(Optionally: A. Container is labeled - __. The specimen is received in formalin and consists of ) 1 fragment(s) of pink-tan tissue with a vaguely recognizable mucosal surface. The tissue measures __ cm. (The surgical margin is inked black. The specimen is bisected and entirely submitted for microscopic examination in one cassette.)
Microscopic evaluation
Anatomic/Histologic location
Describe mucosa as squamous (or ectocervical), endocervical (generally mucinous and glandular) or transformation zone mucosa.
Squamous (or ectocervical) mucosa at left and endocervical (mucinous) mucosa at right, in an example with abrupt transition.
Transformation zone mucosa, consisting of a mix of stratified squamous epithelium and mucinous glands, in an example with gradual transition.
Endocervical mucosa, with mucinous columnar epithelium and mucinous glands. H&E stain
However, the endocervical mucosa may appear columnar and non-mucinous.
A cervical biopsy may contain nabothian cysts, which are single or multiple cysts that contain mucin, lined by a single layer of columnar, cuboidal to flat cells with variable amounts of mucinous cytoplasm and small, basal, round to oval nuclei with fine chromatin, without conspicuous nucleoli or mitotic activity.[1]
The anatomic level of the transformation zone varies:[2] Type 1: Completely ectocervical (common under hormonal influence). Type 2: Endocervical component but fully visible (common before puberty). Type 3: Endocervical component, not fully visible (common after menopause).
If you see fragments of non-mucinous epithelium and glands, it is likely endometrial, so evaluate it like an endometrial curetting.
Pathologies
edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[3]
Spectrum from normal to high grade SIL.[4]
Further information: Cervical dysplasia
edit Other common findings:
Acute cervicitis, having a largely neutrophilic intra-epithelial infiltrate.
Endocervical polyp: With endocervical epithelium and glands (mucinous columnar linings), edematous stroma and clear congestion. H&E stain.[5]
Example report
Endocervix, curettings: Fragments of squamous and endocervical glandular epithelium without significant histopathologic changes. Negative for dysplasia.
|
Notes
- ↑ 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.
Main page
References
- ↑ Gulisa Turashvili, M.D., Ph.D.. Cervix Benign / nonneoplastic epithelial lesions. Nabothian cysts.. Pathology Outlines. Last author update: 1 February 2021. Last staff update: 4 April 2022}}
- ↑ International Federation for Cervical Pathology and Colposcopy (IFCPC) classification. References:
-. Transformation zone (TZ) and cervical excision types. Royal College of Pathologists of Australasia. - Jordan, J.; Arbyn, M.; Martin-Hirsch, P.; Schenck, U.; Baldauf, J-J.; Da Silva, D.; Anttila, A.; Nieminen, P.; et al. (2008). "European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1
". Cytopathology 19 (6): 342–354. doi:10.1111/j.1365-2303.2008.00623.x. ISSN 0956-5507. PMID 19040546.
- ↑ Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
- ↑ Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
- ↑ Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
- This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
Image sources
Cervical cone
Unless otherwise specified, the primary focus is any cervical neoplasia.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
- Measure length, as well as the transverse and sagittal diameter of the ectocervical surface.[1]
- Optionally, weight the sample.[1]
- Note the symmetry of the sample, and the position of the cervical canal.[1]
- Note whether the circumference is complete. If not, and the directions are indicated on the cone, determine the approximate position of the defect.[1]
- Cones excised by knife should be inked on the excision surfaces. Those excised by laser do not need inking.[1]
Selection and trimming
- If the cone is more than 1 cm long, take transverse slices from the top of the cone and towards the ectocervix, and stop when approximately 1 cm of the ectocervical portion of the cone remains.
- Cut the portion into radial or sagittal slices. Sagittal slices are made perpendicularly to the portion surface, and should be divided into at least the four quadrants.[note 1][1]
In cases where the cone is small and fragmented, try to orient the preparations and divide them if possible to obtain sagittal slices.[1]
See also: General notes on gross processing
Microscopic evaluation
Anatomic/Histologic location
Describe mucosa as squamous (or ectocervical), endocervical (generally mucinous and glandular) and/or transformation zone mucosa.
Squamous (or ectocervical) mucosa at left and endocervical (mucinous) mucosa at right, in an example with abrupt transition.
Transformation zone mucosa, consisting of a mix of stratified squamous epithelium and mucinous glands, in an example with gradual transition.
Endocervical mucosa, with mucinous columnar epithelium and mucinous glands. H&E stain
The anatomic level of the transformation zone varies:[2] Type 1: Completely ectocervical (common under hormonal influence). Type 2: Endocervical component but fully visible (common before puberty). Type 3: Endocervical component, not fully visible (common after menopause).
Cervical dysplasia
edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[3]
Spectrum from normal to high grade SIL.[4]
Further information: Cervical dysplasia
Radicality
Locations of non-radicality should be reported in relation to tissue markings (such as needles), or in terms of quadrants or corresponding to a clock face, based on the patient being in supine position.
Look whether there is normal epithelium on each side of all slices where neoplasia is seen, and when the epithelium is missing in any direction, consider ordering additional serial sections or step sections.
HPV changes
Also look koilocytic changes of human papillomavirus (HPV), with such cells typically displaying:
- Nuclear enlargement (two to three times normal size).
- Irregularity of the nuclear membrane contour, creating a wrinkled or raisinoid appearance.
- A darker than normal staining pattern in the nucleus, known as hyperchromasia.
- Perinuclear cytoplasmic vacuolization ("nuclear halo").
Other findings
edit Other common findings:
Acute cervicitis, having a largely neutrophilic intra-epithelial infiltrate.
Endocervical polyp: With endocervical epithelium and glands (mucinous columnar linings), edematous stroma and clear congestion. H&E stain.[5]
Microscopy report
If a neoplasia is found, the report should include:[1]
- The histolopathological type and degree of differentiation
- Location and extent
- Radicality
High-grade squamous intraepithelial lesion (CIN-2), present at 3:00 to 12:00. All margins of excision are negative for CIN-2.
|
Example report in a normal case:
Cervix at transformation zone without significant histopathologic changes. Negative for neoplasia/carcinoma.
|
Endometrial polyp
Author:
Mikael Häggström [note 2]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Microscopic evaluation
The main objectives are:
- Making a diagnosis of endometrioid polyp. An endometrial polyp may be diagnosed in the presence of 2 of the following 3:
- Thick-walled vessels
- Collagenous stroma
- Epithelium on at least 3 sides
- Look for signs of atypia or malignancy.
Endometrial polyp (without atypia), with a thick-walled blood vessel in middle - typical of endometrial polyps. Glands are regular.
Endometrial polyp (without atypia), with tubal metaplasia (black arrow, showing ciliated epithelium) and a thick-walled blood vessel (white arrow). The stroma is hemorrhagic in this case.
Myometrium (smooth muscle cells) versus endometrial stroma (more cellular) versus endometrial polyp stroma (more collagenous).[image 1]
Atypia (mainly seen as signs of endometrial intraepithelial neoplasia (EIN), which has the following criteria:[6] - Architectural gland crowding - Altered cytology relative to background glands - Minimum size of 1 mm - Exclusion of adenocarcinoma - Exclusion of mimics Mitoses should also preferably be seen.
Endometrial adenocarcinoma[7] arising in an endometrial polyp. These are most commonly endometrioid, in which case low-grade carcinoma is distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.[8]
Subserosal pedunculated uterine leiomyomas may present as endometrial polyps. They typically show smooth muscle in a fascicular pattern[9] Further information: Smooth muscle tumor
Reporting
Most importantly:
- Benign versus malignant (or presence or absence of atypia.)
- ((The size of the polyp.))
- ((The type of epithelium at both the surface and gland coverings.))
Example of a minimal report:
Benign endometrial polyp.
|
See also: General notes on reporting
Notes
- ↑ Each slice may be individually numbered.
- ↑ 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.
Main page
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- ↑ International Federation for Cervical Pathology and Colposcopy (IFCPC) classification. References:
-. Transformation zone (TZ) and cervical excision types. Royal College of Pathologists of Australasia. - Jordan, J.; Arbyn, M.; Martin-Hirsch, P.; Schenck, U.; Baldauf, J-J.; Da Silva, D.; Anttila, A.; Nieminen, P.; et al. (2008). "European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1
". Cytopathology 19 (6): 342–354. doi:10.1111/j.1365-2303.2008.00623.x. ISSN 0956-5507. PMID 19040546.
- ↑ Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
- ↑ Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
- ↑ Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
- This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
- ↑ Owings, Richard A.; Quick, Charles M. (2014). "Endometrial Intraepithelial Neoplasia
". Archives of Pathology & Laboratory Medicine 138 (4): 484–491. doi:10.5858/arpa.2012-0709-RA. ISSN 1543-2165.
- ↑ Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites
". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691.
- "Figures - available via license: Creative Commons Attribution 4.0 International"
- ↑ Rabban, Joseph T.; Gilks, C. Blake; Malpica, Anais; Matias-Guiu, Xavier; Mittal, Khush; Mutter, George L.; Oliva, Esther; Parkash, Vinita; et al. (2019). "Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas
". International Journal of Gynecological Pathology 38: S25–S39. doi:10.1097/PGP.0000000000000512. ISSN 0277-1691.
- ↑ Mohamed Mokhtar Desouki. Uterus - Stromal tumors - Leiomyoma. pathology Outlines. Topic Completed: 1 August 2011. Revised: 15 December 2019
Image sources
Endometrial curettings
Gross processing
- Generally submit all tissue for microscopy, even larger volumes.
- Look for products of conception if indicated from referral and/or history
Microscopic evaluation
Describe the anatomic/histologic type of epithelium.
Look mainly for:
Anatomic/histologic epithelium type
(Determine the type or phase of the endometrium:) edit
In contrast, endocervical mucosa typically consists of mucinous columnar epithelium and mucinous glands. Evaluate this like a cervical biopsy or cervical cone.
The most superficial layer of the endometrium usually consists of a simple columnar epithelium.
Postmenopausal (atrophic) endometrium: Thin epithelium, and scattered glands lined by columnar cells with small inactive nuclei, supported by a dense fibrous stroma of spindle cells. (H&E stain)
The phases of endometrium through the menstrual cycle:
Proliferative endometrium: long curving glands (G) and some stromal edema (H&E stain)
Secretory endometrium: Prominent glands (G), which have a dilated lumen and an irregular outer border stretching down into the basal compartment. In the luminal (functional) layer immune cells are readily detected (most of these are likely to be macrophages and uterine natural killer (uNK) cells), as are areas of decidualised fibroblasts (DEC) close to arterioles. (H&E stain)
If you want to specify the phase by day, then it's more accurate to state it as days past ovulation where applicable, since the follicular phase may vary substantially.
Hyperplasia, atypa and/or malignancy
- Look for signs of atypia or malignancy:
edit
Endometrial intraepithelial neoplasia (EIN), has the following criteria:[2] - Architectural gland crowding - Altered cytology relative to background glands - Minimum size of 1 mm - Exclusion of adenocarcinoma - Exclusion of mimics Mitoses should also preferably be seen.
Endometrial adenocarcinoma[3], most commonly endometrioid, in which case low-grade carcinoma is distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.[4]
Microscopy report
Example in a normal case:
(Endometrial curettings: Benign proliferative endometrium and endocervical mucosa without significant histopathologic changes.) Negative for neoplasia ((or viral cytopathic changes)).
|
Endometrial thickening
Hysterectomy sampling
A regular hysterectomy grossing is performed, but with the following sampling:[5]
- 2 longitudinal sections through ecto/endocervix (1 anterior and 1 posterior)
- 2 longitudinal sections through upper endocervix/lower uterine segment (1 anterior and 1 posterior), immediately adjacent to the sections taken from the cervix
- 4 full-thickness representative sections of endomyometrium (2 anterior and 2 posterior)
- Transversely section the remaining anterior and posterior endomyometrium (~1 cm thick). Submit the entire endometrium from the lower uterine segment to the fundus, maintaining orientation.
- Submit entire fimbriae (longitudinally sectioned) and 2 representative cross-sections on each side.
Microscopic evaluation
- Look for signs of atypia or malignancy:
edit
Endometrial intraepithelial neoplasia (EIN), has the following criteria:[2] - Architectural gland crowding - Altered cytology relative to background glands - Minimum size of 1 mm - Exclusion of adenocarcinoma - Exclusion of mimics Mitoses should also preferably be seen.
Endometrial adenocarcinoma[7], most commonly endometrioid, in which case low-grade carcinoma is distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.[4]
Reporting
Most importantly:
- Presence or absence of atypia.
Hysterectomy
For a freshly received uterus, generally gross it fresh to include either opening it up (small specimen, no suspected malignancy seen) and/or serial sectioning, in order to let the formalin penetrate it properly. Ensure the endometrium is immersed in the formalin (such as having the serosa oriented upwards).
See also: General notes on fixation
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
- Other legend
<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page
Gross processing
Gross examination
For orientation:
- The round ligament lies anterior to the tubes and ovaries.[8]
- The peritoneum extends further down along the cervix posteriorly than anteriorly.[9] Its ends bluntly posteriorly and sharply anteriorly.[9]
When received the same day as the surgery, perform the following steps at least to serial sectioning before putting (back) in formalin, preferably with paper towels between slices, so that it fixes properly:[8]
- (Remove the adnexa.[8] Weigh the uterus without the adnexa.)
- Perform a general inspection
- Measure the 3 dimensions, including the cervix. (Also measure the length of the cervix, the maximum diameter of the cervix, and the width of the cervical os.)
- (Ink the surgical margin of the cervix for orientation, such as black on the posterior side.)
- Open the uterus by transmural radial cuts on both sides of the uterine cavity.[note 1] The cavity is sometimes be squeezed or rolled around a leiomyoma, and you'll you have to improvise and perhaps go around the leiomyoma to open the cavity properly.
- Inspect the mucosa. If any polyps: Further information: Endometrial polyp
If more extensive tumor, gross as per endometrial cancer
- Serially section through almost the entire depth of the myometrium at approximately 1 cm intervals, still keeping the specimen together.
- Measure the thickness of the mucosa and myometrium
- Inspect the myometrium. If any tumor: Further information: Smooth muscle tumor
Gross pathology of extensive adenomyosis, contrasted to normal myometrium at bottom in right image.
Gross report
Applicable in bleeding disorders, pain, leiomyoma and endometrial hyperplasia:[8]
Components:[8]
- (Shape of uterus and adnex)
- Measurements
- Mucosa, such as smooth or irregular.
- (Even the absence of) any polyps. Further information: Endometrial polyp
- Mucosal and endometrial thickness. Further information: Endometrial thickening
- (Even the absence of) any smooth muscle tumor. Further information: Smooth muscle tumor
- Example
(A. Labeled - __. The specimen is received in formalin and consists of a resected) uterus with cervix [and bilateral fallopian tubes and ovaries]. The uterus and cervix measure __ ((cm superior to inferior)) x __ ((cm cornu to cornu)) x __ cm ((anterior to posterior,)) and weighs ___ grams. The serosa is [tan-pink and smooth]. The cervix measures ___ cm in diameter and ___ cm in length. The ectocervical mucosa is [tan-pink and smooth] and the cervical os[ is patent] and measures ___ cm in diameter. The specimen is bisected in the coronal plane. The endocervical canal is [patent and displays a tan-pink smooth mucosa]. The endometrial cavity is [triangular] and is lined by[ smooth] endometrium measuring [0.1] cm in average thickness. The myometrium measures up to ___ cm in thickness.[
- It displays __ intramural leiomyomata measuring up to __ cm in greatest diameter.
] The right ovary measures ___ cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions]. The right fallopian tube measures ___ cm in length and ___ cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. The left ovary measures ___ cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions].The left fallopian tube measures ___ cm in length and ___ cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. Representative sections are submitted for microscopic examination in ___ cassettes.
|
Slices for microscopy
Applicable in bleeding disorders, pain, leiomyoma and endometrial hyperplasia:[8]
Submit:[8][10]
- One, (two - at 6 and 12 o'clock), ((or four)) cross-sections from any accompanying ectocervix/endocervix (aiming to include the transformation zone). In subtotal extirpation, a cross-section is taken from the lower resection border.
- ((A transverse slice through the endocervix, possibly divided into two.))
- Endometrium and myometrium, by one slice from the front and one from the back wall of the corpus.
- {{Any mucosal parts with macroscopically abnormal appearance, including polyps.}}
- {{For any area suspicious for malignancy, submit a full cross-section of the uterine wall that includes the serosa. Use multiple contiguous cassettes if needed.}}
- {{Samples from all smooth muscle tumors >5 cm in diameter.}} Further information: Smooth muscle tumor
A specific sampling scheme is used in: Endometrial thickening
See also:
Microscopic evaluation
Look for signs of malignancy:
Cervix
edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[11]
Spectrum from normal to high grade SIL.[12]
Further information: Cervical dysplasia
edit Other common findings:
Acute cervicitis, having a largely neutrophilic intra-epithelial infiltrate.
Endocervical polyp: With endocervical epithelium and glands (mucinous columnar linings), edematous stroma and clear congestion. H&E stain.[13]
Uterine body
(Determine the type or phase of the endometrium:) edit
In contrast, endocervical mucosa typically consists of mucinous columnar epithelium and mucinous glands. Evaluate this like a cervical biopsy or cervical cone.
The most superficial layer of the endometrium usually consists of a simple columnar epithelium.
Postmenopausal (atrophic) endometrium: Thin epithelium, and scattered glands lined by columnar cells with small inactive nuclei, supported by a dense fibrous stroma of spindle cells. (H&E stain)
The phases of endometrium through the menstrual cycle:
Proliferative endometrium: long curving glands (G) and some stromal edema (H&E stain)
Secretory endometrium: Prominent glands (G), which have a dilated lumen and an irregular outer border stretching down into the basal compartment. In the luminal (functional) layer immune cells are readily detected (most of these are likely to be macrophages and uterine natural killer (uNK) cells), as are areas of decidualised fibroblasts (DEC) close to arterioles. (H&E stain)
If you want to specify the phase by day, then it's more accurate to state it as days past ovulation where applicable, since the follicular phase may vary substantially.
- Main pathologic findings
edit
Endometrial intraepithelial neoplasia (EIN), has the following criteria:[2] - Architectural gland crowding - Altered cytology relative to background glands - Minimum size of 1 mm - Exclusion of adenocarcinoma - Exclusion of mimics Mitoses should also preferably be seen.
Endometrial adenocarcinoma[15], most commonly endometrioid, in which case low-grade carcinoma is distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.[4]
Adenomyosis (endometrial glands in the myometrium). Look at these at high magnification to exclude dysplasia, as for endometrium.
Microscopy report
Examples of reports:
- Normal cases
- [note 2]
Uterus, cervix, bilateral tubes and ovaries, abdominal hysterectomy and bilateral salpingo-oophorectomy:
- Benign cervix.
- Benign inactive endometrium.
- {{Leiomyomata and adenomyosis.}}
- Benign ovaries.
- Benign fallopian tubes.
- Negative for malignancy.
|
Microscopy of hysterectomy shows ecto and endocervix without atypia. The glands have columnar epithelium without atypia.
In the uterine cavity, there is endometrial mucosa with ordinary thickness and regularly arranged endometrial glands. (Optionally: Description of likely menstrual phase.) Sharp delimitation between endometrium and myometrium. The myometrium contains no focal changes. No evidence of malignancy.
|
- Endometrial intraepithelial neoplasia
Uterus, cervix, bilateral tubes and ovaries, hysterectomy and bilateral salpingo-oophorectomy:
- Endometrial intraepithelial neoplasia; entire endometrial/myometrial junction submitted for microscopic exam.
- Benign lower uterine segment.
- Benign bilateral tubes and ovaries.
|
Smooth muscle tumor
Smooth muscle tumor (in this case leiomyoma).
Gross processing
Gross examination
When finding fibroids (spherical tumors with whorled pattern, which in the uterus can be presumed to be smooth muscle tumors), examine and describe:[8]
- Location. If in the uterus:
- Intramural/submucosal/subserosal (see image)
- (Posterior/anterior/right or left lateral.)
- Number of tumors, if multiple. May be described simply as "multiple".
- Size (may be described as "up to ___ cm in greatest dimension".
- (Presence or absence of any hemorrhage or necrosis.)
- ((Demarcation))
Selection
In case of hysterectomy, submit pieces from all fibroids >5 cm in diameter.[8]
Submit any macroscopically abnormal parts of the fibroids (hemorrhagic, necrotic, brittle or softening areas, and areas with blurry delimitation).[8]
For fibroids that are significantly calcified, a gross-only description as a calcified fibroid is generally sufficient, without the need to decalcify it to dissect it or sample from it.[note 3]
Microscopic examination
Distinguish leiomyoma (benign) from leiomyosarcoma (malignant) by looking at the latter's criteria:[16]
- Marked cellular atypia
- Mitoses: > 10 mitoses/10 high power fields
- Necrosis
Diagnosis of conventional leiomyosarcoma requires 2 of these 3 histologic features.[16]
Leiomyomas typically show smooth muscle in a fascicular pattern (arrows point at fascicles).[17][image 1]
Leiomyoma, with areas where the cellularity is relatively lower (left) and higher (right).
Leiomyoma with nuclear pleomorphism, yet within benign limits.
Leiomyoma with palisading pattern
Leiomyosarcoma: Variable atypia, often with cytoplasmic vacuoles at both ends of nuclei, and frequent mitoses.[18]
Epithelioid leiomyosarcoma
Further information: Evaluation of tumors
Microscopic report
Report:
- Microscopic findings, including any visible linings
- Diagnosis or most probable one
- Any linings or borders.
Example, for a cervical polyp:
Polyp lined by a single layer of columnar epithelium consistent with endometrium. The interior consists of smooth muscles in a whorled pattern. No atypia. The finding is consistent with a pedunculated submucosal leiomyoma.
|
Intrauterine device
Gross processing
These are generally just visually described, with no samples for microscopic examination. Example report:
T-shaped item with metal-coated arms and stem (Optionally: consistent with an intrauterine device with copper), with attached threads measuring 6.5 cm each.
|
Products of conception
Gross processing
Look up the gestational age of the pregnancy.
- Look for fetal tissue (fetus, fetal membranes or chorionic villi). They are generally easier to distinguish from decidua (which is maternal tissue) when fragments are put in clear fluid and shaken, with chorionic villi having a consistency like orange pulp, whereas decidua is more rubbery. The fluid may be formalin if no sample for genetic workup is needed. If chorionic villi are found, no lengthy search is needed for other kinds of fetal tissue, just a quick look for obvious ones. Membranous material is less reliable, and may still indicate further sampling. Inspect any found fetal tissue for gross anomalies. If found, submit one piece of the fetus and one piece of the placenta.[19]
Fresh chorionic villi (arrows), surrounded by decidua, at 10 weeks of gestational age.
Chorionic villi (arrow) become more characteristic when held in fluid, having a fibrillary shape
Fresh chorionic villi (left) compared to decidua (right).
Chorionic villi become more pale when fixed in formalin.
Macropathology of fixed umbilical cord, amnion and chorionic villi at 7-13 weeks of gestational age
Fresh chorionic villi in a term placenta for comparison, being more granular.
- If fetal parts are not visually found, search for diagnostic placental tissue, which is soft and shaggy or spongy (as opposed to membranous, which is likely to be decidua or blood clots).[19]
- If no fetal or placental tissue is found, all presented tissue generally needs to be submitted.
(If transported or processed together with other cases, put any chorionic villi in thin-mesh cassettes or tissue bags to limit contamination).[note 4]
Gross report
(Labeled - products of conception.) The specimen (is received <<fresh / in formalin>>) and consists of multiple fragments of soft tan-pink decidua, blood clots and amniotic sac measuring about 5 cc in aggregate. The intact amniotic sac measures 2.3 cm in greatest dimension. Fetal tissue is identified within the amniotic sac, measuring 1.0 cm in crown-rump length. Representative sections are submitted for microscopic examination (in 1 cassette).
|
Microscopy
The most important is to detect the presence of chorionic villi.
Products of conception, with chorionic villi (arrow) among decidualized endometrium
Immature chorionic villi, having loose stroma and few capillaries.
Necrotic chorionic villi in a tubal pregnancy.
Scantly cellular decidua may look like chorionic villi, but lack the thick trophoblastic lining.
In the absence of chorionic villi, look for implantation site intermediate trophoblasts (ISITs):
ISITs, having relatively large and dark nuclei.
Histology of decidua for comparison, having smaller and brighter nuclei.
- In the absence of both chorionic villi and ISITs, preferably perform cytokeratin immunostaining of each tissue sample, such as CAM5.2.[20]
- In the absence of chorionic villi and ISITs even after staining, call the clinician, since there may be an ectopic pregnancy.
Microscopy report
Examples:
((Products of conception:)) Products of conception, including immature chorionic villi, corresponding to first trimester pregnancy. ((Spontaneous abortion, clinically.))
|
((Products of conception:)) Fragments of focally necrotic decidua and implantation site, consistent with intrauterine products of conception. Negative for chorionic villi.
|
Fallopian tube
Gross processing
(Look in the history for any intra-fallopian coils (Essure devices).)[note 5]
- For sterilization
- Measure length and average diameter of each tube
- Serially section at 3-4 mm intervals,[21] or 2-3 mm if suspected malignant (including BRCA mutation).[22] Submit
- Submit 1 (or 3) circumferential transverse sections. If the specimen is only a segment of the tube of less than <5mm((, ink the surgical cut surfaces and)) submit all tissue.[21]
Example gross report:
(A. Labeled - __. The specimen is received in formalin and consists of) two fimbriated segments of fallopian tube measuring __ cm in length and __ cm in average diameter. On sectioning, each displays a patent lumen. No gross abnormalities are identified. The tubes are unoriented. The specimen is serially cross-sectioned and representative sections are submitted for microscopic examination in two cassettes.
|
Microscopic examination
Fallopian tubes may be substantially edematous and congested, which can generally be attributed to surgery, in which case it does not need mention in the report.
- Ensure there is at least one full cross-section from each tube, and take further samples otherwise.
- Check for patency of the lumen.
Tumor
The most common tumor of the fallopian tubes is adenomatoid tumor:[23]
An adenomatoid tumor of the fallopian tube, low magnification, displaying infiltrative-like borders.
High magnification of the same case, showing the typical[23] features of tubular spaces of varying size composed of flattened cells resembling endothelium.
Reporting
Example of a normal report in sterilization:
(Right and left fallopian tubes, ((laparoscopic)) bilateral salpingectomy:) Complete cross-sections of histologically unremarkable fallopian tubes.
|
When included in a uterus specimen, normal tubes and ovaries may simply be mentioned as:
Bilateral fallopian tubes and ovaries, unremarkable.
|
Histopathology of an ectopic pregnancy in a fallopian tube, with chorionic villi and implantation site changes Further information: Products of conception .
When done for ectopic pregnancy, report any rupture, either from the gross report or from microscopy, for example:
Benign ruptured fallopian tube with ectopic products of conception, including degenerated immature chorionic villi and implantation site with fresh hemorrhage.
|
Further information: Products of conception
Notes
- ↑
- In the US, the cut goes from side to side, through the cervix and uterine cavity, keeping the anterior and posterior halves attached by a relatively thin connection left at the fundus. It is done by cutting with scissors with the blunt end in the cervix and then uterine cavity, or by a blade guided on each side by the shanks of a pair of forceps inserted through the cervix.
- In Sweden, the uterus is usually opened at the front in the midline, optionally with an incision towards each corner.
It can be done by scissors, or by inserting a probe or forceps to guide a long blade.
- ↑ The first example is used in Connecticut, and the second example is used in Sweden.
- ↑ When a fibroid has calcifications it has been there a long time, and can be assumed to be benign.
- ↑ Chorionic villi are promiscuous contaminants of other tissues, and may cause a false positive finding for another cassette containing products of conception.
- Carll T, Fuja C, Antic T, Lastra R, Pytel P (2022). "Tissue Contamination During Transportation of Formalin-Fixed, Paraffin-Embedded Blocks.
". Am J Clin Pathol 158 (1): 96-104. doi:10.1093/ajcp/aqac014. PMID 35195717. Archived from the original. .
- ↑ For a case with intra-fallopian coils in the medical records, an inability to find them on gross processing must be noted in order to raise the possibility of coil expulsion.
Main page
References
- ↑ Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India
". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851.
- Figure- available via license: Creative Commons Attribution 2.0 Generic
- ↑ 2.0 2.1 2.2 Owings, Richard A.; Quick, Charles M. (2014). "Endometrial Intraepithelial Neoplasia
". Archives of Pathology & Laboratory Medicine 138 (4): 484–491. doi:10.5858/arpa.2012-0709-RA. ISSN 1543-2165.
- ↑ Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites
". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691.
- "Figures - available via license: Creative Commons Attribution 4.0 International"
- ↑ 4.0 4.1 4.2 Rabban, Joseph T.; Gilks, C. Blake; Malpica, Anais; Matias-Guiu, Xavier; Mittal, Khush; Mutter, George L.; Oliva, Esther; Parkash, Vinita; et al. (2019). "Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas
". International Journal of Gynecological Pathology 38: S25–S39. doi:10.1097/PGP.0000000000000512. ISSN 0277-1691.
- ↑ Nicole Cipriani (2020-06-22). Gross Pathology Manual. The University of Chicago Department of Pathology.
- ↑ Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India
". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851.
- Figure- available via license: Creative Commons Attribution 2.0 Generic
- ↑ Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites
". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691.
- "Figures - available via license: Creative Commons Attribution 4.0 International"
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- ↑ 9.0 9.1 . General Specimen Orientation Tips. The University of Michigan (2020-01-29).
- ↑ Nicole Cipriani (2020-06-22). Gross Pathology Manual. The University of Chicago Department of Pathology.
- ↑ Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
- ↑ Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
- ↑ Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
- This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
- ↑ Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India
". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851.
- Figure- available via license: Creative Commons Attribution 2.0 Generic
- ↑ Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites
". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691.
- "Figures - available via license: Creative Commons Attribution 4.0 International"
- ↑ 16.0 16.1 Paulette Mhawech-Fauceglia, M.D.. Uterus - Smooth muscle tumors - Leiomyosarcoma. Pathology Outlines. Topic Completed: 5 December 2019. Minor changes: 11 August 2020
- ↑ Mohamed Mokhtar Desouki. Uterus - Stromal tumors - Leiomyoma. Pathology Outlines. Topic Completed: 1 August 2011. Revised: 15 December 2019
- ↑ Vijay Shankar, M.D.. Soft tissue - Smooth muscle - Leiomyosarcoma - general. Pathology Outlines. Topic Completed: 1 November 2012. Revised: 11 September 2019
- ↑ 19.0 19.1 . Gross Pathology Manual, By The University of Chicago Department of Pathology - Products of Conception. Retrieved on 2020-08-13.
- ↑ Konoplev SN, Dimashkieh HH, Stanek J (2004). "Cytokeratin immunohistochemistry: a procedure for exclusion of pregnancy in chorionic villi-negative specimen.
". Placenta 25 (2-3): 146-52. doi:10.1016/S0143-4004(03)00188-7. PMID 14972447. Archived from the original. .
- ↑ 21.0 21.1 Kerryn Ireland-Jenkin and Marsali Newman. Ovary and fallopian tube -benign setting. Royal College of Pathologists of Australasia. Retrieved on 2020-10-16.
- ↑ Crum, Christopher P.; Mckeon, Frank D.; Xian, Wa (2012). "The Oviduct and Ovarian Cancer
". Clinical Obstetrics and Gynecology 55 (1): 24–35. doi:10.1097/GRF.0b013e31824b1725. ISSN 0009-9201.
- ↑ 23.0 23.1 Nicole Riddle, Jamie Shutter. Fallopian tubes & broad ligament - Fallopian tube tumors - Adenomatoid tumor. Pathology Outlines. Topic Completed: 1 September 2013. Minor changes: 13 December 2019
Image sources
Ovary
Gross processing
"Long" and "short" axis. [1]
The ovary is cut in the longitudinal plane (through the "long axis").
Ovaries, including those with cysts, are almost never inked.
Gross report
Template:
(A. Labeled - __. The specimen is received in formalin and consists of) an ovary measuring ___. The ovarian capsule is tan-pink and smooth. Cut sections reveal solid, white and whorled parenchyma, and no gross lesions. Representative sections are submitted for microscopic examination in __ cassettes.
|
Microscopic examination
Signet ring cell carcinoma metastasis to the ovary, also called Krukenberg tumor: Gross pathology (top, cross-section at right) and histopathology at low and high magnification. [2]
Apart from any obvious tumor, also look for signet ring cells, which is a major feature of metastatic tumors to the ovary.
Placenta
Gross processing
- Determine the shape of the placenta
- Look for any accessory lobes
- Determine the completeness of placental membranes, opacity, color and consistency (slimy/slippery?)
- Determine the point of rupture from nearest margin
- Note where the membranes are inserted
- Examine the umbilical cord
- Measure the distance between the insertion point and the nearest placental margin
- Measure the cord length and give proximal and distal diameter. In placental pathology, the proximal umbilical cord refers to the segment closest to the placenta, and distal is the segment closest to the fetus.[note 1]
- Count the number of vessels away from the insertion
- Weigh the trimmed disk, after having trimmed away the cord and membranes, and after having removed excess amounts of loose retroplacental blood clots over the maternal surface.
- Examine the fetal surface (chorionic plate):
- Note its color, in particular if it is green (often faint and tan-green, brown-green to yellow-green (which indicates meconium staining).
- Look for any pathologies including granular excrescences, subchorionic fibrin or subamniotic hemorrhage
- Look at the integrity and extent of the vasculature, including any traumatic damage. Also palpate the vasculature for any thrombosis. If a thrombus is grossly found for a live birth, the baby may have thrombosis, so the finding must immediately be reported to the clinician in care of the baby.
- Examine the maternal surface (basal plate) for completeness, adherent blood clots, depressions, calcifications and fibrin
- Take a membrane roll and cord sections, before sectioning the placenta
- With the fetal surface down on the cutting board, cut the placenta at 1cm intervals so that it can be reconstructed.
Making a fetal membrane roll.
Placental tissue after cutting, here showing severe intervillositis, with dark red and soggy tissue.
- Palpate the parencyhmal sections for areas of induration.
- Note the color of the parenchyma and describe any pale areas, cysts, thrombi, increased fibrin, calcifications and infarcts. For possible infarcts, estimate the total amount of infarcted tissue as a percentage of the placental volume. Infarction is clinically significant if it involves at least 5-10% of the placental volume.
Gross pathology of placental disorders. [3]
If you see a true knot (rather than "false knots" which are merely bulges or protuberances that may look like knots), report whether the diameter of the cord is significantly different before versus after the knot (which is a sign of constriction caused by the knot).
Tissue selection
- Distal (toward fetus) membrane roll and cross section of distal cord. It should include the area of rupture.
- Proximal (toward placenta) membrane roll and cross section of proximal cord ( 2-3 cm from insertion). They should include membranes up to the chorionic plate.
A membrane roll is created by cutting a strip, about 3 cm wide, of membrane, from the rupture site to the placental insertion. Hold the edge with forceps and roll it around the forceps, and then cut a transverse section of the roll. Cord sections should be no thicker than 4mm.
- Placental section including fetal surface ( full thickness if possible)
- Placental section including maternal surface (full thickness if possible)
- Any lesions or abnormalities
Avoid taking placental sections near the margin. (If transported or processed together with other cases, put the placental in thin-mesh cassettes or tissue bags to limit contamination).[note 2]
Example report:
Container A. Labeled "bladder tumor". The specimen is received in formalin and consists of multiple fragments of tan-gray, friable soft tissue measuring about __ x __ x __ cm in aggregate. The specimen is entirely submitted for microscopic examination in __ cassettes.
|
Gross report
Placenta weight by gestational age.
Example in a normal case:
(A. Labeled with patient's name and medical record number. The specimen is received fresh and consists of a) placenta with attached membranes and umbilical cord. The membranes are tan-red( with a marginal insertion. The site of rupture is __ cm from the nearest placental margin. There is no accessory lobe.) The trimmed placental weight is __ gramsTemplate:Comprehensive-begin-Corresponding to the __th percentile for the gestational age)). The placental disc measures __ cm and varies in thickness from __ to __ cm. The umbilical cord is tan-pink and eccentrically inserted(, __ cm from the nearest placental margin, and measures __ cm in length, __ cm in proximal diameter and __ cm in distal diameter.) Cut sections of the cord reveal three blood vessels. The fetal surface is blue-pink, smooth with normal vasculature and << minimal / moderate / major>> subchorionic fibrin deposition. The maternal surface is complete with <<minimal / moderate / major>> physiologic calcifications. Sectioning reveals a red, spongy, homogenous parenchyma without gross lesions. (Representative sections are submitted for microscopic examination in 4 cassettes.)
KEY OF SECTIONS (example):
- 1- distal membranes and umbilical cord
- 2- proximal membranes and umbilical cord
- 3- placental section including fetal surface
- 4- placental section including maternal surface
|
Microscopic examination
- Look for inflammation, especially by the fetal surface in the intervillous spaces and around the fetal blood vessels.
Acute subchorionic intervillositis, with neutrophils (annotated) in Langhan’s layer of fibrinoid (by the fetal surface, at the base of a chorionic villus, seen at top right).
On the other hand, a small amount of intervillous neutrophils by the fetal surface like this is insignificant.
Umbilical cord: Acute phlebitis and funisitis (inflammation of a vein and the connective tissue, respectively) with neutrophils.
Acute chorioamnionitis, with neutrophils in the chorion. Also seen are fibrin thrombi, which indicate a severe fetal inflammatory response.[4]
Acute choriodeciduitis, with neutrophils seen in the chorion and decidua.
- At least if there is a suspicion of meconium in the amniotic fluid (from clinical history and/or the gross exam), look for the following histopathologic signs of it:[5]
The pigment-laden macrophages are presumably meconium-laden "meconiophages", the pathologic diagnosis can be termed "meconium histocytosis"
Other relatively common findings
Calcifications, are normal in term placentas. Report if seen in a placenta younger than 36 weeks of gestational age.[6]
Chorangiosis, an abundance of blood vessels within the chorionic villi.
Increased syncytial knotting of chorionic villi, with two knots pointed out. Causes include both hypoxia and hyperoxia.[7]
Microscopy report
Generally, also include major gross findings, such as an area of placental abruption.
Example of normal report:
(Placenta, <<vaginal/Caesarean>> delivery:) Third trimester placenta with term villous histology. Placental weight (__ gm), at __th percentile for gestational age. Membranes without significant histopathologic changes((, negative for chorioamnionitis)). Trivascular umbilical cord, with no significant histopathologic changes((, negative for funisitis)).
|
Mild to moderate inflammation in the decidua alone can be ignored (as it is most commonly a physiological response and doesn't have a clinical significance for the fetus).
Example in a twin placenta:
Twin placenta, Caesarean section:
- Third trimester dichorionic, diamniotic twin placenta.
- Villous morphology histologically appropriate for gestational age.
- Placental weight approximately 25th percentile for gestational age.
- Two three-vessel umbilical cords.
- Negative for chorioamnionitis and funisitis.
|
Vulva
Gross processing
Generally as per skin.
Microscopic examination
Histopathology of high-grade squamous intraepithelial lesion (HSIL) of vulva (left in image) with full thickness dysplasia, compared to normal epithelium at right.
Mainly look for squamous vulvar intraepithelial lesions:
- Low-grade squamous intraepithelial lesion (LSIL):[8]
- Acanthosis, papillomatosis, and/or atypical koilocytosis in upper layers
- Usually mild atypia and mitoses, limited to the lower third of stratum spinosum and basale
- Binucleated epithelial cells
- High-grade squamous intraepithelial lesion (HSIL):[8]
- Enlarged atypical nuclei and mitoses involving middle and upper third of the epithelium.
- Also telling are atypical mitoses and/or extension in hair follicles and skin appendages.
Staging of vulvar cancer
Tumors of the vulva are staged as per the AJCC, 8th Ed:[9]
Primary tumor (T)
|
TNM
|
FIGO
|
Criteria
|
TX
|
|
Primary tumor cannot be assessed
|
T0
|
|
No evidence of a primary tumor
|
Tisa
|
|
Carcinoma in situ (preinvasive)
|
T1a
|
IA
|
Lesions ≤2 cm, confined to the vulva or perineum and with stromal invasion ≤1 mmb
|
T1b
|
IB
|
Lesions >2 cm or any size with stromal invasion >1 mm, confined to the vulva or perineum
|
T2
|
II
|
Tumor of any size with extension to adjacent perineal structures (distal third of the urethra, distal third of the vagina, anal involvement)
|
T3
|
IVA
|
Tumor of any size with extension to any of the following proximal two thirds of the urethra, proximal two thirds of the vagina, bladder mucosa, or rectal mucosa or fixed to pelvic bone
|
Regional lymph nodes (N)
|
TNM
|
FIGO
|
Criteria
|
NX
|
|
Regional lymph nodes cannot be assessed
|
N0
|
|
No regional lymph node metastasis
|
N1
|
|
1 or 2 regional (inguinofemoral) lymph nodes with the following features (see N1a, N1b)
|
N1a
|
IIIA
|
1 or 2 lymph node metastases, each < 5 mm
|
N1b
|
IIIA
|
1 regional lymph node metastasis ≥5 mm
|
N2
|
|
Regional (inguinofemoral) lymph nodes with the following features (see N2a, N2b, N2c)
|
N2a
|
IIIB
|
3 or more lymph node metastases, each < 5 mm
|
N2b
|
IIIB
|
2 or more regional lymph node metastases ≥5 mm
|
N2c
|
IIIC
|
Regional lymph node metastasis with extracapsular spread
|
N3
|
IVA
|
Fixed or ulcerated regional lymph node metastasis
|
Distant metastasis (M)
|
TNM
|
FIGO
|
Criteria
|
M0
|
|
No distant metastasis
|
M1
|
IVB
|
Distant metastasis (including to pelvic lymph nodes)
|
Cervical cytology
Clinical information
It is not necessary to look through more than readily available reports from previous cervical cytologies.
Magnification
While being fairly new to cervical cytology, preferably start looking at a high magnification such as 20x objective (with 10x eye piece). For suspicious findings, you may magnify up to maximum. On the other hand, once the pattern feels repetitive you can try switching to a slightly lower magnification such as 10x.
Adequacy
Adequacy should always be stated, either as "Satisfactory" or "Unsatisfactory". For estimating the number of cells, determine the following:
- The area of your field of view at high power (see the Evaluation chapter)
- The total size of the relevant area on the microscope slide. A ThinPrep is about 360 mm2.
- Look at 10 representative high power fields (HPFs) within that area, and calculate the average number of cells per high power field.
HPF example on a ThinPrep (about 360 mm 2). If 10 fields gives a total of 40 cells, it will be 4 cells per HPF. The area of this field is 0.23 mm 2. Therefore, total cellularity is estimated to be: 4 cells * 360mm 2 / 0.23mm 2 = 6260 cells.
You may count 10 fields either across the slide, or 5 fields in each direction.[10]
Total number of cells = Average number of cells per HPF * |
Total size of area HPF area
|
Conventional smear cellularity should be at least 8,000 cells. Liquid-based cytology cellularity should be at least 5,000 cells. Also a conventional smear is inadequate if >75% of cells are obscured by blood, exudate or air-drying artefact.[10]
Eventually you will be able to tell when most cases are adequate or inadequate without performing a detailed calculation.
Transformation zone presence
Squamous metaplasia also counts as endocervix. Typical features are annotated. Pap stain.
State whether the endocervical/transformation zone is present or absent. Count an endocervical component as present if there are 10 or more endocervical or squamous metaplastic cells.[11]
Endocervical cells can be viewed from the side as nuclear polarity (margination towards the same side as others) in a “picket-fence” configuration.
Sheets of endocervical cells have a honeycomb pattern.
In patients with previous hysterectomy, simply report glandular or squamous metaplastic cells as such, rather than stating the presence of a transformation zone, since they are likely vaginal in origin in such patients.[12]
Very common findings
For reporting, acute inflammation should be a background of ample dispersed neutrophils, and not only aggregates of neutrophils with cells or mucus.
Vaginal squamous cell with normal vaginal flora versus bacterial vaginosis on Pap stain. Normal vaginal flora (left) is predominantly rod-shaped Lactobacilli, whereas in bacterial vaginosis (right) there are clue cells, covered in bacteria. A significant amount of clue cells can be reported as "Shift in vaginal flora suggestive of bacterial vaginosis".
Candida, seen as pseudohyphae.
Main conditions to exclude or confirm
Squamous atypia, seen mainly as cells with increased nucleus/cytoplasm ratio, nuclear hyperchromasia and irregular nuclear outline.
Atypical squamous cells of undetermined significance (ASCUS), with only few slightly atypical cells
Low-grade squamous intraepithelial lesion (LSIL), here compared to an unremarkable intermediate squamous cell.
High-grade squamous intraepithelial lesion (HSIL), showing even more prominent features, and decreased cytoplasm, causing a high nuclear/cytoplasmic ratio.
Cytopathology of squamous cell carcinoma, keratinizing variant, with typical features.[13] Pap stain.
LSIL and changes consistent with human papillomavirus (HPV), which is the presence of koilocytes, which show perinuclear cavitation, binucleation, nuclear hyperchromasia, and nuclear enlargement.
Cytopathology of squamous cell carcinoma, nonkeratinizing variant, with typical features. [14] Pap stain. Necrotic debris (dirty background) is a feature that generally makes a HSIL case "suspicious for invasive squamous cell carcinoma". [15] In contrast to the more distinct keratinizing variant, these findings are overall less specific, and most can be seen in other cancers such as adenocarcinoma as well (which, however, tends to have fine chromatin) [16]
Distinguish HPV-changes from glycogenated squamous cells. Glycogen confers a yellowish color to the cytoplasm. It can look like the perinuclear cavitation of koilocytes, but has more rounded edges.
Clinical implication
If you are uncertain of the degree of dysplasia, it can be useful to look up how much difference it will likely make for the management of the patient. You may make an Internet search for the management of abnormal cervical screening in your region (such as The ASCCP tool for management in the US). A change from close follow-up to colposcopy is not that big of a deal, but if one of the alternatives will lead to a diagnostic excision, make sure that the case is looked upon by commensurate expertise.
Report
Example in a normal case:
Cervical/endocervical ThinPrep:
- Negative for intraepithelial lesion or malignancy (NILM).
|
Male reproductive system
Phimosis
Gross processing
Generally sample one or two representative sections in a cassette, in addition to sections of any grossly visible lesions.
See also: General notes on gross processing
Microscopic evaluation
Look for:
Optionally, note any sclerosis and/or fibrosis.
Reporting
- Description of objective findings, and any suspected underlying disease.
- Presence or absence of dysplasia.
Vas deferens
Gross processing in sterilization
In sterilization:[19]
- Measure length and diameter.
- Serially section
- Submit 2 cross sections measuring 5 mm in length.
Communicate to the histology lab to section the specimen as tubular structures, in order to get proper cross-sections.
Microscopic examination in sterilization
Confirm that there is a complete cross-section from each side. Example images of normal vas deferens:
Report
Example report:
Right and left vas deferens segments, excisions: Complete cross-sections of vasa deferentia without significant histopathologic changes.
|
Skin
Suspected malignant skin excisions
Author:
Mikael Häggström [note 3]
Suspected malignant skin excisions:
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Common targets
If directly suspected from the referral, see:
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[21][note 4]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
If the lesion was pigmented on gross examination, evaluate as a dark skin focality. If not:
Look for atypical cells, possibly by scrolling through the epidermis at intermediate magnification and then through the dermis at a lower magnification. If atypical cells are found, look for:
- Similarity to squamous cells: See below:
Squamous cell-like skin proliferations: Differential diagnosis
Main differential diagnoses and their characteristics:[22]
Actinic keratosis: Atypical keratinocytes that do not span the full thickness of the epidermis (or, in Bowenoid variant, are less disordered with less nuclear atypia and crowding).
Keratoacanthoma: Symmetrical and circumscribed proliferation of keratinocytes, with central horn plug, with epidermis that extends over the tumor. It can be regarded as a highly differentiated SCC.
Crush artifacts: Needles used to orient the skin sample may create crush artifacts (black arrow) mimicking cellular atypia with mainly hypereosinophilia and nuclear pleomorphism. Image also shows folding artifacts (white arrows).
Adnexal carcinomas: Squamous differentiation, but does not show connection with the epidermis and highlights adnexal features.
Adenosquamous carcinoma: Mixed glandular and squamous differentiation.
Verruca vulgaris: Marked hyperkeratosis and papillomatosis. Rete ridges slope inward at the borders of the lesion.
Verrucous squamous cell carcinoma[note 5]: Exophytic squamous proliferation with marked papillomatosis and low atypia and the presence of koilocyte-like changes. Found in head and neck locations, as well as in the genitalia and sole of the foot.
Inverted follicular keratosis:[note 6]: Sharply circumscribed endophytic verrucous proliferation with prominent squamous features.
Seborrheic keratosis: Acanthosis, absence of atypia, pseudo-horn cysts, in inflamed lesions, mitoses may be present.
Bowenoid papulosis: Atypical keratinocytes and mitoses. Histology similar to Bowen’s disease.
A melanoma may have relatively plentiful eosinophilic cytoplasm, and be seemingly continuous with the squamous epithelium (at left in image), thus resembling a squamous cell carcinoma. However, the nesting of cells at right in the image is more characteristic of a melanoma.
Metastasis: Personal medical history of the patient, nodular proliferation without connection to epidermis, immunohistochemical evaluation. Squamous-cell carcinoma metastasis from lungs to the skin is pictured.
General benign imitators of skin malignancy
Further workup of malignant findings
In case of skin cancer, determine whether the peripheral/radial and deep margins are clear, close or continuous.[23][note 7] A close margin has various definitions for different malignancies, but for basal-cell carcinoma and cutaneous squamous cell carcinoma it is defined as being closer than 1 mm from the edge (but yet non-continuous with it),[23][24] but 2-3 mm for melanoma.[25]
Previous biopsy
(At least if there is a known previous biopsy, look for changes that are consistent with a biopsy site, to confirm that it was taken from the excised area.) Such changes in the skin include:
- Granulation tissue in more fresh biopsies
- Dense collagen
- Fibrosis with vertical blood vessels
- Fibrosis that replaces solar elastosis
Reporting
Preferably see specific article on the condition at hand, if available.
- Optionally, the presence of a keratinized squamous epithelium.
- Any abnormalities, generally preceded by location in terms of epidermal, dermal or more specific layers thereof.
- If malignant:
- Degree of differentiation
- Radicality, mainly into either of the following: edit
- >___ mm (Definitions vary for the distance as per Further workup of malignant findings above): "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <___ mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Numbers are generally given at an exactness of 0.1 mm.[23]
- Continuous with margin: "Not radically excised at (location)."
- For skin shave biopsies, non-radicality may be reported as: "Extending to base and peripheral edges of biopsy" (as they may not be regarded as "margins" on a biopsy).
- Perineural or vascular invasion if present.
Notes
- ↑ In contrast, in embryology and fetal medicine, the proximal umbilical cord refers to the segment closest to the fetus:
- Wyburn GM (1939). "The formation of the umbilical cord and the umbilical region of the anterior abdominal wall.
". J Anat 73 (Pt 2): 289-310.9. PMID 17104757. PMC: 1252509. Archived from the original. . Harvey J. Kliman, M.D., Ph.D. (2006-10-29). The Umbilical Cord (from The Encyclopedia of Reproduction). Yale School of Medicine.
- ↑ Chorionic villi are promiscuous contaminants of other tissues, and may cause a false positive finding for a cassette containing products of conception.
- Carll T, Fuja C, Antic T, Lastra R, Pytel P (2022). "Tissue Contamination During Transportation of Formalin-Fixed, Paraffin-Embedded Blocks.
". Am J Clin Pathol 158 (1): 96-104. doi:10.1093/ajcp/aqac014. PMID 35195717. Archived from the original. .
- ↑ 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 example shows a superficial basal cell carcinoma.
- ↑ - Buschke–Löwenstein tumor is an alternative name for verrucous squamous cell carcinoma in the ano-genital region.
- Carcinoma cuniculatum is a characteristic form of verrucous squamous cell carcinoma on the sole.
- ↑ Inverted follicular keratosis is generally thought to be a rare variant of seborrheic keratosis, but this position is not universally accepted.
- Karadag, AyseSerap; Ozlu, Emin; Uzuncakmak, TugbaKevser; Akdeniz, Necmettin; Cobanoglu, Bengu; Oman, Berkant (2016). "Inverted follicular keratosis successfully treated with imiquimod
". Indian Dermatology Online Journal 7 (3): 177. doi:10.4103/2229-5178.182354. ISSN 2229-5178.
- ↑ "Peripheral" or "radial" margins are preferred rather than "lateral", since a "lateral" margin may be interpreted as opposite to the "medial margin".
Main page
References
- ↑ Pellerito, John; Polak, Joseph F. (2012). Introduction to Vascular Ultrasonography
(6th ed.). Elsevier Health Sciences. p. 559. ISBN 978-1-4557-3766-6.
- ↑ Nakamura, Yoshiaki; Hiramatsu, Ayako; Koyama, Takafumi; Oyama, Yu; Tanaka, Ayuko; Honma, Koichi (2014). "A Krukenberg Tumor from an Occult Intramucosal Gastric Carcinoma Identified during an Autopsy
". Case Reports in Oncological Medicine 2014: 1–5. doi:10.1155/2014/797429. ISSN 2090-6706.
- Creative Commons Attribution 3.0 Unported (CC BY 3.0) license
- ↑ Chen, Yukun; Zhang, Zhuomin; Wu, Chenyan; Davaasuren, Dolzodmaa; Goldstein, Jeffery A.; Gernand, Alison D.; Wang, James Z. (2020). "AI-PLAX: AI-based placental assessment and examination using photos
". Computerized Medical Imaging and Graphics 84: 101744. doi:10.1016/j.compmedimag.2020.101744. ISSN 08956111.
- Fig 5- available via license: Creative Commons Attribution 4.0 International.
- ↑ Kim, Chong Jai; Romero, Roberto; Chaemsaithong, Piya; Chaiyasit, Noppadol; Yoon, Bo Hyun; Kim, Yeon Mee (2015). "Acute chorioamnionitis and funisitis: definition, pathologic features, and clinical significance
". American Journal of Obstetrics and Gynecology 213 (4): S29–S52. doi:10.1016/j.ajog.2015.08.040. ISSN 00029378.
- ↑ Mandolin S. Ziadie. Placenta - Nonneoplastic placental conditions and abnormalities - Noninfectious - Meconium staining. Pathology Outlines. Topic Completed: 1 October 2011. Minor changes: 27 August 2020
- ↑ Chapter 3. Placental Calcification: Its Processes and Impact on Pregnancy, Kachewar, Sushil (2013). Calcification : processes, determinants and health impact
. New York: Nova Science Publishers, Inc. ISBN 978-1-62618-155-7. OCLC 840507829.
- ↑ Heazell AE, Moll SJ, Jones CJ, Baker PN, Crocker IP (2007). "Formation of syncytial knots is increased by hyperoxia, hypoxia and reactive oxygen species.
". Placenta 28 Suppl A: S33-40. doi:10.1016/j.placenta.2006.10.007. PMID 17140657. Archived from the original. .
- ↑ 8.0 8.1 Matthias Choschzick. Vulva, vagina & female urethra - Squamous carcinoma and precursor lesions - HPV associated SIL. PathologyOutlines. Topic Completed: 6 January 2021. Minor changes: 11 June 2021
- ↑ Amin, Mahul (2017). AJCC cancer staging manual
(8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414.
- For access, see the Secrets chapter of Patholines. - Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)). edit
- ↑ 10.0 10.1 . Criteria for adequacy of a cervical cytology sample. EuroCytology. Retrieved on 2022-08-29.
- ↑ Cibas, Edmund S.; Ducatman, Barbara S. (2021). Cytology : diagnostic principles and clinical correlates
. Philadelphia, PA. p. 9. ISBN 978-0-323-63637-7. OCLC 1138033641.
- ↑ Ramirez NC, Sastry LK, Pisharodi LR (2000). "Benign glandular and squamous metaplastic-like cells seen in vaginal Pap smears of post hysterectomy patients: incidence and patient profile.
". Eur J Gynaecol Oncol 21 (1): 43-8. PMID 10726617. Archived from the original. .
- ↑ - Image annotated by Mikael Häggström
- Reference for entries: Gulisa Turashvili, M.D., Ph.D.. Cervix - Squamous cell carcinoma and variants. Pathology Outlines. Last author update: 24 September 2020. Last staff update: 4 April 2022. - Source image from National Cancer Institute (Public Domain)
- ↑ - Image annotated by Mikael Häggström
- Reference for entries: Gulisa Turashvili, M.D., Ph.D.. Cervix - Squamous cell carcinoma and variants. Pathology Outlines. Last author update: 24 September 2020. Last staff update: 4 April 2022. - Source image by Ravi Mehrotra, Anurag Gupta, Mamta Singh and Rahela Ibrahim (Creative Commons Attribution 2.0 Generic license.)
- ↑ Alrajjal A, Pansare V, Choudhury MSR, Khan MYA, Shidham VB (2021). "Squamous intraepithelial lesions (SIL: LSIL, HSIL, ASCUS, ASC-H, LSIL-H) of Uterine Cervix and Bethesda System.
". Cytojournal 18: 16. doi:10.25259/Cytojournal_24_2021. PMID 34345247. PMC: 8326095. Archived from the original. .
- ↑ Authors: Caroline I.M. Underwood, M.D., Alexis Musick, B.S., Carolyn Glass, M.D., Ph.D.. Adenocarcinoma overview. Pathology Outlines. Last staff update: 19 July 2022
- ↑ Clemmensen, Ole J.; Krogh, John; Petri, Michael (1988). "The Histologic Spectrum of Prepuces from Patients with Phimosis
". The American Journal of Dermatopathology 10 (2): 104–108. doi:10.1097/00000372-198804000-00002. ISSN 0193-1091.
- ↑ Alcides Chaux, Antonio L. Cubilla. Penis and scrotum - Inflammatory lesions - Phimosis. PathologyOutlines. Topic Completed: 1 February 2010. Revised: 13 February 2019
- ↑ . Vas Deferens (Sterilization). Gross Pathology Manual - By The University of Chicago Department of Pathology. Retrieved on 2021-08-27.
- ↑ Vas deferens image available in Public Domain. See https://patholines.org/File:Vas_deferens.jpg
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". 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.
- ↑ Initially copied from: Paolino, Giovanni; Donati, Michele; Didona, Dario; Mercuri, Santo; Cantisani, Carmen (2017). "Histology of Non-Melanoma Skin Cancers: An Update
". Biomedicines 5 (4): 71. doi:10.3390/biomedicines5040071. ISSN 2227-9059.
"This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)."
- ↑ 23.0 23.1 23.2 David Slater, Paul Barrett. Standards and datasets for reporting cancers - Dataset for histopathological reporting of primary cutaneous basal cell carcinoma. The Royal College of Pathologists. February 2019
- ↑ 1 mm as cutoff for close margin: Brodie M Elliott, Benjamin R Douglass, Daniel McConnell, Blair Johnson, Christopher Harmston (2018-12-14). New Zealand Medical Journal.
- ↑ Page 406 in: Klaus J. Busam, Richard A Scolyer, Pedram Gerami (2018). Pathology of Melanocytic Tumors
. Elsevier Health Sciences. ISBN 9780323508681.
Image sources
Basal-cell carcinoma
Author:
Mikael Häggström [note 1]
Nodular basal-cell carcinoma.
Basal-cell carcinoma (BCC):
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[1][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
Broadly consists of determining the following:
- Whether it is basal-cell carcinoma or a differential diagnosis.
- Aggressiveness pattern
- Radicality
Optionally, further subtyping of basal-cell carcinoma can be made.
Characteristics
Nests of cells appearing similar to epidermal basal cells, and are usually well differentiated.[2]
Palisading is a typical feature.
Cleft formation is fairly specific, but may not be seen in smaller nests.
Basal-cell carcinomas may be pigmented as shown (but consider the possibility of melanoma in such cases).
In uncertain cases, immunohistochemistry using BerEP4 can be used, having a high sensitivity and specificity in detecting only BCC cells.[3]
Differential diagnoses
Main histological differential diagnoses of basal cell carcinoma:
- Hair follicles
Hair follicles: Peripheral sections may look like nests, but do not display atypia, and nuclei are smaller.
Also, hair follicles generally display more distinct features when looking at adjacent levels.
Hair follicle tissue may be superficial, resembling a superficial basal-cell carcinoma.
The edges of hair follicle cells may resemble palisades, but are less pronounced, and are generally more diffusely delineated compared to surroundings.
- Squamous-cell carcinoma
Squamous-cell carcinoma of the skin is generally distinguishable by for example relatively more cytoplasm, horn cyst formation and absence of palisading and cleft formations.
edit
Yet, a high prevalence means a relatively high incidence of borderline cases. In such cases, look particularly at the surface and attempt to classify as either of the following:
Basal-cell carcinoma with squamous cell metaplasia or metatypical (squamoid) basal-cell carcinoma. It is basal-cell carcinoma with subepidermal (but no intraepidermal) areas resembling squamous-cell carcinoma.
Basaloid squamous-cell carcinoma, in this case showing a biplastic pattern with basaloid elements associated with both conventional dysplastic squamous surface (arrow heads) and conventional squamous cell carcinoma (arrow).[4]
In unclear cases, the most useful immunohistochemistry marker appears to be MOC-31, which essentially always stains metatypical basal-cell carcinomas but not basaloid squamous-cell carcinomas.[5] UEA-1 appears to be the second most useful marker, staining almost all basaloid squamous-cell carcinomas but only a few metatypical basal-cell carcinomas.[5]
- Others[6]
Trichoblastoma: Absence of cleft, rudimentary hair germs, papillary mesenchymal bodies.
Adenoid cystic carcinoma: Lack of basaloid cells disposed in peripheral palisades; adenoid-cystic lesion without connection to the epidermis; absence of artefactual clefts
Trichoepithelioma:[note 3] Rims of collagen bundles, calcification, follicular/sebaceous/infundibular differentiation and cut artefacts. Cytokeratin (CK)20+, p75+, Pleckstrin homology-like domain family A member 1 + (PHLDA1+), common acute lymphoblastic leukemiaantigen + (CD10+) in tumor stroma, CK 6-, Ki-67- and Androgen Rceptor- (AR-)
Merkel cell carcinoma: Cells arranged in a diffuse, trabecular and/or nested pattern, involving also the subcutis. Mouse Anti-Cytokeratin (CAM) 5.2+, CK20+, S100-, human leukocyte common antigen- ( LCA-), thyroid transcription factor 1- (TTF1-)
Aggressiveness
Aggressiveness can be classified as low-level aggressive, moderately aggressive and highly aggressive, based mainly the cohesion of cancer cells, but also upon other histopathologic subtypes:
- Low-level aggressive patterns
Nodular. Also known as "classic basal-cell carcinoma". It accounts for 50% of all BCC.[6] It typically has relatively cohesive aggregates of basaloid cells with well-defined borders, showing palisading and one or more clefts.[6] Central necrosis with eosinophilic, granular features may be also present, as well as mucin. The heavy aggregates of mucin determine a cystic structure. Calcification may be also present, especially in long-standing lesions.[6] Mitotic activity is usually not so evident, but a high mitotic rate may be present in more aggressive lesions.[6]
Fibroepitheliomatous pattern: anastomosing basaloid epithelial strands enclosing round islands of fibrous stroma[8]
- Moderately aggressive pattern
- Highly aggressive patterns
Cicatricial or morphoeic pattern: Narrow strands and nests of basaloid cells, typically with sharp edges, surrounded by dense sclerotic stroma.[9]
Micronodular pattern: Small and closely spaced nests.
Radicality
Determine if there are basal-cell formations continuous with resection margins, or if they are closer or farther than 1 mm from the closest edge.[10] If closer, measure the distance.
If uncertain, immunohistochemistry with BerEP4 helps in distinguishing the BCC cells.
Comparison H&E stain (left) with BerEP4 immunohistochemistry staining (right) on a pathological section having BCC with squamous cell metaplasia. Only BCC cells are stained with BerEP4. [3]
- Further information: Evaluation of tumors
Reporting
- Aggressiveness pattern, at least if highly aggressive.
- Radicality, mainly into either of the following: edit
- >1 mm (as per Radicality above): "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <1 mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Numbers are generally given at an exactness of 0.1 mm.[10]
- Continuous with margin: "Not radically excised at (location)."
Optionally, subtype of basal-cell carcinoma
Example:
(Skin excision with stratified squamous keratinized epithelium, where the dermis contains) moderately aggressive basal-cell carcinoma, not radically excised at the right margin.[note 4]
|
See also: General notes on reporting
Notes
- ↑ 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 example shows a superficial basal cell carcinoma.
- ↑ Desmoplastic tricoepithelioma is particularly similar to basal-cell carcinoma.
- ↑ The direction was known from needle marking.
Main page
References
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". 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.
- ↑ Robert S Bader. Which histologic findings are characteristic of basal cell carcinoma (BCC)?. Medscape. Updated: Feb 21, 2019
- ↑ 3.0 3.1 Sunjaya, Anthony Paulo; Sunjaya, Angela Felicia; Tan, Sukmawati Tansil (2017). "The Use of BEREP4 Immunohistochemistry Staining for Detection of Basal Cell Carcinoma
". Journal of Skin Cancer 2017: 1–10. doi:10.1155/2017/2692604. ISSN 2090-2905.
- ↑ El-Mofty, SK. (2014). "Histopathologic risk factors in oral and oropharyngeal squamous cell carcinoma variants: An update with special reference to HPV-related carcinomas
". Medicina Oral Patología Oral y Cirugia Bucal: e377–e385. doi:10.4317/medoral.20184. ISSN 16986946.
License: CC BY 2.5
- ↑ 5.0 5.1 Webb, David V.; Mentrikoski, Mark J.; Verduin, Lindsey; Brill, Louis B.; Wick, Mark R. (2015). "Basal cell carcinoma vs basaloid squamous cell carcinoma of the skin: an immunohistochemical reappraisal
". Annals of Diagnostic Pathology 19 (2): 70–75. doi:10.1016/j.anndiagpath.2015.01.004. ISSN 10929134.
- ↑ 6.0 6.1 6.2 6.3 6.4 Paolino, Giovanni; Donati, Michele; Didona, Dario; Mercuri, Santo; Cantisani, Carmen (2017). "Histology of Non-Melanoma Skin Cancers: An Update
". Biomedicines 5 (4): 71. doi:10.3390/biomedicines5040071. ISSN 2227-9059.
- ↑ Inskip, Mike; Magee, Jill (2015). "Microcystic adnexal carcinoma of the cheek—a case report with dermatoscopy and dermatopathology
". Dermatology Practical & Conceptual 5 (1). doi:10.5826/dpc.0501a07. ISSN 21609381.
- ↑ Yonan, Yousif; Maly, Connor; DiCaudo, David; Mangold, Aaron; Pittelkow, Mark; Swanson, David (2019). "Dermoscopic Description of Fibroepithelioma of Pinkus with Negative Network
". Dermatology Practical & Conceptual: 246–247. doi:10.5826/dpc.0903a23. ISSN 2160-9381. Creative Commons Attribution License
- ↑ East, Ellen; Fullen, Douglas R.; Arps, David; Patel, Rajiv M.; Palanisamy, Nallasivam; Carskadon, Shannon; Harms, Paul W. (2016). "Morpheaform Basal Cell Carcinomas With Areas of Predominantly Single-Cell Pattern of Infiltration
". The American Journal of Dermatopathology 38 (10): 744–750. doi:10.1097/DAD.0000000000000541. ISSN 0193-1091.
- ↑ 10.0 10.1 David Slater, Paul Barrett. Standards and datasets for reporting cancers - Dataset for histopathological reporting of primary cutaneous basal cell carcinoma. The Royal College of Pathologists. February 2019
Image sources
Actinic keratosis
Authors:
Mikael Häggström; Authors of integrated Creative Commons article[1] [note 1]
Actinic keratosis may present as suspected malignant skin excisions.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Multiple lesions of actinic keratosis on the scalp.
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Lesions of actinic keratosis are typically ill-marginated, erythematous, scaling, and rough papules or patches. These will typically be found in areas displaying other signs of solar damage, such as atrophy, uneven pigmentation, and telangiectasias.[1]
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[2][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
- Evaluation mainly consists of:
Characteristics
Normal skin (left) and actinic keratosis (right) with the defining characteristic of atypical basal keratinocytes that does not involve the full thickness of the epidermis.
1(a). Actinic keratosis at low magnification, showing discontinuous parakeratosis (as the dysplastic process spares adnexal structures, including sebaceous glands. This specimen also demonstrates dense dermal elastosis). [1]
By definition, actinic keratosis is confined to foci within the epidermis.[1]
it also generally has:[1]
- Aggregates of atypical, pleomorphic keratinocytes which show nuclear atypia, dyskeratosis, and loss of polarity.
- Hyperkeratosis and parakeratosis, the latter overlying the abnormal cells in the epidermis. Due to the sparing of segments of the epithelium overlying adnexal structures, a characteristic pattern of alternating orthokeratosis and parakeratosis, referred to as the “flag-sign,” can often be seen (Figure 1(a)).
- Atypical keratinocytes will not span the full thickness of the epidermis (Figure 1(b)), although those in the basal cell layer will frequently extend into the granular and cornified layers. The exception to this criterion is the Bowenoid variant of actinic keratosis, which resembles cutaneous squamous-cell carcinoma in situ (Bowen's disease) but is less disordered with less nuclear atypia and crowding.
- A more basophilic basal layer than normal, which is generally thought to be a consequence of the close crowding of atypical keratinocytes (Figure 1(b)).
- Some cases will also show basal layer degeneration and the formation of Civatte bodies (Figure 1(c)), the result of a lichenoid infiltrate with irregular acanthosis. This can be distinguished from lichenoid dermatitis by the presence of keratinocyte atypia.
- Dermoepidermal junction irregularities, with small round buds at the basal cell layer that will protrude slightly into the upper papillary dermis (Figure 1(d)).
- There is almost always an associated solar elastosis in the dermis, and a lack thereof can often be sufficient to prompt reconsideration of the diagnosis.
1(b). Early actinic keratosis with keratinocyte dysplasia confined to the lower third of the epidermis.[1]
Civatte body (in a case in lichen planus).
1(d). A more established lesion of actinic keratosis demonstrating nearly full thickness keratinocyte dysplasia and prominent budding of the basal layer into the superficial dermis.[1]
Squamous cell-like skin proliferations: Differential diagnosis
Main differential diagnoses and their characteristics:[3]
Actinic keratosis: Atypical keratinocytes that do not span the full thickness of the epidermis (or, in Bowenoid variant, are less disordered with less nuclear atypia and crowding).
Keratoacanthoma: Symmetrical and circumscribed proliferation of keratinocytes, with central horn plug, with epidermis that extends over the tumor. It can be regarded as a highly differentiated SCC.
Crush artifacts: Needles used to orient the skin sample may create crush artifacts (black arrow) mimicking cellular atypia with mainly hypereosinophilia and nuclear pleomorphism. Image also shows folding artifacts (white arrows).
Adnexal carcinomas: Squamous differentiation, but does not show connection with the epidermis and highlights adnexal features.
Adenosquamous carcinoma: Mixed glandular and squamous differentiation.
Verruca vulgaris: Marked hyperkeratosis and papillomatosis. Rete ridges slope inward at the borders of the lesion.
Verrucous squamous cell carcinoma[note 3]: Exophytic squamous proliferation with marked papillomatosis and low atypia and the presence of koilocyte-like changes. Found in head and neck locations, as well as in the genitalia and sole of the foot.
Inverted follicular keratosis:[note 4]: Sharply circumscribed endophytic verrucous proliferation with prominent squamous features.
Seborrheic keratosis: Acanthosis, absence of atypia, pseudo-horn cysts, in inflamed lesions, mitoses may be present.
Bowenoid papulosis: Atypical keratinocytes and mitoses. Histology similar to Bowen’s disease.
A melanoma may have relatively plentiful eosinophilic cytoplasm, and be seemingly continuous with the squamous epithelium (at left in image), thus resembling a squamous cell carcinoma. However, the nesting of cells at right in the image is more characteristic of a melanoma.
Metastasis: Personal medical history of the patient, nodular proliferation without connection to epidermis, immunohistochemical evaluation. Squamous-cell carcinoma metastasis from lungs to the skin is pictured.
Clinical clues
- Biopsy from sun exposed area (including the face, neck, dorsal hands, and forearms, upper chest, back, and scalp).[1]
- Generally middle-aged or older individuals.[1]
Further workup
Once a diagnosis of actinic keratosis is established, optionally characterize the degree of atypia into either mild, moderate or severe.
Actinic keratosis with moderate atypia, spanning approximately half of stratum spinosum.
Histopathology report
- Objective findings
- A diagnosis of actinic keratosis
- Optionally: The degree of atypia.
- Even absence of evidence of malignancy.
Example for the case in "Further workup":
(Skin excision with squamous stratified epithelium with moderate) atypia in the basal epidermis (, with enlarged and dark cell nuclei as well as slightly disrupted cell arrangements.) No evidence of malignancy.
|
See also: General notes on reporting
Notes
- ↑ 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 example shows a superficial basal cell carcinoma.
- ↑ - Buschke–Löwenstein tumor is an alternative name for verrucous squamous cell carcinoma in the ano-genital region.
- Carcinoma cuniculatum is a characteristic form of verrucous squamous cell carcinoma on the sole.
- ↑ Inverted follicular keratosis is generally thought to be a rare variant of seborrheic keratosis, but this position is not universally accepted.
- Karadag, AyseSerap; Ozlu, Emin; Uzuncakmak, TugbaKevser; Akdeniz, Necmettin; Cobanoglu, Bengu; Oman, Berkant (2016). "Inverted follicular keratosis successfully treated with imiquimod
". Indian Dermatology Online Journal 7 (3): 177. doi:10.4103/2229-5178.182354. ISSN 2229-5178.
Main page
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Initially largely copied from: Yanofsky, Valerie R.; Mercer, Stephen E.; Phelps, Robert G. (2011). "Histopathological Variants of Cutaneous Squamous Cell Carcinoma: A Review
". Journal of Skin Cancer 2011: 1–13. doi:10.1155/2011/210813. ISSN 2090-2905.
-"This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". 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.
- ↑ Initially copied from: Paolino, Giovanni; Donati, Michele; Didona, Dario; Mercuri, Santo; Cantisani, Carmen (2017). "Histology of Non-Melanoma Skin Cancers: An Update
". Biomedicines 5 (4): 71. doi:10.3390/biomedicines5040071. ISSN 2227-9059.
"This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)."
Image sources
Squamous-cell carcinoma of the skin
Authors:
Mikael Häggström; Authors of integrated Creative Commons article[1] [note 1]
Squamous-cell carcinoma (SCC) of the skin may present as suspected malignant skin excisions.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Squamous cell carcinoma in situ.
SCC with scaling and ulceration.
If re-excision, see separate section at bottom.
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Squamous cell carcinoma in situ (essentially synonymous with Bowen’s disease) often presents as an erythematous, well-demarcated, scaly patch or plaque, with a fairly irregular border. They occasionally present as dark skin focalities, especially when found in the genital region and the nails.[1]
Invasive SCC typically has ill-marginated, erythematous, scaling, and rough papules or patches.[1]
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[2][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
Evaluation consists of:
- Determining whether it is a SCC rather than a differential diagnosis.
- Distinguishing a SCC in situ from an invasive SCC
- Radicality, and if radical, determine the least distance to a margin.
Characteristics
Squamous cell carcinoma in situ, showing prominent dyskeratosis and aberrant mitoses at all levels of the epidermis, along with marked parakeratosis. [1]
Main characteristics of squamous-cell carcinoma regardless of location.
- Malignant keratinocytes demonstrating intense mitotic activity, pleomorphism, and greatly enlarged nuclei. They will also show a loss of maturity and polarity, giving the epidermis a disordered or “windblown” appearance.
In situ
In SCC in situ (Bowen’s disease) the epidermis will show:
- Atypia spanning the full thickness of the epidermis, being the main finding.[1]
- Hyperkeratosis and parakeratosis.[1]
- Marked acanthosis with elongation and thickening of the rete ridges. These changes will overly keratinocytic cells which are often highly atypical and may in fact have a more unusual appearance than invasive SCC.
- Typical squamous-cell carcinoma cells are large with abundant eosinophilic cytoplasm and large, often vesicular, nuclei.[3]
- Two types of multinucleated cells may be seen:[1]
- Multinucleated giant cells
- Dyskeratotic cells engulfed in the cytoplasm of keratinocytes.
- Occasionally, cells of the upper epidermis will undergo vacuolization.[1]
There may be a mild to moderate lymphohistiocytic infiltrate detected in the upper dermis.[1]
Atypia spanning the full thickness of the epidermis is enough in this case for the diagnosis of SCC in situ. There is also a lymphohistiocytic infiltrate.
|
In contrast to actinic keratosis, the basal epidermal layer in SCC in situ is frequently spared, and will show little to no visible atypia. Additionally, SCC in situ will almost always involve both the interfollicular and adjacent follicular epithelium and adnexal structures.[1]
Overlap of squamous-cell and basal-cell carcinoma
Basal-cell carcinoma is generally distinguishable by for example relatively less cytoplasm, palisading, cleft formations and absence of horn cyst formation.
edit
Yet, a high prevalence means a relatively high incidence of borderline cases. In such cases, look particularly at the surface and attempt to classify as either of the following:
Basal-cell carcinoma with squamous cell metaplasia or metatypical (squamoid) basal-cell carcinoma. It is basal-cell carcinoma with subepidermal (but no intraepidermal) areas resembling squamous-cell carcinoma.
Basaloid squamous-cell carcinoma, in this case showing a biplastic pattern with basaloid elements associated with both conventional dysplastic squamous surface (arrow heads) and conventional squamous cell carcinoma (arrow).[4]
In unclear cases, the most useful immunohistochemistry marker appears to be MOC-31, which essentially always stains metatypical basal-cell carcinomas but not basaloid squamous-cell carcinomas.[5] UEA-1 appears to be the second most useful marker, staining almost all basaloid squamous-cell carcinomas but only a few metatypical basal-cell carcinomas.[5]
Clinical clues
- Biopsy from sun exposed area (including the face, neck, dorsal hands, and forearms, upper chest, back, and scalp).[1]
- Generally middle-aged or older individuals.[1]
In situ versus invasive
- In situ (Bowen's disease)
- Intact basement membrane.
High magnification, demonstrating an intact basement membrane.[1]
- Invasive SCC
Invasive SCC is defined by dermal infiltration.
Superficially invasive squamous cell carcinoma (SCCSI). These lesions often do not show the marked pleomorphism and atypical nuclei of SCC in situ, but demonstrate early keratinocyte invasion of the dermis.[1]
High magnification demonstrates the pleomorphism of the invading keratinocytes.[1]
Invasive nests with characteristic large celled centers. Ulceration (at left) is common in invasive SCC.
This infiltrate can be somewhat difficult to detect in the early stages of invasion: however, additional indicators such as full thickness epidermal atypia and the involvement of hair follicles can be used to facilitate the diagnosis. Later stages of invasion are characterized by the formation of nests of atypical tumor cells in the dermis, often with a corresponding inflammatory infiltrate.[1]
Radicality
Determine whether the distances between atypical cells are more or less than 1 mm from the deep and radial edges. If less than 1 mm, quantify the distance.[6]
Degree of differentiation
This is applicable to invasive SCC.
edit
Well-differentiated (and yet invasive) SCC, showing prominent keratinization and may form “pearllike” structures where dermal nests of keratinocytes attempt to mature in a layered fashion. Well-differentiated SCC has slightly enlarged, hyperchromatic nuclei with abundant amounts of cytoplasm. Intercellular bridges will frequently be visible.[1]
Moderately differentiated lesions of invasive SCC show much less organization and maturation with significantly less keratin formation.[1]
Poorly differentiated, where attempts at keratinization are often no longer evident. This is a clear-cell squamous cell carcinoma. The dysplastic cells here infiltrate in cords through the dermis. Poorly differentiated SCC has greatly enlarged, pleomorphic nuclei demonstrating a high degree of atypia and frequent mitoses.[1]
Poorly differentiated clear-cell squamous cell carcinoma. For this type of SCC, immunostains will likely be required to classify it unless other areas of the tumor show obvious squamous cell features such as seen here (keratinization in center).
Perineural or vascular invasion
In SCC, look for any perineural invasion,[note 3] and at least a quick glance for any vascular invasion.
Perineural invasion: the arrow indicates a large peripheral nerve that has been surrounded by tumor cells.[1]
Vascular invasion: the arrow indicates a small cluster of atypical squamous cells in a small vessel.[1]
Perineural invasion is defined as tumor in close proximity to nerve and involving at least 33% of its circumference or tumor cells within any of the three layers of the nerve sheath (epineurium, perineurium and endoneurium).[7] First look along the border of the tumor, followed by surrounding tissue, and if still not found, look through the rest of the tumor area as well.[1]
Staging
The AJCC, 8th Ed., does not include any staging system for skin SCC, except for tumors of the vulva.[8]
Optionally: Grading
Multiple variables can be combined to classify a SCC as low or high grade:
Low-Grade SCC[1] |
High-Grade SCC[1]
|
- Well to moderately differentiated: intercellular bridges and keratin pearls
- Tumor cells arranged in solid or sheet-like patterns
- Association with solar damage and precursor actinic keratosis
- Diameter less than 2 cm
- Depth less than 2 mm
|
- Poorly differentiated: clear-cell, sarcomatoid, or single cell features
- Presence of infiltrating individual tumor cells
- Arising de novo or in site of prior injury (ulcer, burn scar, or osteomyleitis)
- Perineural and/or perivascular invasion
- Diameter greater than 2 cm
- Depth greater than 2 mm
|
Further work-up
In vulvar squamous cell carcinoma, generally perform p16 immunohistochemistry, which is considered a surrogate marker for oncogenic HPV infection.[9]
Microscopy report
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Components of the report:
- Diagnosis of squamous-cell carcinoma
- Whether it is in situ or invasive. If invasive:
- Degree of differentiation.
- (High or low grade.)
- Even absence of perineural invasion[note 3]
- ((Even absence of or vascular invasion.))
- Radicality, mainly into either of the following: edit
- >1 mm (as per Radicality above): "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <1 mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]."[6] Numbers are generally given at an exactness of 0.1 mm.
- Continuous with margin: "Not radically excised at (location)."
- Staging is only applicable for the head and neck (lip, ear, face, scalp and neck - see staging at Medscape) and vulva (see staging at cancer.net).
((You may also add a synoptic report (see examples):))
Examples
Squamous cell carcinoma in situ:
((Skin excision with squamous epithelium with))(central parakeratosis. The epidermis is thickened and exhibits disturbed stratification. )All cell layers show atypical epithelial cells with polymorphic and partially hyperchromatic nuclei. The basement membrane is intact. Clear margins. ((There is elastosis and inflammatory cells in the dermis.))
|
Invasive squamous cell carcinoma:
(Skin, right breast, excision:) Invasive keratinizing squamous cell carcinoma, well differentiated, measuring 1.7 cm in greatest dimension. Surgical margins are negative for carcinoma. (Negative for lymphovascular and perineural invasion.) ((Solar elastosis.))
|
((Example synoptic report:))
- Procedure: Skin excision.
- Tumor site: Scalp
- Tumor laterality: Right
- Tumor focality: Unifocal
- Tumor size: 1.6 x 1.4 cm
- Tumor depth of invasion: 0.3 cm
- Histologic type: Squamous cell carcinoma
- Histologic grade: Moderately differentiated
- Specimen margins: Uninvolved by invasive tumor.
- Lymphovascular invasion: Not identified
- Perineural invasion: Not identified
- Regional lymph nodes: No lymph nodes submitted or found.
- Pathologic Stage Classification (pTNM, AJCC 8th Edition):
- Primary Tumor: pT1
- Regional Lymph Nodes: pNX: Regional lymph nodes cannot be assessed
- Additional pathologic findings: Actinic keratosis
Example microscopic description of invasive squamous cell carcinoma:
- Squamous epithelium, with central ulceration, surrounded by hyperkeratosis. In this area in the dermis there are infiltrative nests of epithelioid cells with nuclear pleomorphism and <sparse / moderate / abundant> keratin formation.
See also: General notes on reporting
Re-excisions
Gross processing
edit ((Submit the entire specimen, or)) depending on radicality of previous excision:
- Previously radical (including thin margins): Submit at least one central section across the surgical scar.[10]
- Previously non-radical:
- Visible lesion: Submit the entire scar.[10]
- Lesion not visible: At least one additional radicality slice towards the tips, up to the entire specimen.[11]
Notes
- ↑ 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 example shows a superficial basal cell carcinoma.
- ↑ 3.0 3.1 Presence or absence of perineural invasion in squamous-cell carcinoma affects whether adjuvant radiotherapy will be used.
Main page
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 Yanofsky, Valerie R.; Mercer, Stephen E.; Phelps, Robert G. (2011). "Histopathological Variants of Cutaneous Squamous Cell Carcinoma: A Review
". Journal of Skin Cancer 2011: 1–13. doi:10.1155/2011/210813. ISSN 2090-2905. .
-"This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". 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.
- ↑ Dr Nicholas Turnbull, A/Prof Patrick Emanual (2014-05-03). Squamous cell carcinoma pathology. DermNetz.
- ↑ El-Mofty, SK. (2014). "Histopathologic risk factors in oral and oropharyngeal squamous cell carcinoma variants: An update with special reference to HPV-related carcinomas
". Medicina Oral Patología Oral y Cirugia Bucal: e377–e385. doi:10.4317/medoral.20184. ISSN 16986946.
License: CC BY 2.5
- ↑ 5.0 5.1 Webb, David V.; Mentrikoski, Mark J.; Verduin, Lindsey; Brill, Louis B.; Wick, Mark R. (2015). "Basal cell carcinoma vs basaloid squamous cell carcinoma of the skin: an immunohistochemical reappraisal
". Annals of Diagnostic Pathology 19 (2): 70–75. doi:10.1016/j.anndiagpath.2015.01.004. ISSN 10929134.
- ↑ 6.0 6.1 1 mm as cutoff for close margin: Brodie M Elliott, Benjamin R Douglass, Daniel McConnell, Blair Johnson, Christopher Harmston (2018-12-14). New Zealand Medical Journal.
- ↑ Strowd, Roy (2021). Neuro-oncology for the clinical neurologist
. Philadelphia, PA: Elsevier. ISBN 978-0-323-69494-0. OCLC 1220993756.
- ↑ Amin, Mahul (2017). AJCC cancer staging manual
(8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414.
- For access, see the Secrets chapter of Patholines. - Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)). edit
- ↑ Anjelica Hodgson, M.D., Carlos Parra-Herran, M.D.. p16. Pathology Outlines. Last author update: 1 July 2017. Last staff update: 20 July 2022
- ↑ 10.0 10.1 Katarzyna Lundmark. Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ Pathology Department at NU Hospital Group, Sweden, 2019-2020.
Image sources
Melanoma in situ
Author:
Mikael Häggström [note 1]
Melanoma of the skin generally presents as a dark skin focality and/or a suspected malignant skin excision.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[1][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
Differential diagnoses
Distinguish mainly from dysplastic nevus and invasive melanoma of the skin:
Dysplastic nevus
Comparison of congenital pattern nevus, dysplastic nevus and suspected melanoma edit
Parameter |
Non-atypical congenital pattern |
Low-grade dysplastic nevus |
High-grade dysplastic nevus |
Suspected melanoma in situ
|
Mild dysplasia |
Moderate dysplasia |
Severe dysplasia
|
Macroscopic
|
Lateral circumscription[2]
|
Sharp |
Slightly diminished |
Moderate |
Poor
|
Symmetry[2]
|
Good |
Often broken |
Rare
|
Structural (Low mag.)
|
Delimitation[3]
|
|
Rarely diffuse |
Sometimes diffuse |
Often diffuse
|
Lentiginous proliferation[note 3][3]
|
|
Yes, along with rete pegs |
Yes, along with and focally between rete pegs |
Yes, along with and focally between rete pegs |
Yes partially continuous, multilayered
|
Bridging[3]
|
|
Rarely |
Often
|
Confluent nests[3]
|
|
Rarely |
Sometimes |
Often |
Often widespread
|
Pigment distribution[3]
|
|
Regular |
Irregular
|
Suprabasal presence (less than most superficial third of subcorneal epidermis)
|
Occasionally centrally[2] |
No[3] or rarely[2] |
Occasionally centrally[2] |
Yes, multifocal[3]
|
Pagetoid migration including superficial third of subcorneal epidermis[3]
|
|
No |
No |
Yes, in a maximum of 2 HPF centrally, but not peripherally |
Yes, multifocal and/or in periphery
|
Extended rete pegs
|
Ocassional[2] |
Yes, regular[3] |
Yes, varying[3] |
Yes, often irregular[3] |
Varying, flattened[3]
|
Concentric fibrosis
|
Regressive[2] |
Yes[3] |
Occasional[2]
|
Lamellar fibrosis
|
Rarely[3] |
Often[3] |
Often pronounced[3] |
Occasional[2]
|
Lymphocytic infiltrate[3]
|
|
Mild, perivascular |
Mild or moderate, perivascular |
Varying |
Varying
|
Suprapapillary plate involvement
|
No[2] |
Usually no[2] |
Often[2] |
Yes[2]
|
Cellular (high mag.)
|
Image
|
|
|
|
|
|
Junctional extension[2]
|
Unusual |
Usual |
Extensive
|
Nuclear size[2]
|
Age-related |
Small |
Medium |
Large |
Medium or large. Pleomorphic[4]
|
Nuclear pleomorphism[5]
|
|
Slight |
Prominent
|
Chromatin pattern
|
Uniform[2] |
Condensed[2] |
Partically expanded[2] |
Expanded, coarse in some cells[2] |
Expanded, hyperchromatic, coarse.[2] Usually granular.[5]
|
Nucleoli[2]
|
Age-related |
Small |
Medium |
Large |
Usually[5] large
|
Mitoses[2]
|
Few superficial |
Superficial and deep
|
Histological regression[5][note 4]
|
|
Usually |
Usually not
|
Percentage of atypical melanocytes[3]
|
|
<10% |
About 10 - 50% |
about 50-90% |
Usually> 90%
|
Intradermal melanocytic atypia[3]
|
|
No |
Rarely, in superficial part |
Can be detected in superficial part
|
Intradermal melanocyte maturation[3]
|
|
Yes |
Yes, can be partial |
Yes, can be partial |
Variable
|
In suspected but not certain nevus or melanoma in situ, generally perform immunohistochemistry with SOX10, whereby melanocyte proliferation and nuclear pleomorphism is easier to see.[note 5]
SOX10 immunohistochemistry of a junctional nevus, with atypical melanocytic proliferation, seen mainly in hair follicles.
SOX10 immunohistochemistry of lentigo maligna, showing an increased number of melanocytes along stratum basale, and nuclear pleumorphism.
- Further information: Evaluation of suspected malignancies
Invasive melanoma of the skin
Invasive melanoma of the skin has features melanoma in situ, but also has dermal involvement of atypical melanocytes with cytologic atypia and no maturation.[6]
Further workup
Upon a diagnosis of melanoma in situ, evaluate its margins. Optionally, attempt to determine the histopathologic type and amount of cytoplasmic pigmentation:
- Margins
If melanoma, determine if the distance to any margin is greater or lesser than 2-3 mm.
- 2 mm is used as a cutoff for sharply demarcated, small, superficially spreading or nevoid melanomas.[7]
- 3 mm is used for ill-defined lentigo maligna melanoma in situ.[7]
If lesser, quantify the distance.
If margins are difficult to determine, consider immunohistochemistry with SOX10 to better visualize melanoma nests.[note 5]
- Histopathologic type
Main types of melanoma in situ are:
Type |
Features |
Micrograph
|
Superficial spreading melanoma in situ
|
Melanoma cells with nest formation along the dermo-epidermal junction.
|
|
Lentigo maligna
|
Linear spread of atypical epidermal melanocytes along stratum basale.[8]
|
|
Acral lentiginous melanoma in situ
|
Continuous proliferation of atypical melanocytes at the dermoepidermal junction.[9]
|
|
Report
Most important entries:
- Melanoma area dimensions (width x width)[10]
- Radicality,[10] mainly into either of the following: edit
- >2 or 3 mm (as per Further workup above): "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <2 or 3 mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Numbers are generally given at an exactness of 0.1 mm.
- Continuous with margin: "Not radically excised at (location)."
See also: General notes on reporting
Notes
- ↑ 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 example shows a superficial basal cell carcinoma.
- ↑ Lentiginous proliferation is proliferation along the basal layer of the epidermis
- ↑ Histological regression is one or more areas within a tumor in which neoplastic cells have disappeared or decreased in number. In this case, this means complete or partial disappearance from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation.
- Ribero, Simone; Gualano, Maria Rosaria; Osella-Abate, Simona; Scaioli, Giacomo; Bert, Fabrizio; Sanlorenzo, Martina; Balagna, Elena; Fierro, Maria Teresa; et al. (2015). "Association of Histologic Regression in Primary Melanoma With Sentinel Lymph Node Status
". JAMA Dermatology 151 (12): 1301. doi:10.1001/jamadermatol.2015.2235. ISSN 2168-6068.
- ↑ 5.0 5.1 SOX10 stains cell nuclei of melanocytes.
- Miettinen, Markku; McCue, Peter A.; Sarlomo-Rikala, Maarit; Biernat, Wojciech; Czapiewski, Piotr; Kopczynski, Janusz; Thompson, Lester D.; Lasota, Jerzy; et al. (2015). "Sox10—A Marker for Not Only Schwannian and Melanocytic Neoplasms But Also Myoepithelial Cell Tumors of Soft Tissue
". The American Journal of Surgical Pathology 39 (6): 826–835. doi:10.1097/PAS.0000000000000398. ISSN 0147-5185.
Main page
References
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". 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.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 Arumi-Uria, Montserrat; McNutt, N Scott; Finnerty, Bridget (2003). "Grading of Atypia in Nevi: Correlation with Melanoma Risk
". Modern Pathology 16 (8): 764–771. doi:10.1097/01.MP.0000082394.91761.E5. ISSN 0893-3952.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 Katarzyna Lundmark, Britta Krynitz, Ismini Vassilaki, Lena Mölne, Annika Ternesten Bratel. Histopatologisk bedömning och gradering av dysplastiskt nevus samt gränsdragning mot melanom in situ/melanom (Histopathological assessment and grading of dysplastic nevus and distinction from melanoma in situ/melanoma). KVAST (Swedish Society of Pathology). Retrieved on 2019-09-18.
- ↑ Christopher S. Hale. Skin melanocytic tumor - Melanoma - Invasive melanoma. Topic Completed: 1 May 2013. Revised: 17 September 2019
- ↑ 5.0 5.1 5.2 5.3 Husain, Ehab A; Mein, Charles; Pozo, Lucia; Blanes, Alfredo; Diaz-Cano, Salvador J (2011). "Heterogeneous topographic profiles of kinetic and cell cycle regulator microsatellites in atypical (dysplastic) melanocytic nevi
". Modern Pathology 24 (4): 471–486. doi:10.1038/modpathol.2010.143. ISSN 0893-3952.
- ↑ Christopher S. Hale. Skin melanocytic tumor - Melanoma - Invasive melanoma. Pathology Outlines. Topic Completed: 1 May 2013. Revised: 17 September 2019
- ↑ 7.0 7.1 Measurements used to classify a melanoma as radical: Page 406 in: Klaus J. Busam, Richard A Scolyer, Pedram Gerami (2018). Pathology of Melanocytic Tumors
. Elsevier Health Sciences. ISBN 9780323508681.
- ↑ Error on call to Template:cite web: Parameters url and title must be specifiedHon A/Prof Amanda Oakley (2011). . DermNet NZ.
- ↑ Piliang, Melissa Peck (2009). "Acral Lentiginous Melanoma
". Surgical Pathology Clinics 2 (3): 535–541. doi:10.1016/j.path.2009.08.005. ISSN 18759181.
- ↑ 10.0 10.1 . An Example of a Melanoma Pathology Report. Melanoma Foundation. Retrieved on 2019-09-24.
Image sources
Invasive melanoma of the skin
Author:
Mikael Häggström [note 1]
Melanoma of the skin generally presents as a dark skin focality.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[1][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
Differential diagnoses
Dermal nevus
Comparison of dermal nevus and suspected invasive melanoma edit
Parameter |
Non-dysplastic dermal nevus |
Low-grade dysplastic dermal nevus |
High-grade dysplastic dermal nevus |
Suspected invasive melanoma
|
Mild dysplasia |
Moderate dysplasia |
Severe dysplasia
|
Macroscopic
|
Lateral circumscription[3]
|
Sharp |
Slightly diminished |
Moderate |
Poor
|
Symmetry[3]
|
Good |
Often broken |
Rare
|
Structural (Low mag.)
|
Micrograph
|
|
|
|
|
|
Delimitation[4]
|
|
Rarely diffuse |
Sometimes diffuse |
Often diffuse
|
Confluent nests[4]
|
|
Rarely |
Sometimes |
Often |
Often widespread
|
Pigment distribution[4]
|
Regular |
Irregular
|
Concentric fibrosis
|
Regressive (see below table)[3] |
Yes[4] |
Occasional[3]
|
Lamellar fibrosis
|
Rarely[4] |
Often[4] |
Often pronounced[4] |
Occasional[3]
|
Lymphocytic infiltrate[4]
|
|
Mild, perivascular |
Mild or moderate, perivascular |
Varying |
Varying
|
Cellular (high mag.)
|
Micrographs
|
|
|
|
|
|
Nuclear size[3]
|
|
Small |
Medium |
Large |
Medium or large. Pleomorphic[5]
|
Nuclear pleomorphism[6]
|
Slight superficial |
Slight |
Prominent
|
Chromatin pattern
|
Uniform[3] |
Condensed[3] |
Partically expanded[3] |
Expanded, coarse in some cells[3] |
Expanded, hyperchromatic, coarse.[3] Usually granular.[6]
|
Nucleoli[3]
|
|
Small |
Medium |
Large |
Usually[6] large
|
Mitoses[3]
|
Few superficial |
Superficial and deep
|
Histological regression[6] (see below table)
|
|
Usually |
Usually not
|
Percentage of atypical melanocytes[4]
|
|
<10% |
About 10 - 50% |
about 50-90% |
Usually> 90%
|
Histological regression is one or more areas within a tumor in which neoplastic cells have disappeared or decreased in number. In this case, it means complete or partial disappearance of neoplastic cells from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation.[7]
In suspected but not certain nevus or melanoma, generally perform immunohistochemistry with SOX10 (which stains cell nuclei of melanocytes), whereby melanocyte proliferation and nuclear pleomorphism is easier to see:[8]
SOX10 showing dermal nevus nests.
Further workup
In case a diagnosis of invasive melanoma of the skin can be made, the following are generally mandatory:
- Margins
- Depth
- Any ulceration
- Histopathologic type.[9]
- Presence of mitoses in the intradermal component.[9]
The following aspects are mandatory in some regions:
- Clark's level (not mandatory in the US)[note 3]
Margins
Determine if the distance to any margin is greater or lesser than 3 mm.[10] If a margin is closer, measure it at an exactness of 0.1 mm.
If margins are difficult to determine, consider immunohistochemistry with SOX10 (staining the nuclei of melanocytes), to better visualize melanoma nests.[11]
Depth and ulceration
For invasive melanoma, measure the depth and whether there is ulceration or not, so as to be able to classify the T stage (following table by AJCC, 8th edition):[12]
T Category
|
Thickness
|
Ulceration status
|
TX: primary tumor thickness cannot be assessed (e.g., diagnosis by curettage) |
Not applicable |
Not applicable
|
T0: no evidence of primary tumor (e.g., unknown primary or completely regressed melanoma) |
Not applicable |
Not applicable
|
Tis (melanoma in situ) |
Not applicable |
Not applicable
|
T1 |
≤1.0 mm |
Unknown or unspecified
|
T1a |
<0.8 mm |
Without ulceration
|
T1b |
<0.8 mm |
With ulceration
|
0.8–1.0 mm |
With or without ulceration
|
T2 |
>1.0–2.0 mm |
Unknown or unspecified
|
T2a |
>1.0–2.0 mm |
Without ulceration
|
T2b |
>1.0–2.0 mm |
With ulceration
|
T3 |
>2.0‐4.0 mm |
Unknown or unspecified
|
T3a |
>2.0–4.0 mm |
Without ulceration
|
T3b |
>2.0–4.0 mm |
With ulceration
|
T4 |
>4.0 mm |
Unknown or unspecified
|
T4a |
>4.0 mm |
Without ulceration
|
T4b |
>4.0 mm |
With ulceration
|
Histopathologic type
If needing to evaluate, the main types of invasive melanoma are:[13]
Type |
Features |
Relative incidence (in comparison to all melanomas)[13] |
Photograph |
Micrograph
|
Superficial spreading melanoma
|
Melanoma cells with nest formation along the dermo-epidermal junction.
|
70%
|
|
|
Nodular melanoma
|
Grows relatively more in depth than in width.
|
15% - 20%
|
|
|
Lentigo maligna melanoma
|
Atypical epidermal melanocytes as well as invasion into the dermis.[14]
|
5% - 10%
|
|
|
Acral lentiginous melanoma
|
Continuous proliferation of atypical melanocytes at the dermoepidermal junction.[15]
|
7% - 10%
|
|
|
Clark's level
If needing to evaluate,[note 3] Clark's levels are:[16]
- Level 1: Melanoma confined to the epidermis (melanoma in situ)
- Level 2: Invasion into the papillary dermis
- Level 3: Invasion to the junction of the papillary and reticular dermis
- Level 4: Invasion into the reticular dermis
- Level 5: Invasion into subcutaneous tissue.
Tumor‐infiltrating Lymphocytes (TILs)
Classify as either of the following:[12]
- Absent TIL infiltrate: no lymphocytes present or, if present, they do not interact with tumor cells.
- Non-brisk TIL infiltrate: focal areas of lymphocytic infiltration in the tumor.
- Brisk TIL infiltrate: TIL infiltration of the entire base of the tumor, or diffuse permeation of the tumor.
Lymph nodes
Cells that stain for melan-A but are nevus-like may be a capsular nevus
If negative on H&E stain, generally use immunohistochemistry for melanoma markers (such as a combination of melan-A and HMB-45) to exclude micrometastasis:
Melanoma micrometastases on melan-A stain.
Other parameters
Optionally, the following parameters can be given:[17]
- histological regression, with complete or partial disappearance from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation.[18]
- Further information: Evaluation of tumors
Report
Report when evaluated (as per mandatory vs. optional in Further workup above):
- Melanoma area dimensions (width x width)[19]
- Radicality,[19] mainly into either of the following: edit
- >3 mm : "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <3 mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Numbers are generally given at an exactness of 0.1 mm.
- Continuous with margin: "Not radically excised at (location)."
- Depth or most distant invasion of melanoma cells.[19]
- Ulceration or not, and maximum dimension if present
- Stage as per AJCC
- Clark's level
- Histopathologic type
- Mitotic rate, as amount per mm2
- Significant signs of regression
- Cytoplasmic pigmentation
- Melanoma cell shapes
US example
Skin, mid upper back, excision:
- Malignant melanoma, nodular type, Clark level IV, Breslow thickness 10mm. Surgical margins are negative for melanoma.
See synoptic report.
SYNOPTIC REPORT:
Specimen
Procedure: Excision
Specimen Laterality: Midline
Tumor
Tumor Site: Skin of trunk
Histologic Type: Nodular melanoma
Maximum Tumor (Breslow) Thickness (Millimeters): 10 mm
Macroscopic Satellite Nodule(s): Not identified
Ulceration: Present
Extent of Ulceration (Millimeters): 12 mm
Anatomic (Clark) Level: IV (Melanoma invades reticular dermis)
Mitotic Rate: 18 mitoses / mm2
Microsatellite(s): Not identified
Lymphovascular Invasion: Not identified
Neurotropism: Not identified
Tumor-Infiltrating Lymphocytes: Present, nonbrisk
Tumor Regression: Not identified
Margins
Peripheral Margins: Negative for invasive melanoma
Distance of Invasive Melanoma from Closest Peripheral Margin (Millimeters): 5 mm
Location: 3 o'clock and 9 o'clock
Status of melanoma in situ at peripheral margins: Negative for melanoma in situ
Distance of melanoma in situ from closest peripheral margin (millimeters): Cannot be determined - Ulcerated surface and no in-situ noted in the remaining surface
Location: Lateral
Deep Margin: Negative for invasive melanoma
Distance of Invasive Melanoma from Deep Margin (Millimeters): 2 mm
Status of Melanoma in situ at Deep Margin: Negative for melanoma in situ
Distance of Melanoma in situ from Deep Margin (Millimeters): Cannot be determined (negative for melanoma in situ)
Lymph Nodes
Regional Lymph Nodes: No lymph nodes submitted or found
Pathologic Stage Classification (pTNM, AJCC 8th Edition)
Primary Tumor (pT): pT4b
Regional Lymph Nodes (pN): pNX
|
European example
Sun-damaged skin with central diffusely delimited proliferation of melanocytic cells having polymorphic cell nuclei, distinct nucleoli and uneven light brown pigmentation. An area of pagetoid migration is seen. There is ulceration of a smaller area. The radial margin is over 3.0 mm and the deep margin is 2.0 mm.
- Free margin: Yes
- Margin in mm: 2.0 mm
- Tumor depth: 1.2 mm
- Ulceration: Yes
- Stage: T2b
- Clark's level: IV
- Histopathologic type: Superficial spreading melanoma
- Presence of mitoses: Yes
- Significant signs of regression: No
|
See also: General notes on reporting
Notes
- ↑ 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 example shows a superficial basal cell carcinoma.
- ↑ 3.0 3.1 Clark's level is not included in United States AJCC guidelines, but is mandatory for melanomas in Sweden.
-. Breslow Depth and Clark Level. Melanoma Research Alliance. Retrieved on 2020-02-13. - . Bilaga 6. Kvalitetsbilaga för patologi (KVAST-bilaga). Regionala Cancercentrum i Samverkan, guidelines by Swedish Society of Pathology. Retrieved on 2020-02-13.
Main page
References
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". 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.
- ↑ . Melanoma in situ (stage 0). Cancer Research UK. Last reviewed: 27 Jun 2019
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 Arumi-Uria, Montserrat; McNutt, N Scott; Finnerty, Bridget (2003). "Grading of Atypia in Nevi: Correlation with Melanoma Risk
". Modern Pathology 16 (8): 764–771. doi:10.1097/01.MP.0000082394.91761.E5. ISSN 0893-3952.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Katarzyna Lundmark, Britta Krynitz, Ismini Vassilaki, Lena Mölne, Annika Ternesten Bratel. Histopatologisk bedömning och gradering av dysplastiskt nevus samt gränsdragning mot melanom in situ/melanom (Histopathological assessment and grading of dysplastic nevus and distinction from melanoma in situ/melanoma). KVAST (Swedish Society of Pathology). Retrieved on 2019-09-18.
- ↑ Christopher S. Hale. Skin melanocytic tumor - Melanoma - Invasive melanoma. Topic Completed: 1 May 2013. Revised: 17 September 2019
- ↑ 6.0 6.1 6.2 6.3 Husain, Ehab A; Mein, Charles; Pozo, Lucia; Blanes, Alfredo; Diaz-Cano, Salvador J (2011). "Heterogeneous topographic profiles of kinetic and cell cycle regulator microsatellites in atypical (dysplastic) melanocytic nevi
". Modern Pathology 24 (4): 471–486. doi:10.1038/modpathol.2010.143. ISSN 0893-3952.
- ↑ Ribero, Simone; Gualano, Maria Rosaria; Osella-Abate, Simona; Scaioli, Giacomo; Bert, Fabrizio; Sanlorenzo, Martina; Balagna, Elena; Fierro, Maria Teresa; et al. (2015). "Association of Histologic Regression in Primary Melanoma With Sentinel Lymph Node Status
". JAMA Dermatology 151 (12): 1301. doi:10.1001/jamadermatol.2015.2235. ISSN 2168-6068.
- ↑ Miettinen, Markku; McCue, Peter A.; Sarlomo-Rikala, Maarit; Biernat, Wojciech; Czapiewski, Piotr; Kopczynski, Janusz; Thompson, Lester D.; Lasota, Jerzy; et al. (2015). "Sox10—A Marker for Not Only Schwannian and Melanocytic Neoplasms But Also Myoepithelial Cell Tumors of Soft Tissue
". The American Journal of Surgical Pathology 39 (6): 826–835. doi:10.1097/PAS.0000000000000398. ISSN 0147-5185.
- ↑ 9.0 9.1 - USA: . [https://documents.cap.org/protocols/Skin.Melanoma_4.3.0.2.REL_CAPCP.pdf Protocol for the Examination of Excision Specimens From
Patients With Melanoma of the Skin]. COllege of American Pathologists. Version: 4.3.0.2. Protocol Posting Date: November 2021
-Sweden: . Bilaga 6. Kvalitetsbilaga för patologi (KVAST-bilaga). Regionala Cancercentrum i Samverkan, guidelines by Swedish Society of Pathology. Retrieved on 2020-02-13.
- ↑ Definition of "thin margin": Wolf, Y.; Balicer, R.D.; Amir, A.; Feinmesser, M.; Hauben, D.J. (2001). "The vertical dimension in the surgical treatment of cutaneous malignant melanoma – how deep is deep?
". European Journal of Plastic Surgery 24 (2): 74–77. doi:10.1007/s002380100225. ISSN 0930-343X.
- ↑ Miettinen, Markku; McCue, Peter A.; Sarlomo-Rikala, Maarit; Biernat, Wojciech; Czapiewski, Piotr; Kopczynski, Janusz; Thompson, Lester D.; Lasota, Jerzy; et al. (2015). "Sox10—A Marker for Not Only Schwannian and Melanocytic Neoplasms But Also Myoepithelial Cell Tumors of Soft Tissue
". The American Journal of Surgical Pathology 39 (6): 826–835. doi:10.1097/PAS.0000000000000398. ISSN 0147-5185.
- ↑ 12.0 12.1 Amin, Mahul (2017). AJCC cancer staging manual
(8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414.
- For access, see the Secrets chapter of Patholines. - Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)). edit
- ↑ 13.0 13.1 [https://books.google.se/books?id=wGclDwAAQBAJ&pg=PA805 Page 805 in: Ferri, Fred (2019). Ferri's clinical advisor 2019 : 5 books in 1
. Philadelphia, PA: Elsevier. ISBN 978-0-323-52957-0. OCLC 1040695302.
- ↑ Michael Xiong; Ahmad Charifa; Chih Shan J. Chen.. Cancer, Lentigo Maligna Melanoma. StatPearls, National Center for Biotechnology Information. Last Update: May 18, 2019.
- ↑ Piliang, Melissa Peck (2009). "Acral Lentiginous Melanoma
". Surgical Pathology Clinics 2 (3): 535–541. doi:10.1016/j.path.2009.08.005. ISSN 18759181.
- ↑ . NCI Dictionary of Cancer Terms. National Cancer Institute. Retrieved on 2020-02-13.
- ↑ Rees, Jonathan; Viros, Amaya; Fridlyand, Jane; Bauer, Juergen; Lasithiotakis, Konstantin; Garbe, Claus; Pinkel, Daniel; Bastian, Boris C (2008). "Improving Melanoma Classification by Integrating Genetic and Morphologic Features
". PLoS Medicine 5 (6): e120. doi:10.1371/journal.pmed.0050120. ISSN 1549-1676.
- ↑ Ribero, Simone; Gualano, Maria Rosaria; Osella-Abate, Simona; Scaioli, Giacomo; Bert, Fabrizio; Sanlorenzo, Martina; Balagna, Elena; Fierro, Maria Teresa; et al. (2015). "Association of Histologic Regression in Primary Melanoma With Sentinel Lymph Node Status
". JAMA Dermatology 151 (12): 1301. doi:10.1001/jamadermatol.2015.2235. ISSN 2168-6068.
- ↑ 19.0 19.1 19.2 . An Example of a Melanoma Pathology Report. Melanoma Foundation. Retrieved on 2019-09-24.
Image sources
Dermatitis
Author:
Mikael Häggström [note 1]
Scope: This article deals with skin conditions where inflammation is the main finding, excluding suspected malignant skin excisions (where inflammation is often a concurrent finding).
Sampling
- For punch biopsies, a size of 4 mm is preferred for most inflammatory dermatoses.[1]
- Panniculitis or cutaneous lymphoproliferative disorders: 6 mm punch biopsy or skin excision.[1]
A superficial or shave biopsy is regarded as insufficient.[1]
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross pathology processing of skin lesions with benign appearance, by lesion size:[4]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Staining
3 H&E sections and one section with periodic acid Schiff (PAS)[note 2][1]
- If suspected bacterial and fungal microorganisms, consider Gram stain and Gomori methenamine silver stain.[1]
Microscopic evaluation
One approach is to classify into mainly either of the following, primarily based on depth of involvement:[1]
- Epidermis, papillary dermis, and superficial vascular plexus:
- Vesiculobullous lesions
- Pustular dermatosis
- Non vesicullobullous, non-pustular
- With epidermal changes
- Without epidermal changes. These characteristically have a superficial perivascular inflammatory infiltrate, and can be classified by type of cell infiltrate:[1]
- Lymphocytic (most common)
- Lymphoeosinophilic
- Lymphoplasmacytic
- Mast cell
- Lymphohistiocytic
- Neutrophilic
Continue in corresponding section:
Non vesicullobullous, non-pustular lesions with epidermal changes
Spongiotic dermatitis
It is characterized by epithelial intercellular edema.[1]
|
Characteristics |
Micrograph |
Photograph
|
Acute |
Subacute |
Chronic
|
Generally/Not otherwise specified[note 3]
|
Typical findings:[1]
- Variable degree of epidermal spongiosis and vesicle formation, filled with proteinaceous fluid containing lymphocytes and histiocytes.
- Usually superficial dermal edema with perivascular lymphocytic infiltrate, with exocytosis.
- No acanthosis or parakeratosis.
|
Typical findings:[1]
- Mild to moderate spongiosis and exocytosis of inflammatory cells
- Irregular acanthosis and parakeratosis.
- Superficial dermal perivascular lymphohistiocytic infiltrate
- Swelling of endothelial cells
- Papillary dermal edema are present
|
Typical findings:[1]
- The spongiosis is mild to absent
- Pronounced irregular acanthosis, hyperkeratosis, and parakeratosis
- Minimal dermal inflammation and exocytosis of inflammatory cells are present.
- Possibly fibrosis of papillary dermis
PAS stain is essential to exclude fungal infection.[1]
|
Subacute
|
|
Allergic/contact dermatitis or atopic dermatitis
|
As above. Eosinophils may be present in the dermis and epidermis (eosinophilic spongiosis).[1]
|
|
|
Allergic dermatitis
|
Atopic dermatitis
|
Seborrheic dermatitis
|
Typical findings:[5]
- Focal, usually mild, spongiosis with overlying scale crust, with a few neutrophils
- The crust is often centered on a follicle
- The papillary dermis is generally mildly edematous
- Dilated blood vessels in the superficial vascular plexus
- Mild superficial perivascular infiltrate of lymphocytes, histiocytes and occasional neutrophils. There is some exocytosis of inflammatory cells but not as prominent as in nummular dermatitis
|
Typical findings:[5]
- Psoriasiform hyperplasia, initially slight, with mild spongiosis
- Usually numerous yeast-like organisms in the surface keratin
- Same changes as seen in acute stage.
|
Typical findings:[5]
- More pronounced psoriasiform hyperplasia
- Only minimal spongiosis
- Presence of scaling crusts in a folliculocentric distribution, distinguishes from psoriasis.
|
|
|
In addition to above, an unspecific spongiotic dermatitis can be consistent with nummular dermatitis, dyshidrotic dermatitis, Id reaction, dermatophytosis, miliaria, Gianotti-Crosti syndrome and pityriasis rosea.[1][note 3]
Interface dermatitis
These are sorted into either:[1]
- Interface dermatitis with vacuolar change
- Interface dermatitis with lichenoid inflammation
Interface dermatitis with vacuolar change
Causes of vacuolar interface dermatitis edit
Main conditions[6] |
Characteristics |
Micrograph |
Photograph
|
Generally/Not otherwise specified
|
Typical findings, called "vacuolar interface dermatitis":[6]
- Mild inflammatory cell infiltrate along the dermoepidermal junction (black arrow in image)
- Vacuolization within the basal keratinocytes (white arrow in image)
- Often necrotic, predominantly basal, individual keratinocytes, manifesting as colloid or Civatte bodies
|
|
|
Acute graft-versus-host-disease
|
- Vacuolar alteration of various severity, from focal or diffuse vacuolation of the basal keratinocytes (grade I), to separation at the dermoepidermal junction (grade III)
- Involvement of the hair follicle[6]
- Rarely eosinophils[6]
|
|
|
Allergic drug reaction
|
- Rarely involvement of hair follicles.[6]
- Frequently eosinophils[6]
|
|
|
Lichen sclerosus
|
Hyperkeratosis, atrophic epidermis, sclerosis of dermis and dermal lymphocytes.[7]
|
|
Erythema multiforme
|
|
|
|
|
Lupus erythematosis
|
Typical findings in systemic lupus erythematosus:[8]
- Fibrinoid necrosis at the dermoepidermal junction
- Liquefactive degeneration and atrophy of the epidermis
- Mucin deposition in the reticular dermis
- Edema, small hemorrhages
- Mild and mainly lymphocytic infiltrate in the upper dermis
- Fibrinoid material in the dermis around capillary blood vessels, on collagen and in the interstitium
- In non-bullous cases, perivascular and interstitial neutrophils are sometimes present in the upper dermis, with damage to blood vessels
|
|
|
An interface dermatitis with vacuolar alteration, not otherwise specified, may be caused by viral exanthems, phototoxic dermatitis, acute radiation dermatitis, erythema dyschromicum perstans, lupus erythematosus and dermatomyositis.[1]
Further information: Vacuolar interface dermatitis
Interface dermatitis with lichenoid inflammation
Main conditions[1] |
Characteristics |
Micrograph |
Photograph
|
Generally/Not otherwise specified
|
Typical findings:[1]
- In the papillary dermis: a confluent, band-like, dense inflammation of mainly small lymphocytes and a few histiocytes, along or hugging the dermoepidermal junction.
- Often vacuolar degeneration of basal keratinocytes and apoptotic bodies (colloid or Civatte bodies).
|
|
|
Lichen planus
|
Irregular epidermal hyperplasia with a jagged “sawtooth” appearance, compact hyperkeratosis or orthokeratosis, foci of wedge-shaped hypergranulosis, basilar vacuolar degeneration, slight spongiosis in the spinous layer, and squamatization. The dermal papillae between the elongated rete ridges are frequently dome shaped. Necrotic keratinocytes can be observed in the basal layer of the epidermis and at the dermal-epidermal junction. Eosinophilic remnants of anucleate apoptotic basal cells may also be found in the dermis and are referred to as “colloid or civatte bodies”. Whickham striae are usually seen in the areas of hypergranulosis. Vacuolar degeneration at the basal layer may be noted leading to focal subepidermal clefts (Max Joseph spaces). Squamatization occurs as a result of maturation and flattening of cells in the basal layer. It happens in areas of marked hypergranulosis with prominence of the sawtooth pattern of rete ridges. Wedge-shaped hypergranulosis can occur in the eccrine ducts (acrosyringia) or hair follicles (acrotrichia). In the hypertrophic subtype, the associated hyperkeratosis, parakeratosis, hypergranulosis, papillomatosis, acanthosis, and hyperplasia markedly increased with thicker collagen bundles forming in the dermis. Moreover, the rete ridges are more elongated and rounded as opposed to the typical sawtooth pattern. In atrophic LP, loss of the rete ridges and dermal fibrosis is prominent. In vesiculobullous LP, the disease progression is quicker. Hence, some of the distinctive features such as hyperkeratosis, hypergranulosis, or dense lymphocytic dermal-epidermal infiltrate may not be present. LP lesion may resolve with residual hyperpigmentation caused by a persistent increase in the number of melanophages in the papillary dermis.[9]
|
|
|
Lichenoid drug reaction
|
Can virtually be indistinguishable from cutaneous LP both clinically and histopathologically.
- Typically, lesions have a photodistribution in the absence of oral mucosal involvement.[9]
- Characteristically parakeratosis, a dermal eosinophilic infiltrate, and a perivascular lymphocytic infiltrate affecting the reticular dermis.
- Epidermal changes are less common in lichenoid drug eruptions when compared to classic lichen planus. However, a higher concentration of necrotic keratinocyte and eosinophils in the infiltrate can be helpful in distinguishing lichenoid drug reaction from cutaneous lichen planus. A lengthy interval between the commencement of drug therapy and the onset of lesions does not exclude a diagnosis of lichenoid drug reaction. Resolution of the lesions often occurs within weeks to months after discontinuation of the offending drug.[9]
|
|
|
Lichen nitidus
|
- Localized granulomatous lymphohistiocytic infiltrate in an expanded dermal papilla.
- Thinning of overlying epidermis and downward extension of the rete ridges at the lateral margin of the infiltrate, resulting in a typical "claw clutching a ball" appearance.[10]
|
|
|
Lichen amyloidosus
|
Presence of amyloid, possibly with direct immunofluorescence and Congo red staining.[11]
|
|
Interface dermatitis with lichenoid inflammation, not otherwise specified, can be caused by lichen planus-like keratosis, lichenoid actinic keratosis, lichenoid lupus erythematosus, lichenoid GVHD (chronic GVHD), pigmented purpuric dermatosis, pityriasis rosea, and pityriasis lichenoides chronica.[1] Unusual conditions that can be associated with a lichenoid inflammatory cell infiltrate are HIV dermatitis, syphilis, mycosis fungoides, urticaria pigmentosa, and post-inflammatory hyperpigmentation.[1] In cases of post-inflammatory hyperpigmentation, it is important to exclude potentially harmful mimics such as a regressed melanocytic lesion or lichenoid pigmented actinic keratosis.[1]
Psoriaform dermatitis
Examining multiple deeper levels is recommended if initial cuts do not correlate well with the clinical history.[1]
Psoriaform dermatitis typically displays:[1]
- Regular epidermal hyperplasia, elongation of the rete ridges, hyperkeratosis, and parakeratosis.
- Usually:A superficial perivascular inflammatory infiltrate
- Often: Thinning of epidermal cells overlying the tips of dermal papillae (suprapapillary plates), and dilated, tortuous blood vessels within these papillae
Further histopathologic diagnosis is performed by the following parameters:
Psoriasiform dermatitis[1]
Condition |
Hyperkeratosis |
Parakeratosis |
Acanthosis |
Suprapapillary plate |
Spinous cell layer changes |
Other distinctive feature |
Micrograph
|
Psoriasis
|
Present |
Diffuse |
Regular |
Thin |
Increased mitoses; minimal spongiosis Clubbed rete pegs[12] [13]
|
- Microabscesses
- Thin or absent granular cell layer
|
|
Psoriasiform drug reaction
|
Present |
Focal |
Regular and irregular |
Normal or thick |
Spongiosis; eosinophilic infiltrate |
Basal cell layer with inflammatory cells; Civatte bodies
|
Chronic allergic/contact and atopic dermatitis
|
Present |
Focal; crust may be present |
Irregular |
Normal or thick |
Spongiosis; eosinophilic infiltrate |
|
Fungal infection
|
Compact |
Focal; crust may be present |
Irregular |
Normal or thick |
Occasional neutrophiles; |
|
Lichen simplex chronicus
|
Present |
Focal; thick crust |
Regular or irregular |
Thin or thick |
±minimal inflammatory infiltrate |
Thickened granular cell layer
|
Scabies
|
Present |
Focal or diffuse |
Irregular |
Normal or thick |
Inflammatory infiltrate; eosinophilic spongiosis |
|
Seborrheic dermatitis and HIV dermatitis
|
Present |
Focal |
Irregular |
Normal or thick |
Spongiosis; lymphocytic and neutrophilic infiltrate |
|
Pityriasis rubra pilaris
|
Compact |
Shoulder parakeratosis[note 4]; alternating orthokeratosis and parakeratosis |
Regular or irregular |
Normal or thick |
Spongiosis; lymphocytic infiltrate; rare acantholysis |
|
Pityriasis rosea
|
Present |
Focal |
Irregular |
Normal or thick |
Small foci of spongiosis; lymphocytic infiltrate |
Occasional necrotic keratinocytes of basal layer
|
Syphilis
|
Present |
Focal |
Regular or irregular |
Normal or thick |
Lymphocytes and neutrophils |
Basal layer interface change
|
Pityriasis lichenoides chronica
|
Present |
Caps of parakeratosis |
Irregular |
Normal |
Mild spongiosis, lymphocytic infiltrate; necrotic keratinocytes |
Necrotic keratinocytes of basal layer
|
Mycosis fungoides
|
Present |
Focal |
Regular or irregular |
Normal |
Minimal or no spongiosis; ±Pautrier microabscess |
Atypical lymphoid cells lining the dermo–epidermal junction
|
|
Non vesicullobullous, non-pustular lesions without epidermal changes
Lymphocytic infiltrate
Main conditions[1] |
Characteristics |
Micrograph |
Photograph
|
Urticaria, lymphocyte predominant
|
Perivascular location. Mast cells are relatively sparse, potentially demonstrated with special stains, preferably tryptase stain. Extravasated erythrocytes are present in about 50% of the cases. No vasculitis.[14]
|
Dermal edema [solid arrows in (A,B)] and a sparse superficial predominantly perivascular and interstitial infiltrate of lymphocytes and eosinophils without signs of vasculitis (dashed arrow).[15]
|
|
Fungal skin infection
|
Often visible fungus. Other signs depend on fungus species.[16]
|
|
|
Pigmented purpuric dermatosis
|
- Perivascular infiltrate, but may involve the dermis, further away from blood vessels.[17]
- Sometimes tendency for lichenoid infiltrate[note 5][17]
- Mild vascular damage, mainly endothelial swelling and focal karyorrhectic debris.[17]
- Red blood cell extravasation.[17]
- The epidermis may be normal or may exhibit spongiosis, focal parakeratosis, exocytosis and/or vacuolar change.[17]
|
|
|
Erythema annulare centrifugum
|
- Mild spongiosis, parakeratosis and microvesiculation.
- "Coat-sleeve anomaly": tight lymphohistiocytic infiltrate surrounding superficial vessels
Deep lesions: Sharply demarcated perivascular mononuclear cell infiltrate in middle to deep dermis[18]
|
|
|
Not otherwise specified[note 3]
|
A lesion with superficial lymphocytic infiltrate without additional histopathologic characteristics can be due to for example drug reactions and insect bites.[1][note 3]
|
Lymphoeosinophilic infiltrate
Main conditions[1] |
Characteristics |
Micrograph |
Photograph
|
Urticaria, lymphocyte predominant
|
Perivascular location. Mast cells are relatively sparse, potentially demonstrated with special stains, preferably tryptase stain. Extravasated erythrocytes are present in about 50% of the cases. No vasculitis.[14]
|
Dermal edema (solid arrows) and a sparse superficial predominantly perivascular and interstitial infiltrate of lymphocytes and eosinophils (dashed arrow)
|
|
Prevesicular stage of bullous pemphigoid
|
Image at right shows influx of inflammatory cells including eosinophils and neutrophils in the dermis (solid arrow) and blister cavity (dashed arrows), and deposition of fibrin (asterisks).[19] However, the diagnosis of bullous pemphigoid consist of at least 2 positive results out of 3 criteria:[20]
- Pruritus and/or predominant cutaneous blisters
- Linear IgG and/or C3c deposits (in an n- serrated pattern) by direct immunofluorescence microscopy (DIF)
- Positive epidermal side staining by indirect immunofluorescence microscopy on human salt-split skin (IIF SSS) on a serum sample.
|
|
|
Not otherwise specified[note 3]
|
A lesion with superficial lymphoeosinophilic infiltrate without additional histopathologic characteristics can be due to for example drug reactions and insect bites.[1][note 3]
|
|
|
Lymphoplasmacytic infiltrate
Mastocytosis
Main conditions[1] |
Characteristics |
Micrograph |
Photograph
|
Urticaria pigmentosa
|
Mastocytosis with a clinical picture of darkish spots.
|
|
|
Not otherwise specified[note 3]
|
Includes the rare disease of primary mastocytosis.[1][note 3]
|
|
|
Lymphohistiocytic infiltrate
These include bacterial infections including leprosy, and the sample should therefore be stained with Ziel-Neelsen, acid fast stains, Gomori methenamine silver, PAS, and Fite stains.[1] If negative, an unspecific lymphohistocytic dermatosis may be caused by drug reactions and viral infections.[1][note 3]
Granulomatous inflammation
Further information: Granulomatous skin inflammation
Granulomatous inflammation is defined by the presence of mononuclear leukocytes, specifically histiocytes, appearing as epithelioid cells with round to oval nuclei, often with irregular contours and abundant granular eosinophilic cytoplasm with indistinct cell borders. They may also coalesce to form multinucleated giant cells.[25]
Foreign body: Suture granuloma, with multinucleated giant cells surrounding (grey) suture material.
Neutrophilic infiltrate
No visible pathology
In a referral with a rash or other suspicion of dermatitis, but no visible pathology is seen, generally do a fungal stain, as fungal infections may have no visible pathology on H&E stain.
Notes
- ↑ 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.
- ↑ PAS is for evaluation of the epidermal basement membrane, blood vessels, and the presence of fungal organisms
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 In "not otherwise specified" cases, a description of the findings attained so far is generally enough as a diagnosis, but may mention when it can be consistent with a diagnosis that is clinically suspected according to the referral. A more comprehensive approach is to include a comment such as the following:
"Differential diagnosis for this condition include: ____, ____ and ____. Clinical correlation is recommended.
- ↑ Parakeratotic mounds at the edge of follicular ostia.
- ↑ Pigmented purpuric dermatitis of Gougerot and Blum particularly have a tendency for lichenoid infiltrate.
Main page
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 Alsaad, K O (2005). "My approach to superficial inflammatory dermatoses
". Journal of Clinical Pathology 58 (12): 1233–1241. doi:10.1136/jcp.2005.027151. ISSN 0021-9746.
- ↑ Page 678 in: Chhabra, Seema; Minz, RanjanaWalker; Saikia, Biman (2012). "Immunofluorescence in dermatology
". Indian Journal of Dermatology, Venereology, and Leprology 78 (6): 677. doi:10.4103/0378-6323.102355. ISSN 0378-6323. Archived from the original. .
- ↑ Katarzyna Lundmark, Krynitz, Ismini Vassilaki, Lena Mölne, Annika Ternesten Bratel. Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - Instructions for sampling, cutting and incision. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-09.
- ↑
". 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.
- ↑ 5.0 5.1 5.2 Mowafak Hamodat. Skin inflammatory (nontumor) > Spongiotic, psoriasiform and pustular reaction patterns > Seborrheic dermatitis. PathologyOutlines.com. Topic Completed: 1 August 2011. Revised: 26 March 2019
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Unless else specified in boxes, reference is: Alsaad, K O (2005). "My approach to superficial inflammatory dermatoses
". Journal of Clinical Pathology 58 (12): 1233–1241. doi:10.1136/jcp.2005.027151. ISSN 0021-9746.
- ↑ Lisa K Pappas-Taffer. Lichen Sclerosus. Medscape. Updated: May 17, 2018
- ↑ Mowafak Hamodat. Skin inflammatory (nontumor) > Lichenoid and interface reaction patterns > Lupus: systemic lupus erythematosus (SLE). PathologyOutlines. Topic Completed: 1 August 2011. Revised: 26 March 2019
- ↑ 9.0 9.1 9.2 Gorouhi, Farzam; Davari, Parastoo; Fazel, Nasim (2014). "Cutaneous and Mucosal Lichen Planus: A Comprehensive Review of Clinical Subtypes, Risk Factors, Diagnosis, and Prognosis
". The Scientific World Journal 2014: 1–22. doi:10.1155/2014/742826. ISSN 2356-6140.
- Attribution 3.0 Unported (CC BY 3.0)
- ↑ "Generalized lichen nitidus
". Pediatr Dermatol 22 (2): 158–60. 2005. doi:10.1111/j.1525-1470.2005.22215.x. PMID 15804308.
- ↑ Shenoi, SD; Balachandran, C; Mehta, VandanaRai; Salim, T (2005). "Lichen amyloidosus: A study of clinical, histopathologic and immunofluorescence findings in 30 cases
". Indian Journal of Dermatology, Venereology and Leprology 71 (3): 166. doi:10.4103/0378-6323.16230. ISSN 0378-6323.
- ↑ "Cytokines and cytokine profiles in human autoimmune diseases and animal models of autoimmunity
". Mediators of Inflammation 2009: 1–20. 2009. doi:10.1155/2009/979258. PMID 19884985.
- ↑ "Diagnosis and classification of psoriasis
". Autoimmunity Reviews 13 (4–5): 490–5. January 2014. doi:10.1016/j.autrev.2014.01.008. PMID 24434359.
- ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 Barzilai, Aviv; Sagi, Lior; Baum, Sharon; Trau, Henri; Schvimer, Michael; Barshack, Iris; Solomon, Michal (2017). "The Histopathology of Urticaria Revisited—Clinical Pathological Study
". The American Journal of Dermatopathology 39 (10): 753–759. doi:10.1097/DAD.0000000000000786. ISSN 0193-1091.
- ↑ Giang, Jenny; Seelen, Marc A. J.; van Doorn, Martijn B. A.; Rissmann, Robert; Prens, Errol P.; Damman, Jeffrey (2018). "Complement Activation in Inflammatory Skin Diseases
". Frontiers in Immunology 9. doi:10.3389/fimmu.2018.00639. ISSN 1664-3224.
- ↑ Guarner, J.; Brandt, M. E. (2011). "Histopathologic Diagnosis of Fungal Infections in the 21st Century
". Clinical Microbiology Reviews 24 (2): 247–280. doi:10.1128/CMR.00053-10. ISSN 0893-8512.
- ↑ 17.0 17.1 17.2 17.3 17.4 Stephen Lyle. Pigmented purpuric dermatoses. Dermpedia.org. Retrieved on 2019-11-05.
- ↑ 18.0 18.1 . Histology of erythema annulare centrifugum. DermNet NZ. Retrieved on 2019-11-05.
- ↑ Giang, Jenny; Seelen, Marc A. J.; van Doorn, Martijn B. A.; Rissmann, Robert; Prens, Errol P.; Damman, Jeffrey (2018). "Complement Activation in Inflammatory Skin Diseases
". Frontiers in Immunology 9. doi:10.3389/fimmu.2018.00639. ISSN 1664-3224.
- ↑ "Assessment of diagnostic strategy for early recognition of bullous and nonbullous variants of pemphigoid.
". JAMA Dermatol 155 (2): 158–165. December 2018. doi:10.1001/jamadermatol.2018.4390. PMID 30624575.
- ↑ Celiker, Hande; Toker, Ebru; Ergun, Tulin; Cinel, Leyla (2017). "An unusual presentation of ocular rosacea
". Arquivos Brasileiros de Oftalmologia 80 (6). doi:10.5935/0004-2749.20170097. ISSN 0004-2749.
- ↑ Assoc Prof Patrick Emanuel (2013). Syphilis pathology. Dermnet NZ.
- ↑ 23.0 23.1 Wilson, Thomas C.; Legler, Allison; Madison, Kathi C.; Fairley, Janet A.; Swick, Brian L. (2012). "Erythema Migrans
". The American Journal of Dermatopathology 34 (8): 834–837. doi:10.1097/DAD.0b013e31825879be. ISSN 0193-1091.
- ↑ Soyer, H. Peter; Jakob, Lena; Metzler, Gisela; Chen, Ko-Ming; Garbe, Claus (2011). "Non-AIDS Associated Kaposi's Sarcoma: Clinical Features and Treatment Outcome
". PLoS ONE 6 (4): e18397. doi:10.1371/journal.pone.0018397. ISSN 1932-6203.
- ↑ Shah, Kabeer K.; Pritt, Bobbi S.; Alexander, Mariam P. (2017). "Histopathologic review of granulomatous inflammation
". Journal of Clinical Tuberculosis and Other Mycobacterial Diseases 7: 1–12. doi:10.1016/j.jctube.2017.02.001. ISSN 24055794.
- ↑ 26.0 26.1 26.2 Antiga, Emiliano; Caproni, Marzia (2015). "The diagnosis and treatment of dermatitis herpetiformis
". Clinical, Cosmetic and Investigational Dermatology: 257. doi:10.2147/CCID.S69127. ISSN 1178-7015.
- ↑ Huma A. Mirza; Amani Gharbi; William Gossman.. Dermatitis Herpetiformis. StatPearls at National Center for Biotechnology Information. Last Update: July 11, 2019.
- ↑ Saleem, Maryam; Iftikhar, Hassaan (2019). "Linear IgA Disease: A Rare Complication of Vancomycin
". Cureus. doi:10.7759/cureus.4848. ISSN 2168-8184.
- ↑ Casarin Costa, Jose Ricardo; Virgens, Anangelica Rodrigues; de Oliveira Mestre, Luisa; Dias, Natasha Favoretto; Samorano, Luciana Paula; Valente, Neusa Yuriko Sakai; Festa Neto, Cyro (2017). "Sweet Syndrome: Clinical Features, Histopathology, and Associations of 83 Cases
". Journal of Cutaneous Medicine and Surgery 21 (3): 211–216. doi:10.1177/1203475417690719. ISSN 1203-4754.
- ↑ Giang, Jenny; Seelen, Marc A. J.; van Doorn, Martijn B. A.; Rissmann, Robert; Prens, Errol P.; Damman, Jeffrey (2018). "Complement Activation in Inflammatory Skin Diseases
". Frontiers in Immunology 9. doi:10.3389/fimmu.2018.00639. ISSN 1664-3224.
- "Figures - available via license: CC BY 4.0"
Image sources
Benign non-inflammatory skin conditions
Author:
Mikael Häggström [note 1]
These are aberrations that do not display signs of suspected malignant excisions or dermatitis. These may present as skin cysts.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross pathology processing of skin lesions with benign appearance, by lesion size:[1]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
The primary objective is to determine the location, and then the most likely cell type of the aberration:
Epidermis
Ulceration: On the outer ear, consider chondrodermatitis nodularis chronica helicis (pictured): With the ulceration surrounded by acanthosis and parakeratosis.
Dermis
Elastosis is the buildup of elastin in tissues (actinic or "solar" elastosis pictured).
Sebaceous hyperplasia: Increased volume of multiple, mature sebaceous lobules attached central dilated ducts in the upper dermis.[2]
Edematous granulation tissue, low magnification
Edematous granulation tissue, high magnification, with connective tissue, inflammatory cells and blood vessels.
Keloid: Wide bands of collagen with large, brightly eosinophilic, glassy fibers, parallel to fibroblasts and myofibroblasts.
Hypertrophic scar: Replacement of the papillary and reticular dermis by scar tissue with prominent vertically oriented blood vessels.[3]
Fatty tissue
Notes
- ↑ 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.
Main page
References
- ↑
". 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.
- ↑ Sato, Toshitsugu; Tanaka, Masaru (2014). "Linear sebaceous hyperplasia on the chest
". Dermatology Practical & Conceptual. doi:10.5826/dpc.0401a16. ISSN 21609381.
- ↑ Rabello, FB; Souza, CD; Farina Jr, JA (2014). "Update on hypertrophic scar treatment
". Clinics 69 (8): 565–573. doi:10.6061/clinics/2014(08)11. ISSN 18075932.
Image sources
Keloid
Author:
Mikael Häggström [note 1]
Gross processing
Gross pathology processing of skin lesions with benign appearance, by lesion size:[1]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
A keloid is characterized by wide bands of collagen with large, brightly eosinophilic, glassy fibers, parallel to fibroblasts and myofibroblasts.
- Keloid versus hypertrophic scar - Typical findings
|
Keloid |
Hypertrophic scar
|
|
|
|
Flattening of the overlying epidermis
|
No |
Yes
|
Scarring of the papillary dermis
|
No |
Yes
|
Collagen
|
Thick hyalinized bundles |
Whorl-like or nodular arrangements
|
Vertically oriented blood vessels
|
Yes |
No
|
Prominent disarray of fibrous fascicles/nodules
|
Yes |
No
|
Tongue-like advancing edge underneath normal-appearing epidermis and papillary dermis
|
Yes |
No
|
Horizontal cellular fibrous band in the upper reticular dermis
|
Yes |
No
|
Prominent fascia-like fibrous band
|
Yes |
No
|
Reporting
Example report:
Skin, left earlobe, excision: - Keloid
|
Notes
- ↑ 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.
Main page
References
- ↑
". 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.
Image sources
Hypertrophic scar
Author:
Mikael Häggström [note 1]
Gross processing
Gross pathology processing of skin lesions with benign appearance, by lesion size:[1]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
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.
Further information: Gross processing of skin excisions
Microscopic evaluation
A hypertrophic scar is characterized by replacement of the papillary and reticular dermis by scar tissue with prominent vertically oriented blood vessels. [2]
- Keloid versus hypertrophic scar - Typical findings
|
Keloid |
Hypertrophic scar
|
|
|
|
Flattening of the overlying epidermis
|
No |
Yes
|
Scarring of the papillary dermis
|
No |
Yes
|
Collagen
|
Thick hyalinized bundles |
Whorl-like or nodular arrangements
|
Vertically oriented blood vessels
|
Yes |
No
|
Prominent disarray of fibrous fascicles/nodules
|
Yes |
No
|
Tongue-like advancing edge underneath normal-appearing epidermis and papillary dermis
|
Yes |
No
|
Horizontal cellular fibrous band in the upper reticular dermis
|
Yes |
No
|
Prominent fascia-like fibrous band
|
Yes |
No
|
Notes
- ↑ 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.
Main page
References
- ↑
". 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.
- ↑ Rabello, FB; Souza, CD; Farina Jr, JA (2014). "Update on hypertrophic scar treatment
". Clinics 69 (8): 565–573. doi:10.6061/clinics/2014(08)11. ISSN 18075932.
Image sources
|