Gross processing of skin excisions: Difference between revisions

Revision as of 07:28, 23 December 2019

Lens-shaped excisions

Also called marquise ("lens" or "boat") shape.

Table

Gross pathologic processing of skin excisions^[1]^{[note 2]}
	Lesion size
	<4 mm	4 - 8 mm	9 - 15 mm
Benign appearance	File:Tissue selection from skin excision with lesion less than 4 mm with benign appearance.png	File:Tissue selection from skin excision with lesion 4-8 mm with benign appearance.png	File:Tissue selection from skin excision with lesion 9-15 mm with benign appearance.png
Suspected malignancy	File:Tissue selection from skin excision less than 4 mm with suspected malignant lesion.png	File:Tissue selection from skin excision 4-8 mm with suspected malignant lesion.png	File:Tissue selection from skin excision 9-15 mm with suspected malignant lesion.png

In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.

Surgical margins for suspected melanoma^[2]
In situ	5 mm
≤ 2.0 mm	1 cm
> 2.0 mm	2 cm

Up to the entire specimen may be sliced and submitted if the risk of malignancy is high.^[1] Otherwise the rest may be saved in case microscopy indicates further sampling.

Radicality slices

The example shown for suspected malignancy risks has parallel slices to check for radicality towards the tips.^[1] They are placed at a distance to provide similar margins as the shortest one in the short axis. However, if the shortest margin is narrower than recommended (such as less than 4 mm for a suspected squamous cell carcinoma)^[3], consider expanding the distance towards the tips by taking more slices:^{[notes 1]}

One more slice towards tip in this example.

One more slice towards tip in this example.
If insufficient material for additional radicality slices, make multiple step sections from submitted one.

If insufficient material for additional radicality slices, make multiple step sections from submitted one.

Microtomy should start at the most central surface, leaving the option to perform further microtomy for radicality on the same slice in case the most central part is found to have tumor cells. However, if tumor cells are found near the resection margins on the radicality slices, non-radicality cannot be excluded by additional sampling towards the tips.

Oval excisions

These can often have a parallel radicality cut along each lateral edge.^[4]

Inking

If the sample is marked with a suture or colored nails, apply ink (such as India ink) to one or both of the sides, from one tip to another, and document how the inking relates to any markings before removing them.^[5]

Report

Patient and/or sample data
Optionally, location
Size of sample
If any focality, report its:

Size
Color
Sharp or diffuse border
Any elevation

How inking was done, and how it relates to any markings.^[5]
How much is submitted (such as "entire sample" or "entire lesion")
Contents of each submitted block

Example:

Sample #15315 Joe Bloggs 2000-01-01 Left cheek. Needle-marked skin excision measuring 57 x 20 mm, with a 11 x 10 mm central, large, brownish, relatively well-defined lesion, slightly raised at the edges. Black ink between pink, white and green needle. Yellow inkbetween pink, blue and green needle. A: Tip towards pink needle. B: Tip towards green needle. C: The lesion. The whole lesion is submitted.

Notes

↑ A radicality slice closer the a tip is more likely to miss tumor cells spreading towards the long resection margins.

↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
↑ The excision examples show a normal mole (upper row, benign appearance) and a superficial basal cell carcinoma (lower row, suspected malignancy).

Main page

Main page of Patholines

References

↑ ^1.0 ^1.1 ^1.2
There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
  - For number of slices and coverage of lesions, depending on size.
- Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
  - For slices towards the tips to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each tip.
- . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
  - For microtomy of the most central side at the lesion
- "The principles of mohs micrographic surgery for cutaneous neoplasia
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen.
- It also shows an example of circular coverage, with equal coverage distance in all four directions.
- The entire specimen may be submitted if the risk of malignancy is high.
↑ Shenenberger DW (2012). "Cutaneous malignant melanoma: a primary care perspective. ". Am Fam Physician 85 (2): 161-8. PMID 22335216. Archived from the original. .
↑ Brodland, David G.; Zitelli, John A. (1992). "Surgical margins for excision of primary cutaneous squamous cell carcinoma ". Journal of the American Academy of Dermatology 27 (2): 241–248. doi:10.1016/0190-9622(92)70178-I. ISSN 01909622.
↑ . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
↑ ^5.0 ^5.1 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.

Image sources

[6] A radicality slice closer the a tip is more likely to miss tumor cells spreading towards the long resection margins.

[contributors-1] For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.

[3] The excision examples show a normal mole (upper row, benign appearance) and a superficial basal cell carcinoma (lower row, suspected malignancy).

[processing-2] 1.0 ^1.1 ^1.2 There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
. Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, depending on size.

Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- For slices towards the tips to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each tip.

. Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion

"The principles of mohs micrographic surgery for cutaneous neoplasia
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen.
- It also shows an example of circular coverage, with equal coverage distance in all four directions.
- The entire specimen may be submitted if the risk of malignancy is high.

[5] . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, depending on size.

[6] Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- For slices towards the tips to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each tip.

[7] . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion

[8] "The principles of mohs micrographic surgery for cutaneous neoplasia

[pmid22335216-4] Shenenberger DW (2012). "Cutaneous malignant melanoma: a primary care perspective. ". Am Fam Physician 85 (2): 161-8. PMID 22335216. Archived from the original. .

[BrodlandZitelli1992-5] Brodland, David G.; Zitelli, John A. (1992). "Surgical margins for excision of primary cutaneous squamous cell carcinoma ". Journal of the American Academy of Dermatology 27 (2): 241–248. doi:10.1016/0190-9622(92)70178-I. ISSN 01909622.

[7] . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.

[stora-8] 5.0 ^5.1 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.

[note 1]

[1]

[note 2]

[2]

[3]

[notes 1]

[4]

[5]

@@ Line 20: / Line 20: @@
 The example shown for suspected malignancy risks has parallel slices to check for radicality towards the tips.<ref name=processing/> They are placed at a distance to provide similar margins as the shortest one in the short axis. However, if the shortest margin is narrower than recommended (such as less than 4 mm for a suspected squamous cell carcinoma)<ref name="BrodlandZitelli1992">{{cite journal|last1=Brodland|first1=David G.|last2=Zitelli|first2=John A.|title=Surgical margins for excision of primary cutaneous squamous cell carcinoma|journal=Journal of the American Academy of Dermatology|volume=27|issue=2|year=1992|pages=241–248|issn=01909622|doi=10.1016/0190-9622(92)70178-I}}</ref>, consider expanding the distance towards the tips by taking more slices:<ref group="notes">A radicality slice closer the a tip is more likely to miss tumor cells spreading towards the long resection margins.</ref>
 <gallery heights=240px>
-File:Tissue selection from skin excision with narrow margin.png|One more slice towards tip in this example.
+File:Tissue selection from skin excision with narrow margin and lens shape.png|One more slice towards tip in this example.
-File:Tissue selection from skin excision with very narrow margin.png|If insufficient material for additional radicality slices, make multiple step sections from submitted one.
+File:Tissue selection from skin excision with narrow margin and oval shape.png|If insufficient material for additional radicality slices, make multiple step sections from submitted one.
 </gallery>
 Microtomy should start at the most central surface, leaving the option to perform further microtomy for radicality on the same slice in case the most central part is found to have tumor cells. However, if tumor cells are found near the resection margins on the radicality slices, non-radicality cannot be excluded by additional sampling towards the tips.