The Realm of Grossing Technology in Modern Surgical Pathology Laboratory

Grossing technology has developed into a subspecialty in modern surgical pathology laboratory due to rising number of outpatient surgeries, especially the increasing biopsy specimens. Grossing has become broader than sampling (cut in). While all rules and recommendations of classic grossing techniques remain in place, the assembly line- like processing in surgical pathology laboratories requires a different type of work that takes into account the importance of the silent language of mutual understanding between the pathologist, the grossing person and the histotechnologist. With some local differences in practice, grossing technology includes three main components: specimen accession, grossing (sampling, cut in), and follow- up.

Accession

The large number of biopsies that arrive from different sources in mostly centralized surgical pathology laboratories requires special efforts to prevent specimen misidentification. These measures start upon receipt of the specimen and continue throughout the stages of processing, especially during accession. Advancements, such as bar- coding, gradually become a routine.

During accession, the specimen is triaged according to priority, preservation, ancillary studies, and effective workflow. It is essential to understand the variety of special methods which include, but are not limited to cytology, cytogenetics, molecular pathology, EM, IF, etc. This is the prerequisite for quality assurance, productivity and the turnaround time (TAT).

In surgical pathology laboratory, the surgical number is used for both filing and billing purposes. In many laboratories, the accession process is connected with billing through Current Procedural Terminology (CPT), which requires knowledge of the CPT coding practice.

Grossing itself (sampling, cut in)

Sampling is the “main course” in grossing technology. The grossing technologist’s responsibility is to prepare the specimen for histology processing to make the most diagnostic features of the specimen visible on the slide. The grossing technologist should ensure correct embedding of the specimen or its section. The knife and the ink are the main tools of communication between the grossing technologist, the histotechnologists, and eventually the pathologist. Other numerous responsibilities (description, fixation, etc.) must not obscure this main aim.

Follow- up

Many standard procedures, such as logging in the histology information in the computer, counting cassettes, comparing logs,   etc., are time consuming and boring, but they help the grossing technologist to prevent many mistakes.

The embedding supervision, the correcting gross description and following the pathologist’s diagnoses help to maintain quality and improve performance. Often underestimated, embedding supervision prevents wrong specimen’s presentation on the micro slide, helps histotechs, and teaches the grossing person how to sample the specimen in best way. Occasional embedding some specimens by the grossing technologist ought to be a common practice.

Besides the three main components mentioned above, the grossing technology encompasses more aspects. The safety of the technologists, the co-workers, and the laboratory environment is important part of grossing technology. Maintaining proper condition of the instruments and equipment is also significant part of grossing technologist’s responsibility as well.

Understanding grossing technology details is necessary to ensure the quality of the initial stages of specimen processing in surgical pathology. Grossing technologist, as a subspecialty with broad range of responsibilities in the grossing room, is emerging in surgical pathology laboratory practice.

 

2 Responses to The Realm of Grossing Technology in Modern Surgical Pathology Laboratory

  1. Dan Newfang CIH CSP says:

    G’Day.
    I am a working industrial hygienist at a large research university and have a great opportunity to influence the design of a new Derm/Path lab in one of our clinic/surgical buildings. I was interested in your opinion (if you have one) with the following:

    Personal Background:
    I’m an old experienced guy with ~30 yrs of professional practice during which I became sensitized to formaldehyde (FM). Throughout the rest of my career (to-date) I have been working in/around formaldehyde in one form or another via resins, solutions & gaseous. Your articles & website really speak to my passion which prompted this note.

    This Question Background:
    My current exposure monitoring of our path & histo labs all indicate good ventilation as well as OSHA compliant exposure concentrations to FM. But, there is always one task that “blows our exposure numbers’ and that is the disposal of the gross specimens. The task is disposal of the gross specimens. It’s rather evident that the FM bolus is generated from decanting the formalin into a liquids container as well as the standing red-bag where the specimen is disposed of. There is no local ventilation (whether an exhaust snorkel or slotted hood) for this operation but the lab space has a lot laminar flow through it. Ten, single-pass exchanges per hour which is awesome for general lab work (they also perform their sectioning in grossing hoods which works great with their permanganate exhaust filters). It’s that darn bolus that is generated when the larger samples are decanted. An exhaust snorkel has been proposed but I know via experience (as well as the ventilation equations) the snorkels don’t have a great capture distance nor efficiency. My desire would be to have a “walk-in” style hood that would exhibit a 100-200 fpm velocity thereby having enough air mass to remove the volatiles away from the lab tech and into the exhaust system.

    The grossing storage/disposal station is where I’m looking for your thoughts with regard to my ideas or sharing your own.

    It’s interesting also that no other lab/hospital in the large metro area is worried about this “bolus” exposure. My belief is their IH monitoring has not been granular enough to monitor tasks … they might simply be putting on a passive dosimeter for 8-hrs and call that good.

    Specific Question:
    The new storage shelving for specimens waiting for disposal will be “rear-slot-exhaust type hood” where the shelving sits against the wall. The pathologist & technicians would like to simply pull the sample containers off of the shelving and dispose of the contents right there (in-front of the shelves) for convenience and ease of process. Makes sense. To manage the “Formaldehyde Bolus” I would like to add a larger exhaust fan option to the exhaust slots to where I have a large air mass movement thereby pulling the FM bolus away from the pathologist and routing the volatiles directly into the shelving units ultimately into the exhaust slots. It almost reminds me of a walk-in style hood you would see in a production or research organic lab. This is no small exhaust job though … we would have to move a lot of air. But I truly believe this is the best engineering control solution.

    What have you seen as a “gold standard” for gross specimen disposal stations?

    • Izak B. Dimenstein says:

      Your question is very important regarding formalin safety in the surgical pathology laboratory. I will provide a short answer to your specific question, while posting a special fragment at the Grossing Technology and Beyond blog. For some reasons, the subject of specimens and formalin disposal was limited to two sentences in my article A Pragmatic Approach to Formalin Safety in Anatomical Pathology. LabMedicine 2009 Vol. 40 (12):740-746.
      I do not understand why you need special rear ventilation for specimens that are sitting quietly in containers, most likely plastic, closed by a lid. If there is no leaking or an open lid, these containers are not the sources of formaldehyde overexposure. In my view, it is not reasonable to build new shelving with complicated ventilation engineering. Moving shelves with closed doors were manufactured long ago. They have seven shelves where specimen are placed according the day of processing. They can be moved at your discretion, even out of the laboratory. Moving shelves can easily be cleaned by taking out the shelves, even using a hose in an appropriate place with a floor water drain, like autopsy rooms have. The cleaning issue is very important in specimen storage. Sometimes invisible, formalin spills evaporate formaldehyde after drying.
      There are many wet specimen types of storage equipment. For example, Thalheimer Kuehlung which manufactures Ventilated Specimen Storage Cabinet with connection to on-site exhaust air facility. MEDIS Medical Technology GmbH also manufacturers storage cabinets for wet specimens. In my experience, the best in this field is TBJ. Inc. However, they are suitable for long- term storage; this is not the case in the surgical pathology laboratory with fluent changes of the storage content.
      The main danger is not during storage, but rather during the disposal process when the specimen is taken out from the container. A combination of evaporation, spills, and splashes may occur at that time.
      There are three main conditions that are required for safety and efficiency during specimen disposal. Besides the absolutely obligatory OSHA requirement of PPE, the procedure requires: a large table space, easy availability of water/sink/drain; with corrosion resistant metallic surface; and ventilation more intensive than at the regular grossing station. Where would the technician’s work space during the specimen removal from the fixative? On the floor? On the moving cart? On a stretcher? What about a spill? How to clean? A separate special room is definitely desirable. It is not enough to make a ventilation hood for specimen disposal. There should be a comprehensive approach; of course, this will include local ventilation.
      There is no a golden standard which I am aware of. Actually, such a standard cannot exist because this is a neglected area of safety in the laboratory. Only few like you have raised this question.

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