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Annals of Diagnostic Pathology 12 (2008) 191 – 198

Technical Note

Bone grossing techniques: helpful hints and procedures

Izak B. Dimenstein, MD, PhD⁎
Department of Pathology, Loyola University Medical Center, Maywood, IL 60525, USA

Abstract The present article is intended to offer pathologists and pathology residents helpful hints and
procedures as well as some general approaches to technical questions of bone grossing in a
surgical pathology laboratory. An emphasis on the personal experience of the author in grossing
bones has been made. Three main conditions determine successful gross bone sections: specimen
immobilization, the appropriate cutting instrument, and correct specimen orientation. From the
technical point of view, the most important seems to be immobilization. A variety of devices and
gadgets can be used to make the bone specimen stable while sectioning. Among them, hard-
pressed cardboard cartons are the most helpful. They have the advantage in complicated bone
specimens to allow the grossing person to cut through the immobilization device, thus assuring a
complete section. There are definite particularities in technical approaches to different bone
specimens. Even a femoral head, the most popular specimen, requires different grossing
techniques depending on the clinical circumstances. Examples of grossing techniques for different
bone specimens are described in detail. The technique can be applied in similar clinical situations
to other bone specimens.
© 2008 Published by Elsevier Inc.

Keywords: Grossing; Technique; Bones; Decalcification; Surgical pathology

1. Introduction emphasize microscopy, leaving almost untouched questions

Bone grossing is, generally speaking, cumbersome, dirty,
and physically demanding. However, an accurate diagnosis
often depends on a successfully done bone gross section.
Surgical pathology grossing manuals do not concentrate
on the technical part of bone grossing [1,2]. Some
recommendations, for example, in Hruban's illustrated
manual, are technically unattainable. The section on
“Bones and joints” in the Lester manual includes 5 short
sentences regarding bone sectioning technique with one
questionable recommendation—to make 0.5-cm-wide sec-
tions when the working depth of a standard processing
cassette is 0.48 cm. Surgical pathology manuals [3-6]
This material was presented in part in abstract form at the 31st National
Society of Histotechnology Annual Symposium/Convention, Fort Lauder-
dale, Florida, 2005.
⁎ Tel.: +1 708 354 6903.
E-mail address: idimenstain@hotmail.com.
1092-9134/$ – see front matter © 2008 Published by Elsevier Inc.
doi:10.1016/j.anndiagpath.2007.06.004
of bone grossing techniques.
Although many bone specimens do not require special
techniques, modern surgical practice often requires
answers beyond the bone pathology itself. Sometimes,
questions of tumor–soft tissue–bone relationships are a
significant part of the pathologic diagnosis. Without the
appropriate grossing technique, these questions cannot be
answered. Even femoral heads or knee replacement bones
can reveal many diagnostic findings if proper processing
is applied.
This review is intended to offer pathologists and pathology
residents helpful hints and procedures, as well as some
general approaches to technical questions of grossing bones
in an ordinary surgical pathology department. Specialized
practices (orthopedic, neurosurgery, head and neck surgery,
etc) may have specifics in processing, but the common
principles of bone grossing can be applied to them also.
The materials here described reflect predominately
personal experience accumulated during experimentation
with different approaches and instruments. Every person
192 I.B. Dimenstein / Annals of Diagnostic Pathology 12 (2008) 191–198
inevitably develops preferences and biases while handling
bones at the grossing table on a regular basis.
2. General principles
Bone grossing includes 3 main components: tissue
preservation (fixation, freezing), representative section
(sampling by sawing, cutting), and preparation for micro-
tomy (decalcification, freezing, softening). The key is to get
a representative section ready for processing.
The commonly accepted standard processing formula is
fixation-section-decalcification, although manuals mention
cutting fresh sections. For example, Rosai's [7] manual
considers fresh bone sections as “quite adequate.” Lester's
manual also tends to recommend processing in the fresh state.
In simple bone specimens, fixation may not matter; but in
more or less complicated cases, especially if soft tissues are
attached, the more appropriate processing pattern is section-
ing-fixation-decalcification.
Whereas fixation makes specimens such as a placenta or a
colon more suitable for grossing, in bones with tumor or
attached soft tissue, this is not the case. While preserving
cellular structure, fixation makes bones and especially soft
tissues brittle. Even the finest saw does not have the
sharpness of a knife or a blade. The saw movements strip the
soft tissue from the bone because the natural adhesiveness is
lost during fixation, preventing the pathologist from
answering the important clinical questions of bone–soft
tissue relationships.
Unless some safety considerations, for example, AIDS,
tuberculosis, Creutzfeldt-Jacob disease, dictate preliminary
fixation, bone sectioning in the fresh state assures better
preservation of bone–soft tissue relationships. There are
other advantages of cutting bone specimens in the fresh state.
The anatomical structure of the specimen is more visible
because of natural tissue colors. Fixation of the section is
more uniform. Obviously, fixation of a thin section is faster
than that of an entire bone and shortens turn-around time.
Grossing in the fresh state also provides more options for
ancillary studies.
Of course, safety rules should be followed more strictly
when bones are processed in the fresh state, but these issues
are out of the scope of this article. It is necessary to mention
that bone specimens are hazardous specimens in surgical
pathology from the standpoint of safety. Bone dust, as well
as bone fragments and crumbles, disseminated in working
environment is also potentially biohazardous.
3. Technique
Three main conditions determine successful bone section:
specimen orientation, immobilization, and appropriate cut-
ting instrument. From the technical point of view, the most
important seems to be immobilization, although correct
orientation is crucial for the diagnostic value of the section.
4. Orientation
The pathologist determines the orientation of the bone
specimen for sectioning. Even if the pathologist is not
directly involved in the sectioning, the pathologist's
diagnostic considerations and expectations are the key factor
for the initial and subsequent sections.
During bone specimen orientation for sectioning, it is
necessary to honor the main rules of grossing:
• follow the anatomical structure;
• make sections in 1 direction as much as possible;
• maintain as much as possible the organ/specimen
integrity after the section has been taken.
Longitudinal sections should be avoided as much as
possible. Transverse sections are optimal unless there is a
necessity for demonstration of the tumor for a conference or
publication. Longitudinal sections, as well as sections
through the middle of the specimen, look more impressive
and comprehensive. They are reasonable in bone tumors,
especially after chemotherapy. However, they often interfere
with grossing techniques, especially immobilization of the
specimen, while doing serial sections. Sometimes immobi-
lization considerations make it reasonable to do serial
sections from the periphery of the specimen, choosing later
the necessary representative sections for processing.
The orientation of the first cut should be optimal,
decisive, and the most representative in its diagnostic
value. Just a provisional cut ought to be avoided. Of course,
there are exceptions.
5. Immobilization
Immobilization is the priority among technical questions
in bone grossing, as was mentioned before. A variety of
devices and gadgets can be used to make the bone specimen
stable while sectioning. Two main requirements for this are
accommodation to the bone specimen's form and minimal
interference with the sectioning instrument (in most
instances, a saw). For many years, grossing rooms have
been using different stands, predominately wooden, although
a rusty table vise is used in some institutions.
A modified wooden Davidson's Marking System (Bloo-
mington, MN) stand is optimal as a support and immobilization
Fig. 1. Wooden immobilization gadget.
 I.B. Dimenstein / Annals of Diagnostic Pathology 12 (2008) 191–198 193

device. This stand with round bottle holders and different

shape multiangle notches can adjust to many configurations
of a bone specimen. The wooden surface does not interfere
with a metallic cutting instrument. It holds the specimen
satisfactorily by friction. The pegs are useful also. The stand
is relatively easy to clean in the sink (Fig. 1).
In recent years, I have used hard-pressed packing
cardboard cartons as immobilization gadgets. There are
plenty of them in every laboratory from packing printer's
cartridges to cytologic ThinPrep PreservCyt Solution con-
tainers (Cytyc Corp., Malborough, MA). The disposable
hard-pressed cardboard cafeteria trays with 1, 2, and 4 cup
holders also seem to be ideal for different configurations of
bone specimens. The main advantage of hard-pressed
cardboard cartons, immobilization gadgets is that the cut
can go through them without interfering with the saw, thus
allowing the grossing person to get a complete section in Fig. 3. Vacuum table vise provides immobilization for a mandible specimen.
complicated or fragile bone specimens. Styrofoam gadgets
are less useful. first hand operates the cutting instrument, although some
Being biased by my personal experience, I definitely mechanical saws (band saw) free both hands for operating.
believe that hard-pressed cardboard cartons are the best bone The principle of the third hand in immobilization is in
specimen immobilization gadgets (Fig. 2). By the way, they pressing the surface of the section to be cut against a more
are also disposable and cheap. or less firm border of an immobilization device (Fig. 4).
There are other immobilization devices offered by This principle is used in lumber cutting. It is also applied
manufacturers as parts of bone saws, for example, MOPEC's in ham/cheese/bread cutting in grocery stores. The third
SawBones stand (Oak Park, MI). A vacuum table vise is hand allows the grossing person to make a serial section of
another useful device that can be placed on the grossing bone specimens with different configurations. It is also
station table (Fig. 3). useful to apply while doing fragile bones because the
5.1. The “third hand” pressed surface is less prone to crush under the weight of
the saw.
The “third hand” in immobilization, as I call it, is an
additional support for a bone specimen that can be provided
by different immobilization devices. I use this term in
numerous occasions when additional support makes bone
cutting easier and reliable. The second hand holds forceps
(for example, Russian Tissue Forceps) or a clamp while the

Fig. 2. Hard-pressed cardboard tray as an immobilization device. A section Fig. 4. The third-hand principle: the bone specimen is pressed against the
of sternum/rib specimen is cut through. border of an immobilization gadget.
194 I.B. Dimenstein / Annals of Diagnostic Pathology 12 (2008) 191–198
6. Cutting instrument
Skill in bone cutting depends very much on the choice of
the right cutting instrument. There is a permanent debate
between adherents of handsaws and those of mechanical saws.
Often it is a matter of personal preference and experience.
In reality, the main determining factor is the coarseness
of the saw's blade. The main rule is the finer and more
precise the cut of the section, the higher the teeth per inch
(TIN) of the blade (18-32). Often, a mini hack saw with
minimal coarseness of the blade is optimal, especially in a
fragile bone (Fig. 5). It takes more time to cut, but the bone
is not crushed.
The second rule is the more fragile the bone, the lighter
should the saw be and less pressure should be applied while
sawing. However, a heavy Stanley handsaw sometimes is
useful while cutting a very dense bone. Gigli wire saws and
autopsy saws have limited use in surgical pathology. Both
are inconvenient and too coarse for bone sections.
Mechanical saws, for example, MarMed saw (Cleveland,
OH) with a diamond cutting blade, have an advantage in
longitudinal sections and other physically demanding
occasions. The Stryker-type oscillating autopsy saw and its
varieties used by oral and head and neck surgeons gives
more options in access to bones surrounded by soft tissue or
curved configuration, but they have limitations because of
the size (depth) of the blade. They have other disadvantages
such as dust, heat, and smell of burning bone. The Stryker
saw is also relatively slow.
Band saws have many adherents; however, a high-speed
mechanical saw leaves less space for a mistake in choosing
direction or thickness of the section. Band saws require some
experience to avoid injury. I prefer handsaws. Having many
varieties of them, I use them simultaneously even while
doing one specimen. They give me more options in choosing
immobilization gadgets for different configurations of bone
specimens. Handsaws are also easier to clean in the sink
under running water.
Immobilization devices and gadgets, saws, and holding
forceps are the grossing room staff's turf. They were
mentioned to give the pathologists and pathology residents
a general approach to get diagnostically valuable bone
section. More details on this subject with some illustrations
can be found on the website “Grossing technology in
Fig. 5. Mini hack saw. Indispensable for fine cuts.
surgical pathology” (www.grossing-technology.com) at the
link “Instruments and gadgets.”
7. Decalcification
Decalcification is traditionally the responsibility of the
histology laboratory. However, some laboratories delegate
decalcification to the grossing personnel. In my view, this is
better because the grossing staff definitely knows what
specific type of bone is being decalcified. This determines
the choice of decalcification solution and allows a more
efficient monitoring of the end point of decalcification.
There are 3 main groups of commercially available
decalcification solutions:
1. strong acid or weak acids;
2. strong or weak acid with EDTA;
3. fixative + decalcifier.
Strong acid, for example, 10% hydrochloric acid, such as
in RDO (Rapid Decalcifier, Aurora, IL), is used in histology
for compact bones of not less than 1 mm in thickness,
sometimes for overnight decalcification. Overnight decalci-
fication is undesirable, but it is commonly used. Sometimes
it is necessary, for example, in complex odontoma that
requires 2 to 3 days of decalcification. A temporal bone is
decalcified much longer. There are many supporters of a
weak-acid decalcification. Formic-based decalcifiers, for
example, Immunocal by Decal Chemicals (Tallman, NY),
are less fast but seems better for immunohistochemistry.
Semiconductor grade hydrochloric acid with EDTA, for
example, Surgipath Decalcifier II (Richmond, IL), provides
mild decalcification appropriate for bone and bone marrow
biopsies, as well as pathologic calcium deposits. This
decalcifier is approximately 3 to 4 times slower than RDO-
type solution.
Combination of a fixative (formaldehyde) with a dec-
alcifier (formic acid and ETDA), for example, Formica 4
(Tallman, NY) intends to provide a simultaneous decalcifica-
tion and fixation that is undesirable but sometimes is used in
practice to save time of processing and gives often
satisfactory results.
Both “extremes” in decalcification, as 5% nitric acid and
only EDTA, cannot be used in practical surgical pathology.
The first is so fast that it is difficult to monitor; the second, an
organic chemical with its gradual “biting” calcium ions, is
ideal but too slow.
The most important issue is monitoring the end point of
decalcification to avoid overexposure. Although physical
(radiography) and chemical (sodium hydroxide and ammo-
nium oxalate solution) can be used for determination of the end
point of decalcification, they are cumbersome for ordinary
practice. Simple methods can completely satisfy the goal of
determining the end point of decalcification. The most impor-
tant of them is pliability of the section. If the bone bends without
resistance, the end point is reached for a successful section.
 I.B. Dimenstein / Annals of Diagnostic Pathology 12 (2008) 191–198 195

Table 1 The bone immobilization can be difficult (a round or

Bone decalcification in surgical pathology irregular surface) unless special devices are used. MOPEC's
Type of Strong Strong acid & Formic acid Fixative & saw stand is one of the options. When a mechanical saw,
bone acid EDTA (Surgipath (Immunocal) decalcifier such as MarMed, is used, some holders from the periphery
(RDO) Decalcifier II) (Formica 4)
provide immobilization. For example, a meatball maker is
Compact + − − ± used with a fine-band saw. This method, in my experience, is
(cortical)
inefficient, limited to standard situations, and dangerous.
bone
Spongy ± ± + ± I use improvised wooden gadgets, for example, David-
(cancellous) son's Marking System stand. Round spaces left from the
bone removed bottles and curved-in wood notches make the stand
Bone − + + ± suitable for different shapes and sizes of femoral heads and
biopsy
portions of the shaft. Forceps, such as Russian tissue forceps,
Bone − + ± −
marrow provides additional immobilization.
biopsy As a cutting instrument, I alternate between Stryker
+ indicates optimal; −, not recommended; ±, satisfactory.
oscillating autopsy saw and a hacksaw with an 18-TIN blade.
Usually, the slab requires tailoring to fit the cassette(s) for the
most representative sections. The shaft can be trimmed from
There are many technical details of the decalcification the main slab or cut separately closer to the line of resection.
process, such as changing solution, agitation, rinsing, etc.
Among them, decalcification on the block is an important part 9.2. Avascular necrosis (aseptic necrosis)
of everyday practice. Table 1 summarizes experimentation The bone is orientated in such a way that fragile or
with available decalcification solutions in surgical pathology. detached cartilage is pressed against a firm surface. The
subchondral area should be cut the last. A steady immobiliza-
8. Examples of grossing techniques tion, especially for the final cut, is essential. The optimal
immobilization device would be hard-pressed cardboard
The human body contains 206 bones. From the grossing cartons with a firm border on one side.
standpoint, all bones can be roughly divided into 2 groups: A hacksaw with a 32-TIN blade is preferable. The section
dense, like a femoral head, and fragile, like a rib. However, starts with relatively firm areas, gradually reaching the
bone pathology and diversity of circumstances often require fragile subchondral wedge-shaped area of osteonecrosis and
adjustments to this simplistic division. This section of the then the area of the beginning of cartilage detachment. The
methodological materials attempts to show examples of latter often is fractured, and it cannot be saved as a part of a
standard grossing techniques for different bone specimens. bone section, but the diagnostically important area remains.
The techniques can be applied in a similar situation for other In the case of a femoral head with osteomyelitis, the
bone specimens. procedure is similar owing to the fragility of the bone tissue.
Each example follows a common pattern that reflects the The specimen requires thinner sections with more careful
technical part of the procedure: the specimen's orientation– fixation. A hacksaw with an angled blade is useful to get
optimal immobilization–preferable instrument. multiple sections without cutting the entire bone specimen.
9.3. Fracture
9. Femoral head
Orientation should be made for the maximal presentation
Femoral heads are the most common bone specimens in of a fractured area. The specimen is oriented with the
surgical pathology practice. Let us take the femoral head
specimen as a basic illustration of bone grossing technique in
surgical pathology. There are 3 main types of femoral head
specimens: with degenerative joint disease (osteoarthritis),
with avascular necrosis, and after fracture. Each of them
requires slightly different grossing technique.
9.1. Degenerative bone disease (osteoarthritis)

The bone is oriented for obtaining a section through an

area of cartilage thinning (“eburnation”) and maximal
“lipping” features. The optimal section is made preferably
away from the center for 2 reasons: the pathology, including
subchondral cysts, is more prominent at the periphery; and
cutting trough the shaft is technically more difficult. Fig. 6. Femoral head fracture. The fracture area is oriented up.
196 I.B. Dimenstein / Annals of Diagnostic Pathology 12 (2008) 191–198

fractured area facing up. The bone is immobilized in more or Table 2

less a round space. The Davidson's Marking System stand is Femoral head grossing pattern
optimal for this. Diagnosis Orientation Preferred Optimal
A hacksaw is preferable owing to the fragility of the immobilization saw
fractured area where the most informative material is located. Degenerative Articular surface up Wooden or Hacksaw
Sectioning starts with a 32-TIN blade saw and finishes with bone disease metal stand
Metal clamps Band
an 18-TIN blade if required by the bone density. Several
saw
sections are made: one complete section through the entire Avascular Articular surface Hard-pressed Hacksaw
bone; the rest of the cuts should be near the fractured area necrosis down cardboard
(Fig. 6). Some sections should be submitted from small Fracture Articular surface Wooden stand Hacksaw
fragments of bone and detritus that are usually present in the down
Tumor Depends on clinical Hard-pressed Band
container. Of course, all these sections are made to exclude a
features cardboard mold saw
pathologic fracture. The same principles apply to a femoral Hacksaw
head with nonunion after fracture.
9.4. Femoral head tumor
specimen's pathology by making a section through the
The femoral head is not the most frequent location, for center, although it makes it more difficult for further
example, of osteosarcoma. Bone tumors extending into soft processing. The problem is in securing immobilization for
tissue (a challenge for grossing) also more often occur in a additional sections, especially if mechanical high-speed saws
long bone metaphysis area, for example, in chondromyxoid are used.
fibroma. However, from the technical point of view, a After appropriate staining, the specimen is placed for
femoral head tumor is the most difficult for grossing. immobilization preferably in a hard-pressed cardboard
The pathologist has to answer many questions, including carton mold. There can be other molds for immobilization,
the relationship between the bone tumor and the surrounding for example, Styrofoam; but in my experience, hard-
soft tissues. The bone structure is more heterogeneous and pressed cartons allow the grossing person to adjust the
sometimes necrotic. This determines grossing technique. For immobilization the most congruently to the bone tumor
many technical reasons already mentioned before, grossing specimen (Fig. 7).
ought to be done in the fresh state. A small section of soft tissue is taken by 2 parallel blade
The orientation for the first and following cuts depends on incisions. If the soft tissue were not removed, it would be
the character of tumor growth. An x-ray can be helpful to stripped from bone during the sawing. This circumstance
determine the initial orientation. The optimal orientation is also determines the use of a fine saw in the beginning. Later
along the longer axis of the bone tumor but may be corrected it can be replaced by a saw with a coarser blade (18 or
by considerations of secure immobilization. In most cases, 24 TIN). The final sawing should be also done with a fine-
the pathologist wants to see the overall picture of the blade saw through the immobilization mold and a final cut
with an anatomical knife. The section will maintain the
integrity of the specimen.
The next step is to get a slab or serial slabs. This technical
challenge of the procedure has a practical implication, for
example, in osteosarcoma after chemotherapy; but often it is
necessary to do them in a diagnostic case. (Grossing bone
tumor specimens after chemotherapy has many technical
particularities. This subject requires separate detailed
discussion that is out of the scope of this review.)
My preference for immobilization in this situation is also
to use hard-pressed cardboard carton molds with a relatively
firm side border. The latter serves as the third hand. The
surface of the bone section is pressed against the border by
an instrument (forceps, wooden block, etc), which provides
the specimen to be cut with secure immobilization. I prefer a
handsaw that gives more flexibility while cutting. The slab
will go for fixation that will be even and fast. The slab is then
trimmed and placed in the cassettes for decalcification.
Sometimes, it is placed for decalcification before cutting, and
then it is trimmed to fit the cassettes.
There is a method of freezing the entire fresh specimen
Fig. 7. Femoral head tumor is sectioned on hard-pressed cardboard tray. and slicing it with a band saw. I do not have extensive
 I.B. Dimenstein / Annals of Diagnostic Pathology 12 (2008) 191–198 197

experience with this technique. My observations have given

me the impression that this method requires more skillful
performance owing to uneven thawing of sliced sections and
less stable immobilization. Perhaps it should be reserved for
specialized institutions. This method could be used more
successfully in the processing of a bone specimen with
osteosarcoma after chemotherapy. Table 2 presents the
pattern of grossing a compact bone (femoral head).

10. Fragile bones

Fragile bone specimens sometimes are a challenge in the

grossing room. They are different, but all of them have as a
common technical denominator the necessity for especially
secure immobilization and the use of fine-blade saws.
10.1. Rib

Sectioning of bone for an incidental rib removed during
nephrectomy or a diagnostic rib being evaluated for
metastasis is from the technical standpoint the same; the
only difference is the number of sections obtained. The rib is
placed on a wooden or hard-pressed cardboard surface and
immobilized with firm branch forceps (eg, Russian Tissue
Forceps).
A mini hack saw provides a good transverse section.
Light strikes of the saw, especially to the end, prevent the
bone from being crushed and provides a complete section. If
it is necessary to make numerous sections, the cutting starts
from one of the ends to provide steady immobilization by the
holding forceps. Rarely, for example, in suspected myeloma,
the sections are made longitudinally; and that requires
pressing the rib against the firm border (the third hand). The
rib is preliminary cut in straight sections 2 to 2.5 cm long,
which fill the cassette and are easier for a longitudinal cut.
If the rib is a part of a larger bone specimen, for example,
in a case of osteomyelitis of the sternum with attached parts
of the rib, the procedure includes sectioning of the skin and
Fig. 9. Maxilla bone with exposed sinus.
soft tissue. The goal is to get a complete section while
maintaining the relationships of the tissues. The initial cut in
the skin is made with an anatomical knife or 2 parallel cuts
with a blade to the bone surface. Immobilization is better in
hard-pressed carton mold (4-cup cafeteria tray is optimal).
The preferred blade for the hacksaw is 24 or 32 TIN.
10.2. Facial-maxillary surgery bones
There is a variety of fragile bones after facial-maxillary
surgery. They have in common fragility of some of parts that
determines many technical difficulties.
10.3. Nose resection
Let us take as an example of the procedure on a very
fragile bone the specimen of a resected nose owing to skin
cancer, with an ulcer at the nose bridge. This specimen is
simple, but it involves all technical principles of grossing
fragile bones.
After appropriate inking of the margins of resection, the
specimen is placed in the fresh state at the immobilization
device (hard-pressed cardboard is optimal) with the area of
section against the firm border (Fig. 8). A mini hack saw is
placed in the previously made incision in the skin. The saw's

Table 3
Fragile bone grossing pattern
Type of Orientation Preferred Optimal saw
specimen immobilization
Rib Transverse or Wooden stand Mini hack saw
longitudinal Hard-pressed
sections cardboard
Nose Transverse Hard-pressed Mini hack saw
sections cardboard
Maxillary Depends on Vise Mini hack saw
bone clinical features Hard-pressed Handsaw
cardboard Stryker saw
Fig. 8. Resected nose with an ulcer at the bridge.
198 I.B. Dimenstein / Annals of Diagnostic Pathology 12 (2008) 191–198
movements are short without any pressure owing to the
extreme fragility of the nose's bones at this area. After the
section of the margin of resection, including bone, cartilage,
and turbinates, is made, the specimen is placed on a firm
surface (wooden, hard-pressed carton, Styrofoam) in such a
way that the internal hollow areas are filled with some
supporting material. This prevents bones from being crushed
under the pressure of the saw's movement. The sections are
tailored to meet the cassette size.
10.4. Maxillary bone
Maxillary bone is rarely resected completely, but any
parts of it always present a challenge to grossing. There is a
well-established practice that owing to bone fragility, it is
appropriate to put the complete specimen in the decalcifica-
tion solution after fixation because nobody performs such a
complicated surgery with an unknown diagnosis. However,
the biopsy diagnosis may be wrong or incomplete, and some
questions of soft tissue/bone tumor relationships may not
have been answered appropriately.
The key to get an informative section is to secure and
achieve reliable immobilization for a representative section
of the area of interest. Maxilla has many areas of different
bones from paper-thin sinus to firm alveolar ridge.
If there is enough firm bone, a vise can be used for the
initial immobilization. The maxilla is placed as much as
possible deep in the throat of the vise's jaws, wrapped in
bubble paper (Fig. 9). If any teeth need to be pulled out, the
vise is indispensable for this procedure. It is easy to cut the
fragile bone of the sinus that is exposed with its open part. I
use a table vacuum vise, which is convenient and reliable.
The vise is very useful if serial sections have to be made or
the area of interest is located eccentrically. However, the final
cut(s) cannot be done owing to the interference of the
metallic surface of the vise's jaws and the saw's blade.
In most cases, a secure immobilization requires a special
mold. I use different varieties of hard-pressed cardboard
cartons; I especially prefer cafeteria tray cup holders.
Slightly wet paper is placed beneath and around the
specimen that is gently pressed in the mold. If a sinus is
present, it is useful to stuff it with wet paper for additional
immobilization of fragile thin bones of the sinus. Hard-
pressed carton molds allow the grossing person to make cuts
through the carton. This is especially beneficial for final cuts
when the most damage to the fragile bone section can be
made. In this situation, the relationships between the bone
and tumor or soft tissue are maintained at best.
After sections of bone margins of resection are taken with
a hacksaw (blade, 32 TIN), sinus bones are cut. Sometimes it
is helpful to use a Liston bone-cutting forceps or a regular
pair of scissors. The next cuts are made with a fine-blade
saw. The final cuts are made with a coarser blade or a
mechanical Stryker saw, depending on the thickness of the
bone and the conditions of its configuration, as well as the
attached soft tissue.
These 3 examples do not encompass numerous varieties
of fragile bones. Even a mandible, far from fragile, can have
fragile elements in a cyst of ameloblastoma or calcifying
epithelial odontogenic tumor. Areas of fragile bone include a
semilunar bone with osteochondrosis (Kinckbock disease) or
even a larynx with its hyoid bone and calcified cartilages.
Table 3 presents the pattern of grossing of fragile bones.
11. Summary
Following general principles and specific techniques can
give a satisfactory result almost in every bone specimen. The
techniques and procedures should be adjusted to the specific
situation and clinical diagnosis. For example, a complex
odontoma requires very thin cuts, diligent cleaning of bone
dust from the surface, long decalcification, and more careful
rinsing before microtomy. There is no absolute standard in
bone grossing.
These methodological materials include a very short list
of references. This is a practical report from the grossing
room kitchen, or perhaps from a blacksmith shop. Cooks or,
especially, blacksmiths rarely provide references, although
they also rarely write articles in scientific journals. To extend
the comparison of the grossing room bone processing with a
blacksmith shop, the anvil and tongs (immobilization) as
well as the hammer (saw) are tools. The horseshoe is the end
product (bone section). As a blacksmith always knows what
kind of horseshoe is to be made, the grossing person should
have an image of the bone section, including how it fits the
cassette and the embedding mold. A horseshoe needs a nail.
As the old English rhyme goes, For want of a nail the shoe
was lost…“together with the kingdom.” In bone grossing,
this nail is common sense.
References
[1] Lester SC. Manual of surgical pathology. Churchill-Livingston; 2001.
p. 116-28.
[2] Hruban RH, Westra WH, Phelps TH, et al. Surgical pathology
dissection. An illustrated guide. Springer-Verlag; 1996. p. 90-5.
[3] Dorfman HD. Bone diseases. In: Sternberg S, editor. Diagnostic surgical
pathology. New York: Raven Press; Ltd. 1989. p. 217-8.
[4] Weidner N, Cote RJ, Suster S, et al. Modern surgical pathology.
Saunders; 2003. p. 10-1.
[5] Claus-Peter A. Bone diseases. Springer; 2000. p. 494.
[6] Sternberg SS, editor. Diagnostic surgical pathology. Philadelphia, PA:
Lippincott, Williams & Wilkins; 1999. p. 223-63.
[7] Rosai J. Manual of surgical pathology gross room procedures.
Minneapolis: University of Minnesota Press; 1981. p. A4.