Fixation time is extremely important in breast specimens. Delayed or inadequate fixation has been shown to impact hormone receptor immunoreactivity in breast cancer.
Core biopsies should be placed in formalin as soon as possible. Anything larger than a core biopsy should receive prompt gross examination, inking, and sectioning prior to being placed in formalin. If gross examination is to be delayed, the specimen should be carefully bisected to allow for adequate formalin penetration.
The time that the specimen is placed in formalin must be documented.
Tissue submitted for hormone receptor evaluation should be fixed in formalin for 6 to 72 hours.
Avoid submitting excessive fat unless (1) the entire specimen is being submitted (i.e. small biopsies), (2) fat is part of a margin, or (3) fat is at the interface with tumor.
Sectioning of the specimen should be performed at the thinnest interval that will allow you to take complete cross-sections. If the tissue is very fibrous, sections can be made at 2 mm intervals. Fatty tissue may need to be sectioned at a slightly thicker interval to maintain the integrity of the cross-section; however, sections submitted for histology should be thinned to 2 mm to ensure proper processing.
Every breast excision specimen should be approached with the view that if the specimen reveals carcinoma, the patient may desire breast-conserving therapy. This means close attention to margin status and inking.
Blot the margins free of blood and moisture, then apply ink before submerging in formalin. Ink adheres better to a clean unfixed surface than to a fixed surface. If the specimen is received in formalin, blot the margins dry, including the main crevices, and then apply ink. Wait till the applied ink slightly dry, then blotting the specimen with a paper towel wet with Bouin’s solution or alcohol may assist with ink adherence.
To avoid mismarking non-margin surfaces, do not contaminate the interior of the specimen with ink, and do not let ink run down between fat lobules that do not represent resection surfaces. Always blot dry the surface of the specimen after inking and before sectioning, and clean your blade before slicing a new section.
Use different ink colors to represent each of the six anatomic aspects/margins (anterior, posterior, superior, inferior, medial, and lateral). When fewer colors can be used, indicate the section locations in the gross dictation. When the anterior surface is partly covered by skin, any remaining anterior margin can be inked in the same color as the adjacent superior and inferior margins (e.g. anterior superior and anterior inferior). Unoriented specimens can be inked in one color.
If the nipple is present, it should always be submitted for histologic evaluation. The most thorough approach is to amputate the nipple by grasping it with forceps and shaving it off with 1 cm of areola circumferentially, then slicing it perpendicular to the base. If desired, the base can be shaved off from the nipple, prior to making the perpendicular cuts, and submitted as an en face section.
In re-excision specimens, hemorrhage, fat necrosis, and fibrosis in the vicinity of the previous biopsy site render accurate gross evaluation for the presence or absence or residual neoplasm extremely difficult, if not impossible. This judgment is best deferred to the permanent sections.
It is generally advisable to avoid stating that metastases are grossly present or absent in lymph nodes (unless the tumor is very obvious).