SKIN GROSSING - ORIENTATION
RUSH CASES:
For all RUSH cases, the dermpath fellows AND the skin service resident should be notified via email about the case.
All skin biopsy requisitions must be reviewed and categorized by the FS or on-call
resident/fellow, who must determine:
1. Whether the specimen is “RUSH” or not (and if a RUSH received on Friday, whether itshould be read Saturday or Monday)
2. If there are any additional stains to be ordered up front (see below); if there are any
questions about this, do not hesitate to page the dermpath fellow on service/on call. - All cases should get a “skin package” tag (H&E x 2)
- All inflammatory cases should get a PAS
- If leukemia/lymphoma is in the differential, order unstained slides (USI) x 10
- If you are not sure and have not been able to get in touch with a dermpath
fellow, order USIx 5
- If the rule out is HSV/VZV, order USI x 3
TYPES OF BIOPSY:
- Excisional Biopsy- In this procedure, the entire tumor is excised along with a margin of normal tissue around the lesion.
- Incisional Biopsy- In this procedure, only a portion of the tumor is excised. This is most commonly used for tumors of the skin.
- Shave Biopsy: In this procedure, the surface portion of the lesion is removed with a blade.
- Curette method: In this procedure, the surface of the lesion is scraped off.
NOTE: Methods 3 and 4 are performed to remove small growths and to confirm their nature.
- Punch Biopsy: In this procedure, a small cylinder of skin and subcutaneous tissue is removed.
NOTE:Method 5 is done to sample suspected inflammatory dermatoses and small masses.
FIXATION OF SKIN SPECIMEN:
Fixative for skin specimens is 10% buffered formalin. Formalin should be approximately 10 times by volume that of the specimen.
GROSS DESCRIPTION:
A vivid macroscopic description should be provided so that while reading the report one can actually visualize the specimen and lesion.
I. Specimen-
1. Shape and type of specimen- (e.g. Ellipse, punch, shave, fragmented, etc…)
2. Fixed or unfixed
3. Number of pieces of tissue
4. Dimensions of the specimen in millimeters (length, breadth, and thickness). In the case of small biopsies and punch biopsies, maximum diameter is noted
5. If the specimen is marked with a surgical suture, the position is described in detail.
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
3. Profile- dome-shaped; papillated; verrucous; flat-topped; umbilicated
4. Color- uniform or variegated
Color of Various Skin Tumors:
Dark brown- Melanoma
Brown to red- Pyogenic granuloma
Pink to red- Cylindroma
Yellow- Sebaceous adenoma and Steatocystoma Multiplex
Flesh colored- Spiradenoma
Blue- Blue Nevus
Dark blue, purple- Kaposi Sarcoma
Blue, black- Apocrine hidrocystoma
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. Identification and measurement of the distance between the edge of the dominant lesion and the nearest surgical margin (depending on the type of specimen)
9. Description of any other lesions present (e.g. scar, areas of pigmentation)
10. Configuration (the contour or outline of a single skin lesion, synonymous with shape)
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 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-(e.g. histochemical stains, immunohistochemistry, electron microscopy, cytogenetics etc.)
HANDLING OF GROSS SKIN SPECIMEN:
- In specimens from vesicular diseases, the vesicles should be submitted intact.One
should not cut through the vesicle under any circumstances.
- Small excisional biopsies (up to 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 punch biopsies are orientated on edge.
- In re-excision specimens, if the original lesion was completely excised and if there is
no macroscopic residual lesion other than a scar, only one representative section is
taken from the center of the specimen.
- If the original lesion was incompletely excised or if any residual tumor is evident in the re-excision specimen, then blocks are taken every 2 - 3 mm through the whole scar and embedded for histopathological examination.
- Excisional skin biopsies or formal resections for melanocytic lesions 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 grossing resident/technician to maintain orientation of the specimen while grossing by inking the specimen appropriately. This is necessary so the attending pathologist can accurately evaluate the lateral and the deep margins microscopically.
-All specimens requiring orientation should be inked using standard technique.
Multiple colors 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.
(E.g. 12-3 o'clock margins-blue,3-6 o'clock margin –green, 6-9 o’clock margin –purple, 9-12 o’clock margin –orange,and deep margin -black).
-A diagram of the pertinent anatomy showing the location of the sutures and ink marking is useful for maintaining proper orientation of the specimen.
- If the excision specimen is not oriented by the clinician, then the entire margin can be inked in one color (black).
- The first section should be taken from both “tips” of the specimen and the remaining specimen should be submitted after sectioning the whole specimen every 2 - 3 mm, transversely in a sliced bread pattern
- The two polar ends of the skin ellipse should be placed in either one or two designated cassettes depending on whether the specimen is clinically oriented.
- Oriented- Tips in separate cassette
- Un-oriented- Tips in same cassette
- 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.
- Not more than 3 sections should be processed in each cassette, to make one block.
- In specimens less than 10 mm, the entire lesion must be submitted for histopathological examination or the entire specimen if the lesion cannot be seen.
- In excisional biopsies over 10 mm 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.
* If you ever have a case where over 20 cassettes will be submitted for any single part, please contact the attending on service prior to sectioning.
-Curetted specimens, incisional biopsies, shave biopsies, and punch biopsies donot require the margins to be inked (unless requested by the clinician in Beaker).
NOTE:
Contact the attending on service if there is ever a question about how many sections to submit.
DERMATOPATHOLOGY GROSSING GUIDELINES
Specimen Type:SKIN PUNCH BIOPSY
Gross Template:Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a ***cm in length x *** cm in diameter skin punch biopsy. The epidermis [describecolor, presence/absence of hair, and lesions-including size, borders, shape, distance to peripheral margin]. The specimen is entirely submitted in [describe cassette submission].
Cassette Submission: All tissue submitted
- Punch biopsies 3 mm or less are submitted in their entirety- do not section
- Punch biopsies ≥ 4 mm are bisected/trisected (depending on size)
- Alopecia- often receive two cores in separate containers
- NOTE:
- If only one core is submitted, please contact the attending on service before grossing it in
- 1 punch bx is cut horizontally/transversely- order 5 deepers
- Ink cut surface black and add case note for histology to embed inked surface down
- 1 punch bx is cut vertically- order 2deepers and PAS stain
- Ink cut surface and add case note for histology to embed inked surface down
Specimen Type:SKIN SHAVE BIOPSY
Gross Template:Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a [***x***x***cm] skin shave biopsy measuring. [Describe any lesions – including size, type, borders, color, shape, distance to closest margin]. The specimen is entirely submitted in [describe cassette submission].
Cassette Submission: All tissue submitted
- Shave biopsies 3 mm or less are submitted in their entirety
- Shave biopsies ≥4 mm are bisected/trisected (depending on size)
Specimen Type: SKIN CURRETING
Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] are multiple fragments of [color] skin measuring [***x***x***cm] in aggregate ranging from [***cm] to [***cm] in greatest dimension. The specimen is entirely submitted in [describe cassette submission].
Cassette Submission: All tissue submitted
Specimen Type: SENTINEL NODE FOR MELANOMA
Procedure:
- Measure fibroadipose tissue
- Count and measure lymph node in 3 dimensions
- Serially section lymph node at 2-3mm intervals if large enough, if not bisect the lymph node
- Submit entire LN
- SLN- ensure correct protocol is ordered
Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a [***x***x***cm] portion of a [tan-yellow] fibroadipose tissue. Sectioning reveals [number] lymph nodes measuring [range if multiple/ three dimensions if single LN]. The lymph node is serially sectioned to reveal [describe cut surface]. The specimen is entirely submitted.
Cassette Submission:
1-3 cassettes (submit entire LN)
-Order sentinel lymph node package
Specimen Type: SKIN EXCISION
Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is an [oriented/unoriented] skin ellipse measuring [***x***cm], excised to a depth of [***cm]]. [Describe orientation if provided].The epidermis [Describe any lesions – including size, type, borders, color, shape, distance to all margins].
The specimen is serially sectioned to reveal [describe depth of invasion]. [Describe remaining cut surface and presence of satellite lesion(s)]. The specimen is entirely submitted in [describe cassette submission].
INK KEY (if oriented):
Blue- 12-3 o’clock
Green- 3-6 o’clock
Purple- 6-9 o’clock
Orange- 9-12 o’clock
Deep -black
INK KEY (if unoriented):
Black- resection margin
Cassette Submission: All tissue submitted
- If oriented-submit tips in separate cassettes. Up to 3 central sections can be submitted in the remaining cassettes
- If unoriented-both tips can go in the same cassette
Sample Cassette Submission:
Oriented
A112 o’clock tip
A2-A4Central sections, submitted from 12 to 6 o’clock
A56 o’clock tip
Unoriented
A1Tips
A2-A4Central sections, submitted from 12 to 6 o’clock
Specimen Type: LARGE SKIN EXCISION
Procedure:
- Photograph specimen
- Measure and orient, if applicable
- You may re-designate a suture to a clockface orientation. However, if a suture is designated in a clockface pattern, you must keep provided orientation.
- Suture on tip indicates superior. May be redesignated as 12:00.
- Suture on long edge indicates 12:00. This may NOT be redesignated as 3:00.
- Describe epidermis and note presence of lesion and/or scar- describe size, shape, borders, and distance to margins.
- If lesion is far from peripheral margins- take a thin shave of the peripheral margin and submit, en face. Designate clockface orientation in cassette summary.
- If lesion is close to peripheral margin submit perpendicular sections to closest margin. Submit the remainder of the peripheral margin, en face.
- Serially section and describe cut surface of lesion, measuring the maximum thickness of the lesion and the distance from the deep margin.
Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is an [oriented-describe orientation if provided/unoriented] skin ellipse measuring [***x***cm], excised to a depth of [***cm]. The epidermis [Describe any lesions – including size, type, borders, color, shape, distance to all margins].
The specimen is serially sectioned to reveal [describe cut surface and depth of invasion]. [Describe remaining cut surface and presence of satellite lesion(s)]. The specimen is entirely submitted/Representative sections are submitted.[describe cassette submission].
INK KEY (if oriented):
Blue- 12-3 o’clock
Green- 3-6 o’clock
Purple- 6-9 o’clock
Orange- 9-12 o’clock
Deep -black
INK KEY (if unoriented):
Black- resection margin
Cassette Submission: up to 20 cassettes
- Tips
- Melanoma- block out and submit entire scar/lesion and satellite nodules
- BCC/SCC- submit entirely, unless very large. You may consult with attending
Specimen Type: LIP EXCISION
Gross Template: Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is a [color] lip excision measuring [***x***cm], excised to a depth of [***cm]. [Describe orientation]. [Describe any lesions – including size, type, borders, color, shape, distance to all margins and if involving epidermis/mucosa/both].
The specimen is serially sectioned to reveal [describe depth of invasion]. The specimen is entirely submitted in [describe cassette submission].
Ink key:
Medial = blue
Lateral = green
Deep = black
Cassette Submission: All tissue submitted
Specimen Type:FORESKIN
Gross Template:Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] is an unoriented skin excision [***x***x***cm]. [Describe mucosa if present]. [Describe any lesions – including size, type, borders, color, shape, distance to closest margin]. The specimen is serially sectioned to reveal [describe cut surfaces]. The specimen is entirely submitted. [describe cassette submission].
Cassette Submission:
- Newborns – no tissue submitted (gross only)
- Submit one cassette if gross abnormality identified
- Adults – one cassette of representative tissue
- Submit 1-2 additional cassettes if gross abnormality identified
Specimen Type:FINGERNAILS and TOENAILS
Gross Template:Labeled with the patient’s name (last name, first name), medical record number (#), designated “[***]”, and received [fresh/in formalin] are multiple [color] portions of tan-yellow [firm, soft] nail measuring [***x***x***cm] in aggregate. The specimen is entirely submitted in [describe cassette submission].
Cassette Submission: All tissue submitted. If the clinical rule out is onychomycosis, order PAS-D stain on the block