INTRODUCTION Why this guide?

As medical professionals (Christopher Horn is a pathologists’ assistant, Christopher Naugler is a general pathologist and family physician), we have often wanted a resource with a comprehensive list of gross-descriptive terms and examples of gross specimens. We figured such a resource would help not only us, it would help other professionals as well: it could, for example, help standardize gross-descriptive terminology and make pathology reports more succinct.

We couldn’t find a resource like this, so we created this guide.

This guide pairs a comprehensive list of gross-dissection terms with photographic examples of gross-dissection specimens.

It aims to help pathology professionals—pathology residents, pathologists’ assistants, and medical laboratory technicians—describe surgical and autopsy specimens as they perform gross dissection.

The pathology gross room and autopsy suite are fascinating places that analyze specimens from the operating room. The specimens often involve a variety of disease processes, 1 or many organ systems, and—as a result—a multitude of gross appearances. Quite often, the same disease process appears different on similar specimen types, or different from patient to patient. As a pathology-lab professional, your job is to describe what you see, so that a pathologist or clinician can read the description and visualize the specimen. This can be a daunting task, given the variability and complexity of specimens—especially for new pathology staff at the beginning of their surgical gross-dissection training. A common question in the gross room is: “How would you describe this specimen?”

The flipside of this question, from a clinician’s point of view, is: “What does this specimen look like, based on this description?” This guide also aims to help clinicians and medical students navigate pathology reports.

How to use this guide

Look up terms, look up images

If you are a lab professional who is training to perform gross surgical dissection, you can use this guide, first, as a way to study specimens and the terms to describe them. Then, as you work in the surgical gross area, you can use it to identify appropriate terms by comparing your gross findings with the images. As your skills progress, you can use it to refresh and validate your gross-descriptive skills.

As a clinician or medical student, you can use this guide “in reverse” to help interpret pathology reports: to look up unfamiliar gross-descriptive terms and see examples of specimens they describe.

Combine terms for precise description

As a lab professional, you should combine the terms in this guide as necessary to arrive at the most precise descriptions possible.

For example, to describe the appearance of a fibroid uterus, you might combine the terms whorled and circumscribed: “white-whorled, well-circumscribed masses.” This description avoids words such as fibroid and leiomyoma, which are considered diagnostic terms.

Note the inclusion of some diagnostic terms

The grosser’s job is to describe and the pathologist’s job is to diagnose. So, gross descriptions should not, in general, employ diagnostic terminology.

We have found, however, that some diagnostic terms provide the best way to describe some gross findings, and that pathologists and clinicians often agree. This guide includes these terms.

It includes, for example, the term diverticulum. Although diverticulum is technically a diagnostic term, it is often preferred as a descriptor over the more traditional and wordy “out pouching of mucosa and intestinal wall into the surrounding pericolic fat.”

You may want to check with your pathologists before incorporating these diagnostic terms into your reports.

Apply the sample gross descriptions

We use each term in this guide in a unique gross-description phrase, usually based on the specimen in the accompanying image.

You can use these phrases as the foundation of your own reporting.