HANDLING AND PROCESSING
PIGMENTED SKIN LESIONS.
DRAFT COPY ONLY.
(Procedure 162).

Grace F. Kao, MD,
Chief, Dermatopathology Section.
http://www.netautopsy.org/axsop/axsop162.htm


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United States Government Work, uncopyrighted, public-domain, DRAFT COPY ONLY. This document does not necessarily represent the views or policies of any United States Government agency. This document is provided "as is", without warranty of any kind, express or implied, including but not limited to the warranties of merchantability, fitness for a particular purpose and non-infringement. In no event shall the authors be liable for any claim, damages or other liability, whether in an action of contract, tort or otherwise, arising from, out of, or in connection with the document or the use or other dealings made with the document.



PRINCIPLE OF THE TEST.

      Handling and processing pigmented skin lesions. A pigmented skin lesion is suspicious for malignant melanoma until proven otherwise.



SPECIMEN REQUIRED.


      Pathology cases with a filled-out Tissue Examination Form (USSF-515), including the handwritten MICROSCOPIC DIAGNOSIS, signed by the attending pathologist.



REAGENTS, INSTRUMENTATION.

      Not applicable.



STEP-BY-STEP DESCRIPTION.


1. A pigmented skin lesion is suspicious for malignant melanoma until proven otherwise.

2. Microscopic evaluation of an atypical nevus or malignant melanoma requires careful histologic evaluation and measurement of an appropriately oriented specimen. Freezing and thawing such a specimen obscures the tissue landmarks required for this diagnosis. A SPECIMEN THAT IS SUSPICIOUS FOR MALIGNANT MELANOMA SHOULD NOT UNDERGO FROZEN SECTION DIAGNOSIS, UNLESS SO DIRECTED BY THE CHIEF, DERMATOPATHOLOGY SECTION.

3. A biopsy specimen suspected of being a malignant melanoma is placed into a solution of 10% neutral buffered formalin, or if electron microscopy is also contemplated, in modified Milonig's fixative, which is also suitable for fixation and processing for conventional microscopy. It is important that the specimen be fixed at least overnight, so that it is firm, and the subcutaneous adipose tissue cuts cleanly and exactly.

4. If the specimen is large, it should be place in a container in which the volume of fixative is at least twenty times that of the biopsy specimen, in order to assure adequate fixation. If the laboratory receives the specimen either unfixed or poorly fixed, then the specimen should be fixed overnight before cutting.

5. A gross examination of the tissue is performed and dictated. The margins are inked with dark colors, such as black or dark blue. Cross sections are made at 3 mm intervals, at right angles to the long axis of the specimen. The orientation of the specimen (or lack of orientation, if unoriented), the orientation of the tissue sections in the cassettes, and the position of the ink, is included in the dictation.

6. The two tips at either end of the long axis of the specimen are placed in separate cassettes, and not in the same cassettes as the remainder of the specimen, so that margins can be completely assessed.

7. It is helpful to include a sketch of the specimen in the report, but understanding the report should not depend upon this sketch. Sketches should be described in the text description with the expectation that the paper may be unavailable at some time in the future, and the sketch could be reconstituted using the text alone. Computer texts can be recalled instantly, and survive forever in computer archives.


8. FIGURE 162.001.0. Skin ellipse, sectioned at 2-3 mm.
Skin ellipse, sectioned at 2-3 mm.



9. SAMPLE DICTATION.
     PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
                              
     1.  SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
     NAME AND "SKIN FROM LEFT SHOULDER".  IT CONSISTS OF ONE PORTION OF
     PINK-TAN AND WHITE SKIN, WITH ATTACHED SUBCUTANEOUS TISSUE, WHICH
     MEASURES 1.4 X 0.8 CM, AND AN AVERAGE THICKNESS OF 0.3 CM.  THE DEEP
     MARGIN OF THE SPECIMEN IS INKED BLACK. THE SKIN SURFACE CONTAINS A
     LIGHTLY-PIGMENTED LESION. THE SPECIMEN IS SERIALLY SECTIONED ALONG ITS
     LONG AXIS AND SUBMITTED IN TOTO.
                     
     SUMMARY OF SECTION:
                       
     1-1,  SKIN FROM LEFT SHOULDER, 3 PIECES.
                       
     1-2,  SKIN FROM LEFT SHOULDER, 3 PIECES.



10. SAMPLE MALIGNANT MELANOMA CHECK LIST
    MALIGNANT MELANOMA CHECK LIST
                           
    SPECIMEN TYPE:  Biopsy.
                       
    SITE: Skin, right forearm.
                       
    DIAGNOSIS: Invasive Malignant Melanoma
                              
    SURGICAL INKED MARGINS: Uninvolved.
                      
    HISTOLOGIC SUBTYPE: Superficial spreading.
                                                
    PRECURSOR LESION: Present, Melanoma in situ.
                        
    INTRAEPIDERMAL PATTERN: Irregular nesting pattern.
                         
    CELL TYPE: Mixed epithelioid and small cells.
                             
    MAXIMUM TUMOR THICKNESS: 0.58 mm.
                       
    ULCERATION: Absent.
                                  
    CLARK'S (ANATOMIC) LEVEL: III.
                         
    MITOSES:  0-1/10 HPF.
                           
    VASCULAR OR LYMPHATIC INVASION: No.
                       
    REGRESSION:  Yes, partial.
                       
    PREEXISTING MELANOCYTIC NEVUS: Present.
                           
    TUMOR INFILTRATING LYMPHOCYTES: Absent.
                              
    LYMPHOID RESPONSE: Present, sparse.
                         
    MICROSATELLITES: No.
                    
    DESMOPLASIA: No.
                      
    NEUROTROPISM: No.
                         
    AJCC STAGING SYSTEM: Stage IA, T1a.
                                
    A Vista alert was sent to Dr. Healer on 4/13/2008.




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