SURGICAL PATHOLOGY SPECIMENS:

ROUTINE TISSUE BIOPSIES AND RESECTIONS:

Place all routine tissue biopsies and resections in 10% neutral buffered formalin.  

If 10% formalin is not available and the specimen cannot be sent immediately or will require a long transportation time, wrap the specimen in a slightly saline dampened sterile gauze sponge/Telfa®, place in a sterile container, and keep refrigerated.  For large specimens/amputations that cannot fit in a formalin container, double bag the fresh specimen in a red biohazard bag and keep refrigerated.

FRESH SPECIMENS:

For all fresh surgical pathology specimens, please wrap the tissue in a slightly saline dampened sterile gauze sponge/Telfa® and send to the lab immediately.   Special requests for fresh specimens should be handled as follows:

Frozen section/intraoperative requests:  Send fresh immediately and designate as “FROZEN SECTION REQUEST”.

Lymph node lymphoma protocol/flow cytometry:  Send fresh immediately and designate as “LYMPHOMA PROTOCOL”.  If a lymph node specimen is traveling a long distance or cannot be delivered to the lab immediately, please place the specimen in 10% neutral buffered formalin.

Cytogenetics/Chromosome analysis: Send fresh immediately and designate “SEND FOR CYTOGENETICS”.  If immediate transport cannot be arranged or if the specimen will be traveling a long distance to the lab, please place a small amount of tissue (5-10 mm) in RPMI and refrigerate.  Call our pathologists with any questions on how to divide a specimen.

Medical kidney:  Send fresh immediately and designate as “MEDICAL KIDNEY”.  Our pathologists will perform an immediate adequacy evaluation before dividing the specimen in the appropriate renal fixatives (formalin, glutaraldehyde, and Michel’s or Zeus’s media).  The specimen will then be sent to our participating labs for complete interpretation.

Nerve/Muscle biopsy:  Please notify the lab prior to the muscle biopsy procedure and provide the estimated procedure time.  Optimal sampling includes:

• Muscle: A 2.5 cm in length x 1.5 cm in width x 0.5 cm in depth strip of muscle cut parallel to the direction of the muscle fibers.  A muscle that is moderately but not severely weak should be selected for sampling. 

• Nerve: 1.5-2.0 cm strip of nerve.

Immediately after excision, the muscle/nerve specimen should be stretched in the direction of the fibers to just beyond its in situ resting length and secured at each end to a small stiff card or tongue depressor.  Wrap in a slightly saline damped gauze sponge/Telfa® (too much saline may create artifact within the tissue on histologic examination). Send the specimen to the lab immediately and designate “MUSCLE/NERVE BIOPSY SEND-OUT”.  The specimen will then be appropriately packaged and sent to our participating labs for complete interpretation.

 BODY FLUIDS/CYTOPATHOLOGY:

Body fluid specimens require special media to maintain the integrity and prevent degradation of the cells suspended in the fluid.  When deciding how to send a fluid specimen to the lab there are few questions to consider BEFORE specimen collection:

How much time will it take for the specimen to reach the lab?

Minimal delay in transport (2-3 hours): Specimens can be sent fresh and we will add the appropriate media.  Refrigeration prior to transport is always preferred.

Delay in transport/long travel time: Add appropriate media (see below) to maintain specimen integrity and keep refrigerated until specimen can be processed.

Friday/weekend collection: Add appropriate media (see below) to maintain specimen integrity and keep refrigerated until specimen can be processed.

What type of media is needed for the suspected diagnosis/what ancillary tests might I need?

Routine cytology (no special requests): Add CytoLyt® and keep refrigerated (preferred) or at room temperature.

Lymphoma rule-out/flow cytometry: Add RPMI (pink tissue culture media) and keep refrigerated (preferred) or at room temperature.

Molecular tests: Add CytoLyt® and keep refrigerated (preferred) or at room temperature.

*DO NOT SUBMIT FLUID SPECIMENS IN FORMALIN OR LEAVE ANY SHARPS INSIDE OR ATTACHED TO THE CONTAINER*

RPMI media is not readily available at my facility! What can I do?

If immediate transportation to the lab is available, you can send the specimen fresh in a sterile cup and notify the lab on arrival that RPMI is needed. If immediate transport cannot be arranged or if the specimen will be traveling a long distance, viral culture media (VCM) can also be used to maintain the integrity of the specimen.

How much fluid will be collected?

Small volume:  Generally 3 mL of fluid volume is necessary for processing.  If 3 mL of fluid cannot be obtained, please make a note, and we try our best to process the specimen and provide you with a result.

Large volume (>100 mL): The specimen will need to be agitated and two (at minimum) random 40 mL samples taken.

What amount of media is required for specimen preservation?

A 1:1 specimen-to-media ratio is optimal.  If possible, excess media is preferred.  Example: For 15 mL of specimen add 20 mL CytoLyt®.

What type of specimen container is required for collection?

Any sterile and leak-proof container will be accepted.  Examples of specimen collection vessels include:

Sterile containers

Capped syringes without needles 

RPMI tubes

CytoLyt® cups

CytoLyt® tubes

 CRYSTAL EXAMINATION

Collect as much fresh specimen as possible into a sterile container and send to the laboratory within 24 hours of collection. If the specimen travel/transport will require longer than 24 hours, keep refrigerated until specimen can be processed.

*Please remember specimens for crystal analysis still require the same labeling requirements as all other specimens, including two patient identifiers and specified site (i.e left knee).

 FINE NEEDLE ASPIRATION:

Proper preparation of aspirate slides following a fine needle aspiration is essential for microscopic interpretation.  Improper specimen collection and slide preparation can result in preparation artifacts that impair or inhibit accurate interpretation.  Please use the procedure as outlined below to ensure the proper collection, preservation, and preparation of FNA specimens for cytologic evaluation.  

Materials:

Glass slides with frosted end for labeling

Alcohol fixative (95% alcohol)

Personal protective equipment (gloves at a minimum)

Liquid media (choose based on clinical differential diagnosis):

CytoLyt® (routine cytology evaluation)

RPMI (r/o lymphoma)

Sterile tube with saline (infection)

Afirma collection container (for thyroid FNA, if applicable, see Notes below)

Immediately prior to the FNA:

1. Complete the specimen requisition sheet including: ordering physician, performing physician, department/patient location, patient name, DOB, MRN, date and time of specimen collection, aspiration anatomic site, clinical history, and pertinent radiographic findings.

2. Label the frosted end of 6 to 8 glass slides with the patient’s name and date of birth.

3. Fix a patient label with the patient’s name, DOB and aspiration anatomic site (ie, right thyroid nodule) to the 95% alcohol, liquid media, and Afirma (if applicable) containers. 

4. Open the 95% alcohol, liquid media, and Afirma (if applicable) containers and leave the cap upside down on the countertop.

5. Open an empty syringe and draw the plunger back a few mL

6. Prepare appropriate personal protective equipment (gloves, at a minimum).

Slide Preparation:

1. Carefully obtain the syringe/needle hub from the physician performing the FNA, being careful to prevent needle sticks.

2. If the physician is using a needle only, attach the hub to your prepared empty syringe.  If the physician has used a syringe to aid in aspiration, detach the needle from the syringe, draw the plunger back a few mL to fill the barrel with air, and reattach the needle.  

3. Lightly touch the needle tip, bevel down to the top center of the glass slide (just below the frosted end) and carefully depress the plunger to dispense 1 to 2 drops of aspirate material. Make sure the needle is attached securely to the syringe and hold the needle with one hand to ensure the needle does not fly off when air is forced through.

4. Holding a clean “spreader” slide in one hand (dominant hand), pick up the slide containing the aspirate material (non dominant hand) at a right angle to the spreader slide.  Gently lower the spreader slide on top of the specimen slide until it lightly compresses the aspirated material.  Maintain light and even pressure between the two slides and then pull the spreader slide quickly across the specimen slide to distribute the material evenly.  Proper technique should produce a teardrop or oval shaped spread. 

   *Too much material on the slide will result in a thick smear and/or material flowing off the slide, which can make interpretation difficult and, sometimes, impossible. Even if the syringe contains a large amount of aspirate material, keep to 1 to 2 drops on the slide.  The remainder will be submitted in the liquid media (see below)Immediately place the slide in 95% alcohol, ensuring the slide is completely submerged

5. Rinse the needle, even if no aspirate material can be seen in the needle hub, in the liquid media solution (see above for liquid media selection).  This is done by drawing back on the plunger to allow a small amount of liquid to flow into the syringe, and then depressing the plunger to flush the needle of any residual aspirate material.  Repeat the rinse 2 more times.  Avoid excessive force when depressing the plunger as this can result in damage to the cellular material and may also force the needle off the syringe and into the liquid media container.  

6. Remove the syringe and dispose of the needle.

7. Repeat this procedure for all additional aspirates. All aspirates from the same anatomical site can be rinsed in the same liquid media solution.   

8. For thyroid FNA we ask that 6 aspirations are performed at each anatomic site, resulting in 6 glass slides. If sample collection for potential Afirma thyroid molecular testing is requested by the ordering physician, an additional (7th) aspirate will need to be obtained.  From the 7th aspirate, submit all the material in the Afirma specimen collection container by rinsing the needle in the same manner as described above.

9. Once all aspirate passes from one anatomic site have been obtained, securely fasten the lids to the 95% alcohol, liquid media, and Afirma containers (if applicable).

10. Repeat the above procedure steps for any additional aspiration sites, ensuring proper labeling of each new site.

11. Submit all materials with the corresponding requisition sheet in a biohazard bag and send to the lab.  If the specimen cannot be sent to the lab within the same day, or will require a long transit time, refrigeration of CytoLyt® and RPMI media containers is recommended.  Saline media collection for microbial studies should be maintained at room temperature.

Notes:

1. Aspirates from the same anatomic site should be rinsed in the same liquid media container.

2. When aspirating more than one anatomic site (right superior thyroid nodule, right inferior nodule), designate each new site as “A”, “B”, “C”, etc and provide the alphabetical designation on the glass slides.  Each new site will require a separate liquid media container, which should be appropriately labeled with the alphabetical designation “A”, “B”, “C” and the anatomic site “right superior thyroid nodule, right inferior thyroid nodule, etc”.  This designation should correspond to the documentation on the requisition sheet.

3. Each aspirate site should result in alcohol fixed glass slides, 1 liquid media container, and 1 Afirma collection sample (if applicable).  

4. If more than one evaluation method is requested (cytology with flow cytometry or microbial studies) an additional aspiration can be obtained and submitted entirely in the liquid media for the additional studies (RPMI for flow, saline for culture).

5. If RPMI is not available, viral culture media can be used.  Alternatively, if immediate delivery to the lab is possible, sterile saline can be used.  Please inform the lab when you deliver the specimen that lymphoma is suspected and RPMI was not available.  

 MICROBIOLOGY:

Send fresh in a sterile container and maintain at room temperature. If requesting both microbiology studies and histologic interpretation, please make sure to designate the request on the requisition sheet so we can divide the specimen appropriately.