Tracking skin cancers and melanoma at the microscopic level
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1 Tracking skin cancers and melanoma at the microscopic level Rosalie Elenitsas, M.D. Professor of Dermatology Director of Dermatopathology Hospital of the University of Pennsylvania May 12, 2017
2 Outline Introduction: Dermatopathology Laboratory Processing of Skin Biopsy Melanoma under the microscope
3 Dermatopathology Evaluation of skin biopsies under a microscope
4 Harry Potter and Invisibility Cloak
5 Dermatopathologist Evaluates skin biopsies under microscope TRAINING 4 years medical school 1 year internship 3 years in residency in dermatology or pathology 1 or 2 years in dermatopathology fellowship training
6 What happens to your skin biopsy after your doctor removes a mole?
7 Accessioning: The first stop in Lab
8 Accessioning Confirm bottle and paperwork match Assign bar code
9 Accessioning: Check quality of specimen
10 Grossing: skin taken out of bottle
11 Grossing: measuring the skin
12 Grossing: cut skin into smaller pieces
13 Place skin into plastic cassette
14 Cassettes placed into Tissue Processor
15 The water is gradually removed from the skin Tissue processing
16 Embedding: skin put into paraffin wax
17 Tissue in a cassette filled with paraffin wax
18 Cassettes put on ice to harden the wax
19 Microtomy: cut skin into very thin layers
20 Microtome holding a cassette
21 Microtome holding a cassette
22 Cutting tissue into ultra-thin sections
23 Tissue is put onto a glass slide
24
25 Slides put on a stainer
26 Slides after being stained
27 Technician checks for quality
28 Dermatopathologists evaluate slides
29 Clerical staff help prepare reports and verify insurance information
30 Total time? Average 1 week May be longer 2 weeks Need for special studies Need for consultation with other pathologists
31 Pathology Diagnosis of Melanoma Can be very difficult Not straightforward like some tests Pathologists may disagree on diagnosis Occasionally multiple opinions are needed
32 Consensus Conference
33 Dermatopathology Faculty Dr. Faizan Alawi Dr. Emily Chu Dr. John Seykora Dr. Paul Haun Dr. Carrie Kovarik Dr. Rosalie Elenitsas Dr. Adam Rubin
34 Role of Dermatopathology Make melanoma diagnosis Provide information about prognosis
35 Epidermis Papillary dermis Dermis Reticular dermis Subcutaneous Fat
36 Epidermis Dermis papillary (top) reticular (bottom) Subcutaneous Fat
37 Normal skin Sun damaged skin
38 Cells of the Epidermis Keratinocytes Melanocyte
39 Development of skin cancer Melanocyte melanoma Keratinocyte squamous cell carcinoma Blood vessel angiosarcoma Muscle leiomyosarcoma Fat liposarcoma
40 Development of Melanoma Most melanomas begin in the epidermis, the top layer of the skin
41 Clark Level of Invasion How deep melanoma extends into the skin Level I, II, III, IV, V
42 Normal skin Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
43 Melanoma in situ, Clark level I Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
44 Melanoma in situ: Level I
45 Level II Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
46 Level III Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
47 Level IV Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
48 Level V Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
49 Breslow Thickness Measures the thickness of the melanoma using an ocular micrometer (ruler in the microscope) Measure from the top of the skin (epidermis) to the deepest tumor cell Measure in millimeters 25.4 millimeters = 1 inch
50 Breslow Thickness (millimeters) Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
51 Breslow Thickness (millimeters)
52 Ulceration: Absence of epidermis
53 Tumor Infiltrating Lymphocytes Melanoma lymphocytes
54 Lymphatic/vascular invasion
55 Mitosis: tumor cells dividing
56 Pathology Report for Melanoma Melanoma subtype Growth phase Level of invasion (Clark) Thickness (Breslow) Site on body Ulceration AJCC tumor stage Tumor infiltrating lymphocytes Mitotic count Regression Pre-existing mole Neurotropism Lymphatic invasion Satellite lesions
57 An investment in knowledge always pays the best interest. Benjamin Franklin
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