Patrick Adam

Analysis of incomplete excisions of basal-cell carcinomas after breadloaf microscopy compared with 3D-microscopy: a prospective randomized and blinded study.

Basal‐cell carcinomas may show irregular, asymmetric subclinical growth. This study analyzed the efficacy of ‘breadloaf’ microscopy (serial sectioning) and three‐dimensional (3D) microscopy in detecting positive tumor margins. Two hundred eighty‐three (283) tumors (51.2%) were put into the breadloaf microscopy group; 270 tumors (48.8%) into the 3D microscopy group. The position of any detected tumor outgrowths was identified in clock face fashion. The time required for cutting and embedding the specimens and the examination of the microscopic slides was measured. Patient/tumor characteristics and surgical margins did not differ significantly. Tumor outgrowths at the excision margin were found in 62 of 283 cases (21.9%) in the breadloaf microscopy group and in 115 of 270 cases (42.6%) in the 3D microscopy group, constituting a highly significant difference (p < 0.001). This difference held true with incomplete excision of fibrosing (infiltrative/sclerosing/morpheaform) tumors [32.9% in the breadloaf microscopy group and 57.5% in the 3D microscopy group (p = 0.003)] and also with solid (nodular) tumors [16.1 and 34.2%, respectively (p < 0.001)]. The mean overall examination time required showed no important difference. In summary, for detection of tumor outgrowths, 3D microscopy has almost twice the sensitivity of breadloaf microscopy, particularly in the situation of aggressive/infiltrative carcinomas.

3D Histology Evaluation of Dermatologic Surgery

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Dreidimensionale (3D) Histologie im Routineverfahren: praktische Durchführung und deren Evaluation

Die lückenlose Aufarbeitung der Ränder eines Tumors mittels dreidimensionaler (3D) Histologie erscheint oft kompliziert und auf eine Personalunion von Operateur und Histopathologe reduziert. Wir stellen klare Regeln vor, die eine Kommunikation zwischen allen Beteiligten erlaubt und überprüfen deren Anwendung in der täglichen Routine.

Three dimensional (3D) histology in daily routine: practical implementation and its evaluation.

The continuous evaluation of the edges of a tumor by means of three‐dimensional (3D) histology often appears complicated and require the surgeon and dermatopathologist to work together closely. We present clear rules that allow communication between all parties involved and then verify their application in daily routine.

Communication with the Lab

The management of a full 3D histology needs a tight communication between the surgeon and the pathologist. Clear and safe rules are necessary to enable both the surgeon and the pathologist to point out areas of incomplete tumor excisions very precisely. In Mohs’ micrographic surgery, the surgeon and pathologist is the same person. This has advantages because a communication with other institutions is not necessary.

Dividing Tumors and Topographical Orientation

So far only on examples of small tumors in which the excised tumor specimen fitted completely in the device for histological sectioning were discussed. If tumors are larger due to their advanced growth or larger safety margins, the resulting specimen may not fit completely onto the devices used for histological sectioning. In these cases, the excised specimens have to be divided in parts small enough to be sectioned by either cryo-sectioning or paraffin sectioning raising new complex issues of topographical orientation which will be discussed in the following.

Terminology and Facts

Mohs termed the excision of tumor tissues with the aid of a histological evaluation “microscopically controlled surgery” (MCS), and in its original meaning it is different from the “vertical serial cutting” (loaf-bread technique, see below). A horizontal serial cutting method was described by Burg and Konz in which the tumor would be cut horizontally using a microtome (see below). This has the advantage that the entire tumor can be analyzed histologically with only very small gaps.

Variations for Special Locations and Large, Deep Penetrating Tumors

In this chapter, the excision of tumors growing at special locations such as nose, lips, eyelid, and ear will be discussed. The natural border of the anatomy of these tissues restrains the possibilities for tumor outgrowths and also limits the surgical options to remove the margin. Also, surgery at these locations or the division of the tumor tissue might require special care as the skin can be very thin or very inflexible. Additionally, the excision and division workup of very large tumors which might also penetrate deeper tissues like bones will be described in this chapter in detail. Here particularly, the deep penetration of tumors into other tissues such as bone tissue requires special attention as a full 3D histological workup might not be possible or straightforward. It should be noted that as before, all combinations of excision variations and embedding are freely exchangeable and are only chosen as exemplification. As always, the ultimate goal for all procedures is the full recovery of the entire 3D margin of the tumor specimen for histological evaluation and the following application of these findings onto the respective 3D defect. In this chapter, the plane of the embedded margins and the corresponding histological slide are presented in a simplified margin scheme.

The Basics for Excision and Flattening

In this chapter, the basic principles of tumor excisions will be discussed. By introducing several different methods for tumor excisions and converting 3D margins to a 2D plane, the reader will be given the opportunity to develop her/his own preferred procedure. It should be noted that the choice of method is mainly influenced by the preferences of the executing surgeon, the interaction between surgical team and pathology, and the histological procedure chosen which will be discussed later in this book ( Chap. 5).

Embedding and Sectioning

Following the excision of the tumor tissue and the conversion of the 3D tumor margins into a 2D plane, the tissue samples will have to be embedded and sectioned. There are two alternative commonly used techniques to prepare sections from the tumor samples which both produce sections suitable for a full diagnostics: paraffin sections or cryo-sections. In the following, both techniques will be discussed, and all required procedures for the preparation and the sectioning using either of them will be described and illustrated.