How hard is it to find lymph nodes in anatomical specimens? Generally speaking, it is among the most difficult processes in the gross room. The specific difficulty level depends on (1) clinician roles, (2) the processes that the specimens went through, and (3) the conditions of specific cases, particularly the sizes of the specimens and whether the cases have been treated before surgery.
1. Clinician roles
Pathologists’ Assistants (PAs) and pathology residents generally are responsible for grossing lymph nodes. While residents generally have a more difficult time performing the tasks, it is by no means an easy process for the PAs. Here are some quotes from clinicians that might help shed some light on this issue.
Dr. Rhonda K. Yantiss, Professor of Pathology and Laboratory Medicine from Weill Cornell Medical Center, says: “Some of the lymph nodes you can see are peaking through the fat, like brown round nodules, those are like manna from heaven. Because the rest of them are just harder and harder to find.” 
Benjamin Farmer, an experienced PA from M.E.D. VA Medical Center says: “Going through the fat searching for lymph nodes is the most important staging question in my eyes for grossing a good colon. The rest of the processes, submitting the tumors, taking the margins, is fairly easy. Doing the lymph node (search) is the time-consuming, tedious, mind-numbing thing.” 
Residents, who are generally less experienced in lymph node grossing, are still taking on a huge part of the workload in academic hospitals. According to an article published by College of American Pathologists (CAP) titled “Pathology Resident Burnout”,  the difficulty in finding lymph nodes actually contributes significantly to the residents’ work burnout. The article states:
“This might be a typical anatomical pathology schedule in your institution:
7:30 AM: Morning lecture
8:30 AM: Grab first cases of the day
10:30 AM: Gastrointestinal (GI) consensus conference
11:30 AM: Grab more slides
12 Noon: Eat lunch while you read more cases
1:00 PM: Head and Neck (H&N) consensus conference
2:00 PM: Begin grossing your first specimen for the day
5:00 PM: Get called out of the gross room to review special stains and immunohistochemistry
6:00 PM: Start grossing your next large specimen for the day
8:00 PM: …still looking for lymph nodes…
8:30 PM: Throw in some fat and call it “fat for possible lymph node capture” and call it a night.”
2. The processes that the specimens went through
How difficult this process is also depends on the condition of the specimens. Some institutions, such as the Mayo Clinic, process all of their specimens fresh, which makes lymph node search slightly easier since the texture difference between lymph nodes and fat can be slightly more pronounced. Most institutions fix the specimens in formalin overnight before grossing, which can make lymph nodes generally more difficult to find. There are chemical solutions, such as Dissect Aid, acetone, or a mixture of other chemicals, that can help lymph nodes appear whiter than surrounding fat and easier to find.  However, this procedure requires overnight soaking which significantly prolongs the turnaround time for specimens. Also, these solutions usually have a pungent smell and require designated hazardous chemical disposal protocols. Therefore the adoption rate of this procedure is relatively low.
3. The condition of specimens
The conditions of the specimens themselves are also a huge part of the issue. The two most important factors that affect the difficulty of lymph node grossing are the sizes of the tissues and whether the case has been previously treated before surgery.
The size of the specimen is crucial because pathology can only work with whatever amount of tissue that surgery resects intraoperatively. In fact, it is a common argument between pathology and surgery regarding whose fault it is when the required number of lymph nodes is not met. There are many peer-reviewed articles reporting this “blame game”.   When this happens, PAs and residents usually need to go through another round of grossing, i.e. re-grossing, which is extremely laborious and time-consuming. 
The treatment history of the case also plays a huge role in the difficulty of lymph node grossing and the problem is becoming increasingly common. Neoadjuvant chemotherapy, i.e. chemotherapy performed before surgery, is effective in shrinking the sizes of tumors as well as lymph nodes. Even the most skilled PA would agree that finding lymph nodes in treated cases is extremely difficult because the sizes of lymph nodes are usually on the level of 1 mm or smaller. There have been many peer-reviewed publications reporting decreased lymph node counts for treated cases.   Since the required lymph node counts for treated cases are still the same as the untreated cases, grossing lymph nodes becomes far more laborious and re-grossing is far more common in treated cases. With neoadjuvant chemotherapy becoming increasingly popular, the problem of finding enough lymph nodes in treated cases will only become more and more severe.
In summary, while clinician roles, the processes that specimens went through, and the conditions of specimens all play important roles in the difficulty of lymph node grossing, it is generally speaking among the most difficult tasks in the gross room.
We are Cision Vision, and we help PAs, residents, and pathologists find lymph nodes more quickly and accurately by displaying lymph nodes as the opposite color as the surrounding fat in real-time without radiation or injection. Learn more about how Cision Vision can help you improve clinical workflow and patient care at your facility at cisionvision.com
 (2016). Grossing Colon Pathology Specimens. Youtube. https://youtu.be/1-E4NPLLDnI?t=866
 (2014). Colon CA. Youtube. https://youtu.be/9XLFO7xLYqU?t=453
 (n.d.). Pathology Resident Burnout. College of American Pathologists. https://www.cap.org/member-resources/articles/pathology-resident-burnout
 Ma XL, Ye JX, Su J, Qi FF, Meng QY, Shi XY. A modified GEWF solution is cost-saving and effective for lymph node retrieval in resected colorectal carcinoma specimens. Pathol Res Pract. 2014 Sep;210(9):543-7. doi: 10.1016/j.prp.2014.05.004. Epub 2014 May 22. PMID: 24939144.
 Jakub JW, Russell G, Tillman CL, Lariscy C. Colon Cancer and Low Lymph Node Count: Who Is to Blame? Arch Surg. 2009;144(12):1115–1120. doi:10.1001/archsurg.2009.210
 Schoenleber SJ, Schnelldorfer T, Wood CM, Qin R, Sarr MG, Donohue JH. Factors influencing lymph node recovery from the operative specimen after gastrectomy for gastric adenocarcinoma. J Gastrointest Surg. 2009 Jul;13(7):1233-7. doi: 10.1007/s11605-009-0886-7. Epub 2009 Apr 15. PMID: 19367436.
 Ameer Hamza, Ramen Sakhi, Sidrah Khawar, Ahmed Alrajjal, Jacob Edens, Muhammad Siddique Khurram, Uqba Khan, Susanna Szpunar, Paul Mazzara, “Role of “Second Look” Lymph Node Search in Harvesting Optimal Number of Lymph Nodes for Staging of Colorectal Carcinoma”, Gastroenterology Research and Practice, vol. 2018, Article ID 1985031, 6 pages, 2018. https://doi.org/10.1155/2018/1985031
 Mullen MG, Shah PM, Michaels AD, et al. Neoadjuvant Chemotherapy is Associated with Lower Lymph Node Counts in Colon Cancer. The American Surgeon. 2018;84(6):996-1001. doi:10.1177/000313481808400655
 Erbes, T., Orlowska-Volk, M., zur Hausen, A. et al. Neoadjuvant chemotherapy in breast cancer significantly reduces number of yielded lymph nodes by axillary dissection. BMC Cancer 14, 4 (2014). https://doi.org/10.1186/1471-2407-14-4
 Socha J, Bujko K. Are we already in the era of total neoadjuvant treatment for rectal cancer? Lancet Oncol. 2021 May;22(5):575-577. doi: 10.1016/S1470-2045(21)00127-3. Epub 2021 Apr 13. PMID: 33861999.