How to decipher a pathology report for alopecia

DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Lynne J. Goldberg, MD S063-Hair Disorders Made Easier DISCLOSURES I do not have any relationships with industry relevant to this lecture.

Why give this lecture? Hair loss evaluations are difficult Hair loss patients often see more than one physician Patients often bring their pathology report with the to the visit Sometimes their exam does not match the biopsy findings i.e. there is poor clinicopathologic correlation What do you do? Call the pathologist Request the slides to be reviewed by your pathologist Sometimes a careful reading of the pathology report is all that is necessary

An adequate biopsy Is a punch biopsy Preferably a 4mm punch biopsy Preferably a deep 4mm punch biopsy That does not look like this:

Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Diagnosis Microscopic description Comment Gross Description

Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Age, DOB, phone number, address, insurance info, etc. Diagnosis Microscopic description Comment Gross Description

Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Diagnosis Microscopic description Comment Gross Description

Case #1 Importance of clinical information CLINICAL INFORMATION: 44 year old woman with variation in hair shaft size on dermoscopy and patterned hair loss Ddx - female pattern hair loss vs. telogen effluvium vs. alopecia areata

Case #1 - Pathology Report Diagnosis: Non scarring alopecia with increased catagen/telogen hair follicles and focal inflammation within streamers, suggestive of alopecia areata Comment: There is miniaturization with pinpoint hair shafts. While these findings are not diagnostic, I favor a diagnosis of alopecia areata. Clinicopathologic correlation is recommended.

Case #1 Missing clinical information Patient diagnosed with breast cancer in 2013 She underwent chemotherapy with a regimen including: Docetaxel, carboplatin, and transtuzumab Still on Tamoxifen She had the typical anagen effluvium within the first month of treatment Regrowth began two months after completion, but she is left with half of what she had prior, and has had no new growth in the last year DIAGNOSIS: Permanent chemotherapy induced alopecia

Did the report really read alopecia areata? Diagnosis: Non scarring alopecia with increased catagen/telogen hair follicles and focal inflammation within streamers, suggestive of alopecia areata Comment: There is miniaturization with pinpoint hair shafts. While these findings are not diagnostic, I favor a diagnosis of alopecia areata. Clinicopathologic correlation is recommended.

Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Diagnosis Microscopic description Comment Gross Description

Case #2 Importance of sampling 68 year old white female with a clinical diagnosis of lichen planopilaris vs. seborrheic dermatitis DIAGNOSIS: Scarring alopecia MICROSCOPIC DESCRIPTION: 24 hair follicles, predominantly in anagen and terminal in size. Half of the specimen exhibits loss of sebaceous glands and perifollicular fibrosis, and some of these follicles exhibit thinning of follicular epithelium. Dilated eccrine ducts and naked hair shafts are noted.

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Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Diagnosis Microscopic description Comment Gross Description

Clinical impression From the dermatopathologist s point of view Clinical information is crucial More than alopecia What would I like to know? Pattern diffuse or patchy Duration Where the biopsy was taken from Additional pertinent history, treatment, etc. Why do I need to know this? Because CPC is essential in the diagnosis of hair loss It will make my report more useful to you!

Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Diagnosis Microscopic description Comment Gross Description

What do you want from a biopsy report? You want the diagnosis There are other things beside the diagnosis that may help you to manage the patient As a dermatopathologist, I have received biopsies to Assess degree of inflammation Assess response to therapy Assess potential donor grafts

Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Diagnosis Microscopic description Comment Gross Description

Microscopic description Sometimes scanty or lacking A diagnosis of TE requires normal follicular size A diagnosis of FPHL requires normal follicular number Controls CTE AGA Total cases 22 355 412 Avg # total hairs 40 39 35 Avg # term hairs 35 35 23 Avg # vellus hairs 5 4 12 T:V ratio 7:1 8.8:1 1.9:1 % telogen hairs 6.5% 11% 17% Whiting D. J Am Acad Dermatol 1996

As the clinician, to manage my hair patients I need the following: Hair follicles Total number Size Cycle Sebaceous glands present, absent, focal loss Inflammation Type, degree, depth Fibrosis Location - perifollicular, intrafollicular Presence of fibrous tracts or scars Misc findings pigment casts, naked hair shafts, mucin, etc.

A diagnosis of scarring alopecia requires The specific inflammatory cell type(s) present, if any A description of the scarring loss of follicular units, thinning of follicular epithelium, naked hair shafts Whether or not the inflammation is perifollicular, perivascular or both A description of changes to the overlying epidermis A comment on the presence or absence of sebaceous glands

Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Diagnosis Microscopic description Comment (Note) Gross Description This is where the thinking takes place. Sometimes the differential diagnosis is found here.

Components of a pathology report Demographic Information Clinical Information Location Clinical Impression Diagnosis Microscopic description Comment Gross Description

The gross description often overlooked! Should indicate 3 dimensions width, length and depth Will often tell you if the biopsy was adequate A 4 mm punch that is only 0.1 mm deep is as good as a shave! A 2 mm punch will likely not have enough follicles for adequate assessment The gross description will also tell you how the biopsy was cut horizontal or transverse ( Headington technique ) or standard vertical sections Vertical sections are often inadequate for non-scarring alopecia

Issues with gross descriptions Examples: 3mm punch Cylindrical specimen of skin measuring 4 mm in diameter Dimensions: 2.5 mm What is missing? The depth!

More problematic is a shallow specimen Case #3 Received in formalin labeled left parietal scalp are two irregular ovoid tan skin fragments measuring 0.2 x 0.1 x 0.1 cm and 0.2 x 0.1 x 0.1 cm. The first is inked blue at the margin. The second is inked red at the deep margin and submitted for Headington procedure. The specimen is entirely submitted in two cassettes 1-2, respectively What is wrong?

More problematic is a shallow specimen: Received in formalin labeled left parietal scalp are two irregular ovoid tan skin fragments measuring 0.2 x 0.1 x 0.1 cm and 0.2 x 0.1 x 0.1 cm. The first is inked blue at the margin. The second is inked red at the deep margin and submitted for Headington procedure. The specimen is entirely submitted in two cassettes 1-2, respectively What is wrong?

Case #3 Importance of gross description CLINICAL INFORMATION: Diffuse, non-scarring hair loss. Ddx: Alopecia. Punch biopsy parietal scalp DIAGNOSIS - Early scarring alopecia with focal lichenoid interface folliculitis s/o lichen planopilaris COMMENT - Discoid lupus is a consideration but not favored. No fungi or BMZ thickening on PAS stain, and no mucin on Alcian blue stain. GROSS DESCRIPTION - Two fragments measuring 0.2 x 0.1 x 0.1cm and 0.2 x 0.1 x 0.1 cm

Case # 3 Importance of gross description CLINICAL INFORMATION: Diffuse, non-scarring hair loss. Ddx: Alopecia. Punch biopsy parietal scalp DIAGNOSIS - Early scarring alopecia with focal lichenoid interface folliculitis s/o lichen planopilaris COMMENT - Discoid lupus is a consideration but not favored. No fungi or BMZ thickening on PAS stain, and no mucin on Alcian blue stain. GROSS DESCRIPTION - Two fragments measuring 0.2 x 0.1 x 0.1cm and 0.2 x 0.1 x 0.1 cm

What do you do if things do not add up? Call your pathologist Discuss the case Do another biopsy if necessary Another biopsy was done, and then came the call

Case #3 Repeat biopsy CLINICAL INFORMATION: Lichen planopilaris DIAGNOSIS Sparse perivascular inflammation, without evidence of follicular destruction COMMENT The changes are subtle and non-specific. There is no interface dermatitis at the DEJ. In general, a 4mm punch biopsy from the active border is recommended for definitive diagnosis GROSS DESCRIPTION 0.2 x 0.1 x 0.2 cm cylindrical piece of tan skin ADDENDUM REPORT - The findings on the current specimen have limited perifollicular inflammation and no evidence of destruction. Overall, a diagnosis of lichen planopilaris is favored given the findings on the prior biopsy

The clinician does a repeat biopsy CLINICAL INFORMATION: Lichen planopilaris DIAGNOSIS Sparse perivascular inflammation, without evidence of follicular destruction COMMENT The changes are subtle and non-specific. There is no interface dermatitis at the DEJ. In general, a 4mm punch biopsy from the active border is recommended for definitive diagnosis GROSS DESCRIPTION 0.2 x 0.1 x 0.2 cm cylindrical piece of tan skin ADDENDUM REPORT The findings on the current specimen have limited perifollicular inflammation and no evidence of destruction. Overall, a diagnosis of lichen planopilaris is favored given the findings on the prior biopsy

The clinician does a repeat biopsy CLINICAL INFORMATION: Lichen planopilaris DIAGNOSIS Sparse perivascular inflammation, without evidence of follicular destruction COMMENT The changes are subtle and non-specific. There is no interface dermatitis at the DEJ. In general, a 4mm punch biopsy from the active border is recommended for definitive diagnosis GROSS DESCRIPTION 0.2 x 0.1 x 0.2 cm cylindrical piece of tan skin ADDENDUM REPORT - The findings on the current specimen have limited perifollicular inflammation and no evidence of destruction. Overall, a diagnosis of lichen planopilaris is favored given the findings on the prior biopsy

Case #3 - The CPC This patient had an exam diagnostic of female pattern hair loss She was reassured and treated with topical minoxidil with improvement Take home message Shallow biopsies are treacherous for dermatopathologists Many of us are reluctant to say when a biopsy is too superficial

Take home points Do adequate biopsies Give generous clinical information Read all pathology reports carefully Make sure the biopsy was deep enough Make sure you have enough information in the microscopic description Do not hesitate to call your dermatopathologist If there is poor CPC If the patient is not responding to therapy Have the slides reviewed or rebiopsy if necessary

Thank You!