Gross examination

In pathology, the term “gross” refers to observations made by examining tissues or organs with the naked eye, without the use of a microscope or any magnification tools. Gross examination involves assessing the general appearance and physical features of a tissue sample or organ, including its size, shape, color, texture, and the presence of any visible abnormalities, such as lesions, tumors, or scars. The term “gross” in this context refers to the scale of observation, rather than implying anything unpleasant.

Information typically found in a gross description

The gross description section of a pathology report typically includes detailed observations about:

• Size and measurements: The exact dimensions and weight of the tissue or organ.
• Shape and appearance: Descriptions of how the specimen looks, including whether it’s smooth, rough, irregular, or has any distinctive patterns.
• Color: The color or any unusual discolorations observed.
• Texture and consistency: Whether the tissue is soft, firm, hard, or rubbery.
• Presence of abnormalities: Notes on any visible tumors, lesions, cysts, or other irregularities.
• Surgical margins: Whether the edges of a specimen appear involved by disease or look clear.

Gross description of a biopsy

A biopsy is a small tissue sample removed for examination and analysis. Gross descriptions of biopsies usually focus on basic details such as the number of tissue fragments, their size, shape, color, and consistency. Pathologists also note if the biopsy appears adequate to make a diagnosis. For instance, a biopsy of the skin may include the size and color of the skin sample, any visible abnormalities, and the method of collection (e.g., “one tan-colored tissue fragment measuring 0.4 cm”).

Gross description of larger specimens

For larger surgical specimens, such as resected tumors or organs, the gross description is more detailed. Pathologists document the overall size and weight of the specimen, describe its external appearance, and carefully examine and describe the cut surfaces. They record the location, size, and appearance of tumors or lesions, as well as whether they appear contained or extend beyond specific boundaries, and their relationship to surrounding structures, such as blood vessels or nerves. Larger specimens also include careful documentation of surgical margins to assess whether the disease has been completely removed.

Why is the gross description important in a pathology report?

The gross description is important because it provides initial and critical clues about the nature and extent of a disease. It helps pathologists determine the areas that require further microscopic examination, which reveals more detailed information at the cellular level. This section of the pathology report helps doctors make an accurate diagnosis, assess the disease’s progression, and develop appropriate treatment plans.