Grossing Technology Today and Tomorrow

Izak B. Dimenstein, MD, PhD, HT (ASCP)

Disclosures

Lab Med. 2020;51(4):337-344. 

In This Article

Grossing Technology Components

Figure 1 presents main grossing technology components in the modern surgical pathology laboratory.[1] The different sizes of the boxes reflect the approximate relative significance of the components in laboratory practice, which also depend on the profile, type, and size of the laboratory.

Figure 1.

Grossing technology components.

The measures to prevent specimen misidentification start upon receipt of the specimen during accession and continue throughout the stages of processing. Advancements such as barcoding have gradually become routine. In the 2000s, barcoding was a novelty and a desirable recommendation in the stage of the initial implementation. Barcodes are now printed or engraved on the processing cassettes and corresponding slides.

Barcoding revolutionized quality control (QC) in the histology laboratory by putting in place quality assurance (QA) and quality improvement systems for prevention of specimen, block, and microscope slide mix-up errors. QA should and can be a comprehensive effort which is designated to detect, control, and prevent the occurrence of errors during various procedures in the histology laboratory, including specimen misidentification. In this regard, root cause analysis in its original form, as the Eindhoven model of incident causation taxonomy, includes the following 3 main causes of error: technical failure (equipment and software); organizational policies, procedures, and protocols; and human operator mistakes and violations.[2] As a tool used for the internal investigation, this method provides a framework for analysis along with practical recommendations for the error prevention.[3] For example, root cause analysis can be used for the prevention of extraneous tissue occurrences during grossing and embedding in the surgical pathology histology laboratory.[1]

The variety of modern ancillary studies require triage by different forms of specimen preservation, of which formalin fixation is only a part, though a significant one. Examples of its use are with lymph nodes for a lymphoma workup or with placentas for special studies. In triage, it is also essential to understand the variety of specialty methods, which include cytology, cytogenetics, molecular pathology, electron microscopy, immunofluorescence, etc.

Increased requirements for a specimen's achievable turnaround time (TAT) and the advancements in modern processing equipment make the triage of workflow a significant part of a grossing person's responsibilities. Triage is the prerequisite for quality assurance and productivity.

For billing purposes in the United States, a Current Procedural Terminology (CPT) code is assigned during accession.[4,5] The grossing person has the necessary information that can ensure the right preliminary code is used, which is usually final unless the pathologist's report determines the need for a change.

Sampling is apparently the main part of grossing technology (shown as the largest box in Figure 1). Although sampling is different with large specimens and minute gastrointestinal biopsy specimens, the main goal remains the same in ensuring that as many diagnostic features as possible are visible on the microscope slide. The knife and ink are the main tools of silent communication between the grossing person, the histotechnologists, and, eventually, the pathologist. Other numerous responsibilities (description, fixation, etc) must not obscure this main aim. Small biopsy specimens look indistinguishable to the inexperienced grossing eye. The specimens are destined for simple transfer from the container into the processing cassette. In reality, there are definite features (area of excision and mucosal part) which should be noticed for diagnostically informative embedding orientation.[6]

The embedding follow-up is a natural step in self-correction that teaches the grossing person the best way to sample the specimen. This does not mean that embedding should be the responsibility of the grossing technologist. On occasion, the grossing technologist can even participate in embedding, though the histotechnologist can perform this work faster and more efficiently, because this skill involves many technical details and some trained dexterity.[7]

The presented principles of grossing technology can be applied to all activities in the grossing room with some corrections for so-called large surgical pathology specimens. The grossing person assuming responsibility in the grossing room should be in charge at this stage of all specimen processing aspects, irrespective of whether the person is a histotechnologist, a pathologist's assistant, a pathology resident, or even a pathologist.

The surgical pathology histology laboratory has changed in many ways; for instance, the number of specimens and biopsies among them have increased dramatically. The pressure for a shorter TAT has changed the technology of processing substantially, especially with the introduction of microwave-assisted processing. A completely different mode of loading the tissue processing equipment (conventional and microwave processors) is now being established. Most biopsy specimens arrive in the laboratory in containers with prefilled fixative or in the fresh state. This means that contact with 10% formalin is substantially diminished.[8] New equipment, like the portable Milestone automatic tissue fixation system FixSTATION 1RH, can be useful for both decreasing TAT and monitoring the fixation process. Its small footprint makes it fit the grossing station.

New technologies have brought grossing technology, the initial stage of specimen processing, additional challenges. For example, laboratories have been asked to triage specimens to perform a molecular assay, including on smaller specimens. From a practical perspective, the interaction of grossing technology and digital pathology is one of the immediate challenges.

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