Introduction to dermatopathologySW Training Day 12 June 2019

Dr Paul Craig DipDerm (RCPath) FRCPA FRCPath

Gloucestershire Hospitals NHSFT (& previously UH Bristol)paul.craig2@nhs.net

1. Brief overview of inflammatory skin biopsies

2. Overview of Dermatopathology as a subspecialty

Dermatopathology of Inflammatory Disease

• historically MDT meetings for inflammatory skins: clinicopathologic correlation vital – clinical photos

• use a textbook with clinical photos

• requires knowledge of dermatology • relatively few specific well-defined entities• incomplete clinical details• atypical rash biopsied only

• evolution of signs• clinical impression changes with time(often by the time you have the slides)

Dermatopathology of Inflammatory Disease

Dermatopathology of Inflammatory Disease

• variation in disease by skin type

• variation in clinician skill

• general pathologists often struggle with inflammatory cases –

more recognised diseases than most organs, teaching variable

• Practically for clinician and patient:

pathologist often can’t make definitive diagnosis

BUT can exclude important differential diagnoses

• Use reaction pattern (Ackerman, Weedon)

• Psoriasiform• Spongiotic• Granulomatous• Lichenoid (interface)• Vesiculobullous• Vasculopathic (vasculitis, thrombo-embolic)

First chapter in Weedon’s skin pathology lists them

Dermatopathology of Inflammatory Disease

• in conclusion of report use Ackermann/Weedon reaction patterns

• follow by adding further features

• then add differential diagnosis (if you can think of useful ones!)

Dermatopathology of Inflammatory Disease

e.g. Conclusion: Punch biopsy skin left leg –

spongiotic dermatitis with parakeratosis and a mixed, superficial dermal, predominantly perivascular, chronic inflammatory cell infiltrate including a few eosinophils.

Possible diagnoses include a form of eczema or spongiotic drug reaction.

Biopsy principles – inflammatory pathology

• The larger the biopsy the more chance there is of getting useful report – complain and ask for incisional biopsies

• Deep biopsy needed if e.g. panniculitis or vasculitis suspected

• Biopsy normal into abnormal area, or

• Biopsy normal and separate abnormal especially if connective tissue abnormality – normal can be v. difficult to assess

• Cut levels!

Cut deeper levels if you don’t have a diagnosis!

Lesion missed as not deep enough into tissue

Now deep enough into tissue so lesion seen

Level 2 Level 10

Punch biopsy

Level 3

Punch biopsy

Level 10

Excoriation

Incisional biopsy

Level 1

Incisional biopsy

Level 9

Excoriation on level 1 after bisecting punch biopsy!

Initial levels 1-3

? lichenoid: BUT also

spongiosis and neutrophils

Deeper level 9: acute pustular folliculitis

PAS: septate

branched fungal

hyphae and spores

• historically MDT meetings for inflammatory skins :clinicopathologic correlation vital

• Requires knowledge of dermatology

• Relatively few specific well-defined entities

• Incomplete clinical details

• Atypical rash biopsied only

• Variation in disease by skin type

• Variation in clinician skill

• Evolution of signs and clinical impression changes (e.g. by the time you have the slides)

• Often no definitive diagnosis reached but exclude important

differentials

Dermatopathology of Inflammatory Disease

History Of Dermatopathology

• Paul Gerson UNNA

• Dermatologist in Hamburg, Germany

• 1884. Histopathologie der Hautkrankheiten(Histopathology of Skin Diseases)

History Of Dermatopathology• USA: New York / Philadeplhia

• Bernie Ackermann: An algorithmic approach based on pattern analysis: 1970s

• Ackermann Academy of Dermatopathology

UK: subspecialty of Dermatopathology

RCPath Diploma in Dermatopathology

• At least equivalent of 6 months dermatology training

• Can be from attending clinics, local clinical meetings, regional and national dermatology meetings

“The standard required to pass the Diploma in

Dermatopathology is that of a medical expert

specialist offering a diagnostic opinion in

dermatopathology to local and often more

distant colleagues.”

UK: subspecialty of Dermatopathology

RCPath Diploma in Dermatopathology

“Candidates for the examination will be expected to demonstrate considerable knowledge in all aspects of dermatopathology, at a standard beyond that required to pass the FRCPath examination in histopathology.”

Part 1: 2x3hr essay papers - if pass thenPart 2 is a 2 day practical: 20 short cases

6 long casesviva

Current Chief Examiner: Asok Biswas (Edinburgh)

RCPath Dermatopathology Special Advisory Committee: Chair: Lynne Jamieson (Salford)

UK: subspecialty of dermatopathology

• Approx 220 members• Only £15/year• The British Society for Dermatopathology is a Specialist Interest Group of

the British Association of Dermatologists.

• Annual Self Assessment 1st Monday in July• Annual meeting on the first day of the British Association of

Dermatologists Annual Meeting (1st Tuesday in July)• Annual Trainee Workshop ?this year

• britsocdermpath.co.uk• Email sara.edward@nhs.net for membership enquiry

britsocdermpath.co.uk

http://www.virtualpathology.leeds.ac.uk/eqa/bsd.php?circ=2

Dermatopathology and Dermatology Annual Meetings in the UK include:

• British Society for Dermatopathology (at the Brit Assoc Dermatologists Annual Meeting) – 1st week July – 2 days dermpath (4 days total)

• London Dermatopathology Symposium – May – 3 days

• Edinburgh Dermatopathology Symposium – June – 2 days

• Leeds Dermatopathology & soft tissue – Oct – 1-2 days

• St John’s Update in Dermatopathology – April – 1 day

• RCPath Update in Dermatopathology – variable – 1 day

• National Specialist Dempath EQA Review Meetings- May/Nov- 2x1 day

• British Division of the IAP/PathSoc Joint meeting – July – 1 day (skin)

• Royal Society of Medicine Dermatology Monthly Meeting

• St John’s Society of Dermatology Meetings etc.

https://badannualmeeting.co.uk99th Annual Meeting of the British

Association of Dermatologists2nd - 4th July 2019

ACC Liverpool

Dermatopathology and Dermatology Annual Meetings overseas include:

• French/Anglo/Belgian Dermpath – Spring/Autumn – 2 x 1 day

• International Society of Dermatopathology – Sep/Oct – 3 days

• American Society of Dermatopathology – Oct/Nov – 4 days

• Joint Int Soc & Am Soc Dermatopathology – March – 2 days

• EADV

• European Soc of Path

• USCAP

• World Congress of Dermatology

• Various melanoma conferences etc .

The XXXIII International Congress of the International Academy of Pathology and the 32nd Congress of the European Society of Pathology

• Visit: iap2020.com• Jointly sponsored by the ESP and the British Division of the IAP.• 29 August – 2 September 2020• Scottish Exhibition & Conference Centre (SECC), Glasgow, UK

Leeds Pathology 2019 Thursday 4 July 2019 at the Harrogate Convention Centre

path.org.uk & bdiap.org

• Daniela Massi “4th Edition of the WHO Classification of Skin Tumours – Melanocytic tumours”

• Paul Craig “Determining risk status from pathology, genetics and outcome data in cutaneous squamous cell carcinoma; a UK national project”

• John Goodlad – “Cutaneous lymphoma”

• Laszlo Igali & Ferenc Igali - "Touchable pathology - on new pathways in Dermatopathology

UK: subspecialty of dermatopathology

• Also a subspecialty of dermatology

• Dermatopathology Department,St. John’s Institute of Dermatology

(part of St. Thomas’ Hospital, London)

• Edward Wilson-Jones• Neil Smith• Philip McKee (St. Thomas’)

• Eduardo Calonje: Advanced Course in Dermatopathology(now stopped)

• Catherine Stefanato (alopecia)

USA

• Separate Boards exam in Dermatopathology

allows dermatologists to report, similar to Diploma in Dermatopathology UK but not as rigorous

• 1-2yrs after qualifying as dermatologist or pathologist

(need 6/12 dermatology training)

Germany

• approx. 20 main dermpath labs

• also separate Boards equivalent exam in dermpath

• Some report 50 000 cases each

• Very lean processes

• 8 Euros only per case!

Dermatopathology:some available textbooks/ebooks?

Mckee’s Pathology of the skin

5th edition 2020 out now – Calonje et al

(HAS CLINICAL PHOTOS

AND CLINICAL FEATURES

YOU MUST LOOK AT THESE WHEN DOING DERMPATH)

Weedon’s Skin Pathology

2nd edition 2014 (ebook 2016)

Dermatopathology:which textbooks/ebooks to read?

Neoplastic DermatopathologyDavid Cassarino 2nd ed 2017

WHO Classification of Skin Tumours 2018 Elder, Massi, Scolyer, Willemze

Others: eg Lever’s Histopathology of the skin

Clinical dermatology:Rook’s Textbook of Dermatology(UK) Dermatology: Bolognia (USA)

Dermatopathology:which textbooks/ebooks to read?

Histological Diagnosis of Nevi and Melanoma

Guido Massi and Phil LeBoit

Dermatopathology:journals include

• American Journal of Dermatopathology (ISDP)

• Journal of Cutaneous Pathology (ASD)

• Journal of American Academy of Dermatology

• British Journal of Dermatology

• Archives of Dermatology

• Clinical and Experimental Dermatology

• Am J Clin Path, Am J Surg Path, Human Pathology, Histopathology, J Clin Pathol etc.

Websites include:

• Dermnetnz – for all general dermatology stuff – clinical photos, brief discussion of entities and their management (+ a little dermpath)

• Dermpathpro (set up by Iskander Chaudhry, UK, clinical leads in USA

• britsocdermpath.co.uk

• intsocdermpath.org

• asdp.org