introduction to dermatopathology sw training day …...introduction to dermatopathology sw training...
TRANSCRIPT
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