What specimens does your department fix overnight?

[pathstudent]

---

Members don't see this ad.

How long does your department fix specimens.

Here is mine.

Always fixed over night no matter why they were taken out: Ovarian Tumors, Testicals, Lumps/masts, Gi Resections, Pancs, Liver lobes, Prostates, Thyroidectomies, Sarcomas, Placentas, Uteruses, Bladders, ENT composite resections, Salivary Glands, Lung wedges or bigger. If worthwhile on unknown tumors a thinly sliced pilot section well be put through to get the immuno work-up going the same day.

Sometimes fixed over night or sometimes put in same day if small/received early: Skin/vulva wide excision, Cervical Cones, Big Brain Tumors, liver Wedges.

Grossed same day: All biopsies, appendix, hernia sacs, gallbladders, and everything else.

Personally I like the overnight fixation. The histo is usually superior and you can get better sections.

 

[Gene_]

We must be the opposite of your program. Nothing is required to be fixed overnight and the staff prefer to have everything grossed the day it comes in. Personally, I don't want to be grossing on the day I am supposed to be signing out, so I do my best to put everything through day 1. I do insist on overnight fixation occasionally, usually on friable tumors of the bladder or colon.

 

[pathstudent]

We must be the opposite of your program. Nothing is required to be fixed overnight and the staff prefer to have everything grossed the day it comes in. Personally, I don't want to be grossing on the day I am supposed to be signing out, so I do my best to put everything through day 1. I do insist on overnight fixation occasionally, usually on friable tumors of the bladder or colon.

How the hell can you read a lung resection for ILD or cancer without fixing it. How the hell can you diagnose a lymph node that isn't properly fixed. I hope I never have surgery at your institution.

 

[path19]

In my experience at several institutions, this is pretty commonplace. Not too many places have the luxury of fixing things overnight, most stuff is cut fresh or after minimal fixation.

We must be the opposite of your program. Nothing is required to be fixed overnight and the staff prefer to have everything grossed the day it comes in. Personally, I don't want to be grossing on the day I am supposed to be signing out, so I do my best to put everything through day 1. I do insist on overnight fixation occasionally, usually on friable tumors of the bladder or colon.

 

[KeratinPearls]

In my experience at several institutions, this is pretty commonplace. Not too many places have the luxury of fixing things overnight, most stuff is cut fresh or after minimal fixation.

How about breast mastectomies/lumpectomies? Melanomas from wide excisions with a fair amount of subcutaneous fat? If I were submit these specimens same day, usually the tissue would be too raw and your sections would come out like crap (holes in your sections)...then the blocks would have to be reprocessed. On top of that, the histo supervisor would yell at you for the unnecessary work you've given them.

I usually submit everything same day except for breasts, melanomas and colons for colon ca. If I could I would try to submit everything same day so I could look at my slides the next day, but its impossible to fix the above specimens well enough in a day.

 

[icpshootyz]

Depends on what time it comes into the department, but nothing is required to fix overnight at all where I am. We have a 3pm cutoff for all large specimens, meaning if it comes in before 3pm it gets assigned to that days cutting residents. That doesn't mean you can't fix it overnight, just that it's yours and not the next day team's. That being said, I RARELY let anything fix overnight and I have had very few fixation/histology problems. Just because I cut something fresh doesn't mean it won't sit in a cassette in formalin for several hours before getting processed, which is far better than a whole organ or specimen sitting in a bucket of formalin where the formalin is only slowly penetrating the specimen. Usually I will slice a specimen fairly thin while it's fresh, let the slices firm up for a couple hours, then take my sections and let the cassettes fix longer until processing. If you cut your tissue thin enough it should process with no trouble, even if it only has minimal time in formalin prior to going on the machines. The machines have many fixation steps built in. The number and types of cases listed above that are mandatorily fixed overnight seems very excessive to me.

One exception is bone and bone tumors, since the formalin penetrates rather slowly, and the decal process can damage the histology if fixation was not appropriate prior to decal. If I can't guarantee several hours of fixation prior to decal I let them fix overnight.

 

[KeratinPearls]

Depends on what time it comes into the department, but nothing is required to fix overnight at all where I am. We have a 3pm cutoff for all large specimens, meaning if it comes in before 3pm it gets assigned to that days cutting residents. That doesn't mean you can't fix it overnight, just that it's yours and not the next day team's. That being said, I RARELY let anything fix overnight and I have had very few fixation/histology problems. Just because I cut something fresh doesn't mean it won't sit in a cassette in formalin for several hours before getting processed, which is far better than a whole organ or specimen sitting in a bucket of formalin where the formalin is only slowly penetrating the specimen. Usually I will slice a specimen fairly thin while it's fresh, let the slices firm up for a couple hours, then take my sections and let the cassettes fix longer until processing. If you cut your tissue thin enough it should process with no trouble, even if it only has minimal time in formalin prior to going on the machines. The machines have many fixation steps built in. The number and types of cases listed above that are mandatorily fixed overnight seems very excessive to me.

One exception is bone and bone tumors, since the formalin penetrates rather slowly, and the decal process can damage the histology if fixation was not appropriate prior to decal. If I can't guarantee several hours of fixation prior to decal I let them fix overnight.

So if you got a mastectomy/lumpectomy for cancer late (let's say 3pm), you would take your sections and put them in cassettes and let them fix in formalin, until it was time to load the processor? How thin are we talking? 3 mm or less? What time do you need to load the processor by? We also have a 3 pm cutoff time as well and have to load the processor by 630 pm.

I was told by our histo supervisor, there's a minimum time your breasts need to be fixed prior to submission. I think this is a CAP requirement. I think it's like 6-12 hours?

 

[yaah]

Breast tissue has to be fixed for at least 8 hours - although I believe this can include time spent in formalin while in the processor. It is supposed to be no more than 72 hours.

You don't really need to fix lung specimens overnight, nor thyroids. They fix quite well. It is more the fatty or dense tissues (breast, lymph nodes, prostates) that need fixing for optimal histology. Tissues that are hard to cut like bladders, colons are usually fixed for ease of grossing.

 

[2121115]

If a specimen comes in at 3pm it can easily be cut in the same day. 6-7 hours in formalin means you can gross it at 9-10pm. Even at 4 or 5 pm you can still let it fix and be out by midnight. That is plenty of time to fix and there is no need to wait until the next day. I suppose the only exception would be mastectomies or lumpectomies that are treated with neoadjuvant and might need to fix longer or be radiographed to make sure you find the tumor/clip/biopsy site/etc.

 

[icpshootyz]

So if you got a mastectomy/lumpectomy for cancer late (let's say 3pm), you would take your sections and put them in cassettes and let them fix in formalin, until it was time to load the processor? How thin are we talking? 3 mm or less? What time do you need to load the processor by? We also have a 3 pm cutoff time as well and have to load the processor by 630 pm.

I was told by our histo supervisor, there's a minimum time your breasts need to be fixed prior to submission. I think this is a CAP requirement. I think it's like 6-12 hours?

The short answer is yes. We have multiple processors that run at different times. The processors that start the earliest are the biopsy/smalls processors, then the later runs are all the large tissues. I don't believe our late processors even start until 9:30 or 10pm, so things grossed by 3pm would have ample time in formalin prior to processing. We never have breasts fix overnight unless they come in after 3pm, and our breast pathologists have been instrumental in our grossing policies since they are keenly aware of the CAP policies.

 

[GeoLeoX]

I was told by our histo supervisor, there's a minimum time your breasts need to be fixed prior to submission. I think this is a CAP requirement. I think it's like 6-12 hours?

It is a recommendation, not a requirement:

Also, it's important to consider fixation time and the effect on IHC, especially Her2/neu (though if you only do FISH it's not as big a deal).

 

[horrendoma]

So if you got a mastectomy/lumpectomy for cancer late (let's say 3pm), you would take your sections and put them in cassettes and let them fix in formalin, until it was time to load the processor? How thin are we talking? 3 mm or less? What time do you need to load the processor by? We also have a 3 pm cutoff time as well and have to load the processor by 630 pm.

I was told by our histo supervisor, there's a minimum time your breasts need to be fixed prior to submission. I think this is a CAP requirement. I think it's like 6-12 hours?

Yup. For C-erbB2 validity, specimens need to be fixed for 6-48 hours.

 

[member0007]

interesting thread.... it could be an interesting read for certain residents at a certain institution where pathology is not practiced as in the real world. GL.

 

[Euchromatin]

About the only things that our institution *always* fixes overnight before grossing are prostates. Some, but not all, of our staff prefer you to pin out bladders and big GI resections (or insufflate lobectomies for tumor) for easier grossing the following day. We will cut breasts and lymph nodes fresh, then the cassettes containing these specimens are kept separate and have their own special overnight fixation and extra-long program on the processor. Obviously some things, like bone tumors or lung resections for interstitial lung disease need special treatment.

I agree with previous comments that it is generally better (if you can do it neatly) to cut thin sections of fresh tissue and just let the sections in cassettes get optimal formalin time since the penetration into large, solid pieces of tissue is so slow.

I don't know what benefit there would be in fixing a lot of the stuff pathstudent mentioned overnight (i.e. ovaries and uteri, breast tissue, Whipples, liver, thyroids, placentas, salivary glands). These are mostly solid pieces of tissue that formalin would only penetrate very slowly overnight...and if it is possible to cut them thinly while they were fresh (to help formalin penetrate), why not just take your sections at that time as well?

 

[KCShaw]

I don't recall us having hard & fast rules. Anything that came in early would pretty much always be cut, and anything that came in with the last pickup (3 PM or so?) would be triaged, but still usually cut same day. As pointed out, specimens continue to fix in cassettes and while waiting in the processor, but if we had an early processor run and a really late case, sometimes it would be cut but the cassettes left to fix overnight and put on the processor early the next day. Depends. Some specimens are easier to cut fresh (or at least are not significantly harder), and some ain't. Prostates tend to warp with incomplete or irregular fixation, and bladders tend to denude at the best of times, so we -usually- fixed those longer or used various techniques to improve their fixation. Colons might cut easier fixed, but for some people node searches were easier fresh.

As far as histology goes, I don't recall any real problems related to grossing them "too soon" or not fixing long enough before the processing cycle started. Rare at best, unless someone stayed way too late and took the cassettes straight from the gross bench to the processor and immediately started the processor, or somesuch. Or occasionally poor grossing technique, with far too thick sections in the cassettes. Frankly, with the pressure for quicker turnaround times, I don't see how a group could compete without grossing at least most of their stuff same day.

 

[NuckingFuts]

Interesting- no one has mentioned injecting formalin with a syringe into solid organs to facilitate fixation.

 

[lipomas]

Interesting- no one has mentioned injecting formalin with a syringe into solid organs to facilitate fixation.

I use mouth pipetting.

 

[Euchromatin]

Interesting- no one has mentioned injecting formalin with a syringe into solid organs to facilitate fixation.

We do use a syringe to inject formalin into some lung specimens so the airways aren't all collapsed (especially if the specimen is for interstitial lung disease)...not sure if that is what you meant by "solid" organs.