The role of gross and microscopic descriptions in pathology reports

Abstract

Background: The implementation of mandatory synoptic templates in the final diagnosis section of pathology reports has been associated with increased uniformity and clarity though the content and format of other pathology report sections have yet to be examined. This study appears to be the first of its kind to examine the importance of gross and microscopic descriptions for pathologists and clinicians.

Methods: Survey invitations were forwarded to both pathologists and clinicians on their use and their perceived value of the gross and microscopic description sections. A retrospective review of pathology reports of the specimens most commonly submitted to pathology was then performed to determine the elements currently included in/ omitted from microscopic descriptions.

Results: Overall, the majority of pathologists indicated they at least usually read the gross descriptions of biopsies (73.59%) and excisional specimens (91.18%) but rarely felt that microscopic descriptions should be included for biopsies (81.25%) nor excisional specimens (78.13%). Pathologists also indicated they believed gross and microscopic descriptions were rarely read (72.73% and 57.58% respectively), understood (54.55% and 42.42% respectively), or utilized by clinicians. However, the majority of clinicians indicated that they always read pathology reports (94.94%) and at least usually read and understood the gross (79.66% and 85.80% respectively) and microscopic descriptions (91.23% and 87.06% respectively) and found these sections valuable. The pathology report review revealed that microscopic descriptions were included most frequently for renal (100%) and hepatic (45%) biopsies and dermatological excisions (53.85%) and consisted of histological descriptions and ancillary studies of the respective tissues. Other specimen types including pulmonary, and breast biopsies along with gynecological excisions included this information in the comments section.

Conclusion: In summary, pathologists are advised to be cognizant that clinicians read and find value in the gross and microscopic description sections. Furthermore, there appears to be a discordance between where elements are included in pathology reports depending on specimen type. For increased consistency and clarity, it is recommended that elements be included in designated sections across all specimen types.