Maximizing diagnostic outcomes of skin biopsy specimens

Malignant wound aetiology, diagnosis and management: a case series and literature review

OBJECTIVE

Malignant wounds develop when neoplastic cells invade the skin either locally or by lymphatic and haematogenous spread. They can present as hard-to-heal wounds and underlying causes include: primary skin cancer; metastasis of extracutaneous primary malignancy; malignant transformation of a hard-to-heal wound; iatrogenic injury; and cutaneous forms of cancers of non-skin origin. High clinical suspicion for a malignant wound should be confirmed with skin biopsy. The aim of this case series is to highlight a combination of both clinically clear cutaneous malignancies and not-so-obvious wounds caused by malignancy.

METHOD

This case series examines patients with malignant wounds of varying aetiology and appearance. For each case, we explain the pathophysiology, atypical features, diagnostic approach and treatment. We also discuss types of wound biopsy and general wound management principles.

RESULTS

Among the 11 cases analysed using descriptive statistics, median wound duration before presentation at our clinic was one year, while median age at presentation was 65 years. Our case series included the following diagnoses: cutaneous metastasis of invasive ductal carcinoma of the breast (n=2); cutaneous metastasis of colorectal adenocarcinoma (n=1); Marjolin's ulcer (n=1), basal cell carcinoma (BCC) (n=2), primary cutaneous squamous cell carcinoma (SCC) (n=1), metastatic malignant melanoma (n=1), cutaneous T-cell lymphoma (n=1), cutaneous angiosarcoma (n=1), Kaposi sarcoma (n=1) and recurrent tonsillar SCC with osteoradionecrosis (n=1); one case had both BCC and SCC.

CONCLUSION

Punch and excisional biopsies were the most frequently used diagnostic techniques. Local wound therapy addressed bleeding, malodour, exudate, pain and infection. However, wound healing is usually achieved once the underlying malignancy is treated. In advanced or metastatic disease, palliative wound care aims to prevent exacerbation of existing wounds and focuses on patient comfort.

Clinical-pathologic correlation: The impact of grossing at the bedside

The unenlightened clinician may submit a skin specimen to the lab and expect an "answer." The experienced clinician knows that in performing skin biopsies, it is critical to select the most appropriate: 1) anatomic location for the biopsy1,2; 2) type of biopsy1,2; 3) depth and breadth of the biopsy; and 4) medium for hematoxylin and eosin staining (formalin) or direct immunofluorescence (Michel's Transport Medium or normal saline).2 Demographic information, anatomic location, clinical context, and differential diagnosis are all critical components of a properly completed requisition form.3-5 Proper biopsy design and appropriate grossing of the tissue at the bedside should be added to this list. In this article, we review the basics of gross pathologic examination and then provide four examples to demonstrate that optimal clinical-pathologic correlation requires the clinician consider the needs of the pathologist when tissue is presented to the lab.

Impact of trainee experience on shave biopsy specimen size

BACKGROUND

Skin biopsies are crucial for the diagnosis of many cutaneous pathologies, yet specimen adequacy is essential for definitive diagnosis. Recent literature has noted a trend in decreasing biopsy size over time, which has created concern over implications regarding adequacy for diagnosis.

METHODS

This study sought to evaluate if clinician training length or type of residency training impacted the average biopsy size and sample adequacy. Dermatopathology reports for shave biopsies between January 1, 2021, and June 30, 2021, at Penn State Health were queried through PathNet, the software application for pathology reports in this health system's electronic medical record system. Biopsy dimensions, volume, diagnosis, location, clinician training level, and descriptions of evaluation of deeper sections (recuts) and superficial sampling were recorded for each biopsy. Basic statistical calculations were performed to assess the mean and standard deviation for biopsy sizes per clinician group.

RESULTS

Differences in biopsy size between training levels were statistically significant despite qualitatively similar biopsy locations and final diagnosis categories for each clinician training group. After evaluating measures for sample adequacy, our data showed significantly smaller biopsies; however, overall frequencies were minimal. Additionally, more inadequate specimens were noted for clinician groups with the least amount of dermatology experience.

CONCLUSIONS

The results of this study identify a correlation with decreasing biopsy size amidst increased experience in dermatology training but find no evidence to support that this trend currently threatens sample adequacy.

Overdiagnosis of melanoma - causes, consequences and solutions

Malignant melanoma is the skin tumor that causes most deaths in Germany. At an early stage, melanoma is well treatable, so early detection is essential. However, the skin cancer screening program in Germany has been criticized because although melanomas have been diagnosed more frequently since introduction of the program, the mortality from malignant melanoma has not decreased. This indicates that the observed increase in melanoma diagnoses be due to overdiagnosis, i.e. to the detection of lesions that would never have created serious health problems for the patients. One of the reasons is the challenging distinction between some benign and malignant lesions. In addition, there may be lesions that are biologically equivocal, and other lesions that are classified as malignant according to current criteria, but that grow so slowly that they would never have posed a threat to patient's life. So far, these "indolent" melanomas cannot be identified reliably due to a lack of biomarkers. Moreover, the likelihood that an in-situ melanoma will progress to an invasive tumor still cannot be determined with any certainty. When benign lesions are diagnosed as melanoma, the consequences are unnecessary psychological and physical stress for the affected patients and incurred therapy costs. Vice versa, underdiagnoses in the sense of overlooked melanomas can adversely affect patients' prognoses and may necessitate more intense therapies. Novel diagnostic options could reduce the number of over- and underdiagnoses and contribute to more objective diagnoses in borderline cases. One strategy that has yielded promising results in pilot studies is the use of artificial intelligence-based diagnostic tools. However, these applications still await translation into clinical and pathological routine.

Survey of pathology reports with no definitive diagnosis in oral lesions: the necessary skills for the clinicians

Purpose

Biopsy plays a crucial role in definitive diagnosis of lesions and consequently, appropriate treatment of them. Clinicians should correctly do the biopsy in accordance to the existing principles and guidelines to prevent adverse effects on the pathologist's diagnosis. This study aimed to determine the frequency and reasons for not providing definitive histopathological diagnosis of the biopsy samples belong to the laboratory of the Department of Oral and Maxillofacial Pathology, Faculty of Dentistry, Hamadan University of Medical Sciences.

Methods

Archival reports belong to 2006–2016 period of the related laboratory were studied to determine the reports with no definitive histopathological diagnosis.

Results

Out of 1018 archived reports; 90 reports (8.84%) had no definitive diagnosis. The most common reasons found were incompatibility between the clinical/radiographical diagnosis and histopathological findings for 42 cases (46.66%), absence of adequate information about the clinical/radiographical findings for 17 cases (18.88%) and inappropriate quality of samples for 13 cases (14.44%), respectively.

Conclusion

The reasons for not providing definitive histopathological diagnosis of the biopsy samples in present study indicated that preparation, assessment and diagnosis of microscopic slide by pathologists do not separate from the clinician performance.

Diagnoses of hospitalized patients with skin abnormalities prompting biopsy by consulting dermatologists: A 3-year review from a tertiary care center

Background

Dermatologists play an important role in diagnosing and managing hospitalized patients with cutaneous abnormalities. Skin biopsies remain an indispensable tool for aiding dermatologists in accurate diagnosis and treatment. We aimed to determine the range of conditions, and the most common conditions, prompting skin biopsy by dermatology hospital consultation (HCON) services to aid in evaluation of hospitalized patients.

Methods

All hospitalized patients seen by a single tertiary care center dermatology HCON service between 2015 and 2018 who had associated skin biopsies were identified. Histologic features and clinical diagnoses of each patient were classified into 13 histologic reaction pattern categories.

Results

Eight hundred and thirty one inpatients evaluated by our dermatology HCON service had 914 skin biopsies. The most frequent diagnostic categories prompting biopsy were vasculopathic (17.6%), interface dermatitis (16.5%), infectious (12.6%), and spongiotic dermatitis (10.9%). The most frequent diagnostic categories included drug reaction (13.2%), leukocytoclastic vasculitis (8.5%), skin cancer (5.4%), graft‐vs‐host disease (3.5%), connective tissue disease (3.3%), and calciphylaxis (3.0%).

Conclusion

Our study suggests a variety of serious diseases affecting inpatients prompts biopsy by dermatology consultation services. Educational curricula for dermatology and pathology residents, fellows, and staff designed with these data may enhance knowledge that improves the quality of inpatient dermatology care.

Clinicopathological concordance in the diagnosis of skin diseases: a retrospective analysis of 5000 histopathology reports

BACKGROUND

The accuracy of clinical diagnoses of skin diseases has not been researched in Saudi Arabia.

OBJECTIVES

Assess concordance between the histopathological and clinical diagnosis in skin diseases.

DESIGN

Retrospective.

SETTING

Academic tertiary care center.

METHODS

Demographic, clinical and pathological data were collected from the medical record for the period 1997-2013.

MAIN OUTCOME MEASURES

Concordance between the pathological and clinical diagnosis.

SAMPLE SIZE

4268 cases.

RESULTS

Of 4268 biopsies, 2440 (58.1%) were females. The mean age (SD) of patients was 36.9 (17.8) years. The three most common locations from which skin biopsies were retrieved in descending order were the lower extremity (1123; 29.1%), head, neck, scalp and hair (1033; 26.7%) and trunk (853; 22.1%). Overall concordance was 75.9% (partial concordance 47.6%, full concordance 28.3%). Biopsies from the oral mucosa and lips had the lowest concordance (overall 58.5%, full 26.4%) at P=.004. Overall concordance was highest for the following three diagnoses: malignant neoplasms, 88%; vesiculobullous diseases 87%; urticarias, erythemas, and purpuras 87%.

CONCLUSION

There is considerable variability in concordance among different histopathological diagnoses. The full concordance between the clinical diagnosis and the pathological diagnosis is low. This is a reflection of the fact that the biopsies were obtained only in cases where the clinical diagnosis was a dilemma.

LIMITATIONS

Single center, retrospective, incomplete medical records, low percentage of biopsies were assessed by dermatopathologists.

CONFLICT OF INTEREST

None.

KNEMIDOKOPTINID (EPIDERMOPTIDAE: KNEMIDOKOPTINAE) MITE INFESTATION IN WILD RED-CROWNED PARAKEETS (CYANORAMPHUS NOVAEZELANDIAE): CORRELATIONS BETWEEN MACROSCOPIC AND MICROSCOPIC FINDINGS

During a study on health and disease in Red-crowned Parakeets (Cyanoramphus novaezelandiae) on Tiritiri Matangi Island and Little Barrier Island (Hauturu-o-Toi) in New Zealand between 2011 and 2013, an outbreak of feather loss prompted the collection of skin biopsies (n = 135) under anesthesia from the head of captured birds. A subset of samples (n = 7) was frozen to obtain whole specimens for identification of ectoparasites. Mites (range 1-11) were observed in 79/135 (58.5%) skin biopsies, whereas feather loss was only found in 47/142 (33.1%) birds captured during the sampling period. Compact orthokeratotic hyperkeratosis and acanthosis were found in association with mites. Procnemidocoptes janssensi (Acari: Epidermoptidae, Knemidokoptinae) was identified from whole mites obtained from skin biopsies. We describe the presence, pathology, and stages of infestation for knemidokoptinid mange in a wild parrot population in New Zealand. Given the clinical and pathologic changes observed and poor knowledge of the parasite's New Zealand host and geographic distribution, further work is recommended for this and sympatric parrots, to understand relationships between the host, parasite, environment, and expression of disease. Results from this study reinforce the value of including biopsy samples for the investigation of skin disease in wild birds, particularly to link etiologic agents with pathologic changes.

Skin biopsy in the context of dermatological diagnosis: a retrospective cohort study

Background. Skin biopsy is an established method for allying the dermatologist in overcoming the diagnostic dilemmas which occur during consultations. However neither do all skin biopsies produce a conclusive diagnosis nor the dermatologists routinely perform this procedure to every patient they consult. The aim of this study was to investigate the favourable clinical diagnoses set by dermatologists when performing skin biopsy, the diagnoses reached by the dermatopathologists after microscopic examination, and the relationship between them and finally to comment on the instances that skin biopsy fails to fulfill the diagnostic task. Methods. Six thousand eight hundred and sixteen biopsy specimens were reviewed and descriptive statistics were performed. Results. The mean age of the patients was 54.58 ± 0.26 years, the most common site of biopsy was the head and neck (38.3%), the most frequently proposed clinical diagnoses included malignancies (19.28%), and the most prevalent pathological diagnosis was epitheliomas (21.9%). After microscopic examination, a specific histological diagnosis was proposed in 83.29% of the cases and a consensus between clinical and histological diagnoses was observed in 68% of them. Conclusions. Although there are cases that skin biopsy exhibits diagnostic inefficiency, it remains a valuable aid for the dermatology clinical practice.