Excision without orientation - one ink color margin
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. Gross examination of complex excisions (excisions that are round, square, triangular, or have indicators) should be supervised by a pathologist.
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. Although, excisions can take any shape from round to triangular specimens, each with its own 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.
In the images, the surgical margin has been inked green and the ellipse was serially sectioned, or bread-loafed.
Excisions without orientation can be 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 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. Often the phrase "Don't think, ink!" is used when in doubt.
- Blot the specimen before inking and blot the specimen after inking.
- Choose one ink color and ink all of the surgical margins the same color, being 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 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 in sequential order in the cassettes, without cramming the tissue and leaving room for proper processing.
- Note the number of cassettes submitted on the gross dictation and which cassette 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 tissue should be saved in case more tissue is required for diagnosis.
- Excisions require longer processing times and should not be placed on the same processing program with biopsies.