Gross and Microscopic Pathology


Gross and Microscopic Pathology


To be assigned by Pathology

  • 88300 – Level I;  Surgical pathology, gross examination only
  • 88302 – Level II; Surgical pathology, gross and microscopic examination
  • 88304 – Level III; Surgical pathology, gross and microscopic examination
  • 88305 – Level IV; Surgical pathology, gross and microscopic examination
  • 88307 – Level V; Surgical pathology, gross and microscopic examination
  • 88309 – Level VI Surgical pathology, gross and microscopic examination


Biopsy; Histopathology; Microscopic Section; Pathologic Examination; Pathology; Surgical Pathology; Surgical Tissue; Tissue Examination; Tissue Pathology


Gross examination only, and/or gross and microscopic examination and diagnosis.  Imprints may be made if the tissue is fresh and unfixed, and if indication for imprints exist.  Special studies if needed.


  1. Fresh tissue must be refrigerated.  Label with <REFRIGERATE SPECIMEN> label, and send to the laboratory immediately  OR
  2. Tissue fixed in 10% buffered neutral formalin.


  1. Plastic container with lid for fresh specimens with <REFRIGERATE SPECIMEN> label OR
  2. Plastic container with lid, containing 10% buffered formalin for preserved specimens.


Complete a <Anatomical Pathology Requisition>.


Information regarding type of specimen, admitting diagnosis, and pertinent clinical history (i.e. age, clinical impression, past diagnosis, radiographic findings, and history of radiation or chemotherapy) is essential to interpretation and should be noted on the requisition.  Special handling requirement (isolation) should clearly be noted on the request form.


Small biopsy specimens are to be placed immediately in 10% formalin solution.  Use approximately ten to twenty times as much formalin solution as the bulk of the tissue.  Small tissues such as those from bronchoscopic biopsy, bladder biopsy, and endometrium can be ruined in a short time by placing in saline or allowed to dry.  The following tissue should always be placed in formalin:

  • Small skin tumors
  • Moles
  • Uterine currettings
  • Cervical biopsy
  • Breast biopsy
  • Nerve
  • Brain tissue
  • Tumors
  • Prostate tissue from TUR
  • Bladder tumors
  • Nerves and ganlia
  • Rectal polyps
  • ENT (biopsies)
  • Bone tumors
  • Intervertebral disc
  • Gallbladder
  • Liver biopsies
  • Bronchoscopic biopsy
  • Fallopian tube segments
  • All other biopsies from any other side unless otherwise indicated

Gallbladders undergo rapid degeneration and require immediate fixation in 10% formalin.

Label with patient’s name, date, time of collection, and type of specimen.

All specimens should be sent to the laboratory as soon as conveniently possible in order to expedite the processing which leads to the eventual microscopic diagnosis.


Incomplete patient/ history, mislabeled specimen container, unlabeled specimen, or no Surgical Pathology request form


Tissue fixed in formalin cannot be used for bacterial culture, immunopathology, certain types of histochemistry, flow cytometry, cytogenetics, or frozen section.


Gross and microscopic examination with hematoxylin and eosin (H&E) stain.  Special stains and special studies (IHC, ISH, etc.) if needed.


Cultures of tissue are best taken in the operating room, where a sterile field exists.  A piece of tissue should be placed in culture tubes or sterile containers for anaerobic and aerobic culture with request for smear, culture, anaerobic culture, acid-fast bacilli (AFB), or fungus, as needed.

Large specimens:  Definitive large resection specimens (e.g. colectomy, gastrectomy, etc.) do best if opened promptly after excision in the pathology laboratory, then allowed to “fix” overnight.

Work-up cases:  The pathologist reserves the right to work-up cases according to their best medical judgment.  This sometimes requires special stains but a biological work-up as well.