Elliptical (and cylindrical) excisions

Pathology of challenging melanocytic neoplasms. Diagnosis and Management. Christopher R. Shea, Jon A. Reed, Victor G. Prieto (Editors). Springer (2015)

Excisions are, by definition, specimens intended to excise a lesion. As such, assessment and reporting of margins is usually required. Most excisions are elliptical; however, cylindrical specimens may be taken from certain anatomic sites where optimum lines of surgical closure are not clinically evident prior to the procedure. In this case, additional detached tips (“dog ears”) may be submitted separately, and should be treated as true “tip” margins. Larger excisional specimens often are oriented to identify a specific anatomic site on the patient such that a positive margin may be treated locally and less aggressively. Any surface lesion should be described noting its size, circumscription, color(s), and proximity to the peripheral margins.

Un-oriented specimens are marked with indelible ink along the entire peripheral and deep surgical margin similar to a shave biopsy. The ellipse (or cylinder) is then serially sectioned along the entire specimen (bread-loafed) to produce parallel sections perpendicular to the epidermal surface. Each section should be no greater than 2–3 mm in thickness to facilitate optimum tissue fixation and to allow examination of a larger area of surgical margin. Any lesion present on the cut surface should be noted, especially satellite lesions outside of the prior biopsy site in larger excisions.

Larger oriented specimens are treated somewhat differently than un-oriented excisions.

A suture often is used to orient an excisional specimen. The suture may be placed at one end (on a tip) and/or along one long axis (edge). Occasionally, two sutures may be used (different colors or lengths to differentiate). Some surgeons use a standard designation of “Short suture— Superior, Long suture—Lateral” to simplify communication with the laboratory. Others may place a nick/slice along one border to designate orientation, but this practice is not advised as formalin fixation may result in tissue shrinkage that obscures the mark [6].

Regardless of the method used to identify a specific margin, specimens are differentially inked to reflect the orientation. The easiest way to orient an excisional specimen is by quadrant using a clock face for landmarks. Assuming that a marking suture at one tip of an ellipse is designated 12 o’clock, the specimen can be divided into 12–3, 3–6, 6–9, and 9–12 o’clock quadrants. Each quadrant could then be marked with a different color of indelible ink along the peripheral and deep surgical margin.

Another approach using only three colors of ink produces similar results. The 12–3 and 3–6 o’clock quadrants are differentially inked, whereas the 6–9–12 o’clock half is marked with one color. As such, the 12 o’clock half can be distinguished from the 6 o’clock half based on the unique pairing of the ink colors.

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