Surgical Pathology Specimens Laboratory Protocols

Embed intact and level

Dermis and subcutis

Epidermis

Figure 37.1. Punch, ellipse or shave biopsy embedded intact.

Dermis and subcutis

Lesion

Epidermis

Figure 37.1. Punch, ellipse or shave biopsy embedded intact.

Figure 37.2. Punch, shave or ellipse bisected and embedded.

Diagnostic punch biopsy: diagnostic punch biopsies come in a variety of sizes ranging from 2 mm to 8 mm. The smaller-sized punch biopsies are usually for diagnostic purposes. The size of the punch is recorded and a description of any lesion seen. Small punches less than 4 mm are submitted in total and will require examination of multiple levels (Figure 37.1). Punch biopsies 4 mm and above are bisected and then submitted in total. Bisecting the specimen through the centre of the lesion results in its representation in the initial levels.

Punch biopsy for alopecia: punch biopsies are taken to establish the cause of alopecia and are embedded in the usual manner. In some centres, depending on the experience of the dermatopathologist, the punch biopsy may be bisected, with one half embedded and sectioned in the usual vertical fashion and the other half sectioned transversely. This is thought to give a better view of the hair follicle structures and assist in the diagnosis of alopecia (Figure 37.3).

Punch excision: punch excisions, like diagnostic punch biopsies, come in a variety of sizes, usually 4 mm and greater. The size of the punch is measured and the edges inked. Depending on the size the punch may be embedded intact and adequate sections cut to see the full face of the lesion (Figure 37.1). Larger punch biopsies are bisected (Figure 37.2) or sliced through to examine the lesion (Figure 37.4). All punch excision biopsies and lesions present are described and measured in millimetres.

Elliptical biopsy: small ellipses of skin may be removed for diagnosis. They are usually processed intact or bisected longitudinally and examined through multiple levels (Figures 37.1 and 37.2). Biopsies are measured in millimetres and any lesion seen described and measured. They may have their edges inked.

Punch Biopsy LympnodesPunch Biopsy Alopecia

Figure 37.3. Vertical and horizontal sections of a punch biopsy for the diagnosis of alopecia.

Elliptical excision: skin ellipses are used to remove tumour with a rim of normal tissue around the lesion. The pathologist needs to see the full face of the lesion and examine for adequacy of excision. All skin ellipses are measured and described. Any sutures and pins, etc., placed by the clinician for orientation are noted and if any specific questions are asked on the request form regarding the excision, these are considered when sectioning the skin ellipse. Most elliptical skin excisions are not photographed unless the gross appearance is unusual when often it will have been photographed by the clinician before surgical removal. Photography or a photocopy of the lesion surface may be useful if sampling of the lesion is complex to indicate where blocks have been taken, but usually a diagram is adequate. The edges of the ellipse are inked to indicate the true surgical margins.

Elliptical excisions are dealt with in the laboratory in a variety of ways:

1. If small (< 6 mm), they can be processed intact and cut along the long axis. Multiple levels need to be examined to see the full face of the lesion (Figure 37.1).

2. Small ellipses may be bisected across the short axis and embedded to show the centre of the lesion. This provides information on the deep limit and nearest peripheral margins at the short axis but not the long axis (Figure 37.2).

3. Quadrant blocks of the lesion. A block is taken through the centre of the lesion across the short axis and two lateral blocks are taken across the long axis. This gives the full face of the lesion and margins on four quadrants (Figure 37.5).

Multiple sections

Epidermis

Dermis and subcutis

Epidermis

Dermis and subcutis

Blocks a and c

Block b c

Figure 37.4. Serial section of a skin ellipse.

4. Skin ellipses may be serially sectioned or sliced like a loaf of bread through the lesion at 2-3 mm intervals. This ensures that the whole of the lesion is examined and is useful in melanocytic lesions of the skin (Figure 37.4).

Wedge excisions: wedge excisions are used to remove skin from the eyelid, lip, ear and vulval areas. These and any gross lesions are described and measured. The surgical limits are the outer margins of the wedge and these are sampled for histology. A section is then taken through the centre of the tumour (Figure 37.6).

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