Gross Examination of the Skin Specimen
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
Clinician must provide
the following clinical information:
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
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
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 .
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).
Specimen may be placed in modified Millonig's fixative or glutaraldehyde rather than in formalin.
|Handling of Gross Skin
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.
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.
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
In case of basal cell carcinoma and squamous cell carcinoma blocks are
taken from areas of maximum lesional thickness, ulceration and nearest
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.
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.
One should not cut through the vesicle under any circumstances.
Step-levels should be undertaken in case of severely dysplastic,
in-situ or any difficult melanocytic lesion.
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.
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