Occasionally, the laboratory will receive excisions with orientation markings, such as sutures, pins, staples, notches, or inks. The grossing and diagnosis of such excisions are 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 most efficient outline. Pathology assistants or pathologists should gross these complex excisions and supervise gross examination.
Excisions with orientation can be inked and sectioned in the following manner:
- All excisions must be adequately fixed before grossing. Once fixed, the tissue will be firmer and easier to section.
- Evaluate the sample, recognizing all the layers involved, including the subcutaneous layer.
- Note all three dimensions.
- Note and diagram all identifiers of orientation, such as sutures, notches, inks, etc.
- 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 selected 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 skin's surface or the keratin layer.
- Inks that bleed 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 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 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 as biopsies.
