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    Skin

    Background

    Skin biopsies are frequently undertaken to investigate or remove a range of lesions. Specimens can be punch and shave biopsies, curettings or skin ellipses. Radical dissections that include lymph nodes may be received in advanced disease.1-3 Dissection and sampling of skin specimens are important factors in accurate evaluation of surgical margins.4-7


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
        • Immunofluorescence7
        • Flow cytometry
        • Microbiology
        • Cytogenetics
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify the anatomical features of the specimen.

    An annotated permanent record of the specimen such as a drawing or photograph may be helpful when correlating the microscopic appearances.

    Describe the following features of the specimen:3-5

    Procedure/specimen type

    ​Record as stated by the clinician.

    • Excision
      • Ellipse, with orientation
      • Ellipse, without orientation
      • Polygonal or irregular
      • Wedge
    • Punch
    • Shave
    • Re-excision
    • Curette
    • Incision
    • Other
      • Moh's specimens
      • Scalp biopsies for alopecia
      • Nail bed biopsies
      • Other, describe

    Specimen orientation

    Record additional orientation or designation provided by operating clinician:

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of orientation (e.g. suture, incision)
      • Describe orientation of the marker at cut-up (e.g. 12 o'clock)
      • Record any coloured inks applied and to which margin
      • Describe any dermoscopically identified areas

    Specimen integrity

    • Intact
    • Disrupted/fragmented, describe
      • Number of pieces

    Anatomical components present

    • Epidermis
    • Dermis
    • Subcutis
    • Skeletal muscle
    • Cartilage
    • Bone
    • Large vessels
    • Large nerves

    Specimen size (mm)

    • In three dimensions3-5

    Lesion

    • Absent
    • Present
      • Number; if more than one lesion, designate and describe each separately noting the distance between each lesion.

    Lesion size (mm)

    • In three dimensions3

    Distance to margins (mm)

    • Distance of lesion to closest margin
    • Specify margin if orientated

    Lesion description

    • Macule
    • Papule
    • Vesicle
    • Bullae
    • Nodule
    • Plaque
    • Scar
    • Ulcer
    • Cyst
      • Describe contents
    • Keratotic
    • Ulcerated/ulceration
      • Maximum dimension
    • Pigmented, describe colour(s) and variability
      • Uniform
      • Variegated
    • Roughened
    • Papillomatous
    • Skin-covered
    • Telangiectasia
    • Haemorrhagic
    • Necrotic
    • Colour, describe
    • Border
      • Smooth
      • Irregular
      • Distinct
      • Indistinct

    Dissection

    • No dissection is required for shave biopsies, curettings and punch biopsies <3mm.
    • Punch/shave biopsies >3mm should be bisected.
    • Ellipses of skin can be serially sectioned transversely at 2-4mm intervals. 3,4
    • Usually, lip biopsies will be wedge-shaped and can be sectioned coronally at 3mm intervals to assess the distance of lesions to both lateral margins. Alternatively, dissect sagitally at 3mm intervals with longitudinal or shave sections at both lateral margins. See Head and neck > lip resection protocol for more detail.

    The method of orientation (e.g.suture) and what is indicated (e.g. superior margin) should be recorded. Its placement at the time of macroscopy should also be recorded. In many laboratories the suture is generically placed at the 12 o’clock position and the specimen is painted along one margin as a minimum. The protocol shown in the illustration above uses three different coloured inks enabling clear identification of the four quadrants.

    Please note painting protocols differ between laboratories.

    • Large specimens, 50-100mm, will require targeted sectioning guided by visual inspection. The margins of oriented specimens may be painted with ink.
    • Record colour of inks applied and their corresponding margins.
    • Section transversely (“breadloaf”) and lay out slices in sequential order to demonstrate maximum depth of the lesion and its relationship to margins. Photograph and record a block allocation key if required.
    • One method for very large specimens, >100mm, is to section radially round the perimeter of the lesion, then bread-loaf as for other specimens. Inspect carefully for multiple/multifocal lesions, lymph nodes, large nerves, blood vessels and attached tissues (e.g. salivary gland, bone and cartilage). Photograph to record a block allocation key.
    • Record the plane of dissection in orientated specimens or indicate in a diagram or photograph of the dissected specimen.

    Internal Inspection

    Describe the cut surface appearance including the following items:

    • Sentinel lymph nodes
    • Regional lymphadenopathy

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of grossly identified lymph nodes submitted
    • Maximum diameter of each (mm)

    If tumour macroscopically involves any lymph nodes, record:

    • Number of macroscopically-involved nodes out of total number of lymph nodes retrieved
    • Maximum dimension of largest metastasis
    • Note any visible extranodal spread;and its proximity to the surgical margin

    Photograph the dissected specimen if required.


    Processing

    Submit all tissue for processing.3 Biopsy pads or similar are required to prevent loss of tissue during processing.

    Serially section the specimen sequentially to demonstrate maximum depth of the lesion and its relationship to the margins. A photograph of the dissected specimen may be useful and can facilitate block identification.

    It is recommended that most, or all, of the lesion is examined focusing on parameters which may upstage the tumour or affect prognosis.

    The extent of sampling should take into account the following factors of the lesion:

    • Maximum thickness3
    • Any unusual features
    • Heterogeneous areas3
    • Areas of ulceration
    • Proximity to the margins3 (sampling of polar margins is undertaken at the discretion of the laboratory but is recommended if the lesion is within 1-2mm of the margin)4
    • Pay careful attention to the possibility of multiple lesions in large specimens. Each lesion must be sampled as well as the area between lesions to determine if truly separate lesions are present
    • For large lesions with prior biopsies, the earlier report may also indicate a need for greater sampling e.g. where there is perineural spread, lymphovascular invasion etc.
    • Keratin may need to be trimmed to allow hyperkeratotic lesions to fit in cassettes.

    Additional targeted sampling of the following is recommended:

    • Darker areas
    • Pale possible regressed areas
    • Heterogeneous foci
    • Crusted foci
    • Separate smaller (satellite) lesions
    • Ulceration/erosion

    Ink marking will assist in correlating areas of dermatoscopic concern at subsequent microscopic examination.

    One suggested method is to submit all radial sections from the perimeter of the specimen. Submit representative or alternate sections from the remainder of the bread-loafed specimen using the targeted sampling described for large specimens.

    Where the specimen is a macroscopically atypical melanocytic lesion or previously diagnosed on biopsy as melanoma, submit all sections of the whole lesion. Where the edge of the lesion is indistinct the whole specimen should be embedded including the poles from the long axis.

    Sample any macroscopic residual tumour and separate pigmented lesions. More sampling is suggested where there was microscopic perineural invasion, neurotropism, extensive regression, amelanotic tumour, lymphovascular invasion, satellites, angiotropism in the original specimen.

    No clear recommendation exists but in the absence of a previous positive margin and no macroscopic abnormality, the minimum regime is to sample the specimen in its shortest transverse axis, incorporating the area from where the scar3 appears to the margins. This can generally be achieved in 1-4 cassettes.8,9

    • Record a diagram of inking and sampling of orientated re-excision specimens.

    No clear recommendation exists. One approach is to submit all lymph nodes <10mm whole. Lymph nodes >10mm may be "bread-loaf" sectioned into 3-5mm slices and nodes macroscopically suspicious for metastases sampled.10

    See Sentinel and regional lymph nodes -melanoma for more detail.

    Levels and additional stains will be required routinely on skin punch biopsies <3mm in maximum dimension. Routine special staining with periodic acid Schiff’s diastase (PAS-D) will be required on inflammatory cases. Laboratories usually have procedures for communicating these requirements (e.g. notation on the cassette, different coloured cassettes) before processing.

    Record details of each cassette.

    An illustrated block key similar to those provided below may be useful.

    Block allocation keys

    Cassette id
    Site
    No. of pieces
    A-B
    Skin, all tissue submitted
     
    Cassette id
    Site
    No. of pieces
    A
    Lesion, point of deepest invasion
     
    B-C
    Margins
     
    D
    Lesion, at max. thickness
     
    E+
    Lesion, representative sections
     
    Cassette id
    Site
    No. of pieces
    A-B
    Lesion (or whole specimen) all sections
     
    Cassette id
    Site
    No. of pieces
    A-D
    Representative sections including scar to margins
     

     

    Acknowledgements

    Dr Craig James for his contribution in reviewing and editing this protocol.


    References

    1. Rapini RP. Obtaining a skin biopsy specimen and interpreting the results. Dermatol Clin 1994;12(1):83-91.
    2. Sardi JR. The histologic grossing and reading of wedge-shaped specimens from malignancies taken from the oral lips. J Dermatol Surg Oncol 1979;5(3):219.
    3. Scolyer R, Ellis D, Heenan P, James C, Kelly J, McCarthy S, Stevens G, Swain S and Thompson J. Primary cutaneous melanoma structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2010.
    4. Slater D and Walsh M Dataset for the histological reporting of primary cutaneous malignant melanoma and regional lymph nodes, The Royal College of Pathologists, London, 2014.
    5. Slater D, Biswas A, Cerio R, Cook M, Fallowfield M, Furness P, Kavanagh G and Walsh M. Tissue pathways for inflammatory and non-neoplastic dermatoses and non-neoplastic lesions, The Royal College of Pathologists, London, 2008.
    6. Weinstein MC, Brodell RT, Bordeaux J and Honda K. The art and science of surgical margins for the dermatopathologist. Am J Dermatopathol 2012;34(7):737-745.
    7. Sleiman R, Kurban M, Abbas O. Maximizing diagnostic outcomes of skin biopsy specimens. Int J of Dermatol. 2013;52(1):72-8.
    8. Martin HM, Birkin AJ and Theaker JM. Malignant melanoma re-excision specimens--how many blocks? Histopathology 1998;32(4):362-367.
    9. Johnson and Sviland. Is extensive histological examination of wide excision specimens necessary following a diagnosis of melanoma? Histopathology 1998;32(4):379-380.
    10. Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand, Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group, Wellington, 2008.

    Jump To

      Skin 1

      Skin punch biopsy

      Skin 2

      Skin punch biopsy bisected, cut surface down for processing

      Skin 3

      Skin ellipse orientated with suture at 12 o'clock

      Skin 4

      Skin ellipse orientated with suture at 12 o'clock

      Skin 5

      Skin ellipse unorientated

      Skin 6

      Skin ellipse serially sectioned

      Skin 7

      Skin from ear

      Skin 8

      Skin from ear, serially sectioned for processing


      Skin ear wedge identification

      Skin ear wedge identification

      RCPA | 12 December 2014

      Skin ear wedge orientation and dissection

      Skin ear wedge orientation and dissection

      RCPA | 12 December 2014

      Skin lesion behind ear

      Skin lesion behind ear

      RCPA | 12 December 2014

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      27-Mar-2019
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