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Dermpath-India

Gross Examination of the Skin Specimen

 Dr Sampurna Roy MD      

 

                                                                                                                      

 

Types of Biopsy: 

1. Excisional Biopsy:  In this procedure the entire lump or tumour is excised and a margin of normal tissue is present around the lesion together with subcutaneous fat.

2. Incisional Biopsy:  A portion of the lump is removed surgically. This is most commonly used for tumours of the skin.

A.  Shave Biopsy:   In this procedure the surface portion is sliced off with a blade.

B. Curette method: In this procedure the surface of the lesion is scrapped off.

These methods are done to remove small growth and to confirm its nature.

C. Punch Biopsy:  This procedure is done to sample skin rashes and small masses. A small cylinder of skin is removed. 

 

Information required in the request form:

1. Patient identification - Name ;  Age ; Hospital number; Gender

2. Name of the clinician/surgeon

3. Date of procedure

4. Procedure-  Excisional biopsy, Incisional biopsy  etc

5. Anatomic site of specimen

6. Clinical information (see below)

7. Clinical diagnosis

Note: Five painful tumours of Skin

1. Angiolipoma ; 2. Angio-leiomyoma ; 3. Glomus tumour ; 4. Spiradenoma

5. Neurilemmoma

Clinician must provide the following clinical information: 

Relevant history :

I.    Duration of lesion

II.   Previous excision of the lesion

III.  Family history of skin rashes or cutaneous neoplasm such as melanoma

IV. History of immunosuppression (HIV infection, transplant recipients, steroid and cytototoxic therapy.)

V.  History of radiation exposure, arsenic, toxic chemical

VI. History of rheumatoid arthritis, diabetes mellitus, pregnancy internal malignancy (Example: Colonic carcinoma or renal cell carcinoma)

VII. History of travel to foreign countries

Relevant findings:

I.   Lesion number and distribution

II.  Description of lesion -nature of pigmentation,colour, nature, shape, outline, ulceration, haemorrhage.

(Note - Shape may be annular, figurate, gyrate or irregular)

III.  Palpable quality of lesion (Example.  hard, painful, non tender)

IV. Fixation to deeper tissue on palpation    
 
Gross description by Histopathologist:

I. Specimen-

1. Shape and type of specimen-  (Example. Ellipse, punch core, shave fragments)

2. Fixed or unfixed

3. Number of pieces of tissue

4. Dimensions of specimen in millimetres (length, breath and thickness).

In case of small biopsies and punch biopsies  maximum diameter is noted.

5. If the specimen is marked with surgical suture, the position is described in details.

II. Characteristics of the lesion -

1. Dimensions- Length and width of the lesion or diameter of the dominant nodule.

2. Nature-  (macule, papule, nodule, patch, plaque )  Glossary

3. Profile - Domed ;  Papillated ; Verrucous ; Flat-topped ; Umbilicated

4. Colour - whether uniform or variegated

5. Surface - intact or ulcerated , regularity and symmetry.

6. Margins - sharp or ill defined, flat or elevated

7. Satellite nodules with dimensions and measurement of distance from the main lesion and nearest margin.

8. Measurement  of the distance between the edge of the dominant lesion and the nearest surgical margin .

9. Description of any  other lesions present (Example:  Scar, areas of pigmentation).

Colour of Skin Tumours:

Dark brown-  Melanoma ; 

Brown to red-  Pyogenic granuloma

Pink to red- Cylindroma

Yellow- Sebaceous adenoma ; Steatocystoma Multiplex

Flesh coloured- Spiradenoma

Blue- Blue naevus ;   Dark blue, purple-  Kaposi Sarcoma

Blue, black-  Apocrine  hydrocystoma

 

Configuration is the contour or outline of a single skin lesion and is synonymous with shape.

Configuration:

A) Linear - in a line.

B) Arciform - in the form of an arc, curved.  

1. Arcuate: having an outline of a curved line or arc. 

2. Annular: ring-shaped 

3. Serpentine: having an outline like a serpent, coiled. 

4. Polycyclic: having two or more rings or whorls. 

5. Targetoid:  resembling a target, rings within rings.

C) Circular - Having an outline of a full circle without central clearing.

(Guttate- like a gutt or drop. Nummular or discoid - having the shape and size of a coin or a disc.)

III. Tissue submitted- 

A.  Must mention whether the entire tissue has been submitted for histopathological examination.

B.  Tissue submitted for special studies-

(Example: Histochemical  stains, immunohistochemistry, electron microscopy, cytogenetics etc.) 

 

Fixation of Skin Specimen:

Fixative for skin specimens is 10% buffered formalin.

Formalin should be approximately 20 times by volume that of the specimen.

Direct immunofluorescence - 

To detect antibodies and/or complement localized in the skin .

i) Vesiculobullous diseases: Example: Bullous Pemphigoid, pemphigus vulgaris, and Dermatitis Herpetiformis.  

Biopsy specimen for direct immunofluorescence must be taken from skin contiguous to a newly formed lesion.

The nonvesicular 'perilesional zone' should not be eroded or crusted. 

ii) Vasculitis - Biopsy may be taken of the lesion itself (must be an early lesion).

Electron microscopy:

Specimen may be placed in modified Millonig's fixative or glutaraldehyde rather than in formalin.

 

Handling of Gross Skin Specimen:

 

 

Unorientated excision specimen

 

 

                 \

 


Orientated excision specimen

 

                  

Large Excision Specimen                                 Small Excision Specimen

 


 

Incisional Biopsies:


Punch Biopsies:

 

A Practical Guide for Residents and Junior Doctors 

Excisional skin biopsies or formal resections for melanocytic lesion and proven or suspected skin cancer are usually sent to the laboratory with one margin appropriately marked with an orientation suture. 

It is important for the pathologist to evaluate the lateral and the deep margins.

This will help the attending clinician to identify the specific site of an existing tumour and its probable extent beyond the surgical margin of resection.

Re-excision of the involved margin can be performed.

The specimens requiring orientation should be marked using standard technique of painting.

Multiple colours allow identification of two short axis margins, two long axis margins.

(denoted as 3, 6 , 9 and 12 o'clock margins) and the deep margin.

( Example. 12 and 3 o'clock margins -red,   6 and 9 o'clock margins -blue and  deep margin -black).

A diagram of the pertinent anatomy showing the location of the sutures and ink marking is useful for guaranteeing the orientation of the specimen.

The commonly employed substances used for marking of surgical margins include Indian ink , alcian blue or commercial preparations.

Curetted specimens, incisional biopsies, shave biopsies and punch biopsies do not  require the margins to be inked.

All specimens from excisional biopsies should be sectioned transversely in a 'sliced bread' pattern.

The first section should be taken from the centre of the lesion and this should be followed by sectioning the whole specimen every 2 - 3 mm. 

Not more than 3 sections should be processed in each cassette, to make one block.

In specimens less than 10mm the entire lesion must be submitted for histopathological examination or the entire specimen if the lesion cannot be seen.

In excisional biopsies over 10mm containing melanoma , the entire lesion is embedded.

In case of basal cell carcinoma and squamous cell carcinoma blocks are taken from areas of maximum lesional thickness, ulceration and nearest margins.

The two polar ends of the skin ellipse should be placed in two designated cassettes depending on whether the specimen is clinically orientated.

The polar ends are embedded and cut from the 'face down' aspect .

If the initial sections show malignant involvement , step levels can be undertaken  to assess clearance up to the extreme peripheral margin.

In a large circular specimen cruciate margins at 3, 6, 9, and 12 o'clock can be sampled.

One should always use a fresh, sharp blade to cut the specimen.

If the knife is blunt then the delicate melanocytes in the junctional component of the lesion may be disrupted when the specimen is sliced, causing problem in diagnosis.

Good quality thin sections are essential for accurate diagnosis.

Excisional biopsies of melanocytic lesions should not be sectioned by cruciates because this makes interpretation of the architecture of the lesion more difficult.

In specimens from vesicular diseases, the vesicles should be submitted intact.

One should not cut through the vesicle under any circumstances.

Small excisional biopsies (upto 5mm) are submitted in toto.

Step-levels should be undertaken in case of severely dysplastic, in-situ or any difficult melanocytic lesion.

Make sure that the punch biopsies are orientated on edge. 

In re-excision specimen, if the original lesion was completely excised and if there are no macroscopic residual lesion other than a scar, only one representative section is taken from the centre of the specimen.

If the original lesion was incompletely excised or if any residual tumour is evident in the re-excision specimen, then blocks are taken every 2 - 3 mm through the whole scar and embedded for histopathological examination.

 

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)


 

 

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