In SSA, this diagnostic procedure serves the purpose of providing a diagnosis, staging and grading and guiding clinical management including surgery, chemotherapy or radiotherapy. The use of the appropriate fixative for the preservation of tissues obtained at surgery as well as the cold ischaemia time is of importance as is the duration of fixation. The sample should be immersed in preservative as soon as it is removed, and not at the end of the surgical procedure. A container that is large enough to contain the sample as well as a volume of preservative that is at least 10 times the volume of the sample should be used. In breast cancer, the ratio of tissue/fixative of 1:20 was recommended and the sample must be placed in fixative within 1 h of removal. For breast specimens, the sample must remain in the fixative for no more than 8 h (Yaziji et al. 2008). Improper fixation and long cold ischaemia time have negative effects on the preservation of DNA.

The most commonly used fixative is 10% buffered formal saline (formalin) which is suitable for all tissues, it is cheap and easy to prepare. Paraffin-embedded tissue processing and staining using routine haematoxylin and eosin stains is provided by the pathology laboratories in most centres in SSA. Proper tissue processing can be done with manual, semi-automated or fully automated tissue processors. Manual tissue processing is the most prevalent in SSA due to a lack of availability of the tissue processing machine. This may result in the tissue becoming overly processed (‘fried’ or ‘cooked’ tissue). Sometimes poor quality paraffin wax is supplied for use at the laboratory since, in many countries; the procurement of laboratory consumables is done by non-technical personnel. This issue is further compounded by poor storage facilities of these consumables due to erratic power supply. Inappropriate tissue processing and poor facilities for storage and archival of tissue blocks and histopathology slides constitute major obstacles to conducting cancer research in many parts of SSA. In a molecular study investigating the incidence of K-RAS and BRAF mutations among patients with colorectal cancers in Nigeria, a high failure rate of 112 of the 200 cases (56%) of pyrosequencing was recorded and this was attributed to poor fixation of the tissues (Abdulkareem et al. 2012).

Pathology services in most parts of SSA are concentrated in major cities and therefore transportation of samples to these centers from remote areas remains a challenge, with these services being largely inaccessible to the rural areas. Poor road networks and difficulties with finding the funds to pay for transportation contribute to this problem. Where these samples are sent to the laboratories with pathologists, the Turn Around Time (TAT) is prolonged by the delay between obtaining the specimen and depositing it at the laboratory, the time lag being that required for transportation. Nelson et al. reported that the case loads of surgical samples processed each year ranged from less than 100 in Burundi to >20,000 in Nigeria, Kenya and >40,000 per year in South Africa while TAT ranged from 1–3 days to as long as 21–28 days in some countries (African Pathologists’ Working Groups 2015). They reported that there is statistically significant correlation between the number of pathologists and histotechnologists and the case load but TAT was inversely correlated and not significant.

In order to standardize practice, The AORTIC Pathology Summit has therefore recommended step-by-step process of tissue handling from specimen acquisition, processing to final reporting as shown in the Table 4.1 below (Fitzgibbon and Wallis 2014).