Purpose:

To ensure proper handling and testing of breast tissue by following the guidelines for ER/PR testing. Specimens that are improperly handled may yield false negative results and may negatively impact patient care.


Guidelines:

1. The time at which the specimen is removed from the patient should be recorded.
2. The time at which the incised specimen is placed in formalin should be recorded.
3. The specimen should be sectioned prior to being placed in formalin.
4. Tissue should be placed in 10% Neutral Buffered Formalin (NBF) within an hour of extraction.
5. Tissue is to be fixed in 10% NBF at a ratio of 10:1 (formalin : tissue).
6. The specimen must fix in 10% NBF for at least 6 hours and no longer than 72 hours.

Protocol:

1. The requisition is to be properly filled out, including:
   • a. The time the specimen is removed from the patient.
   • b. The time at which the specimen is placed in formalin.
   • c. Orientation of the specimen (including color code for ink and/or suture designation).
2. Needle Core Biopsies:
   • a. Document the time of excision.
   • b. Document the time the specimen is placed in formalin.
   • c. Any needle core breast biopsies done for microcalcification must be accompanied by the specimen x-ray.
3. Lumpectomy:
   • a. Document the time of excision.
   • b. Note the orientation. Mark the specimen with sutures if necessary.
   • c. If the specimen is not delivered to the Dahl-Chase Diagnostic Services (DCDS) laboratory within 1 hour of excision, perform steps d-i.
   • d. Ink the specimen using q-tips or gauze:
     • Anterior – Green
     • Posterior – Black
     • Superior – Red
     • Inferior – Blue
     • Medial – Yellow
     • Lateral – Orange
   • e. The ink should be blotted.
   • f. A mordant (e.g., acetone, vinegar) should be applied, and the specimen blotted dry a second time.
   • g. Incise the specimen perpendicular to the long axis to expose the tumor or area of suspicion to formalin. Avoid cutting all the way through the specimen.
   • h. Insert gauze or paper towel into the incision site to allow formalin to directly contact the area of interest.
   • i. Place the specimen in formalin. Document the time at which the tissue is submerged in formalin. The lab may need to record the time at which the specimen is placed in formalin.
4. Needle Localization Biopsies:
   • a. Document the time of excision.
   • b. Mark the orientation of the specimens with sutures.
   • c. Send the specimen to radiology. Ink the specimen after it has been x-rayed or use a dye that minimizes the risk of radiology artifacts (e.g., Vector Margin Marker).
   • d. If the specimen is not delivered to the DCDS laboratory within 1 hour of excision, perform steps e-j.
   • e. Ink the specimen using q-tips or gauze:
     • Anterior – Green
     • Posterior – Black
     • Superior – Red
     • Inferior – Blue
     • Medial – Yellow
     • Lateral – Orange
   • f. A mordant (e.g., acetone) should be applied, and the specimen blotted dry a second time.
   • g. Incise the specimen perpendicular to the long axis to expose the tumor or area of suspicion to formalin. If it is not clear where the area of interest is located, make an incision along the length of the wire. Avoid cutting all the way through the specimen.
   • h. Insert gauze or paper towel into the incision site to allow formalin to directly contact the area of interest.
   • i. Place the specimen in formalin. Document the time at which the tissue is submerged in formalin. (Radiology or the lab may need to record the time at which the specimen is placed in formalin.)
   • j. Needle localization breast biopsies should be submitted with the wire in place and must be accompanied by the specimen x-ray.
   • k. Specimens with a needle or wire should be placed in a puncture-proof container with a warning on the outside of the container that says “needle” or “wire”.
5. Mastectomies:
   • a. Document the time the specimen is removed from the patient.
   • b. If the specimen is not delivered to the DCDS laboratory within 1 hour of excision, perform steps c-g.
   • c. Ink the deep margin with black ink using q-tips or gauze.
   • d. Blot dry. Spray with mordant. Blot dry again.
   • e. Incise the specimen from superior to inferior to expose the tumor/area of interest to formalin. Avoid cutting all the way through the specimen.
   • f. Insert gauze or paper towel into the incision site to allow formalin to directly contact the area of interest.
   • g. Place the specimen in formalin. Document the time at which the tissue is submerged in formalin. (The lab may need to record the time at which the specimen is placed in formalin.)
     

Conclusion: By adhering to these guidelines and protocols, we will better serve the patient with accurate assessment of the margins and valid ER/PR testing. 

Materials:

1. Non sterile marking dyes: Cancer Diagnostics Tissue Marking Dyes is the product that DCDS currently uses to mark the specimens. 
   • https://www.cancerdiagnostics.com/
2. Sterile dyes: Vector Surgical Margin Marker offers a sterile product with proven results.
   • https://www.vectorsurgical.com/