The amount of information conveyed through the gross examination of any excision is very individualized and most often tailored to the dermatologist or dermatopathologist interpreting the slides. A pathologist should supervise the gross examination of complex excisions (i.e., excisions that are round, square, triangular, or have indicators).
Most excisions are submitted as elliptical (or football-shaped) samples. This type of excision allows for easy closure and proper cosmetic healing. Skin cancers, as well as cysts, are typically excised in this oval fashion. However, excisions can take any shape, from round to triangular specimens, each with its unique grossing challenge. Excisions do not have an orientation unless there are indications such as sutures, pins, staples, notches, or inks. If a sample has none of those, then it is much easier to gross. Only one ink color will help determine which margins are involved.
The surgical margin has been inked green in the images, and the ellipse was serially sectioned or bread-loafed.
Excisions without orientation can be sectioned in the following manner:
- All excisions must be adequately fixed before grossing. Once fixed, the tissue will be firmer and more manageable to section.
- Evaluate the sample, recognizing all the layers involved, including the subcutaneous layer.
- Note the dimensions.
- Excisions of skin cancer must be inked. Cysts typically do not have to be inked unless they do not look like cysts upon examination, in which case the suspect excision should be inked. "Don't think... ink!" is often used when in doubt.
- Blot the specimen before inking and blot the specimen after inking.
- Be careful not to ink the skin's surface or the keratin layer. Choose one ink color and ink all surgical margins the same color.
- Bleeding inks should be fixed with a weak acetic acid solution (0.5–5.0%) before sectioning.
- Distal tips of the ellipse should be cut with a sharp blade and submitted in one cassette. Tips should not be more than 5 mm across.
- The remainder of the excision should be serially sectioned or "bread-loafed" at 3–4 mm intervals perpendicular to the long axis.
- Sections are submitted sequentially in the cassettes without cramming the tissue and leaving room for proper processing.
- Note the number of cassettes submitted in the gross dictation and which contains the tips.
- Cysts and samples of benign conditions may be sectioned, and the central section of interest should be submitted as a "representative section." The remainder of the tissue should be saved if more tissue is required for diagnosis.
- Excisions require longer processing times and should not be placed on the same processing program as biopsies.
