Skin ellipse and tip margin significance

[CrazyEBV]

Why do surgeons excise skin lesions as ellipses? and what is the significance of submitting o'clock tips separately. What if a tip section has basal cell carcinoma but not touching the ink? How to report this?

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[Dral]

Skin will not close correctly if a perfect circle is taken. By just doing an ellipse from the start along skin tension lines, the defect can easily be closed in a linear fashion without cutting out extra dog ears.

So if one has a skin lesion that is roughly circular, someone may take a 4mm margin around the lesion. The tips (dog ears) are in addition to that margin.

I think reporting will depend on how the sample was grossed/oriented.

 

[icpshootyz]

If you find tumor in the tip margin but not at ink in that tip, you should level through that block to make sure no tumor touches ink as you get closer and closer to the true tip.

 

[Autopsy101]

Find out how the tip is grossed and how the histotechs embed the tip if you don't know. Do they embed the whole tip with the point up or down in the block? If the point is up, if there is tumor present in the tip, the en-face margin so to speak is positive. If the point is down, you need to level the block and see if the basal cell disappears. If it disappears, tip margin is close, but negative. If you want to save histotechs time and levels, have them flip the block and cut sections from the true en-face tip margin to see if basal cell is present.

If the tips are bisected through the point at the time of grossing it usually makes the sections more straight forward because it turns the en-face margin into a perpendicular and you are looking for ink on tumor which is easier to interpret on slides, but more problematic for the techs to get embedded exactly and not tangentially. I prefer this method, but most dermpath trained people I have worked with prefer the tips be embedded whole. Hope that this makes sense and is helpful.

 

[Dral]

Find out how the tip is grossed and how the histotechs embed the tip if you don't know. Do they embed the whole tip with the point up or down in the block? If the point is up, if there is tumor present in the tip, the en-face margin so to speak is positive. If the point is down, you need to level the block and see if the basal cell disappears. If it disappears, tip margin is close, but negative. If you want to save histotechs time and levels, have them flip the block and cut sections from the true en-face tip margin to see if basal cell is present.

If the tips are bisected through the point at the time of grossing it usually makes the sections more straight forward because it turns the en-face margin into a perpendicular and you are looking for ink on tumor which is easier to interpret on slides, but more problematic for the techs to get embedded exactly and not tangentially. I prefer this method, but most dermpath trained people I have worked with prefer the tips be embedded whole. Hope that this makes sense and is helpful.

We have a unique way of doing excision margins here, but I like the method you mention in your second paragraph.

How many sections do you usually look at? I guess if you face your tissue and cut a slide or two from each half, and if your most adjacent debulk breadloaf is clear at the ink, things should be good.

 

[Autopsy101]

Usually look at 2 levels unless it is an issue, then cut deepers.

 

[schrute]

Why do surgeons excise skin lesions as ellipses?

...isn't that kind of a basic medical question? Do any surgery rotations in med school? Hard to close a jig-saw puzzle-piece excision or a circle...there's anatomic finesse involved.

and what is the significance of submitting o'clock tips separately. What if a tip section has basal cell carcinoma but not touching the ink? How to report this?

The latter questions involve applying your basic grossing skills: margins matter, and consequently how a block is going to be faced & cut matters, because being able to relate the histologic findings to a 3-dimensional piece of tissue in the event further excision/resection is required matters.