Philosophy of an Approach to a Slide

Jane M. Grant-Kels

UCHC Dermatopathology Laboratory, Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut, U.S.A.

By way of introduction, I would like to review with you my personal approach to a slide. None of the ideas presented herewith are original; they represent a compendium of ideas that have been borrowed from my teachers, especially my first mentor in dermatopathology, Dr. A. Bernard Acker-man, and all of my friends and colleagues I had taken training with and have collaborated with over the years, many of whom are authors of chapters in this book.

Remember, how well you perform as a dermatopathol-ogist is directly correlated to the development of the proper philosophical and intellectual approach to our specialty and each individual slide that crosses the stage of your microscope.


1. It is important to approach the pathology you see under the microscope from the clinician's point of view. Clinical-pathological correlation is essential. When you gaze on the histologic changes you should be able to imagine how the lesion looked clinically.

2. Know normal anatomy at various anatomic sites and learn to recognize changes that may be normal due to age or exposure to the elements. Once you know normal histology and its variants you will be able to recognize what is abnormal on the slide.

3. Learn to recognize common artifacts of either processing or biopsy technique.

4. The criteria applied to each case must be repeatable and well established.

5. The language of your report must be precise.

6. Be willing to admit when you do not know the diagnosis and appropriately seek the opinion of others.

7. Diseases are dynamic and demonstrate changes that correspond to their chronology or "lives." Learn to recognize the changing histologic features of an acute, fully developed, and resolving lesion.

8. Our knowledge of diseases is also dynamic. Therefore, keep an open mind. Criteria for diagnoses may evolve over the years with increased experience and new staining techniques. Be willing to learn and be open to new ideas.

9. Finally, there is much that is subjective in dermato-pathology; mistakes are inevitable. Learn from errors rather than hide from them. Mistakes and malpractice are not synonymous.

Your practical approach to the slide should demonstrate a methodical approach following a checklist of sequential steps (algorithmic method) utilizing pattern analysis. Sign out of slides should be done in a quiet place without distractions. All slides should be initially examined without knowledge of the clinical history. Prior to reviewing the slide under the microscope, examine the slide with the naked eye: make note of how the specimen was grossed and how many pieces of tissue are present to be examined on each slide. Establish the kind of biopsy technique used, that is, shave, punch, curette, or excision. If there are multiple small fragments, circle them to ensure that all pieces of tissue are reviewed.

Once you have placed the slide on your microscope stage (Table 1):

1. Employ scanning magnification. Try to establish the pattern of the infiltrate of cells. Is this an inflammatory or neoplastic infiltrate? Higher magnification should be used later to review cytologic changes.

2. Try to determine the anatomic site of the biopsy. Various anatomic locations have key distinguishing features. Certain diseases favor certain anatomic sites and, therefore, this information will help in clinical-pathological correlation. In addition, some locations may alter the appearance of the pathology. For example, overlapping stasis changes often alters a lesion on the leg of an older adult.

3. Try to determine the approximate age of the patient. Is there solar elastosis suggesting a sun-damaged adult? Are there effete sebaceous glands as would be seen in a young child? Many diseases have a tendency to occur in certain age groups as well as locations.

4. Confirm your impression regarding how the biopsy was obtained.

5. Look at all the sections on the slide.

6. Learn to recognize artifacts so that you do not assign inappropriate import to these changes.

7. Develop a systematic approach to looking at the sections of skin. Some dermatopathologists study the biopsy from top to bottom (stratum corneum ! rest of epidermis ! dermis ! subcutaneous tissue). Others prefer to first determine the pattern of changes in the dermis and then proceed to the epidermis and subsequently to the changes in the subcutis. Although I prefer the latter style, it is irrelevant which technique you use as long as you are methodical, consistent, and systematic in your approach.

8. Apply pattern analysis to help you determine whether a lesion is inflammatory, malformation, deposition, or neoplastic. This seemingly simple step is not always easy. It is not uncommon for neoplasms to be associated with significant inflammation and for inflammatory conditions to mimic a neoplastic process. Therefore, a specific diagnosis cannot always be achieved. However, the system works in most cases and one's

Table 1 Algorithmic Approach to a Slide

Scanning magnification:

1. look at all the sections and pieces of skin present on the slide

2. assess how specimen was obtained—punch, shave, etc.

3. determine anatomic site

4. determine approximate age of patient

5. imagine the clinical appearance of the lesion (CPC)

6. Is the lesion:

Inflammatory or

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