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Gelerstein 2011

Topic 23. Basics of dermatohistopathology Histologic Diagnosis Principles Indications for a histological examination include: 1. All excised tumors and pigmented lesions. 2. Differential diagnostic questions. 3. Help with difficult or unclear diagnoses. 4. Legal or cautionary reasons; Sometimes, even though the diagnosis is clear, histologic proof is wise before embarking on potentially dangerous therapy The choice of an appropriate site and lesions, the care with which the biopsy is taken, the method of fixation and processing, and the provision of all relevant clinical data all contribute greatly to the utility of a skin biopsy. Importance of additional information: The histological diagnosis of tumors can usually be made without a history, but is much easier and effective when historical data is available. In the case of inflammatory dermatoses, very few have a pathognomonic histological picture, so that the quality of the additional information almost directly correlates with the quality of the histological diagnosis. Taking the biopsy: The biopsy must be large and deep enough. Avoid squeezing by trying to pop out or lift out w/o a forceps. Place immediately in fixative; do not let the biopsy dry out. Intact lesions should be biopsied; ruptured blisters or excoriated papules provide little information. Punch biopsies should just include lesional skin, since they cannot be oriented during processing. Tension applied perpendicular to the skin; tension lines will produce a more easily closed biopsy site. Punch biopsies in hair-bearing areas (Scalp biopsy) should be parallel to the direction of hair shafts. If you are considering atrophy or cutaneous tissue changes, then an elliptical biopsy from the edge of the lesion, including peri-lesional skin is helpful for orientation and comparison. Spindle-shaped excision; perpendicular incision, insuring a broadbased biopsy with an adequate sampling of subcut. fat. Only very small pieces of tissue (< 1mm3) are needed for electron microscopy.

Punch biopsy

Scalp biopsy

Spindle-shaped excision

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Fixation 1. Light microscopy: Solution: Standard is 10% buffered formaldehyde; Minimum fixation period is 24hours. Be sure there is enough solution; the ideal proportion is at least 10x as much solution as tissue. Formaldehyde solution is not well suited for molecular biological investigations. 2. Immunofluorescence, immunohistochemical staining, and molecular biological studies: Immunofluorescence special transport medium or freezing is usually chosen. a. Direct immunofluorescence (DIF) b. In indirect immunofluorescence (IIF) c. Uses: Bullous autoimmune dermatoses, lupus erythematosus, other collagen vascular disorders, lichen planus, and vasculitis. Frozen sections placed in a special plastic tube (filled with 0.9% NaCl solution), closed and immediately frozen in liquid nitrogen. Immunohistochemical and in-situ hybridization formalin-fixed, paraffin-embedded tissue. a. This technique is critical for the identification and classification of lymphomas as well as for the diagnosis of a wide variety of sarcomas and other tumors. In addition, the nature of inflammatory infiltrates can be assessed. 3. Electron microscopy: Special fixatives, which usually have a limited shelf life, are required; most often Karnovsky solution is used. Electron microscopy is reserved for special situations such as: a. Rapid identification of viruses b. Assessment of ichthyosis and epidermolysis bullosa c. Identification of Birbeck granules in Langerhans cell histocytosis d. Identification of vascular deposits in Fabry disease e. Diagnosis of unclear carcinomas and sarcomas. Submission Slip The submission slip or form must include the following information: 1. Type of biopsy (punch, partial / total excision, re-excision, tangential (shave) excision, curettage). 2. Exact location of biopsy. 3. Important clinical details including duration of disease, age and type of lesion biopsied, size and distribution, previous treatment, associated diseases, and any other relevant clinical data. 4. Clinical diagnosis and reasonable differential diagnostic considerations.

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Orthokeratosis - The formation of an anuclear keratin layer Hyperkeratosis - A condition marked by thickening of the outer layer of the skin, which is made of keratin Parakeratosis - A microscopic term referring to the retention of nuclei in the keratinocytes of the keratinizing layer of epidermis (stratum corneum). Dyskeratosis - abnormal, premature, or imperfect keratinization of the keratinocytes. Acanthosis - Thickening of the epidermis resulting in the formation of papules and plaques. Acantholysis - A microscopic term referring to the intraepidermal separation of keratinocytes from each other with rounding up of keratinocytes due to loss of desmosomal attachments acantholytic cells - Refers to an epithelial cell that has undergone dyshesion (i.e separation from another epithelial cell) by dissolution of intercellular bridges and has consequently become round. Microabscesses - a very small, localized collection of pus. Munros microabscess - A microscopic collection of polymorphonuclear white blood cells found in the stratum corneum in psoriasis. Also called Munro's abscess. Pautriers microabscess - one of the well-defined collections of mycosis cells located within the epidermis in T-cell lymphoma and mycosis fungoides