Fixation on Histology

Alopecia Specimen Orientation

  
Alopecia If you have worked in a laboratory that processes dermatology specimens, you might be familiar with punch biopsies that are ruling out the diagnosis of Alopecia. Alopecia is an autoimmune disease where your immune system attacks hair follicles, ultimately leading to hair loss. The most common areas of hair loss with Alopecia are on the scalp and the thigh. These specimens are oriented in a particular manner at the embedding center. Because of this, it is important to check the differential diagnosis when receiving punch biopsies from these two areas, especially ones that mention hair loss.

The orientation of Alopecia specimens is specific to each pathologist. Some prefer that they get embedded like a regular punch, laying down on its side so you can see all layers of the skin. Others, however, prefer that you stand the punch up, with the margin down in your embedding mold and the skin facing the ceiling (my favorite way to describe this orientation when training employees is “like an ice cream cone”). This allows the doctor to see cross sections of the punch biopsy, and they can count the individual hair follicles. You even have some very particular pathologists that like a combination of the two, where the specimen is bisected and oriented in two separate blocks. One half is oriented cut side down like a regular punch biopsy, then the other half with the margin down.

I work in a private reference laboratory where we process both dermatology and GI specimens. We have ten dermatopathologists who all have different preferences for Alopecia specimen orientation. So, to make sure that we are orienting the specimen properly at the embedding center, I send out a list of embedding preferences (see image) to the pathologists and ask them to pick either A, B, or C. If the specimen is bisected, the green arrows in the photo indicate which part of the specimen goes down into the embedding mold.

Alopecia Specimen Orientation


We flag the Alopecia specimens at the gross station by putting them in their own color cassette (in our case, that color is yellow), so when the tech at the embedding center receives the cassette, they know that it needs to be oriented differently. In our lab, we know who will be reading the case based on the client who submits the biopsy, but this might differ from where you work. In other settings where case assignment isn’t determined until slide distribution, I would encourage pathologists to agree on one preference to make this process easier.

If you were intimidated by Alopecia specimens before, hopefully, you will have the confidence to deal with these types of biopsies in the future, but if you ever have any doubts, talk with your pathologists. I promise they won’t bite, and in my career – I have discovered they are truly great resources!

Written by Nicole Robinson, BS, HTL(ASCP)

#2022
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#GeneralAnatomicPathology
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03-25-2022 19:25

Thanks Nicole for this blog. 


At the labs I have worked, Alopecia specimen are always treated like Preference A in your diagram.

The only difference has been the lab’s respective procedure at grossing, to ink or stain the cut sections, to aid the embedder in placing the cut sections faced down in the mold.

At one lab, the grossers placed eosin on the cut surfaces to help the embedder know that those surfaces should be placed faced down in the mold. 

At another lab, where eosin was being used in the processors, the grossers inked the cut surfaces red to indicate to the embedder to place the inked surfaces down in the mold. 

Preference B in your diagram is only used for routine punch biopsies at the labs I have worked. 

03-18-2022 10:26

Thank you very much indeed!! For me I have never thought of Alopecia cases for embedding!! Great article and great lesson!!
George