5.1. Gross descriptions must be clear, concise and to contain adequate information regarding type, size and/or weight of specimens, measurements, and extent of gross lesions.

5.2. All gross descriptions include a section key at the end of the gross note. This section key includes block and slide designations for sections, explaining any specific significance of each section (e.g., margins of resection, deepest penetration of tumor, breast quadrants, lymph node levels, etc.)

5.3. The attending pathologist reviews the gross description for completeness, and is responsible for the completeness of the final report. The attending pathologist also assures that the pathologic diagnosis relates sensibly with the history provided by the clinician, the post-operative diagnosis provided by the clinician, and the gross description provided by the resident pathologist. Cases where the microscopic diagnosis does not correspond with the post-operative diagnosis provided by the clinicians become cases for review by the Invasive Procedures Review Committee (IPRC, formerly SCRC). In order to assure that the case is reviewed by the IPRC, the attending pathologist who signs out the case must SNOMED-code the case under the Procedure axis with the code term SCRC. This SNOMED-code is picked up by a monthly search for new IPRC cases by the Pathology representative for the IPRC who prepares the pathology monitor. In most cases, a "Microscopic description" is not included as part of the surgical pathology report. Instead, the pathologists use a "Comment" section in which any information of clinical, pathologic or administrative interest (e.g., documentation that the clinician was notified of a new "positive" diagnosis other than basal cell carcinoma) is included.

5.4. The COMMENT section also must include the results of special stains or ancillary studies (e.g., immunohistochemistry, nucleic acid probes, cytogenetics) with the morphologic diagnosis. When the results of special studies come in after the case has been released, the pathologist issues a SUPPLEMENTAL REPORT, which the VISTA Computer System automatically adds on to the permanent copy of the report kept in the computer files. In addition, a typed signed copy of the entire report including the Supplemental report is issued. If the Supplemental report contains information that is of direct clinical importance (i.e., that may change treatment), then the attending pathologist notifies the clinician and documents the notification in the Supplemental report.

5.5. The final reports of tumor diagnoses always provides sufficient information as to the grade of tumor and extent of disease. We generally do not use clinical staging terminology in our reports, preferring to provide all the pathology information that the clinicians would need to stage their patient for use in standard systems of grading. We feel this is important to make sure that our diagnoses stand against changes and modifications introduced to staging classifications.

5.6. The exceptions consist of cases that are being prepared for the cancer evaluation program of the American College of Surgeons. See Procedure 141: CAP ANATOMIC PATHOLOGY REPORTING PROTOCOLS. For these reports, TNM staging should be reported, as indicated in the protocols for individual organs.

5.7. After the Resident's examination and description, specimens are placed in cassettes, and then into formalin. Small specimens (less than 0.5 cm) are wrapped in teabags, or blue sponges, before they are put in cassettes.

5.8. All specimens are submitted for microscopic examination, except for amputations due to peripheral vascular disease; degenerative joint disease; bunions; and hernia sacs; and metal or plastic prosthetic devices.

5.9. The laboratory does not accept tissues or other materials that may contain radioactive material.