Introduction to dermatopathology SW Training Day …...Introduction to dermatopathology SW Training...
Transcript of Introduction to dermatopathology SW Training Day …...Introduction to dermatopathology SW Training...
Introduction to dermatopathologySW Training Day 12 June 2019
Dr Paul Craig DipDerm (RCPath) FRCPA FRCPath
Gloucestershire Hospitals NHSFT (& previously UH Bristol)[email protected]
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 [email protected] 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