Here

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Skin,Part3
Grossing,DIF,MOHS,CaseStudy
JacquelineBrooks
RonnieDavis
October13,2015
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Housekeeping
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NSHInstrucJons
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ObjecJves
•  Fundamentalsofgrossingskin
•  MOHStechnique
•  DIF
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HBDO-1726
Originalbx-Melanoma
Shape
Ellipse
5.6x2x0.3cm
Graytan
SJtch
Centraleschar
1.4cmdiameter
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HBDO-1726
Cutsurface
Fat
SJtch
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HBDO-1726
12-3:00orange
3-6:00blue
Remainingblack
SJtch
Skinsurface
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HBDO-1726
Surgicalmargin
12-3:00orange
3-6:00blue
Remainingblack
SJtch-superiorJp
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HBDO-1726
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HBDO-1726
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HBDO-1726-1A
Inkedmargin
clear
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HBDO-1726-1B
Inkedmargin
Clear
Dermis
Glands
Fat
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HBDO-1726-1C
Dermis
Gland
Lymphocytes
Inkedmargin
epidermis
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HBDO-1726-1D
Eschar
Epidermis
Dermis
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HBDO-1726-1E
Fat
Glands
Inkedmargin
Dermis
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HBDO-1726-1F
Dermis
Fat
Inkedmargin
Sebaceousgland
glands
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HBWO-2790
Ellipseof
Skin
Onsurface
Hasraised
Area
sutures
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HBWO-2790
• 
Surgicalmargins
• 
suture
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HBWO-2790
• 
SkinSurface
• 
12-3marginorange
• 
3-6:00marginblue
• 
6-12marginblack
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HBWO-2790
•  SurgicalMargin
•  6-12:00black
•  3-6:00blue
•  12-3:00orange
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HBWO-2790
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HBWO-2790-1A
Nicethin
Cut
Cansee
Individual
cells
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HBWO-2790-1B
Lymphocytes
Chronic
inflammaJon
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HMEO-1786
•  Lipof
Nasolabial
Fold
•  Raised
Lesions
eschar
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HMEO-1786
Skinsurface
3-6:00blue
suture
12-3:00orange
Remainingblack
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HMEO-1786
SurgicalMargin
Remainingblack
3-6:00blue
12-3:00orange
Suture
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HMEO-1786
9-12-3:00
Casse]e1a,1b
3-6-9:00
Casse]e1c,1d
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HMEO-1786
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HMEO-1786-1A
Inkedmargin
FreeofBCC
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HMEO-1786-1B
Basalcell
carcinoma
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HMEO-1786-1C
Basalcell
Carcinoma
eschar
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HMEO-1786-1C-HIGH
Basalcell
Carcinoma
Highpower
floater
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HMEO-1786-1D
Clearinked
Margin
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HSVI-11026
•  Un-orientedroughlyovalshaped
PorJonofskinwithacentral
Ulceratedlesion
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HSVI-11026
Beforesurgicalmargin
Isinked
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HSVI-11026
Hair-bearing
Surgicalmargininkedblack
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HSVI-11026
SecJonsshowing
Inkedmarginand
Centralulcerated
area
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HSVI-11026
Inkedmargins
SubcutaneousJssue
Isbrightyellowand
soa
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HSVI-11026-1A
Squamous
Cell
carcinoma
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HSVI-11026-1C
Squamouscell
Carcinoma
Marginsfreeof
Oftumor
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HSVI-11026-1D
Highpower
Squamous
Cell
carcinoma
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HSVI-11026-1E
Inkedmargins
Freeof
tumor
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HSVI-11026-1F
Inkedmargins
Freeof
tumor
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Immunofluorescence
•  Immunofluorescenceisatechniqueusedforlight
microscopywithafluorescencemicroscope.This
techniqueusesthespecificityofanJbodiesto
theiranJgentotargetfluorescentdyesto
specificbiomoleculetargetswithinacell,and
thereforeallowsvisualizaJonofthedistribuJon
ofthetargetmoleculethroughthesample.
Immunofluorescenceisawidelyusedexampleof
immunostainingandisaspecificexampleof
immunohistochemistrythatmakesuseof
fluorophorestovisualizethelocaJonofthe
anJbodies.
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Immunofluorescence
•  ImmunofluorescencecanbeusedonJssue
secJons,culturedcelllines,orindividualcells,
andmaybeusedtoanalyzethedistribuJonof
proteins,glycans,andsmallbiologicalandnonbiologicalmolecules.Immunofluorescencecanbe
usedincombinaJonwithother,non-anJbody
methodsoffluorescentstaining,forexample,use
ofDAPItolabelDNA.Severalmicroscopedesigns
canbeusedforanalysisofimmunofluorescence
samples.
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DIFIgA
Epidermis
IgAdeposits
Inthewalls
Ofsmall
Superficial
Capillaries
Dermis
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Primary(direct)
•  Primary,ordirect,immunofluorescenceusesasingle,primaryanJbody,
chemicallylinkedtoafluorophore.TheprimaryanJbodyrecognizesthe
targetmolecule(anJgen)andbindstoaspecificregioncalledtheepitope.
Thea]achedfluorophorecanbedetectedviafluorescentmicroscopy,
which,dependingonthemessengerused,willemitaspecificwavelength
oflightonceexcited.DirectImmunofluorescence,althoughsomewhatless
common,hasnotableadvantagesoverthesecondary(indirect)
procedure.Thedirecta]achmentofthemessengertotheanJbody
reducesthenumberofstepsintheprocedure,savingJmeandreducing
non-specificbackgroundsignal.ThisalsolimitsthepossibilityofanJbody
cross-reacJvityandpossiblemistakesthroughouttheprocess.However,
sincethenumberoffluorescentmoleculesthatcanbeboundtothe
primaryanJbodyislimited,directimmunofluorescenceissubstanJally
lesssensiJvethanindirectimmunofluorescenceandmayresultinfalse
negaJves.Directimmunofluorescencealsorequirestheuseofmuchmore
primaryanJbody,whichisextremelyexpensive.
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Secondary(indirect)
•  Secondary,orindirect,immunofluorescenceusestwo
anJbodies;theunlabeledfirst(primary)anJbody
specificallybindsthetargetmolecule,andthe
secondaryanJbody,whichcarriesthefluorophore,
recognizestheprimaryanJbodyandbindstoit.
MulJplesecondaryanJbodiescanbindasingle
primaryanJbody.ThisprovidessignalamplificaJonby
increasingthenumberoffluorophoremoleculesper
anJgen.ThisprotocolismorecomplexandJme
consumingthantheprimary(ordirect)protocolbut
allowsmoreflexibilitybecauseavarietyofdifferent
secondaryanJbodiesanddetecJontechniquescanbe
usedforagivenprimaryanJbody.
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Limita6ons
• 
• 
• 
Aswithmostfluorescencetechniques,asignificantproblemwith
immunofluorescenceisphoto-bleaching.LossofacJvitycausedbyphotobleachingcanbecontrolledbyreducingtheintensityorJme-spanoflight
exposure,byincreasingtheconcentraJonoffluorophores,orbyemployingmore
robustfluorophoresthatarelesspronetobleaching.
Immunofluorescenceisonlylimitedtofixed(i.e.,dead)cellswhenstructures
withinthecellaretobevisualizedbecauseanJbodiescannotcrossthecell
membrane.Proteinsinthesupernatantorontheoutsideofthecellmembrane
canbeboundbytheanJbodies;thisallowsforlivingcellstobestained.
DependingonthefixaJvethatisbeingused,proteinsofinterestmightbecome
cross-linkedandthiscouldresultineitherfalseposiJveorfalsenegaJvesignals
duetonon-specificbinding.
AnalternaJveapproachisusingrecombinantproteinscontainingfluorescent
proteindomains,e.g.,greenfluorescentprotein(GFP).Useofsuch"tagged"
proteinsallowsdeterminaJonoftheirlocalizaJoninlivecells.Eventhoughthis
seemstobeanelegantalternaJvetoimmunofluorescence,thecellshavetobe
transfectedortransducedwiththeGFP-tag.
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lupuserythematosus
SkinDIFusing
AnJ-IgG
IgGdepositsat
Twoplaces
Epidermal
Basement
Membrane(lupus
Bandtest)
Epidermalcells
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AfluorescentstainforacJninthe
smoothmuscleoftheskin
Smooth
Muscle
AcJn
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Lisa
Arkulary
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DIF
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DIF
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MOHS
•  InMohssurgeryprocedure,thesurgeon
removesaskincancerwhichisimmediately
examinedbyfrozensecJontoaccessthe
resecJonmargin.MostcriJcaltoaccurate
specimenpreparaJonistheproperonface
embeddingofJssuessuchthattheepidermal
edge,deepandlateralmarginsareembedded
inasingleflatplane.Techniquesforrelaxing
theJssuesarediscussedandillustrated.
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Mohssurgery
•  Mohssurgery,alsoknownaschemosurgery,developedin
1938byageneralsurgeon,FredericE.Mohs,is
microscopicallycontrolledsurgeryusedtotreatcommon
typesofskincancer.Duringthesurgery,aaereachremoval
ofJssueandwhilethepaJentwaits,theJssueisexamined
forcancercells.ThatexaminaJoninformsthedecisionfor
addiJonalJssueremoval.Mohssurgeryisoneofthemany
methodsofobtainingcompletemargincontrolduring
removalofaskincancer(CCPDMA–complete
circumferenJalperipheralanddeepmarginassessment.)
usingfrozensecJonhistology.CCPDMAorMohssurgery
allowsfortheremovalofaskincancerwithverynarrow
surgicalmarginandahighcurerate.
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Mohssurgery
•  ThecureratewithMohssurgerycitedbymoststudiesis
between97%and99.8%forprimarybasalcellcarcinoma,
themostcommontypeofskincancer.Mohsprocedureis
alsousedforsquamouscellcarcinoma,butwithalower
curerate.Twoisolatedstudiesreportedcureratefor
primarybasalcellcarcinomaaslowas95%and
96%.Recurrentbasalcellcancerhasalowercureratewith
Mohssurgery,moreintherangeof94%.Ithasbeenused
intheremovalofmelanoma-in-situ(curerate77%to98%
dependingonsurgeon),andcertaintypesofmelanoma
(curerate52%).Anotherstudyofmelanoma-in-situ
revealedMohscurerateof95%forfrozensecJonMohs,
and98to99%forfixedJssueMohsmethod.
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Mohssurgery
•  OtherindicaJonsforMohssurgeryinclude
dermatofibrosarcomaprotuberans,keratoacanthoma,
spindlecelltumors,sebaceouscarcinomas,microcysJc
adnexalcarcinoma,merkelcellcarcinoma,Paget'sdisease
ofthebreast,atypicalfibroxanthoma,and
leiomyosarcoma.BecausetheMohsprocedureis
micrographicallycontrolled,itprovidespreciseremovalof
thecancerousJssue,whilehealthyJssueisspared.Mohs
surgeryisalsomorecosteffecJvethanothersurgical
methods,whenconsideringthecostofsurgicalremoval
andseparatehistopathologicalanalysis.However,Mohs
surgeryshouldbereservedforthetreatmentofskin
cancersinanatomicareaswhereJssuepreservaJonisof
utmostimportance(face,hands,feet,genitals).
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Mohssurgery
DividedMohsSecJon
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MOHS-Pacman1Piece
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MOHS-DoublePacman
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MOHS-Indica6ons
•  Mohssurgeryshouldnotbeusedonthetrunk
orextremiJesforuncomplicated,nonmelanomaskincanceroflessthanone
cenJmeterinsize.Onthesepartsofthebody,
therisksexceedthebenefitsoftheprocedure.
Duetohighriskofrecurrenceamongother
reasons,Mohssurgerycouldbeconsidered
forskincancersonhands,feet,ankles,shins,
nipples,orgenitals.
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MOHS-Technique
•  TheAmericanAcademyofDermatologyhas
developeditsfirstappropriateusecriteria(AUC)
onMohsmicrographicsurgeryincollaboraJon
withthefollowingorganizaJons:American
CollegeofMohsSurgery;AmericanSocietyfor
MohsSurgery;andtheAmericanSocietyfor
DermatologicSurgeryAssociaJon.Morethan75
physicianscontributedtothedevelopmentofthe
MohssurgeryAUC,whichwerepublishedinthe
JournaloftheAmericanAcademyof
DermatologyandDermatologicSurgery.
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MOHS-Technique
•  TheMohsprocedureisapathologysecJoning
methodthatallowsforthecomplete
examinaJonofthesurgicalmargin.Itis
differentfromthestandardbreadloafing
techniqueofsecJoning,whererandom
samplesofthesurgicalmarginareexamined.
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Mohssurgeryisperformedin
foursteps:
•  SurgicalremovalofJssue(SurgicalOncology)
•  MappingthepieceofJssue,freezingandcumng
theJssuebetween5and10micrometersusinga
cryostat,andstainingwithhematoxylinandeosin
(H&E)orotherstains(IncludingToluidineBlue)
•  InterpretaJonofmicroscopeslides(Pathology)
•  PossiblereconstrucJonofthesurgicaldefect
(ReconstrucJveSurgery)
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MOHS
•  Theprocedureisusuallyperformedinaphysician'sofficeunder
localanestheJc.AsmallscalpelisuJlizedtocutaroundthevisible
tumor.AverysmallsurgicalmarginisuJlized,usuallywith1to
1.5mmof"freemargin"oruninvolvedskin.Theamountoffree
marginremovedismuchlessthantheusual4to6mmrequiredfor
thestandardexcisionofskincancers.Aaereachsurgicalremovalof
Jssue,thespecimenisprocessed,cutonthecryostatandplacedon
slides,stainedwithH&EandthenreadbytheMohssurgeon/
pathologistwhoexaminesthesecJonsforcancerouscells.Ifcancer
isfound,itslocaJonismarkedonthemap(drawingoftheJssue)
andthesurgeonremovestheindicatedcancerousJssuefromthe
paJent.ThisprocedureisrepeatedunJlnofurthercancerisfound.
ThevastmajorityofcasesarethenreconstructedbytheMohs
surgeon.
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MOHS
• 
Themethodiswelldescribedincurrentreferences.Themappingcombinedwith
the"smashingthepiepan"methodofprocessingistheessenceofCCPDMA
surgery.Ifoneimaginesanaluminumpiepanasthebloodcoveredsurgical
margin,andthetopofthepieisthecrustcoveredsurfaceoftheskin–thegoalis
tofla]enthealuminumpiepanintooneflatsheet,markit,stainit,andexamineit
underthemicroscope.Anotherauthorusestheexampleofpeelingtheskinoffan
orange.ImagineanorangecutinhalfastheCCPDMAlayer.Thepeelisthesurgical
margin.Onecanremovethispeelandfla]enitoutonaglassslidetoexaminethe
rootsoftheinvasivecancer.Themappingissimplyhowonestainsandlabelsthe
secJonsforamicroscopicexaminaJon.ThesecJonscanbeprocessedinonepiece
(usingrelaxingincisionsatmulJplepoints,orhemisecJonedlikea"Pac-Man"
figure),cutinhalves,cutinquarters,orcutinmulJplepieces.Singlepiece
processingisacceptableforsmallcancers,andmulJplepiecesecJoningfacilitates
processingandpreventarJfacts.SinglepiecesecJoningpreventserrors
introducedbysoa,hard-to-handleJssue;orfromaccidentaldroppingor
mislabelingofspecimen.MulJplesecJoningpreventscompressionarJfacts,
separaJonofJssue,andotherlogisJcalproblemswithhandlinglargethinsheets
offrozenskin.
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MOHS
• 
• 
SomephysiciansbelievethatfrozensecJonhistologyisthesameasMohs
micrographicsurgery,butitisnot.MohssurgeryisperformedusingfreshJssue
whilefrozensecJonhistologymayormaynotbeCCPDMA.Non-CCPDMA
histologyusuallyuJlizesarandomJssuesamplingtechniquecalled"bread
loafing".BreadloafingisastaJsJcalsamplingmethodwhichexamineslessthan
5%ofthetotalsurgicalmargin(imaginepulling5slicesofbreadoutofawhole
loafofslicedbreadandexaminingonlythose5slicestovisualizethewholeloaf).
InCCPDMAprocessing,theenJresurgicalmarginisexamined(imagineonewho
examinedtheenJreoutsidecrustofthesameloafofbread).InstaJsJcalterms,
themoreslicesofbreadoneexamines,thelowerthe"falsenegaJve"ratewill
become.FalsenegaJvesoccurwhenapathologistreadscancerexcisionas"freeof
residualcarcinoma",eventhoughcancermightbepresentinthewoundand
missedbecauseoftherandomsampling.Inreality,mostpathologylabsexamine
only3to8secJonsofthe"loaf"intheirmargindeterminaJon.ThealternaJvesto
MohssurgeryareCCPDMAbasedsurgicalexcisionandnon-CCPDMAsurgical
excision.MohsandCCPDMApathologistshaveperfectedmethodsofexamining
theenJresurgicalmargin.
Mohssurgeryoaenleavesanopenwound,whichmostoaenisreconstructed
(closed)bytheMohssurgeon.
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TheMohsSurgeryTeam
•  TheteamconsistsoftheMohssurgeon,histotechnician,andassisJng
nurses.TheMohssurgeonidenJfiesthecanceranditsmargin,oaenwith
theaidofdermatoscopy.Heorsheremovesthecancerunderlocal
anestheJcandpreparesitforhistologyprocessing.Thisisaccomplished
bycumngthespecimen(ifrequired),stainingthespecimenfor
orientaJon,andsendingittothelab.
•  ThehistotechnicianpreparestheJssueforMohsprocessingbyfla]ening
thesurgicalmarginonaflatsurfacefirst.Thentheflatsurgicalsurfaceis
mountedonacryostattobesecJonedandpreparedforglassslidestobe
readbythepathologist.
•  InMohssurgery,thesurgeonactsasthepathologist.Heorsheexamines
theslideforresidualtumors,andmarksthelocaJonofthetumoronthe
pathologyreport.
•  TheMohssurgeonmostoaenfuncJonsasthereconstrucJvesurgeon.
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StainingConven6on
•  EachsurgeonhashisorherownconvenJon.A
typicalconvenJonisasfollows
•  Epidermisllllllllll
•  BLUE---------
•  RED---------------------------------
•  YELLOWOOOOOOO
•  GREENXXXXXXX
•  MissingEpidermisVVVVVVVVVV
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Differencesbetweenhistologyof
transversesec6onsandver6calsec6ons
SomeJmes,forconfirmaJonpurposes,asecond
opinionwillbeaskedofapathologisttoreview
pathologyslidesfromMohscases.TradiJonal
histologyofskinJssueusesverJcalsecJoning–
withthesubcutaneousJssueatthebo]omand
theepidermisatthetop.Mohssurgeryuses
tangenJalorhorizontalsecJoning,whichcan
confusethepathologiststrainedinthe
tradiJonalmethod.
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Differencesbetweenhistologyof
transversesec6onsandver6calsec6ons
First,onehastodeterminethemethodof
chromacodingorcolor-coding.TheorientaJon
oftheMohsmapmustbeabletodisJnguish
betweenmedial,lateral,superior,andinferior.
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Differencesbetweenhistologyof
transversesec6onsandver6calsec6ons
•  Next,onehastodetermineifthesurgeonfollowedthe
convenJonofmounJngonly2secJonspercase;as
preferredbysome;ordidhe/sheperformserial
secJoningthroughtheblockaspreferredbyothers.If
serialsecJoningisperformed,thedistancebetween
secJonsshouldbeconfirmed.SomesurgeonsuJlize
100micrometresbetweeneachsecJon,andsome
uJlize200micrometresbetweenthefirsttwosecJons,
and100micrometresbetweensubsequentsecJons
(10crankofJssuesetat6to10micrometreisroughly
equalto100micrometresifoneallowsforphysical
compressionduetotheblade).
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Differencesbetweenhistologyof
transversesec6onsandver6calsec6ons
Next,onedeterminesiftheenJreepidermalborderis
present.Ideally100%oftheepithelialbordershouldbe
present.ConvenJonrequiresatleast95%ofthe
epidermistobepresent.However,somesurgeonswill
makeanexcepJonforsomemissingepitheliumatthe
apicesofanellipJcalexcisionaroundthespecimen.
Ideally,ovalsecJonsshouldbeperformed.However,for
pracJcalpurposesonsomelesions,asurgeonmightcut
theMohssecJontoapproximatethefinalclosuredefect.
Theapexesareoaen1cmormorefromthetumor,so
clearmarginsattheapicescanbeignored.Thisisnotthe
idealbyconvenJon,butisappropriateonacasebycase
basis.
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Differencesbetweenhistologyof
transversesec6onsandver6calsec6ons
Next,onedeterminesifthesurgicalmarginisclear.Withserial
secJoning,onehastorecreatethesurgicalspecimenina3dimensionalway.ThefirstsecJonthattouchesthebladebeginsthe3dimensionalreconstrucJon.Byusingthe3-DreconstrucJonofthe
specimen,onecansaythatalltheepithelialmarginispresentasone
progressesfromdeeptosuperficial.Ifonly2secJonsarepresent,
ideally,boththesecJonsshouldbeclear.IfthedeepersecJonis
posiJve,onehastoascertainthedistancebetweenthesecJons.
ConvenJonoaencallsforaclearmarginofatleast200micrometres.
Forambiguousstructuresthatresemblebothadnexalstructureand
carcinoma,followingtheserialsecJonswillallowforonetoidenJfy
thestructureasbenignormalignant.Withthe2slidesmethod,this
mightbeimpossibletoperform,asno3-DreconstrucJonispossible
withonly2secJons.
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Differencesbetweenhistologyoftransverse
sec6onsandver6calsec6ons
CarcinomaappearanceunderMohs
micrographicsecJoningcanbedifficult.
TangenJalcutofsquamouscellcanmimic
squamouscellcarcinoma(butwithoutthe
atypia).SecJonsthroughthebudsofhair
folliclescanresembleisolatedislandsofbasal
cellcancers,oaenevenwithretracJonarJfact.
SerialsecJonanalysisisbestforMohssurgery.
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MohsSurgeryandBlood
Thinner
Thetrendinskinsurgeryoverthelast10years
hasbeentoconJnueanJcoagulantswhile
performingskinsurgery.Mostcutaneous
bleedingcanbecontrolledwithelectrocautery,
especiallybipolarforceps.Thebenefitgainedby
easeofhemostasisisweighedagainsttheriskof
stoppinganJcoagulants;anditisgenerally
preferredtoconJnueanJcoagulants.
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Curerate
Fewindividualsargueaboutthecureratefor
Mohs,especiallypathologistsfamiliarwiththe
procedure.However,inrecentyears,afew
authorssuggestedthatMohssurgeryisno
be]erthanstandardexcision.
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Comparisontoothermodali6esof
treatment
Mohssurgeryisnottheanswerforallskincancers.
Underselectcircumstances,radiaJon,topical
chemotherapy,cryosurgery,electrodesiccaJonand
cure]age,andstandardexcisionarebe]erthanMohs
surgery.StudiescomparingtheeffecJvenessofMohs
surgerytoothermodaliJesoaenfailtospecifysurgical
margin,methodofprocessing(breadloafingwith3or4
secJons,breadloafingwith0.1mmspacing,margin
controlled,frozensecJonvs.standardhistology);leaving
li]leargumentonewayoranother.Onceapathologist
understandsthesimplisJcnatureofMohssurgery,and
itsmargincontrolability–li]leneediscalledforclinical
trialcomparingMohssurgerytosurgicalexcision.
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PictogramofCCPDMAor
MarginControlledHistology
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PictogramofStandard
BreadLoafingHistology
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FalseNegaJveinStandard
BreadLoafingHistology
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ComparingMohsMethodto
SmashinganAluminum
Piepan
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HowaMohsSecJonis
Fla]enedwithRelaxing
Incisions
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HSVO-3252
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95
HSVO-3252
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96
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HSVO-3252-1A
Sebaceousgland
Inkedmargin
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HSVO-3252-1B
Inkedmargin
Sebaceous
Gland
Fat
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HSVO-3252-1C
Epidermis
Sebaceous
Gland
Hair
Follicle
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HSVO-3252-1D
Inked
Margin
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HSVO-3252-1D
Inked
Margin
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HSVO-3252-1F
HighPower
Glands
InkedMargin
Fatcells
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HSVO-3333
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HSVO-3333
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105
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HSVO-3333-1A
InkedMargin
Epidermis
Dermis
Glands
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HSVO-3333-1B
Residual
Melanoma
Insitu
Extendingto
Blueink
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HSVO-3333-1C
NegaJve
For
Residual
melanoma
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HSVO-3333-1D
NegaJve
For
Residual
melanoma
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HSVO-3333-1E
NegaJve
For
Residual
melanoma
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HSVO-3333-1F
Incidental
Basal
Cell
carcinoma
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CPTCodes
SurgicalPathology
Services88300through88309include
accession,examinaJon,andreporJng.
Theydonotincludetheservicesdesignatedin
codes88311through88365and88399,which
arecodedinaddiJonwhenprovided.
Theunitofserviceforcodes88300through
88309isthespecimen
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113
CPTCodes
SurgicalPathology
AspecimenisdefinedasJssueorJssuesthatis
(are)submi]edforindividualandseparate
a]enJon,requiringindividualexaminaJonand
pathologicdiagnosis.
Twoormoresuchspecimenfromthesame
paJent(eg.SeparatelyidenJfiedendoscopic
biopsies,skinlesions)areeachappropriately
assignedanindividualcodereflecJveofits
properlevelofservice.
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CPTCodes
Surgicalpathology
Servicecode88300isusedforanyspecimen
thatintheopinionoftheexaminingpathologist
canbeaccuratelydiagnosedwithout
microscopicexaminaJon.
Servicecode88302isusedwhengrossand
microscopicexaminaJonisperformedona
specimentoconfirmidenJficaJonandthe
absenceofdisease.
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CPTCodes
Surgicalpathology
Servicecodes88304through88309describeall
otherspecimenrequiringgrossandmicroscopic
examinaJon,andrepresentaddiJonal
ascendinglevelsofphysicianwork.
Levels88302through88309arespecifically
definedbytheassignedspecimens.
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CPTCodes
Surgicalpathology
Anyunlistedspecimenshouldbeassignedtothe
codewhichmostcloselyreflectsthephysician
workinvolvedwhencomparedtoother
specimensassignedtothatcode
Donotreport88302-88309onthesame
specimenaspartofMohssurgery
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CPTCodes
Surgicalpathology
88304-Skincyst/tag/debridement
88305-Skin,otherthancyst/tag/debridement/
plasJcrepair
88307-Breast,excisionoflesion,requiring
microscopicevaluaJonofsurgicalmargins
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TheEnd
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