Introduction to Skin Grossing

Just a remainder of skin morphology.

The histomorphology of the skin varies depending on the anatomical site. For example, hair follicles extend through the dermis into subcutis (subcutaneous fat). Or the skin of the face has numerous pilosebaceous elements. Or the skin of the trunk has thick reticular dermis. The palms and soles have a thick compact cornified layer when usual basket-weave pattern is not seen. Muscle fibers are more prominent in the dermis of genitalia and areola.

 Most skin diseases do not require a surgical pathology laboratory diagnosis. Among numerous skin diseases and cutaneous reactions to systemic disease, there are three main types of skin pathology which determine different approach/predilection in grossing techniques:

degenerative (seborreic keratosis);

inflammatory skin disease (vasculitis, herpes zoster);

neoplastic (carcinoma, melanoma).

Epydermolysis and nonscar alopecia are stand alone pathological processes requiring specific grossing techniques.

 Although dermatopathology gross description terms are different from clinical dermatology, it is reasonable to use as much as possible the same terminology that clinicians have.

 The dermatologists distinguish primary and secondary lesions.

 The primary lesions include

Maculae (spots) –circumscribed changes in skin color without elevation or depression.

Papulae –circumscribed (acuminate, rounded, conical, flat or umbilicated) different color (white, red, yellow, brown, black) solid (soft or firm consistency) elevations with smooth or rough surface and with no visible fluid.

Nodule – larger, solid papules.

Wheals (urticae) – evanescent, edematous, flat elevations of various sizes, discrete or coalesce in plaques with evident dermographism. They are not the material for surgical pathology.

Vesicle (blisters – circumscribed epidermal elevations of 1 to 4 mm in size containing usually a clear fluid. Breaking spontaneously or developing in blebs or pustules.

Bullae (blebs) – vesicles more than 5 mm rounded or irregularly shaped blisters containing serous, hemorrhagic or seropurulent fluid.

Pustule (pimples) – small elevations of the skin (original or developed from papules and vesicles) containing pus.

Cysts

Polyps (skin tags)

Wheals, vesicles, bullae, and pustules are not the material for surgical pathology, except in a case of epydermolysis bullosa.

The secondary lesions include

Scales (exfoliations, squames) – laminated masses of keratin

Excoriations (abrasions, scratch marks) – small linear bright red or dark color lesions at the epidermal surface.

Fissures (Cracks, Rents, Clefts, Rhagades) – a linear cleft through the epidermis in the thickened skin with definite margins.

Crusts (Scabs) – dried masses of serum, blood, or pus mixed with epithelial and bacterial debris.

Erosions (Erosio) – loss of epidermis after vesicles rupture.

Ulcers (Ulcera) – rounded or irregular shaped excavations that result from loss epidermis and dermis.

Scars (Cicatrices) – new formations of connective tissue as part of healing process.

Only ulcers, cysts, tags, and scars might be the surgical pathology diagnostic material. Scars after melanoma excision have special diagnostic significance.

All dermatological procedures have three main purposes: Diagnostic only; Diagnostic therapeutic; Cosmetic only. Although there can be overlapping diagnostic and treating outcomes.

Main four types of dermatology surgery procedures and their modifications: shave, punch, excisional, and incisional.

Shave, Sauserization, Curetting, Scraping (for adult mites) –diagnosis, may be therapeutic

Punch, Punch excision – diagnosis, rarely therapeutic

Bullous in toto without sectioning

Alopecia

Excisional, Deep excision, Square procedure, Scar excision – diagnosis, often therapeutic

Deep excision is not a biopsy at all, but it has diagnostic features in melanoma to present Clark and McGovern penetration levels and Breslow invasion measurements

Lip excision- diagnosis, treatment

Pilonidal sinus- diagnosis, treatment

.Incisional – diagnosis

Redundant skin – therapeutic, rarely diagnostic

Aggregate (“debulking” technique close to curetting)diagnosis

 Mohs microsurgery. There are books and manuals on this subject. This procedure is not presented in the manual

The punch, shave, and elliptical (wedge) techniques are the ones most often send to dermatopathology.

Familiarity with a variety of dermatopathology lesions is important in providing gross descriptions without attempting to make any diagnostic suggestions. The goal is to use precise words of the descriptive lexicon with specific characteristics of size, color, surface appearance and texture, shape and margins with modifiers of distribution of lesions. Tumors or other diagnostic definitions ought to be avoided.

A responsible gross description is indispensible part of the dermatopathology examination, because in most cases, the initial prior dissection picture cannot be reconstructed. The template dictation is an useful fact of a standard procedure in the modern surgical pathology laboratory. Every pathology group has its own gross descriptive guidelines. What is presented here is only a suggestion of the template algorithm. Here is a roster of images that may be included in the template of the specimen gross description. Although dermatopathology gross description terms are different from clinical dermatology, it is reasonable to use the same terminology that clinicians have already used as much as possible.

A suggested template for skin grossing dictation

Skin of (face, back, leg, etc.)

Type of specimen (shave, punch, excision) ‘

in fresh/fixative state

shape (ellipse, oval, irregular, verrucous, lobulated)

size (three dimensional measurement)

mark of orientation orienting suture

lesion’s characteristics

size

color, (black, brown, variegated)

consistency (firm, rubbery, hard, friable, hemorrhage, necrosis)

contour (rounded, bossed, vesicular, bulloius, irregular, macular, papillar, plaque,     circumscribed)

texture (granular, glossy, ulcerated, papillary)

shape        form homogeneity or variations

configuration extension growth infiltrative

distance from margins

Distribution into cassettes is obligatory to mention, if there are any specifics.

 

 

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