Template:Skin - entire topic
Contents
- 1 Microscopic evaluation
- 2 Reporting
- 3 Suspected malignant skin excisions
- 4 Basal-cell carcinoma
- 5 Actinic keratosis
- 6 Squamous-cell carcinoma of the skin
- 6.1 Fixation
- 6.2 Gross processing
- 6.3 Microscopic evaluation
- 6.4 Re-excisions
- 6.5 Notes
- 6.6 Main page
- 6.7 References
- 6.8 Image sources
- 7 Melanoma in situ
- 8 Invasive melanoma of the skin
- 9 Dermatitis
- 10 Benign non-inflammatory skin conditions
- 11 Keloid
- 12 Hypertrophic scar
Microscopic evaluation
If the referral does not point to any particular request (see "Most common requests" above), the following algorithm may be applied:
- Is it a suspected malignant skin excision? If not:
- If primarily inflammatory, evaluate as dermatitis. If none of these, evaluate as:
- Benign non-inflammatory skin conditions, including skin cysts
In intraoperative consultations by frozen section, it is generally sufficient to report clear margins if present, and specification of the type of tumor can be deferred to permanent sections.
Reporting
Preferably see specific articles from algorithm in section above.
- 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/Least distance to a margin
- Perineural or vascular invasion if present
Suspected malignant skin excisions
Author:
Mikael Häggström [note 1]
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:
- Melanoma
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
See separate article in case of dark skin focalities
Tissue selection
<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 epidermal basal cells, evaluate as suspected basal-cell carcinoma
- Similarity to squamous cells: See below:
Squamous cell-like skin proliferations: Differential diagnosis
Main differential diagnoses and their characteristics:[2]
Invasive squamous-cell carcinoma of the skin: Atypical and pleomorphic keratinocytes, involving the dermis and the sub-cutis with a potential metastatic spread.
Squamous-cell carcinoma in situ (Bowen’s disease): Atypical keratinocytes at every layer of epidermis.
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).
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.
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.
General benign imitators of skin malignancy
Granulomatous skin inflammation often contains giant cells that may appear atypical.
Further workup of malignant findings
In case of skin cancer, determine whether the peripheral/radial and deep margins are clear, close or continuous.[3][note 5] 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),[3][4] but 2-3 mm for melanoma.[5]
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:
- >___ 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.[3]
- 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
- ↑ 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: . 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
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, depending on size. - Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- For slices towards the pointy ends to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each pointy end. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ 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: . 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/)." - ↑ 3.0 3.1 3.2 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]
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
<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]
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
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.
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:
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
Microcystic adnexal carcinoma: Bland keratinocytes, keratin cysts, ductal differentiation. BerEp4- (in 60% of cases)[7], CEA+, EMA+
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]
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.
- Further information: Evaluation of tumors
Reporting
- Aggressiveness pattern, at least if highly aggressive.
- Radicality, mainly into either of the following:
- >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:
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, depending on size. - Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- For slices towards the pointy ends to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each pointy end. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ 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: . 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: . 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: . 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: . 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: . 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: . 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: . 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
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
<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:
- Establishing a diagnosis of actinic keratosis rather than differential diagnoses:
- Excluding any presence of cutaneous squamous cell carcinoma in the lesion.
Characteristics
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]
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]
Invasive squamous-cell carcinoma of the skin: Atypical and pleomorphic keratinocytes, involving the dermis and the sub-cutis with a potential metastatic spread.
Squamous-cell carcinoma in situ (Bowen’s disease): Atypical keratinocytes at every layer of epidermis.
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).
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.
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.
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.
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: . 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: . 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:
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, depending on size. - Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- For slices towards the pointy ends to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each pointy end. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ 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: . 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
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
<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
- 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.
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:
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]
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.
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]
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] |
---|---|
|
|
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:
- >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
((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:
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: . 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:
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, depending on size. - Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- For slices towards the pointy ends to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each pointy end. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ 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: . 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: . 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)). - ↑ 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
<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
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]
- 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:
- >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: . 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: . ISSN 0147-5185.
Main page
References
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, depending on size. - Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- For slices towards the pointy ends to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each pointy end. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ 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: . 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: . 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: . 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
<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
Melanoma in situ, where melanoma cells are limited to the epidermis.[2]
Dermal nevus
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]
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
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:
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):
- >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:
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.
|
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:
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, depending on size. - Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- For slices towards the pointy ends to determine radicality, which can be parallel to the slices through the lesions (shown), or as longitudinal slices that go through each pointy end. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ . 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: . 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: . 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: . 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: . 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: . 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: . 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)). - ↑ 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: . 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: . 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: . 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.
- Suspected immunologic disease:[2] Fixation for immunofluorescence, with for example Michel's solution.[3] For details, see immunofluorescense of skin tissues
See also: General notes on fixation
Gross processing
<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
- No visible pathology
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]
|
Typical findings:[1]
|
Typical findings:[1]
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]
|
Typical findings:[5]
|
Typical findings:[5]
|
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
Main conditions[6] | Characteristics | Micrograph | Photograph | |
---|---|---|---|---|
Generally/Not otherwise specified | Typical findings, called "vacuolar interface dermatitis":[6]
|
|||
Acute graft-versus-host-disease | ||||
Allergic drug reaction | ||||
Lichen sclerosus | Hyperkeratosis, atrophic epidermis, sclerosis of dermis and dermal lymphocytes.[7] | |||
Erythema multiforme | ||||
Lupus erythematosis | Typical findings in systemic lupus erythematosus:[8]
|
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]
|
||
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.
|
||
Lichen nitidus |
|
||
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:
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] |
|
|
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 |
|
||
Erythema annulare centrifugum |
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]
|
||
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
Main conditions[1] | Characteristics | Micrograph | Photograph |
---|---|---|---|
Rosacea | Typically enlarged, dilated capillaries and venules located in the upper dermis, angulated telangiectasias, perivascular and perifollicular lymphocytic infiltration, and superficial dermal edema.[21] | ||
Secondary syphilis | Various, but often one or a combination of:[22]
|
||
Erythema migrans | Typically a superficial and deep perivascular lymphocytic infiltrate.[23] Plasma cells are typically located at the periphery of the lesion, whereas eosinophils are in the center.[23] | ||
Kaposi’s sarcoma in patch stage | The patch stage typically shows irregular proliferation of jagged vascular channels in the dermis below an integral epidermis. The so-called promontory sign is sometimes found in patch stage lesions and denotes vascular spaces surrounding pre-existing blood (see image).[24]
vessels |
||
Not otherwise specified[note 3] | A lesion with superficial lymphoplasmacytic infiltrate without additional histopathologic characteristics can be due to for example trauma, ulceration, scar and early cutaneous connective tissue diseases.[1][note 3] |
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]
Neutrophilic infiltrate
Main conditions[1] | Characteristics | Micrograph | Photograph |
---|---|---|---|
Urticaria, neutrophil predominant | |||
Dermatitis herpetiformis |
|
||
Early linear IgA bullous dermatosis | Subepidermal blister formation.[28] | ||
Early febrile neutrophilic dermatosis (Sweet's syndrome) | Neutrophilic and lymphohistiocytic infiltrate and edema.[29] | ||
Connective tissue disorders |
|
||
Cutaneous small-vessel vasculitis |
|
||
Acute inflammation (not otherwise specified) |
|
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: . 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: . 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.
- ↑
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, as well as including sections from each edge in case of diffuse border. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ 5.0 5.1 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: . 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: . ISSN 2356-6140.
- Attribution 3.0 Unported (CC BY 3.0) - ↑ "Generalized lichen nitidus ". Pediatr Dermatol 22 (2): 158–60. 2005. doi: . 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: . ISSN 0378-6323.
- ↑ "Cytokines and cytokine profiles in human autoimmune diseases and animal models of autoimmunity ". Mediators of Inflammation 2009: 1–20. 2009. doi: . PMID 19884985.
- ↑ "Diagnosis and classification of psoriasis ". Autoimmunity Reviews 13 (4–5): 490–5. January 2014. doi: . 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: . 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: . 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: . 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: . 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: . PMID 30624575.
- ↑ Celiker, Hande; Toker, Ebru; Ergun, Tulin; Cinel, Leyla (2017). "An unusual presentation of ocular rosacea ". Arquivos Brasileiros de Oftalmologia 80 (6). doi: . 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: . 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: . 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: . 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: . 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: . 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: . 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: . 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
<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
Perinuclear vacuolization, most likely insignificant as an isolated finding. In case of dermatitis, consider Vacuolar interface dermatitis
Hyperkeratosis, a thickening of stratum corneum
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]
Desmoplasia of the skin, an increase of fibrous or connective tissue
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
Lipomatous tumors cause expansion of 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
- ↑
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, as well as including sections from each edge in case of diffuse border. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ Sato, Toshitsugu; Tanaka, Masaru (2014). "Linear sebaceous hyperplasia on the chest ". Dermatology Practical & Conceptual. doi: . ISSN 21609381.
- ↑ Rabello, FB; Souza, CD; Farina Jr, JA (2014). "Update on hypertrophic scar treatment ". Clinics 69 (8): 565–573. doi: . ISSN 18075932.
Image sources
Keloid
Author:
Mikael Häggström [note 1]
Gross processing
<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
- 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
- ↑
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, as well as including sections from each edge in case of diffuse border. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
Image sources
Hypertrophic scar
Author:
Mikael Häggström [note 1]
Gross processing
<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
- 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
- ↑
- . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- For number of slices and coverage of lesions, as well as including sections from each edge in case of diffuse border. - . Dermatopathology Grossing Guidelines. University of California, Los Angeles. Retrieved on 2019-10-23.
- For microtomy of the most central side at the lesion - "The principles of mohs micrographic surgery for cutaneous neoplasia
- 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. - . Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ Rabello, FB; Souza, CD; Farina Jr, JA (2014). "Update on hypertrophic scar treatment ". Clinics 69 (8): 565–573. doi: . ISSN 18075932.
Image sources
Notes
Main page
References
Image sources