Introduction to Grossing Case Studies

Can the grossing procedure influence the pathologist’s report? The answer is: yes, it can.

Does the pathologist pay attention to the grossing and gross description of biopsies and small specimens? Not so often, except in dermatopathology.

The grossing case studies presented  here intentionally discuss predominately small, or “routine”, specimens the grossing of which is often delegated to histotechnologists, pathology assistants, although they are also done by pathologists’ assistants and pathology residents. The current increase in the number and variety of specimens and the detachment of the pathologist and the grossing person make the situation dangerous for diagnostically significant material, such as biopsy specimens. It is common to assign grossing biopsies and small specimens to on –the-job trained laboratory workers, especially in commercial laboratories and POLs (physician office laboratories). The paper piles, which are often “Potemkin villages”, conceal on-the job-training problems as insufficient knowledge of surgical pathology and general pathology.  Whenever this question is posted on HistoNet, barrage of discussions periodically appears. The discussion is usually concentrated on formal eligibility rather than ability of histotechnologists to perform grossing since the latter is taken for granted.

In surgical pathology practice these issue is overlooked. As a person who spent considerable time carrying out both microscopy and grossing, I definitely know that surgical pathologists are hostages of the defects in grossing, especially in biopsies and small specimens. The grim truth is that pathologists cannot control many grossing outcomes. Pathologists are fully aware of so -called “sampling variations.” In legal terms, the principle res ipsa loquitur, meaning the thing speaks for itself, works for every day practice, but patient safety remains the more important question.  Surgical pathology does not acknowledge issue for fear of opening a can of worms. By refusing to recognize the problem, the surgical pathology practice has a swelling abscess on its hands.

Perhaps, a personal encounter might illustrate the role of pathology assistant’s, e.g. morgue attendant, (attention not pathologists’ assistant) employment for grossing biopsies and small specimens. A morgue attendant with a mortuary school background moonlighted for grossing biopsies and small specimens (grossing of large specimens was done by pathology residents) in an academic institution. When I asked him why he was hired to do grossing he said: “I have a tissue touch.” He worked late in the evenings, under “the close pathologist’s supervision,” of course.

This question has been discussed on the website in the post “Grossing Histotechnologist as a Subspecialty in Surgical Pathology Laboratory” in the section “Perspectives in Grossing Technology.”  The post presents not only the problem, but also one of the ways to its solution.

The case studies describe how the grossing procedure and gross description can help or hinder the pathologist’s report. They can serve to illustrate the above mentioned considerations. The case studies emphasize that specimens are not as simple as they appear at first glance when a clinical approach is applied, which is the core of surgical pathology. Sampling in the surgical pathology laboratory is not like cutting salami.

I will not nitpick the unfortunate words or clumsy choices of definitions in gross description. Actually, only patients and layers read these descriptions attentively. Nevertheless, the pathologists ought to correct the gross descriptions, if they read them; however, pathologists do not tend to read the descriptions for most biopsy and “routine” specimens. I shall mention only descriptions that might influence in positive or negative, more likely, the pathologist’s report. Furthermore, the pathologist’s report will be discussed only if it is somehow influenced by grossing quality.

The case studies are presented in a similar format: a/ available clinical data; b/ a copy of the pathologist’s; c/ analysis the sampling, including cassetting / miscellaneous remarks, if any. Sometimes, the posts will be accompanied with photos. Of course, the patient’s name, the name of the institution and the participants are blacked out. The case studies are not about institutions; rather, they are about typical grossing scenarios.