Gross Description: Definition

The gross description in a pathology report is an important section that provides a detailed description of the physical characteristics of the specimen received by the pathology lab before it undergoes any microscopic examination. This description is “gross” in that it relates to what can be observed with the naked eye, without the aid of a microscope.

Information commonly found in the gross description

The information included in the gross description varies depending on the type of specimen being examined and the specific protocols in place at the hospital or laboratory. However, it generally contains several key pieces of information:

• Type and source of the specimen: This includes the type of procedure performed, the amount of tissue received, and where it was taken from in the body. For example, “a biopsy of the left breast” or “a resected segment of the colon.”
• Size, weight, and volume of the specimen: These measurements give an idea of the overall dimensions and mass of the specimen, which can be important for understanding the extent of a disease process or for surgical planning.
• Color, texture, and consistency: Descriptions might include color (e.g., pink, tan, brown), texture (e.g., smooth, nodular, granular), and consistency (e.g., firm, soft, cystic). These characteristics can provide clues about the nature of the pathology present.
• Identifiable anatomic structures: If the specimen includes recognizable anatomical features (e.g., blood vessels, nerves, specific organ parts), these are noted.
• Lesions or other abnormalities: Any visible lesions, masses, or anomalies are described in detail, including their size, location, color, and any other distinctive features. If there are multiple lesions, each might be described separately.
• Margins: For surgical specimens, the margins (edges of the specimen where it was cut from the rest of the tissue or organ) are described. This is particularly important in cancer surgery to determine if the disease has been completely removed.

Why is the gross description important?

The gross description section of a pathology report is important for several reasons:

• Basis for further examination: It provides a roadmap for the microscopic examination that follows, helping pathologists decide which areas of the specimen to focus on under the microscope.
• Quality control: It ensures that the specimen has been properly identified and documented, reducing the risk of errors.
• Diagnostic clues: Some diseases have characteristic gross features that can immediately suggest a diagnosis or narrow down the possibilities.
• Correlation with clinical findings: It allows pathologists and surgeons to correlate what they see in surgery with the pathological findings.
• Surgical margin assessment: For cancer specimens, the description of margins can immediately signal whether the surgery might have been curative or if residual disease might be left behind.

Who performs the gross description?

In most hospitals and laboratories, the gross description is prepared by a Pathologist’s Assistant, a specially trained laboratory professional who conveys their observations to the Pathologist. Specifically, the gross description tells the Pathologist how the tissue looked before it was processed for microscopic examination. Anatomical pathology residents or fellows may also perform the gross description.