Specimen Handling Handbook
This handbook section provides information on the handling of specimens.
Please use this resource for your in-office questions.
If you print this page for in-office reference, please know that only this web page represents the most up-to-date information, and may be updated or changed on a regular basis without notice.
If you have any suggestions for additions, clarifications or other improvements, please forward them to: 4info@4path.com or contact laboratory at 1-877-884-7284 during normal working hours.
This page is divided into five sections:
- Specimen Labeling – Specimen labeling requirements common to all specimens
- General – Specimen instructions common to all specimens
- Surgical Pathology – Information related to biopsy and tissue specimens
- Cytology – Information related to cytology specimens
- Clinical Pathology – Information related to “blood and culture laboratory tests”
In addition, there is a “tips” section for the collection and fixation of cytology specimens.
Labeling
Note: The individual(s) obtaining and/or preparing the specimen(s) are responsible for the proper labeling of each specimen container and the requisition, in accordance with the following regulatory requirements. Proper labeling STARTS with proper patient identification using either wristband, picture ID, verbal confirmation by the patient or by a responsible party for the patient. Accurate labeling is the first step in ensuring a quality result for the patient!
Specimen Container Labeling
ALL specimens and requisitions must be properly labeled with at least TWO unique identifiers:
- Patient First and Last Name
- Date of Birth (or other unique patient specific identification)
- Source of Specimen
- Date specimen was obtained
Specimen Request Form
ALL specimens must have a specimen request form which includes:
- Patient Identification Data
- Pertinent History (include any relevant descriptions of lesion/tissue)
- Location/Source of Specimen
- Time and date of procedure.
- Insurance Information
- Recently the CMS has suspended the requirement for a physician signature on the test request form.
Specimen Request Form Downloads
4path provides multi-part request forms for use by out clients. However should those not be available, you may download the form from this site and utilize that print-out as a suitable replacement for the pre-printed multipart form.
General Surgical Pathology Form
Podiatry Form
General Information
Requisitions: All specimens must be submitted to 4path with a properly completed requisition.
Labeling: All specimens must be submitted labeled with two different patient identifiers, date and source. (Breast Biopsies also require the following times documented: Time removed from patient and time specimen was placed in formalin.)
Timing: Specimens should be submitted promptly to the laboratory and labeled with time and date of collection.
Collection Container: Always be sure that transport media, formalin, microbiology transport, etc. are not past expiration dates. Contact laboratory promptly for replacement when expiration dates approach.
NEVER send sharps or other hazardous materials by courier or other transportation means (FedEx, other) (i.e. hypodermic needles; punch biopsy tools, scalpels or other sharps items should be removed and discarded in an appropriate sharps containers at your locations. Do not send to “sharps” to laboratory!)
Patient Preparation: No specific requirements for pathology specimens – Use standard procedure preparation as determined by the submitting institution.
Patient Clinical Data: Please provide all patient clinical data appropriate for specimen type to ensure optimal pathology review and diagnosis.
Surgical Pathology
Punch Biopsies can be sent normally in formalin, unless for TENFD or IF studies (Contact laboratory for these studies prior to biopsy procedure.)
Breast Biopsies must have the time specimen was collected and placed into formalin. Must be received in laboratory within 36 hours of being placed in formalin. Document the following times on the specimen requisition: Time when specimen was removed from patient and time specimen was placed into formalin.
Frozen Sections should be kept on a damp sterile gauze and immediately transported to laboratory (contact laboratory for availability, scheduling and transportation prior to the performance of any frozen sections; Distance limitations apply)
Nerve Fiber Density Testing requires the use of special fixatives and processing; Contact laboratory for kits and submission instructions.
Nail Specimens Use the special dry nail submission kit; Submit to laboratory via US postal service in supplied Tyvec envelope (postage paid). NOTE: US Postal Tyvec envelopes are for DRY nail specimens or DRY skin scrapings ONLY. Do NOT send any other type of specimen (i.e. No cultures; No formalin fixed specimens) in US postal service envelopes. Please note: All nail specimens submitted will have a minimum of routine H&E evaluation and a PAS-F stain for fungus. Additional services, including reflex GMS and/or fungal culture are performed as an addition to those initial basic services.
Specimens for flow cytometry (Lymph nodes and other) Submit specimen in flow cytometry media, available from laboratory. Must be transported to laboratory immediately. Contact laboratory for specific instructions. Do not collect after hours, holidays or weekends without first receiving confirmation from laboratory ensuring proper processing will be available. This service may not be available for some locations.
Specimens for immunofluorescent studies. Submit specimen in IF transport media, available from laboratory. Contact laboratory for transport media prior to procedure.
Specimens for culture. Samples of the specimen should be submitted in microbiology transport media, available from laboratory. DO NOT SENT IN FUNGAL NAIL TYVEC ENVELOPES.
Other For any other unusual specimen or questions, contact laboratory for assistance.
TRANSPORTATION: For DRY nail or skin specimens (ONLY): Use Tyvec US postal service envelopes.
For all other specimens use laboratory courier or commercial transport (FedEx / UPS).
Cytology
Cytology specimens should be submitted in cytology fixative, supplied by laboratory, appropriately labeled.
Cytology Fixation Tips
Brushes (GI,etc): Submit in cytology fixative. Brush can be cut off and submitted in container
Aspirations: Submit in cytology fixative. Express aspiration into fresh cyto fixative gently and ensure all material is removed from hypodermic needle and syringe barrel. DO NOT SUBMIT ANY HYPODERMIC NEEDLES to laboratory. Dispose of all hypodermic needles at your location in a proper sharps container.
Gout Analysis should be prepared in one of two manners:
Same day transport (i.e. courier): specimen may be submitted without fixative in a red-top vacutainer (NO ADDITIVES; NO GEL TUBES) or other type of clean collection tube without any additive.
Remote transport: Place 1-2 drops of fluid on clean, labelled microscope slide and let dry completely, and place in slide transport container. Remainder of fluid can be placed into cytology fixative. Submit both specimens to laboratory.
Clinical Pathology
- Contact laboratory for instructions on submission of clinical laboratory specimens including: Cultures and blood specimens.
- Specimens outside of courier service area should not be submitted via FedEx or other carriers unless specifically instructed by laboratory.
- Most clinical laboratory specimens are sent to a local clinical laboratory for analysis.
- Specimens for clinical laboratory services should be sent to ensure receipt in laboratory by 4:30 PM M-F and by noon Saturdays.
- Clinical laboratory specimens outside of these hours should be sent only by prior arrangement with laboratory after confirmation by laboratory personnel.
Cytology Fixation Tips
Optimal cytologic examinations are highly dependent on the quality of the smears and/or materials provided. Please review these “tips” to help improve the quality of materials submitted for examination to optimize the diagnostic potential of the specimen.
FNA Specimens
When preparing for a FNA aspiration:
Determine the anticipated number of unique “passes” or “sites” that need to be separately analyzed.
Determine if immediate slides are to be made (usually NOT necessary). If so, pre-label 2 slides per “pass” or “site”.
Label a bottle of cytology fixative fluid (available from 4path) for each “pass” or “site” (Note: Usually multiple passes from a single site can all be placed in a single bottle of cytology fixative)
Have a clean syringe for needle flushing.
FNA Collection Tips
When collecting a Fine Needle Aspiration (FNA), regardless of the site, the operator should try to minimize the amount of blood that obtained with the specimen. Often this can be done by using only the minimal amount of “suction” or “vacuum” on the syringe during the procedure. When properly done, solid lesions may not have any material identified in the syringe. All of the aspiration is maintained in the needle. (This is not true for cystic lesion which may have a greater volume.)
Putting the specimen into the fixative
The specimen should be put into the cytology fixative as quickly as possible because these types of specimens can become dry and destroyed very quickly (literally seconds can make a difference). You should try to have the time from the aspiration is done to the material is in fixative to be as short as possible. Typically with advanced preparation and organization, this can be done in under 30 seconds.
During the preparation of the specimen, you should try to minimize the passing of the specimen back and forth through the needle. This can destroy the cells and make the aspiration unreadable.
- Put a small drop of the material on a slide, if you plan on making an immediate smear. (see next section)
- Push all remaining material from the needle into the cyto fixative.
- You can rinse the needle in two ways (Optional, but increases yield of diagnostic material)
- If there was NO material in the syringe barrel, remove the needle and put it on to a second clean syringe containing cytology fixative. Use that fixative to flush the needle into the labeled cytofixative jar.
- If there IS aspiration material in the syringe, draw up cytofixative into the syringe through the needle, pulling the needle contents into the syringe barrel.
- Remove needle.
- Express the fluid from the barrel into the labeled cytofixative jar. (Rinse a second time to optimize the yield of the cytologic material into the fixative).
NOTE: In ALL cases, handle the needle with great care to avoid accidental needle sticks. Use universal precautions at all times. Assume ALL patient specimens are infectious.
Slide preparation (optional)
Note: Please READ AND PREPARE for this type of preparation. Cytologic specimens can dry out very quickly and be ruined (yes…in just a few seconds. Minimizing time is ESSENTIAL).
- From the needle tip, express only the smallest amount of material. This should be just a fraction of a drop. If the amount of the specimen is minimal, don’t make slides. It is better to put all the material in liquid cytology fixative.
- Place that material on a pre-labeled slide (patient name, site and pass number (if appropriate).
- IMMEDIATELY take a similarly labeled slide and touch them together (flat side to flat side) and let the drop spread to a small circle (about 1 second).
- IMMEDIATELY pull the slides apart, sliding across each other.
- IMMEDIATELY put one of the slides in ethanol (95%) to fix (or using a pipette, you can put 1-2 mL of clean alcohol fixative on the slide), OR spray with spray cytology fixative.
- Allow the second slide to air dry.
- The slide in alcohol should be fixed at least 1 minute, but can remain in the alcohol until the end of the procedure without damage.
- Remove the alcohol fixed slide and allow to dry.
Aspiration Liquid Fixation
Liquid Fixation of the aspiration is the MOST IMPORTANT aspect of the specimen preparation. This should be done as quickly as possible with minimal trauma to the specimen. This technique is for solid aspirations. If there is cystic fluid see next tab.
- In a clean syringe, draw up clean cytology fixative from the cytology fixation vial that you are going to place the specimen. (Note: This syringe should NOT be used for the patient procedure. It is for the specimen preparation ONLY.)
- If all of the specimen is in the needle (i.e. no visible material in the syringe barrel), take the PROCEDURE syringe and gently express it’s contents into the small amount of cytology fixative in the labeled bottle. Then go to step 4.
- If there is visible specimen in the syringe barrel, the immediately go to the next step.
- CAREFULLY remove the needle from the syringe, and attach it to the clean syringe filled with fixative. Rinse the needle out into the labelled specimen container with this clean fixative. You can use a small amount of fixative and save the remainder for other passes from the same site. Regardless, when that sites passes are complete, return all unused fixative into the collection vial to optimize fixation. At that point, all of the material from the same-site passes are now in the single cytology fixative container.
- If there is material in the syringe barrel, you can carefully draw up fixation fluid (even using a second, clean, unused similar specimen vial) and rinse the barrel contents into the final specimen vial. Do not rinse through the needle, but express the material directly out of the barrel hub.
Note: You CAN use fixation fluid from a second clean cytology fixation vial to wash out the needle into the fixation fluid, provided that it is of the same type. Avoid mixing different cytology fixation types. NEVER re-use a needle or use a syringe with fixation media for a patient aspiration.
Dispose of all used needles and syringes in a safe manner.
REMEMBER: ALL PATIENT MATERIALS SHOULD BE HANDLED WITH UNIVERSAL PRECAUTIONS AND ASSUMED TO BE INFECTIOUS.
Cystic Aspirations
Fluids from cystic aspirations can simply be expressed expressed into the cytology fixation fluid. Removal of the needle first and expression from the barrel hub directly may help eliminate the risk of specimen damage from expressing it through the needle under pressure.
REMEMBER: ALWAYS HANDLE SPECIMENS WITH UNIVERSAL PRECAUTIONS. ASSUME ALL PATIENT SPECIMENS ARE INFECTIOUS.
High Volume Specimens
For high volume specimens (such as paracentesis specimens) send ONE bottle with greatest turbidity to the laboratory (Keep refrigerated/cool (not frozen) if possible prior to transport) , OR, preferably, a sample of the specimen can be obtained from a representative bottle and placed into cytology fixative media. Be sure to fully mix the specimen prior to removing a representative sample for fixation in a secondary container. Ensure all containers are properly labelled at all times with the patients identification.
In these cases, use a specimen that is most turbid, but try to avoid bloody specimens, if possible.
Please record the volume of fluid on the specimen requisition.
REMEMBER: HANDLE ALL SPECIMENS WITH UNIVERSAL PRECAUTIONS. ASSUME ALL PATIENT SPECIMENS ARE INFECTIOUS.