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
Outline Introduction: Dermatopathology Laboratory Processing of Skin Biopsy Melanoma under the microscope
Dermatopathology Evaluation of skin biopsies under a microscope
Harry Potter and Invisibility Cloak
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
What happens to your skin biopsy after your doctor removes a mole?
Accessioning: The first stop in Lab
Accessioning Confirm bottle and paperwork match Assign bar code
Accessioning: Check quality of specimen
Grossing: skin taken out of bottle
Grossing: measuring the skin
Grossing: cut skin into smaller pieces
Place skin into plastic cassette
Cassettes placed into Tissue Processor
The water is gradually removed from the skin Tissue processing
Embedding: skin put into paraffin wax
Tissue in a cassette filled with paraffin wax
Cassettes put on ice to harden the wax
Microtomy: cut skin into very thin layers
Microtome holding a cassette
Microtome holding a cassette
Cutting tissue into ultra-thin sections
Tissue is put onto a glass slide
Slides put on a stainer
Slides after being stained
Technician checks for quality
Dermatopathologists evaluate slides
Clerical staff help prepare reports and verify insurance information
Total time? Average 1 week May be longer 2 weeks Need for special studies Need for consultation with other pathologists
Pathology Diagnosis of Melanoma Can be very difficult Not straightforward like some tests Pathologists may disagree on diagnosis Occasionally multiple opinions are needed
Consensus Conference
Dermatopathology Faculty Dr. Faizan Alawi Dr. Emily Chu Dr. John Seykora Dr. Paul Haun Dr. Carrie Kovarik Dr. Rosalie Elenitsas Dr. Adam Rubin
Role of Dermatopathology Make melanoma diagnosis Provide information about prognosis
Epidermis Papillary dermis Dermis Reticular dermis Subcutaneous Fat
Epidermis Dermis papillary (top) reticular (bottom) Subcutaneous Fat
Normal skin Sun damaged skin
Cells of the Epidermis Keratinocytes Melanocyte
Development of skin cancer Melanocyte melanoma Keratinocyte squamous cell carcinoma Blood vessel angiosarcoma Muscle leiomyosarcoma Fat liposarcoma
Development of Melanoma Most melanomas begin in the epidermis, the top layer of the skin
Clark Level of Invasion How deep melanoma extends into the skin Level I, II, III, IV, V
Normal skin Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
Melanoma in situ, Clark level I Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
Melanoma in situ: Level I
Level II Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
Level III Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
Level IV Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
Level V Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
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
Breslow Thickness (millimeters) Epidermis Papillary dermis Reticular dermis Subcutaneous Fat
Breslow Thickness (millimeters)
Ulceration: Absence of epidermis
Tumor Infiltrating Lymphocytes Melanoma lymphocytes
Lymphatic/vascular invasion
Mitosis: tumor cells dividing
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
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