Occasionally, the laboratory will receive excisions that do have orientation markings such as: sutures, pins, staples, notches or inks. The grossing and diagnosis of such excisions is greatly aided by the use of several colored inks and a diagram of the sample with the orientation mapped out. The gross examination of these excisions can vary from lab to lab, and the procedure below is a generally accepted outline that is most efficient. These complex excisions should be grossed by pathology assistants or gross examination should be supervised by a pathologist.
Excisions with orientation can be inked and sectioned in the following manner:
- All excisions must be properly fixed prior to grossing. Tissue will be more firm and easier to section once fixed.
- Evaluate the sample, recognizing all of the layers involved, including the subcutaneous layer.
- Note all three dimensions.
- Note and diagram all identifiers of orientation, such as sutures, notches, inks, and so on.
- Blot the specimen before inking and blot the specimen after inking
- Looking at the excision like the face of a clock, designate the identifier (such as a suture) at 12 o'clock (if the suture has not been designated already by the surgeon).
- Map out the excision with the suture and colors used for inking the margins. Refer to the images on the right.
- Using two ink colors (in this image, green and orange), ink the cut surface from 9 to 12 to 3 o'clock green, and ink the cut surface from 3 to 6 to 9 o'clock orange. The two colors will meet at the "spine" of the excision's deep margin (fatty layer). Be careful not to ink the surface of the skin, or the keratin layer.
- Inks that bleed should be fixed with a weak acetic acid solution (0.5-5.0%) prior to sectioning.
- Distal tips of the ellipse should be cut with a sharp blade and submitted in two separate cassettes. 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 in sequential order 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 cassettes contain the tips.
- Submit the excision entirely, unless otherwise directed by a pathologist.
- Excisions require longer processing times and should NOT be placed on the same processing program with biopsies.