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Vertical and transverse sections of alopecia biopsy specimens: Combining the two to maximize diagnostic yield
Vertical and transverse sections of alopecia biopsy specimens: Combining the two to maximize diagnostic yield LTC Dirk M. Elston, MC, USA, LTC Martha L. McCollough, MC, USA, and MAJ Vincent L. Angeloni, MC, USA Fort Sam Houston, Texas Background: Traditional vertical sections of scalp biopsy specimens contain few hair follicles. For this reason transverse sections of scalp biopsy specimens have been advocated. Both methods have advantages and disadvantages. We have developed a simple method that we believe offers the best of both methods. Objective: Our purpose was to assessthe impact of combining vertical and transverse sections of scalp biopsy specimens. Methods: Two 4 mm punch biopsies are performed. One specimen is bisected vertically: half for hematoxylin-eosin (H-E) staining, half for direct immunofluorescence. The second specimen is bisected transversely and submitted for H-E. The three pieces of tissue for H-E staining are embedded in a single cassette. Results: Because a biopsy specimen for direct immunofluorescence is commonly obtained in casesof alopecia, our method does not add a surgical procedure. All three pieces of tissue for H-E staining are embedded in a single paraffin block. Therefore the cost of histologic interpretation is not increased. Our diagnostic yield improved. Transverse sections were superior in cases of lupus erythematosus and lichen planopilaris with focal follicular involvement. Features of the follicular degeneration syndrome were also best demonstrated in transverse sections. Interface changes, lupus panniculitis, miniaturized hairs, and trichomalacia were better demonstrated in vertical sections. Conclusion: Our method exploits the advantages of both vertical and transverse sections and improves diagnostic yield without increasing cost. (J AM ACAD DERMATOL 1995;32:454-7.)
The histologicdiagnosisof alopeciacan be challenging.Traditional vertical sectionsgenerallydemonstrateonly four to six terminal hairs.Stepsections through the block can demonstratemany more follicles,but this methodis labor intensive.Transverse sections,popularizedby Headington,’ may contain 20 to 30 follicles in a single section.2However, transversesectionsfail to demonstratechangesat the dermoepidermaljunction, within the papillary dermis,andwithin the subcutaneousfat. Again, step sectionsthroughthe block could be usedto demonFrom the Dermatology Service Army Medical Center.
and Department
of Pathology,
Brooke
The views expressed are those of the authors and are not to be construed as official or as representing those of the U.S. Army Medical Department or the Department of Defense. Accepted Reprints 16/I/60523
454
for publication Sept. 11, 1994. not available from authors.
stratethesechangeq3but this is labor intensiveand the resultsare generallysuboptimal. Someinvestigatorshavesubmittedpairedbiopsy specimens:one sectionedvertically, the other sectioned transversely.Each specimenis embedded separately.2v4This providesthe advantageof both vertical and transversehistologicstudy but doubles the costof processingandstaining.In addition,with this method patientsmay haveto undergothreebiopsies:onefor vertical sections,a secondfor transversesections,and a third for immunofluorescence. We describea method that providesvertical and transversesectionsplus immunofluorescencewith only two biopsy specimensand at no extra cost. PATIENTS
AND METHODS
During the past year all biopsy specimens of alopecia at Brooke Army Medical Center’s dermatology clinic have been handled in the same fashion. Two 4 mm punch biopsy specimens are obtained. One is bisected vertically.
Journal of the American Academy of Dermatology Volume 32, Number 3
Elston, McCollough, and Angeloni 455
Fig. 1. Right, Vertically bisected biopsy specimen. Half is submitted for direct immunofluorescence (DIF), half for histologic study (H&E). Left, Transversely bisected biopsy specimen. Both halves are added to formalin bottle that already contains half the vertical biopsy specimen,
Half is submitted for direct immunofluorescence, and half is placed in formalin for routine histologic study. The second specimen is bisected transversely, approximately 1 mm above the dermosubcutaneous junction (Fig. 1). Both pieces of the transversely bisected specimen are added to the formalin bottle that already contains half the first specimen. The routine patient identification label is placed on the side of the specimen bottle. A special “alopecia biopsy” label is placed on the cap of the specimen bottle. This label reads as follows:
Scalp Biopsies One-half punch, bisectedvertically One punch, bisectedtransversely Embed all piecesin one cassette Each piece cut sidedown
The label alerts the histology technicians that the specimen requires special handling. The technicians embed each of the three pieces, cut side down, in a single cassette. To assessthe impact of our new method, we reviewed the past year’s biopsy specimens and compared them with those of previous years. RESULTS
We found numerous advantages to our new method. First, all alopecia biopsy specimens are handled in the same manner. Once our technicians
became familiar with the new routine, specimens were consistently embedded correctly. Laboratory costs decreased because the combination of transverse and vertical sections increased the likelihood that diagnostic features would be seen on the initial routine sections. Therefore deeper levels were requested less frequently. Because all three tissue fragments are contained within a single block, recuts for deeper levels and special stains are not duplicated on multiple blocks. Our diagnostic yield increased. In many cases transverse sections allowed for easy diagnosis when vertical sections did not demonstrate diagnostic changes. In other cases the reverse was true. The combination allowed a specific diagnosis in many cases in which either vertical or transverse sections alone would have been inadequate. Diagnostic features that were seen only in vertical sections included interface changes of lupus erythematosus (Fig. 2) and lichen planopilaris. Other findings that were better seen in vertical sections included changes of lupus panniculitis, trichomalacia, and the miniaturized follicles of alopecia areata and androgenic alopecia. Perifollicular infiltrates and follicular interface changes in lupus erythematosus and lichen planopilaris were often focal and were seen more easily in transverse sections. Other features that were seen
456 Elston, McCollough, and Angeloni
Journal of the American Academy of Dermatology March 1995
Fig. 2. Lupus erythematosus. Prominent basement membrane zone thickening is seen in vertical section. (Periodic acid-Schiff stain; original magnification x 100.)
Fig. 3. Asymmetric thinning of follicular epithelium in follicular degeneration syndrome is seen in transverse section. (Hematoxylin-eosin stain; original magnification X 100.)
more easily in transverse sections included anagen/ telogen ratios, elastotic degeneration and melanoderma within fibrous tracts, lymphocytic peribulbar infiltrates, pigment casts, and catagen hairs. A newly described disorder, the follicular degeneration syndrome,5 is characterized by an asymmetric thinning of the follicular epithelium. These findings were best demonstrated in transverse sections
(Fig. 3).
DISCUSSION
In the histologic diagnosis of alopecia both transverse and vertical sections offer advantages. In transverse sections more follicles are visible in a single section. Because histologic changes may be evident in only a few follicles, it is often helpful to examine all follicles in the biopsy specimen.6-8 With vertical sections dozens of sections may be required to demonstrate diagnostic changes.g In general, fo-
Journal of the American Academy of Dermatology Volume 32, Number 3
cal changesare demonstratedmore easily in transversesections.The main advantageof vertical sections is that they demonstratechangesat the dermoepidermal junction, papillary dermis, and subcutaneoustissue.Somecasesstill requiremultiple step sections.Lichen planopilaris may involve only the superficialfollicular infundibulum.6In such casesmultiple vertical sectionsmay be requiredto demonstratethe findings. Our methodprovidesvertical andtransversesectionswithout increasingthe costto the patientor the workloadfor our histologysection.In fact, it hasdecreasedthe frequencyof recut requests. Our method has other advantages.In teaching dermatologyand pathologyresidentsit is helpful to haveboth the vertical and transversesectionson a singleslidefor purposesof comparison.Our method alsooffers a choicebetweenvertical and transverse sectionswhenphotomicrographsaretaken for publication. We cannot overemphasizethe importance of communicatingwith the histologytechnicians.We havefoundthat a labelplacedon the lid of the spec-
E&on,
McCollough,
and Angeloni
45’7
imen bottle is the most effectivemeansof alerting the techniciansthat the specimenrequiresspecial handling. A line diagram depictingvertical versus transversesectioningcan alsobe helpful. REFERENCES
1. Headington JT. Transversemicroscopicanatomy of the human scalp.Arch Dermatol 1984;120:449-56. 2. Whiting DA. Diagnostic and predictivevalue of horizontal sectionsof scalpbiopsy specimensin male pattern androge netic alopecia.J AM ACADDERMATOL1993;28:755-63. 3. SolomonAR. The transverselysectionedscalpbiopsy specimen: the technique and a algorithm for its usein the diagnosisof alopecia.Adv Dermatol 1994;9:127-57. 4. Sperling LC, Winton GB. The transverse anatomy of androgenicalopecia.J Dermatol Surg Oncoll990;16: 112733. 5. SperlingLC, Sau P. The folhcular degenerationsyndromein black patients. Arch Dermatol 1992;128:68-4. 6. Mehregan DA, Van Hale H, Muller SA. Lichen planopilaris [Abstract]. J Cutan Path01 1991;18:380. 7. Mehregan DA, Van Hale HM, Muller SA. Lichen planopilaris: clinical and pathologic study of forty-five patients. J AM ACADDERMATOL1992;27:935-42. 8. LachapelleJM, Pierard GE. Traumatic alopeciain trichotillomania. J Cutan Path011977;4:51-67. 9. Ionnides G. Alopecia: a pathologist’sview. Int J Dermatol 1982;21:316-28.
The histologicdiagnosisof alopeciacan be challenging.Traditional vertical sectionsgenerallydemonstrateonly four to six terminal hairs.Stepsections through the block can demonstratemany more follicles,but this methodis labor intensive.Transverse sections,popularizedby Headington,’ may contain 20 to 30 follicles in a single section.2However, transversesectionsfail to demonstratechangesat the dermoepidermaljunction, within the papillary dermis,andwithin the subcutaneousfat. Again, step sectionsthroughthe block could be usedto demonFrom the Dermatology Service Army Medical Center.
and Department
of Pathology,
Brooke
The views expressed are those of the authors and are not to be construed as official or as representing those of the U.S. Army Medical Department or the Department of Defense. Accepted Reprints 16/I/60523
454
for publication Sept. 11, 1994. not available from authors.
stratethesechangeq3but this is labor intensiveand the resultsare generallysuboptimal. Someinvestigatorshavesubmittedpairedbiopsy specimens:one sectionedvertically, the other sectioned transversely.Each specimenis embedded separately.2v4This providesthe advantageof both vertical and transversehistologicstudy but doubles the costof processingandstaining.In addition,with this method patientsmay haveto undergothreebiopsies:onefor vertical sections,a secondfor transversesections,and a third for immunofluorescence. We describea method that providesvertical and transversesectionsplus immunofluorescencewith only two biopsy specimensand at no extra cost. PATIENTS
AND METHODS
During the past year all biopsy specimens of alopecia at Brooke Army Medical Center’s dermatology clinic have been handled in the same fashion. Two 4 mm punch biopsy specimens are obtained. One is bisected vertically.
Journal of the American Academy of Dermatology Volume 32, Number 3
Elston, McCollough, and Angeloni 455
Fig. 1. Right, Vertically bisected biopsy specimen. Half is submitted for direct immunofluorescence (DIF), half for histologic study (H&E). Left, Transversely bisected biopsy specimen. Both halves are added to formalin bottle that already contains half the vertical biopsy specimen,
Half is submitted for direct immunofluorescence, and half is placed in formalin for routine histologic study. The second specimen is bisected transversely, approximately 1 mm above the dermosubcutaneous junction (Fig. 1). Both pieces of the transversely bisected specimen are added to the formalin bottle that already contains half the first specimen. The routine patient identification label is placed on the side of the specimen bottle. A special “alopecia biopsy” label is placed on the cap of the specimen bottle. This label reads as follows:
Scalp Biopsies One-half punch, bisectedvertically One punch, bisectedtransversely Embed all piecesin one cassette Each piece cut sidedown
The label alerts the histology technicians that the specimen requires special handling. The technicians embed each of the three pieces, cut side down, in a single cassette. To assessthe impact of our new method, we reviewed the past year’s biopsy specimens and compared them with those of previous years. RESULTS
We found numerous advantages to our new method. First, all alopecia biopsy specimens are handled in the same manner. Once our technicians
became familiar with the new routine, specimens were consistently embedded correctly. Laboratory costs decreased because the combination of transverse and vertical sections increased the likelihood that diagnostic features would be seen on the initial routine sections. Therefore deeper levels were requested less frequently. Because all three tissue fragments are contained within a single block, recuts for deeper levels and special stains are not duplicated on multiple blocks. Our diagnostic yield increased. In many cases transverse sections allowed for easy diagnosis when vertical sections did not demonstrate diagnostic changes. In other cases the reverse was true. The combination allowed a specific diagnosis in many cases in which either vertical or transverse sections alone would have been inadequate. Diagnostic features that were seen only in vertical sections included interface changes of lupus erythematosus (Fig. 2) and lichen planopilaris. Other findings that were better seen in vertical sections included changes of lupus panniculitis, trichomalacia, and the miniaturized follicles of alopecia areata and androgenic alopecia. Perifollicular infiltrates and follicular interface changes in lupus erythematosus and lichen planopilaris were often focal and were seen more easily in transverse sections. Other features that were seen
456 Elston, McCollough, and Angeloni
Journal of the American Academy of Dermatology March 1995
Fig. 2. Lupus erythematosus. Prominent basement membrane zone thickening is seen in vertical section. (Periodic acid-Schiff stain; original magnification x 100.)
Fig. 3. Asymmetric thinning of follicular epithelium in follicular degeneration syndrome is seen in transverse section. (Hematoxylin-eosin stain; original magnification X 100.)
more easily in transverse sections included anagen/ telogen ratios, elastotic degeneration and melanoderma within fibrous tracts, lymphocytic peribulbar infiltrates, pigment casts, and catagen hairs. A newly described disorder, the follicular degeneration syndrome,5 is characterized by an asymmetric thinning of the follicular epithelium. These findings were best demonstrated in transverse sections
(Fig. 3).
DISCUSSION
In the histologic diagnosis of alopecia both transverse and vertical sections offer advantages. In transverse sections more follicles are visible in a single section. Because histologic changes may be evident in only a few follicles, it is often helpful to examine all follicles in the biopsy specimen.6-8 With vertical sections dozens of sections may be required to demonstrate diagnostic changes.g In general, fo-
Journal of the American Academy of Dermatology Volume 32, Number 3
cal changesare demonstratedmore easily in transversesections.The main advantageof vertical sections is that they demonstratechangesat the dermoepidermal junction, papillary dermis, and subcutaneoustissue.Somecasesstill requiremultiple step sections.Lichen planopilaris may involve only the superficialfollicular infundibulum.6In such casesmultiple vertical sectionsmay be requiredto demonstratethe findings. Our methodprovidesvertical andtransversesectionswithout increasingthe costto the patientor the workloadfor our histologysection.In fact, it hasdecreasedthe frequencyof recut requests. Our method has other advantages.In teaching dermatologyand pathologyresidentsit is helpful to haveboth the vertical and transversesectionson a singleslidefor purposesof comparison.Our method alsooffers a choicebetweenvertical and transverse sectionswhenphotomicrographsaretaken for publication. We cannot overemphasizethe importance of communicatingwith the histologytechnicians.We havefoundthat a labelplacedon the lid of the spec-
E&on,
McCollough,
and Angeloni
45’7
imen bottle is the most effectivemeansof alerting the techniciansthat the specimenrequiresspecial handling. A line diagram depictingvertical versus transversesectioningcan alsobe helpful. REFERENCES
1. Headington JT. Transversemicroscopicanatomy of the human scalp.Arch Dermatol 1984;120:449-56. 2. Whiting DA. Diagnostic and predictivevalue of horizontal sectionsof scalpbiopsy specimensin male pattern androge netic alopecia.J AM ACADDERMATOL1993;28:755-63. 3. SolomonAR. The transverselysectionedscalpbiopsy specimen: the technique and a algorithm for its usein the diagnosisof alopecia.Adv Dermatol 1994;9:127-57. 4. Sperling LC, Winton GB. The transverse anatomy of androgenicalopecia.J Dermatol Surg Oncoll990;16: 112733. 5. SperlingLC, Sau P. The folhcular degenerationsyndromein black patients. Arch Dermatol 1992;128:68-4. 6. Mehregan DA, Van Hale H, Muller SA. Lichen planopilaris [Abstract]. J Cutan Path01 1991;18:380. 7. Mehregan DA, Van Hale HM, Muller SA. Lichen planopilaris: clinical and pathologic study of forty-five patients. J AM ACADDERMATOL1992;27:935-42. 8. LachapelleJM, Pierard GE. Traumatic alopeciain trichotillomania. J Cutan Path011977;4:51-67. 9. Ionnides G. Alopecia: a pathologist’sview. Int J Dermatol 1982;21:316-28.