Suspected malignant skin excisions: Difference between revisions
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==Common targets== | ==Common targets== | ||
If directly suspected from the referral, see: | If directly suspected from the referral, see: | ||
*[[Melanoma]] | *Melanoma | ||
:*[[Melanoma in situ]] | |||
:*[[Invasive melanoma of the skin]] | |||
*[[Basal-cell carcinoma]] | *[[Basal-cell carcinoma]] | ||
*[[Squamous-cell carcinoma of the skin]] | *[[Squamous-cell carcinoma of the skin]] | ||
==Gross processing== | ==Gross processing== | ||
{{Basic gross evaluation of suspected malignant skin lesions}} | {{Basic gross evaluation of suspected malignant skin lesions}} | ||
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{{Tissue selection from suspected malignant skin lesions}} | {{Tissue selection from suspected malignant skin lesions}} | ||
==Microscopic evaluation== | ==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 epidermal basal cells, evaluate as suspected '''[[basal-cell carcinoma]]''' | ||
<gallery widths=245 heights=240> | <gallery widths=245 heights=240> | ||
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*Similarity to squamous cells: See below: | *Similarity to squamous cells: See below: | ||
{{Squamous-cell like proliferations - differential diagnosis}} | {{Squamous-cell like proliferations - differential diagnosis}} | ||
===General benign imitators of skin malignancy=== | |||
<gallery widths=245 heights=240> | |||
File:Histopathology of granulomatous inflammation by a ruptured inclusion cyst.jpg|'''[[Granulomatous skin inflammation]]''' often contains giant cells that may appear atypical. | |||
</gallery> | |||
===Further workup of malignant findings=== | ===Further workup of malignant findings=== | ||
In case of skin cancer, determine whether the peripheral/radial and deep margins are clear, close or continuous.<ref name=rcpath>{{cite web|url=https://www.rcpath.org/asset/53688094-791E-4AAA-82CEC42C3CB65E35/|author=David Slater, Paul Barrett|title=Standards and datasets for reporting cancers - Dataset for histopathological reporting of primary cutaneous basal cell carcinoma|website=The Royal College of Pathologists}} February 2019</ref><ref group= | In case of skin cancer, determine whether the peripheral/radial and deep margins are clear, close or continuous.<ref name=rcpath>{{cite web|url=https://www.rcpath.org/asset/53688094-791E-4AAA-82CEC42C3CB65E35/|author=David Slater, Paul Barrett|title=Standards and datasets for reporting cancers - Dataset for histopathological reporting of primary cutaneous basal cell carcinoma|website=The Royal College of Pathologists}} February 2019</ref><ref group=note>"Peripheral" or "radial" margins are preferred rather than "lateral", since a "lateral" margin may be interpreted as opposite to the "medial margin".</ref> 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),<ref name=rcpath/><ref name=Elliott2018>1 mm as cutoff for close margin: {{cite web|title=Cutaneous squamous cell carcinoma: predictors of positive and close margins and outcomes of re-excision in Northland, New Zealand|author=Brodie M Elliott, Benjamin R Douglass, Daniel McConnell, Blair Johnson, Christopher Harmston|title=New Zealand Medical Journal|volume=131|issue=1487|date=2018-12-14|url=https://www.nzma.org.nz/journal-articles/cutaneous-squamous-cell-carcinoma-predictors-of-positive-and-close-margins-and-outcomes-of-re-excision-in-northland-new-zealand}}</ref> but 2-3 mm for [[melanoma of the skin|melanoma]].<ref name=busam2018a>[https://books.google.se/books?id=oepmDwAAQBAJ&pg=PA406 Page 406] in: {{cite book|title=Pathology of Melanocytic Tumors|author=Klaus J. Busam, Richard A Scolyer, Pedram Gerami|publisher=Elsevier Health Sciences|year=2018|isbn=9780323508681}}</ref> | ||
===Previous biopsy=== | |||
{{Moderate-begin}}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.{{Moderate-end}} 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== | ==Reporting== | ||
''Preferably see specific article on the condition at hand, if available.'' | ''Preferably see specific article on the condition at hand, if available.'' | ||
*Optionally, the presence of a keratinized squamous epithelium. | *Optionally, the presence of a keratinized squamous '''epithelium'''. | ||
*Any abnormalities, generally preceded by location in terms of epidermal, dermal or more specific layers thereof. | *Any '''abnormalities''', generally preceded by location in terms of epidermal, dermal or more specific layers thereof. | ||
*If malignant: | *If '''malignant''': | ||
:*Degree of differentiation | :*Degree of '''differentiation''' | ||
{{Skin radicality report|indentation=yes|margin=___|margin-comment=Definitions vary for the distance as per [[#Further workup of malignant findings|Further workup of malignant findings]] above|exactness-ref=<ref name=rcpath/>}} | {{Skin radicality report|indentation=yes|margin=___|margin-comment=Definitions vary for the distance as per [[#Further workup of malignant findings|Further workup of malignant findings]] above|exactness-ref=<ref name=rcpath/>}} | ||
:*Perineural or vascular invasion if present | :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. | |||
{{Bottom}} | {{Bottom}} | ||