Overview of Mohs Micrographic Surgery Section of Specimens Using Cryostat, Stain, and Immunostain
Mohs micrographic surgery (MMS) is a special type of surgery that is used to treat skin cancer. The main benefits of this surgery are that it allows doctors to control and remove cancer cells very accurately, while leaving as much healthy tissue as possible. This is achieved by using special techniques to examine the tissue under a microscope. However, the quality of these techniques is extremely important, as errors could lead to the loss of important information about the cancer. This in turn may lead to harm for the patient, an increase in disease recurrence and higher medical costs.
In MMS, the process of creating and examining tissue sections is similar to other methods used in pathology. However, doctors and technicians use a variety of methods to prepare the tissue. The goal is to create a section that allows for examination of all the outer and deeper parts of the tissue in one go. This is done by carefully arranging the sample and freezing it. The frozen tissue is then cut into thin sections using a special tool called a microtome.
Once the tissue is cut, a process called staining is used to highlight specific parts of the cells. In MMS, the most commonly used stain is called hematoxylin and eosin (H&E). Other stains, like toluidine blue, are used mainly for a type of skin cancer called basal cell carcinoma. Certain specialized dyes, or immunohistochemistry stains, are used particularly for melanomas, a type of skin cancer. While some similar dyes can be used to detect other types of skin cancers, such as basal cell carcinomas and squamous cell carcinomas, they are not used as often because they are more expensive and time consuming.
When examining the tissue slides, doctors need to watch out for changes in the quality of the slide that might be related to errors during processing. If any errors are detected, the doctors must communicate their findings and plans to correct these errors to the entire team, especially the technicians who prepare the tissue. Some common errors that can occur include tears or holes in the tissue sections, staining that is too much or too little, and the presence of bubbles or water droplets. Recognizing these issues quickly is very important, as it allows the team to correct them promptly with appropriate solutions.
Why do People Need Mohs Micrographic Surgery Section of Specimens Using Cryostat, Stain, and Immunostain
Mohs surgery is a type of procedure used to treat skin cancer. A guideline called “Mohs appropriate use criteria (AUC)” helps doctors determine if the surgery is suitable for a specific skin tumor. This guideline gives a score (up to 9 points) based on factors like the tumor’s size, where it’s located on the body, if it’s a new or recurring cancer, the health of the immune system, and the microscopic details of the cancer cells. If the score is between 7 and 9, Mohs surgery is generally considered the right choice. It is used to treat various types of skin cancer, such as basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma, among others.
In order to make fast decisions during surgery, a method called “frozen sectioning” is used. This approach allows the surgeon to quickly and accurately check the edges of the removed tissue for any remaining cancer cells. It’s particularly useful in Mohs surgery because it helps surgeons decide on further treatments based on what they see at that moment. However, if the findings don’t immediately impact treatment plans, frozen sectioning might not be recommended.
To identify different cell types and essential structures under the microscope during Mohs surgery, doctors use chemicals to stain the tissue. Hematoxylin and Eosin (H&E) are most commonly used, while Toluidine blue is specifically used to treat BCCs; it turns the tissue a reddish-purple color. For melanoma, a marker called MART-1 is used to highlight cancerous cells.
Equipment used for Mohs Micrographic Surgery Section of Specimens Using Cryostat, Stain, and Immunostain
If your doctor is preparing for Mohs Micrographic Surgery (MMS), a procedure used to remove skin cancer with precision, they need to have specific tools and materials handy. These include:
- A scalpel handle with a 15 blade, a surgical knife used in operations
- Gloves for hygiene and safety
- Tissue forceps, a tool used to hold and manipulate tissues
- A Petri dish, a small dish used for holding biological samples
- Mohs map, a diagram used as a guide to track cancerous cells
- Patient labels to organize and keep track of the samples
- Nonadherent gauze, a special bandage that does not stick to wounds
- Tissue marking ink/dye in various colors, used to map out areas of interest on the sample
- Microscope slides and cover slips for preparing samples to be viewed under a microscope
- Liquid nitrogen or other cryogen spray, used in freezing tissues
- Embedding medium, a material in which tissue is enclosed for easy slicing
- Mounting medium, a substance used to preserve specimens on a slide
- Cryostat chuck, a device used to hold the sample while it’s being sliced
- Cryostat machine, a device used to freeze and slice thin sections of tissue
- Microtome blade, a very sharp knife used for cutting thin sections of tissue
- Camel hair paintbrush, a brush used in the process of mounting and staining samples
- Various stains or chemicals used to make different parts of the tissue visible under a microscope
- A manual or automated staining reservoir with a cover and a fume hood to safely hold and apply stains
- A microscope to examine the prepared tissue sample
- Optional Histobath, a special bath that rapidly cools tissue samples
- Personal protective equipment (PPE) and lab safety equipment to protect the doctor and the medical team
- Material Safety Data Sheets, documents that contain information about handling, use, storage, disposal and emergency procedures for certain substances
- Flammable liquid storage cabinet, a safe container for storing flammable liquids
These tools are all essential for performing MMS effectively and safely, ensuring that the doctor can remove the cancerous tissue without damaging the healthy surrounding skin.
Who is needed to perform Mohs Micrographic Surgery Section of Specimens Using Cryostat, Stain, and Immunostain?
The team involved in preparing and looking at MMS (Mohs Micrographic Surgery, a type of skin cancer treatment) samples include:
– The Mohs surgeon, who is a type of doctor specialized in removing skin cancer.
– A Histology technician, who helps to examine tissue from your body under a microscope.
– A Surgical technician, who helps the surgeon during the operation.
– A Medical assistant, who helps out in general during your treatment.
– A Medical student, resident, or fellow, who are all learning and gaining experience, and may assist during your procedure.
How is Mohs Micrographic Surgery Section of Specimens Using Cryostat, Stain, and Immunostain performed
If you’re having MMS, or Mohs Micrographic Surgery, it’s helpful to know what steps your doctor will take to prepare your tissue for examination and treatment. Here’s what you can expect during this procedure:
Before anything else, the surgeon will mark the location of the cancer to be removed. They may also make a small, shallow incision in the skin so the cancer can be seen more easily. This is called orientation. The surgeon may also carry out a process known as debulking. This involves reducing the size of large or bulky tumors because they can make it difficult to arrange the tissue properly for testing.
After this, they will remove the tumor. Dead skin cells and debris around and within the tumor will be delicately removed. This helps to allow the skin and tissue around the tumor to lie flat, which makes it much easier for the tissue to be prepared for examination under a microscope. It’s crucial to use the right angle when removing the tissue; otherwise, it might lead to a tumor not being fully removed or complications in the analysis of the tissue.
After the tumor is removed, the surgeon marks the location again for reference and it is kept moist to avoid getting dry and rigid. This is important as a dry specimen can be more challenging to handle.
Next, the removed tissue is either kept whole or cut into smaller sections for examination. The surgeon then draws a detailed diagram or map of the specimen and uses different colored inks to mark different areas. Details such as the time and location of the removal are also recorded to help with the microscopic analysis.
Before the tissue is prepared for examination under a microscope, small incisions termed “relaxing incisions” can be made. This helps the tissue to lie flat and easier to manipulate. However, it’s important for the surgeon to be careful not to cut through the tissue completely as this can cause errors in reading the margins of the cancer.
Finally, the tissue is placed on a labeled glass slide with the margins carefully aligned to node down the areas. It is then frozen and mounted, ready to be examined under a microscope. Making sure the tissue lies perfectly flat is crucial for an accurate examination. Care is also taken to ensure there are no air pockets which might affect the microscopic analysis.
This explanation should help give you an understanding of how your tissue is prepared and treated during MHS surgery. Keep in mind, however, that your doctor will explain everything to you in more detail before your procedure.
Possible Complications of Mohs Micrographic Surgery Section of Specimens Using Cryostat, Stain, and Immunostain
Processing tissue samples properly is fundamental to ensuring good quality microscope slides, which in turn helps accurately identify any issues or diseases. However, common mistakes can sometimes happen during the process, affecting slide quality. Here are some common problems that can occur, along with ways to avoid them:
1. Floaters: These are small bits of extra tissue that can appear during the process where tissue is scraped away, cut or stained. The recommended way to avoid floaters is to cleanse the tissue with saltwater (saline) after removal, keep the cutting blades clean, and change the staining solution frequently.
2. Folds on Edges: This usually happens when dealing with a large section of tissue. To prevent this, you can cut the bigger tissue samples into multiple smaller ones before you freeze and cut them further into thin slides.
3. Rips and Tears in the Skin or Below (Epidermis and Dermis): These can occur if the blade used to cut the tissue is damaged. It’s necessary to replace this blade carefully, as they’re very sharp. Also, it’s important to keep the tissue slices even. These issues can also happen if the tissue is too cold. Usually, it should be cut at temperatures between -20 and -22°C.
4. Rips in Fat Tissue: These are often caused from not freezing the fat well enough before cutting. You can try reducing the freezing temperature to between -28 and -32°C, increase freezing time or use a special type of spray or bath intended for tissue preparation.
5. Chunky Sample: Sometimes tissue can become too cold during the cutting process causing chunks to come out of the block of tissue.
6. Vacuoles and Clefts/Ice Crystals: If the tissue freezes too slowly, it can create vacuoles (empty spaces) or clefts (cracks). Quickening the freezing process, such as reducing the freezing temperature or using specific laboratory equipment, can help.
7. Chatter (Venetian Blind Effect): This is usually due to a loose blade or not enough lubrication.
8. Accordion Folds: If tissue folds resemble an accordion, the cutting instrument could be too warm or the cutting process should be slowed down.
9. Dark Sections: These occur when the tissue is cut too thick, resulting in too much stain absorption. Ensuring correct thickness and proper staining practices can help prevent this issue.
10. Overly Pink Tissue with Weak Stain of Cell Centers (Nuclei): Increasing the staining duration, reducing time in acid alcohol, changing the staining solution, adjusting the stain’s pH and cutting thicker tissue sections, can help address this.
11. Leaking Bright Red or Pink Stain (Eosin): This can occur when too much alcohol remains in the tissue. Spending more time on the alcohol removal process can help resolve this.
12. Water Beads, Blurry Spots, and Haziness: These issues usually happen because of improper final dehydration of the tissue. Extra washing with alcohol and extended wash times can help.
13. Slides with bubbles: This happens when too little mounting medium is used or bubbles form due to the process of mounting the sample onto the slide. Avoid creating bubbles by carefully applying the mounting medium and gently pressing out any bubbles.
What Else Should I Know About Mohs Micrographic Surgery Section of Specimens Using Cryostat, Stain, and Immunostain?
Mohs micrographic surgery (MMS) is a procedure that removes skin cancer layer by layer. The benefits of this procedure include the ability to effectively cure the disease while preserving as much healthy tissue as possible. Understanding the characteristics of the tumor, such as how deeply it has spread, the type of cells it contains, and whether it has spread to the nerves around it, is crucial because these factors directly influence the treatment plan and the patient’s health outcome.
For example, if the tumor has spread to the area surrounding it, more layers of tissue may need to be removed. Also, if it’s a type of skin cancer called squamous cell carcinoma that has spread to nearby nerves, the patient may be referred for radiation therapy. Research has found that errors in understanding the disease and the accidental loss of tissues are major reasons why skin cancer may come back after MMS.
That’s why it’s so important to prepare high-quality tissue samples that are free from processing errors. If the samples are not prepared well, it can cause issues like distortions of cell features, tissue loss, or misinterpretation of the cancer’s characteristics. This can lead to problems such as the unnecessary removal of healthy tissue, a higher chance of the cancer returning, longer surgery and preparation times, more complicated post-surgery recovery, inefficient care after surgery, and increased costs.
