Orient the specimen if orienting sutures or clips are present. Contact the surgeon or staff pathologist if necessary.
If the intact specimen has not been x-rayed yet, do so now. Place metal markers adjacent to the specimen in the x-ray machine to provide orientation. Ensure that the x-ray is tagged (either electronically or in writing, if film is used) with patient-identifying information, date, specimen accession number, site of biopsy, and anatomic location (e.g. lateral and superior) of the markers.
Measure the size of the specimen in three dimensions and note the general shape (e.g., ovoid, spherical).
Record the presence of skin, fascia, and/or skeletal muscle. Measure these structures.
Blot dry the specimen and ink with multiple colors, if oriented, or with one color if unoriented; blot with paper towel wet with Bouin’s solution or alcohol.
Serially section the specimen in 2-3 mm intervals (perpendicular to the needle wire, when possible).
If a mass or discrete nodule is identified, process as described in Excisional Biopsy/Lumpectomy for Mammographic Density or Palpable Mass.
Arrange the slices in order and x-ray them, using metal markers to provide orientation. If film is used, mark the x-ray with consecutive numbers and orientation of each slice; indicate the areas from which sections were submitted.
For microcalcifications without identifiable mass: submit all slices with microcalcifications and the slices immediately preceding and following these slices.
For an identifiable mass with or without microcalcifications: submit the entire mass and adjacent margins (or at least four sections of the lesion if very large); sample margins not included with sections of the mass.
Received without fixative/in formalin labeled ______ and "___" is a __ x __ x __ cm ____ (shape) piece of fibroadipose tissue with a needle wire in situ coursing from the ___ (e.g. superior-lateral) to the ___ aspect. ___ sutures are present: short suture = ___; long suture = ___; short double suture = ___.- The specimen is inked as follows: superior = blue; inferior = green; anterior = yellow; posterior = black; medial and lateral = red. On specimen x-ray, microcalcifications are identified ____ (e.g. near the tip of the wire). It is serially sectioned perpendicularly to the wire into ____ slices, consecutively numbered 1 to ___ from (e.g. lateral to medial). The specimen has a _____ (color, fibrofatty/fleshy) cut surface with a ___ x ___ x ___ cm ___ (e.g. nodule / firm area) ___ (e.g. near the wire tip) in sections # ___. It is ___ cm from the closest (_____) margin. X-ray shows microcalcifications in ____ (location) in sections # ___, #___ and # ___, located __ cm from the nearest (_____) margin. The sections are serially labeled on the X-ray film and are representatively / entirely submitted as follows:
#__ - #__ = microcalcifications (entirely submitted) in slices __ and __, with _____ (i.e. nearest) margin(s) margins.
#__ - #__ = area around the wire tip (slice #___) (if not included above)