General Advice on Gross Examination
1. Gross examination requires hands-on practice: The process of gross examination and description is a specialized professional skill obtained through training. It is erroneous to assume that general literacy and rudimentary medical knowledge are sufficient for performing an accurate and revealing gross examination. In-depth knowledge of anatomy, diagnostic pathology, clinical medicine, and patient management are pre-requisites for training. Like all other skills, gross examination requires hands-on practice over a period of time, and can not be professed by reading a manual or book only.
2. Document essential ID information: Gross description is an important form of medico-legal documentation. Information such as the patient's name, medical record number, and specimen designation, though repetitive, should be included in the gross description. The regular practice of including these identifiers in the report helps ensure that the prosector correlates all identifiers and serves as a permanent means of documenting that said correlation is performed. See also Key Elements to Observe.
3. Organize the gross description by specimen components: The components (or parts) of a specimen should be stated and measured before elaborating on morphological findings. Subsequently, description should be organized by each component (or part) in an orderly fashion. A gross description that jumps around among various specimen components makes for an incoherent and incomprehensible report and should be avoided. See also Key Elements to Observe.
4. Gross description should describe, not diagnose: The purpose of the gross description is to document the macroscopic findings as objectively as possible. Although it is often possible to recognize specific diagnostic entities based on their gross features, it is best to reserve this classification for the microscopic examination. For example, “solid, stellate, white-tan mass” is preferred over “carcinoma” or “cancer”. In addition, although the word “tumor” technically can refer to any mass-like process, it is often considered to be equivalent to “neoplasm”; therefore, some may advocate avoidance of the word “tumor” in a gross description.
5. Use likely differential diagnoses to guide the gross examination (and sampling): Your description and specimen sampling should reflect your differential diagnoses, based on the submitting physician’s opinion or inquiry, clinical history and findings, other laboratory or radiologic studies, and, finally, your macroscopic assessment. Although the general and accepted format should be followed, focus should be given to the important aspects related to clinical scenario.
6. Content and format are more important than style: Individuals may differ in their descriptive styles, but their coverage of key elements of a given specimen type should be relative consistent. These essential elements can be well conveyed by a small group of key words. For example, “vermiform”, “serosal exudate”, and “transmural defect”, are key words used in describing an appendix with appendicitis.
7. Collect essential information required in the final pathology report: The final pathology report includes more than just the diagnosis. For malignant neoplasms, size, grade or degree of differentiation, extent of involvement, (lymphovascular) invasion status, and resection margin status are additional elements which must be reported (see also Key Elements to Observe). In addition, key elements unique for some organs / sites or tumors should also be included. It is very helpful to consult the appropriate cancer reporting template or AJCC staging scheme to find out what data elements are required for a specific specimen prior to starting your gross examination.