen descriptions, and lack of precision in sample selection for special
studies. This clearly impacts the quality of surgical pathology practice and, inevitably, the
quality of patient care
What is the gold standard of pathology?
Morphology is subjective and affected by the examiner’s experience
the most appropriate is to determine the accuracy, as a measure of diagnostic
adequacy; it suggests that the majority of qualified pathologists will agree on a
similar diagnosis when analyzing the same specimen
The gross description is important mainly to ensure that what is received in the
pathology laboratory and submitted for microscopic examination matches the
slides returned from the histology laboratory for the pathologist to examine.
Disparity between the findings on a slide and those expected based on the gross
description is often the only clue that a slide or block may have been mislabeled. A
good gross description therefore should be precise and brief
For operative specimens, particularly those containing a malignancy, information
in the surgical pathology report should describe the extent of the tumor and
specific features that relate to prognosis and staging. The adequacy of the surgical
treatment as well as the need for additional therapy depends on these findings
Examples of specimens with gross examination:
1. Solitary secondary infected amoebic liver Abscess
a. Specimen: Slice of the liver
b. Shape: Wedge shaped
c. Border: Thick capsule
d. Consistency: firm
e. C/S: Single cavity
f. Size: 16 X 7 cm
g. Shape: oval
h. Site: extending toward the surface of the
liver
i. Lining: yellow shreddy necrotic tissue
surrounded by red zone of hyperemia due
to associated secondary infection
2. Familial polyposis coli
a. Specimen: one is segment of colon & the other
one includes terminal ileum, caecum & ascending
colon
b. Size: Each segment measures about 30 cm
c. Lesion: Both colonic segments show polyps,
Innumerable & condensed on each other
d. Size: ranging from few mms → 1.5 cm
e. Tips → of some are dark red (hemorrhagic)
f. Mucosa in between polyps no apparent healthy
mucosa
g. The lower part of ileum → free of polyposis
3. Malignant ulcer lower third esophagus
a. Specimen: esophagus
b. Size: 15 cm in length
c. Lower part shows ulcer:
i. Site: lower part with its longitudinal axis
parallel to that of the esophagus
ii. Size: 5 x 3 cm
iii. Shape: oval
iv. Edge: elevated everted
v. Floor: necrotic
vi. Base: hard fixed
