Am J Clin Pathol 2007;127:271-272 271
© American Society for Clinical Pathology
Anatomic Pathology / INKING BREAST CORES TO REDUCE MIX-UPS
The Value of Inking Breast Cores to Reduce
Andrew A. Renshaw, MD, Richard Kish, MHS, and Edwin W. Gould, MD
Key Words: Surgical pathology; Quality; Error; Inking; Breast core
A b s t r a c t
Accidental switching of tissue specimens in the
histology laboratory can result in significant medical
error. We sought to evaluate inking breast core needle
specimens as a method to reduce the chance of
specimen mix-up. We sequentially inked 1,000
consecutive breast core specimens with 6 different
colors. Review of the color of the ink revealed 3
discrepancies: 1 related to blocks being switched, 1
related to incorrect labeling, and 1 was a typographical
error. Inking of breast core specimens is a simple,
inexpensive, and effective way to help reduce the
chance of specimen mix-up.
Specimen mix-up is a potentially devastating source of
medical error in the histology laboratory. When the potential
for a mix-up is noticed, there are several methods to determine
the identity of a particular specimen.1-10However, when a lab-
oratory is processing a relatively large number of cases that
have similar physical and clinical features, recognizing that a
case has been switched can be extremely difficult. To ensure
that the correct tissue is cut for each specimen, we have been
inking breast core specimens with different color inks for sev-
eral years. While we are aware that other groups have also
used this technique, we are unaware of any literature quantify-
ing the effectiveness of it. To address this, we reviewed our
experience with inking a large series of breast core specimens.
Materials and Methods
We reviewed 1,000 breast core needle biopsy specimens
interpreted between December 1, 2005, and May 31, 2006, at
Baptist Hospital of Miami, Miami, FL. All breast core needle
biopsy specimens were obtained by radiologists and consisted
of 11-, 12-, and 14-gauge core needle biopsy specimens per-
formed under ultrasound or stereotactic guidance; 11-gauge
cores were obtained using vacuum assistance.
All specimens were received fixed and placed in a nylon
bag by the radiologist. At the time of grossing, each specimen
was directly inked through the bag in one of 6 colors. The col-
ors were always applied in the same sequence. The dissector
would write the color used on the original requisition slip and
dictate the color for the gross description. Each block was then
routinely processed and entirely sectioned to produce at least
5 slides and 2 levels per slide.11
Am J Clin Pathol 2007;127:271-272
© American Society for Clinical Pathology
Renshaw et al / INKING BREAST CORES TO REDUCE MIX-UPS
When the slides from the cases were reviewed, the
pathologist compared the color of the ink in the tissue with
that written in the gross description.
Of the 1,000 consecutive breast core specimens reviewed,
the color of ink revealed 3 discrepancies (0.3%). In 1 case, the
discrepancy related to blocks being switched and the incorrect
specimen placed on the slide. This error was identified by
review of the color of the tissue on the slides and correlation
with the colors dictated by the prosector and the ink left in the
tissue blocks. In the second case, the correct blocks were sec-
tioned and tissue placed on the correct slides; however, the
incorrect labels were placed on the slides. The error was iden-
tified as in the first case, and, in addition, the correct slide
number was written on the slide under the label. In the last
case, a discrepancy appeared to be present, but on review, it
was discovered that the color of the ink was incorrectly typed
in the gross description.
The purpose of this article is simple. We demonstrated
that routine inking of breast core specimens allows rare inad-
vertent specimen mix-ups to be identified and corrected
before a diagnosis is given. While the incidence of this is rel-
atively low, because of the relatively high number of cases
received by this laboratory, this problem occurs several times
It is certainly true that some of these errors could be iden-
tified by other means. If the pathologist routinely examined
the number of the case written under the label, he or she could
have identified our second case. It is also true that when the
clinical history and the pathologic findings do not match,
additional testing can demonstrate the identity of specific tis-
sue specimens.1-10However, this testing is complex and
expensive and would rarely be used unless a significant clini-
cal suspicion was identified. As the clinical presentations of
more and more of our cases become similar, the ability to
identify such cases becomes less likely.
However, inking works in every single case and is easy
and inexpensive to perform. It is true that inking is not perfect.
It is possible that 2 cases with the same ink could be mixed up
and we would be unable to distinguish this problem. Our solu-
tion to this problem has been to use 6 ink colors, making this sce-
nario less likely. It is also true that in some cases a discrepancy
raises the possibility of a mix-up when none is present, as in
our case 3. However, from review of the original submission
form and the tissue blocks, it is easy enough to determine
whether this is the case. It is our opinion that advantages of
this technique far outweigh the disadvantages. We believe the
technique can be used for a wide variety of specimens, includ-
ing prostate biopsies, in which the possibility of inadvertent
switching of specimens might be an issue.
We have shown that routine inking of breast core speci-
mens is an easy and inexpensive way to reduce the possibility
of specimen mix-up.
From the Department of Pathology, Baptist Hospital of Miami,
Address reprint requests to Dr Renshaw: Dept of Pathology,
Baptist Hospital of Miami, 8900 N Kendall Dr, Miami, FL 33176.
1. Hunt JL, Swalsky P, Sasatomi E, et al. A microdissection and
molecular genotyping assay to confirm the identity of tissue
floaters in paraffin-embedded tissue blocks. Arch Pathol Lab
2. Ramsay AD. Errors in histopathology reporting: detection
and avoidance. Histopathology. 1999;34:481-490.
3. Ritter JH, Sutton TD, Wick MR. Use of immunostains to
ABH blood group antigens to resolve problems in identity
of tissue specimens. Arch Pathol Lab Med. 1994;118:293-297.
4. Lagaaij EL, Cramer-Knijenburg GF, Van der Pijl JW, et al.
Rapid verification of the identify of questionable specimens
using immunohistochemistry with monoclonal antibodies
directed against HLA-class I antigens. Histopathology.
5. Shibata D. Identification of mismatched fixed specimens
with a commercially available kit based on the polymerase
chain reaction. Am J Clin Pathol. 1993;100:666-670.
6. Tsongalis GJ, Wu AH, Silver H, et al. Application of forensic
identity testing in the clinical laboratory. Am J Clin Pathol.
1999;112(1 suppl 1):S93-S103.
7. O’Brian DS, Sheils O, McElwaine S, et al. Sorting out mix-
ups: the provenance of tissue sections may be confirmed by
PCR using microsatellite markers. Am J Clin Pathol.
8. Horn LC, Edelmann J, Hanel C, et al. Identity testing in
cervical carcinoma in case of suspected mix-up. Int J Gynecol
9. Tsongalis GJ, Berman MM. Application of forensic identity
testing in a clinical setting: specimen identification. Diagn Mol
10. Abeln EC, van Kemenade FD, van Krieken JH, et al. Rapid
identification of mixed up bladder biopsy specimens using
polymorphic microsatellite markers. Diagn Mol Pathol.
11. Renshaw AA. Adequate histologic sampling of breast core
needle biopsies. Arch Pathol Lab Med. 2001;125:1055-1057.