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About Pathology Reports

The Gross Description

The pathologist begins the examination of the specimen by dictating a description of the specimen as it looks to the naked eye. This is the "gross exam" or the "gross." Some pathologists may refer to the gross exam as the "macroscopic." Most biopsies are small, nondescript bits of tissue, so the gross description is brief and serves mostly as a way to code which biopsy came from what area and to use for troubleshooting if there is a question of specimen mislabeling. A typical gross description of an endoscopic colon biopsy follows:

"Polyp of sigmoid colon." An ovoid, smooth- surfaced, firm, pale tan nodule, measuring 0.6 x 0.4 x 0.3 cm. Cassette 'A', all, bisected.

In the above example, the first item (in quotes) is an exact recitation of how the specimen was labeled by the doctor who took the biopsy. After that is a textual description of what the specimen looked like, followed by measurements indicating its size. The "Cassette 'A', all, bisected" phrase indicates that the specimen was cut in half ("bisected"), submitted for tissue processing in its entirety ("all") in a small container (cassette) labeled "A," which will eventually be placed in the tissue processor.

Larger organs removed as biopsies have correspondingly longer and more detailed gross descriptions. The following is the gross description of a spleen removed to assess whether Hodgkin's disease (a cancer of lymph tissues) has spread into it:

"Spleen". An entire spleen, weighing 127 grams, and measuring 13.0 x 4.1 x 9.2 cm. The external surface is smooth, leathery, homogeneous, and dark purplish-brown. There are no defects in the capsule. The blood vessels of the hilum of the spleen are patent, with no thrombi or other abnormalities. The hilar soft tissues contain a single, ovoid, 1.2-cm lymph node with a dark grey cut surface and no focal lesions.

On section of the spleen at 2 to 3 mm intervals, there are three well-defined pale-grey nodules on the cut surface, ranging from 0.5 to 1.1 cm in greatest dimension. The remainder of the cut surface is homogeneous, dark purple, and firm.

Summary of cassettes: 1, hilar blood vessels; 2, hilar lymph node, entirely submitted; 3 - 6 spleen nodules, entirely submitted; 7 - 8, spleen, away from nodules.

In the spleen described above, the pathologist found a few lumps (nodules), representing the most important data in this gross examination. These possibly represent the tumors of Hodgkin's disease, subject to confirmation by the microscopic examination. Much of the remainder of the verbage relates to "pertinent negatives," or things that were routinely looked for but not found, such as a rupture of the spleen capsule (suggesting an intraoperative accident), blood clots ("thrombi") in the vessels supplying the spleen, and evidence of an infection (in which case the cut surface of the spleen would be soft instead of firm). In addition, a lymph node was serendipitously found adherent to the spleen, and this was briefly described as having a normal appearance.

The last paragraph of the gross description gives the identifying "codes" of the slices of the specimen submitted for microscopic examination in cassettes. The microscope slides prepared from the processed samples will be labeled with the same numbers as the cassettes, and the pathologist doing the microscopic examination can, by referring to the typed gross description, know from what part of the specimen the tissue on the slide came.

The Microscopic Description

The microscopic description, or the "micro" is a narrative description of the findings gained from examination of the glass slides under the microscope. The micro is considered somewhat "optional" in a written report. In such a case, the diagnosis (see below) is considered to speak for itself. Here is a the microscopic description on the report of the colon biopsy given above:

Specimen A: The sections show a polypoid structure consisting of a central fibrovascular core, surrounded by a mantle of mucosa showing an adenomatous architecture with a predominantly tubular pattern. The tubules are lined by tall columnar epithelium showing nuclear pseudostratification, hyperchromasia, increased mitotic activity, and loss of cytoplasmic mucin. There is no evidence of stromal invasion.

It can be readily seen that the language of microscopy is much more arcane than that used for gross descriptions. It is way beyond the scope of this monograph to cover the nuances of descriptive microscopic pathology. In general, microscopic descriptions are communications between pathologists for referral and quality assurances purposes.

The Final Diagnosis

This is analogous to the "bottom line" of a financial report. The purpose of the gross examination, the processing of the tissue, and the microscopic examination is to build a logical argument toward a terse assessment of what significance the biopsy has in regard to the patient's health. Here is the diagnosis for the colon biopsy, above:

Colon, sigmoid, endoscopic biopsy: tubular adenoma (adenomatous polyp)

This format is widely used, but variations occur. The first term is the organ or tissue involved ("colon"). The second term ("sigmoid") specifies the site in the colon from which the biopsy was obtained. The next term ("endoscopic biopsy") denotes the type of surgical procedure used in obtaining the biopsy. Then follows the diagnosis proper, in this case "tubular adenoma," a common benign tumor of the large intestine and rectum, which increases the risk for developing colorectal cancer in the future. In this particular case, an older synonym for tubular adenoma, "adenomatous polyp," follows in parentheses. Reference Edward O. Uthman, MD.

Much of the information physicians use to make a cancer diagnosis comes from clinical laboratory tests and tissue biopsies. These tests are usually overseen or interpreted by a pathologist. If you have just been diagnosed with a sarcoma and are not being treated by a sarcoma specialist you should consider having your pathology sent to a pathologist who specializes in soft tissue or bone sarcoma for review and second opinion. Diagnosis of a soft tissue sarcoma may be difficult and the rarity of these tumors adds to such difficulties. In 5-20% of cases a second pathological opinion has changed the diagnosis from sarcoma to a non-sarcoma. The reproducibility rate among different pathologists with regard to the histotype averages 45-60%. The reproducibility rate with regard to the malignancy grade is higher, around 75% . It is recommended that the histopathological evaluation is performed by a pathologist who is experienced with soft tissue sarcomas. See the bottom of this page for references to sarcoma pathologists in the US.

Pathology diagnosis of sarcoma is one critical element to developing a treatment plan. There are numerous (over 50) subtypes of sarcoma related to both soft tissues and bone sarcomas.

Clinical evidence of a genetic predisposition to developing sarcoma is rare. It may be associated with uncommon syndromes, mainly neurofibromatosis and Li Fraumeni syndrome. This is a frequently asked question by adults diagnosed with sarcoma and often relates to their concern for their children. (Reference State of the Art Oncology in Europe ).

Some chemical carcinogens such as phenoxy herbicides, chlorophenols and dioxin, have been linked to the occurrence of soft tissue sarcomas. Also, exposure to chemotherapeutic drugs has similarly been associated with the risk of developing sarcomas. Exposure to ionizing radiation can increase the risk of soft tissue sarcomas and osteosarcomas developing. In fact, although a rare event, sarcomas may arise in previously irradiated fields even in the absence of a predisposing syndrome. The median time from radiotherapy treatment is in excess of 10 years, although the interval may be much shorter. The frequency of occurrence increases with dose and is only rarely seen after low doses. (Reference State of the Art Oncology in Europe ).

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