Log Book Abbreviations

One of our responsibilities as Mohs techs is to make sure the slide labels and logbook information is correct and CLIA compliant. Here are the most commonly abbreviated orientation and directional terms:

The following terms should never be abbreviated in the logbook or label, even if its written shorthand on the map:

Less common directional terms (eg. pareital, distal, radial, ulnar, dorsal, etc) should be written out as well. If you see any abbreviated term on a map that you are unsure of, ask the staff what it stands for and write out the whole word  in the logbook/labels.

TROUBLESHOOTING: Cry-Ac

Problem: Trigger handle sticks open, won't stop spraying.
Solution: Rotate the trigger to the side until the next time you need to use it. If this doesn't work, depressurize it by unscrewing the top.

Problem: Excessive leaking/hissing from the relief valve.
Solution: The exterior of the Cry-Ac has too much frost built up. Try pushing down on the relief valve and twisting it back and forth to break up the ice. You can also clean the frost with alcohol and gauze.

Problem: Sprays only intermittently.

Solution: The liquid nitrogen supply may be contaminated with water. Check for cloudy droplets of ice.

Problem: Does not spray

Solution A) Trigger is too close. Twist the round silver part to adjust the trigger position.

Solution B) The Cry-Ac has been over-filled and there is insufficient air space inside the bottle to create an adequate build up of pressure required to spray. Do not fill past this line.

Solution C) Check that the rubber gasket is in place inside the cover and is not split or missing.

Solution D) The position of the trigger should be directly to the left or right of the delivery tube.

HOW TO PREP AND CUT: Biopies

Occasionally, the doctor may find a suspicious spot and will want to do a biopsy before going ahead with Mohs. Instead of the usual horizontal sectioning, biopsies are sectioned vertically. You may have heard it referred to as "bread-loafing."

A biopsy can reveal whether there are any cancer cells present and can help differentiate between the various types of cancer. It will not, however, tell you WHERE those cells are or if the margins are clear. 

There is no need to bisect or ink the tissue because you will be cutting through the entire piece. Squeeze some OCT onto a disc on the cold bar. Once the base of the OCT has turned white, hold the biopsy specimen vertically in the OCT until it's frozen enough to stand up on its own. Add more OCT on top so that none of the tissue is exposed.

Don't worry about lining it up perfectly, just eyeball it and do your best. The FBX slide must show sections from the entire specimen, so you'll be cutting through quite a bit of tissue in between the sections that you actually pick up. Advance the wheel manually several times then use the hand-crank wheel to discard a few regular cuts before picking up a nice wafer.

As always, be careful that the tissue sections are not placed on top of OCT from a previous section or it will all wash off in the stains. There won't be any tissue left to do a recut!

Repeat until you have at least 8 sections and you've cut through the entire biopsy specimen. Stain as usual.

Large Biopies
If you get a biopsy that's bigger than usual, you can save time by bisecting it and placing the halves vertically on a slide. Freeze the back of the slide and make a regular mount as if you're processing a normal mohs specimen. Since the piece is now essentially half the depth, you won't waste as much time cutting through the specimen to get your 8-10 sections.

Slide Review: Thick skin and sun damaged skin

Thick and/or sun damaged skin will appear as a translucent layer of cells outside the epidermis. This section shows scabby, sun damaged tissue, so the layer of cells is rough and uneven. In the mid dermis, the grayish/lavender area is most likely actinic elastosis, or the accumulation of abnormal elastic tissue in the dermis, also a result of sun damage.

This next section shows the thick skin found in the palms of the hand or the soles of the feet. Note that even though the image (courtesy of http://www.dartmouth.edu) points out the "thickened layer of squamous cells," it is not referring to SCC. Healthy squamous cells are a normal part of the superficial epidermis. The outermost squamous cells are heavily keratinized, creating a thick layer of dead cells that protects our hands and feet. 

For comparison, here is a section of normal tissue only a thin layer of dead squamous epithelial cells.

Slide Review: Water in the slide

At the end of staining, tissue sections must be fully dehydrated by alcohol before applying Cytoseal. If you rush the process and leave water mixed with the alcohol and glue, the tissue will have strange dark flecks in it. Notice how the tissue in the far lower right corner of this picture is not contaminated as much. The cytoseal was probably dropped directly on that area of tissue.

You will also notice what looks like streams of bubbles. Since cytoseal is toluene-based and toluene is insoluble in water, any water left on the slide will create this cloudy mess of bubbles.

Solution: Recoverslip. Slide off the coverslip. Give the slide a few good swishes in the alcohol, a few drops of glue, and a brand new coverslip. 

Moisture will damage the cryo paint

This cryo/truck was parked next to the sprinklers and the water must have soaked into the blanket overnight. At the job the next morning, the cryo looked like this. I'm not sure how it's any different from driving through heavy rain on the way to or from a job but for whatever reason, those sprinklers really did a number on the paint job.

I imagine car washes will do the same thing eventually, so if it's not too much of a hassle:

-Leave the cryo at home when you get your truck washed.
-If there's nowhere to put it at home, you can drop the cryo off at the office and pick it up afterwards.
-You could also just leave the cryo on the truck and wash the truck at home, being careful not to get cryo wet.

Slide Review: Monsel's Solution

Monsel's solution, also known as ferric subsulfate solution, is a styptic agent used to stop bleeding after superficial skin biopsies.  It works by contracting tissue to seal injured blood vessels. Here, we see residual Monsel from a biopsy done several days before Mohs surgery.

Slide Review: Milial Cyst

A milial cyst is a small, keratin filled cyst, often found on the face. This lesion is quite common in women who apply moisturizers, and can also be a complication of facial cosmetic dermatology such as dermabrasion, chemical peels, and laser resurfacing.

The hardened keratin sounds like a grain of sand embedded in the tissue, making a scraping sound at each pass of the blade. 

In these sections, you can see the stratified layers of keratin lining the cyst. 

Slide Review: Tattoo Ink

TROUBLESHOOTING: Loose Knife Clamp Arm

Rolling the cryostat over bumpy cobblestone or tactile pavement can loosen the pins that hold the knife clamp arms. The microtome will probably look something like this:

Assuming everything was working just fine at the last job, all the parts should be rolling around somewhere at the bottom. Put the knife clamp arm back where it belongs. 

Now find the pin and insert it into the hole.

Use your heat sink to tap the pin all the way in. 

All fixed! 

The next time you need to go over bumpy pavement, ROLL THE CRYO SLOWLY. 

TROUBLESHOOTING: OCT mount falls off the disc

Sad mount misses his disc.

Sometimes, when you're making rough cuts or even just regular cuts, the OCT mount gets knocked off the disc. This can be caused by several things, the most common reason being:

-You took too much time putting the mount together.
Once you get the disc onto the cold bar, you need to apply OCT immediately, before the disc has a chance to get too cold. If you take too long, the pre-chilled disc will freeze the OCT before it has a chance to ooze into those tiny nooks, crannies, and holes.

You can preheat your discs on the hotplate to give yourself a few seconds leeway and some burned fingers.

The most reliable way to make sure your mounts stay on the disc is to touch the tip of the OCT bottle to one of the holes and give it a good squeeze to force the OCT into the hole.

In figure A, the OCT froze before getting into the holes, making it the type that's likely to fall off the disc. You want the OCT to freeze inside the holes as shown in B, C, or D.

Other reasons why your mounts are getting knocked off the discs:

-The surface of the disc needs to be roughed up. Refer to the post below. 
-There are loose screws.  Check the knife screws, blade screws, etc. Check everything!
-Your cryo has been off for several hours and is too warm to cut on.  The OCT block isn't frozen solid enough to hold on to the disc. Bend a Freeze-It straw so that you can freeze the backside of the disc as well as the front.
-Your rough cuts are too aggressive.  When you're advancing the wheel by hand (e.g. cutting through the safety layer), avoid cutting too deeply with each turn.

How to Rough Up Your Discs

Roughing up your discs provides extra grooves for the OCT to cling on to, hopefully preventing the OCT block from falling off when you're cutting sections. There are a few different types of discs that we work with:

Copper discs without holes: This type is excellent at gripping the OCT. Personally, I've never felt the need to rough these discs up, as they do a perfectly good job as they are. They DO, however, take more time to get cold.

Aluminum discs without holes: This type freezes quicker than the copper discs. The circular ridges seem to grip the OCT relatively well, but you might want to rough up the surface for added gripping power, just in case.

Aluminum discs with holes: These are the discs that give techs the most problems. I absolutely recommend roughing these up.



There are two ways to rough up a disc (plus one extra that I'll explain later but won't recommend):

Method #1 - Rub the surface of your disc against cement.  You'll probably find a suitable surface in a parking lot.

Method #2 - Use a screwdriver and your body weight.  This is my favorite method, since you can do it in the office and don't need to remember to do it on the way home. Place your disc ON A CARPETED FLOOR ONLY with your screwdriver at the center of the disc. Lean your body weight into it until the screwdriver slides down to the edge of the disc.  Turn the disc and repeat until you get several grooves radiating out from the center.

Method #3 - Garbage disposal. Obviously, I can't recommend putting your disc through a garbage disposal. I only discovered this method by accident. Ironically, it transformed a problem disc into one of the best discs I've ever worked with. Again, don't do this!

Making Slanted OCT Blocks

Why:  With some cryostats, you NEED to make slanted OCT blocks in order to line up.  (Note that I said “some.”  You never know which cryos require it.  It keeps things exciting.)

If you make a perfectly level block and try to line it up on one of said cryos, you’ll find that it's impossible to close the gap between the top of the block and the blade.  Your options at this point are:

1. Rotate the block upside down. You'll also have to pick up the sections with an upside-down slide so that piece 1 is still on the left side. Or,
2. Melt it down and remake it as a slanted block.

Since you never know which cryos require this, it’s best to just get into the habit of making slanted mounts every single time. 

How:  When sandwiching the tissue between the heat sink and the disc on the cold bar, angle the mounting slide so that the OCT block is thinner on the side closest to the cryostat wall.  It doesn’t need to be steeply slanted, just a subtle slant that you probably won’t be able to see until you take the frozen block off the cold bar.  

Be careful not to make the OCT block so thin on one side that it cuts directly into the disc.  You won’t be able to get any sections from it and you’ll have to melt it down and start over. 

Overview of Cancer Types

Basal Cell Carcinoma

Basal Cell Carcinoma (BCC) is the most common form of skin cancer, with over two million cases being diagnosed every year in the United States alone.  This type of cancer is slow growing and rarely spreads to other parts of the body.  If left untreated, however, it can cause disfigurement by invading and damaging the surrounding nerves and tissues.  Most cases of BCC are caused by cumulative UV exposure but can also occur in areas that are protected from the sun.  

Basal cells line the deepest layer of the epidermis.  They are responsible for producing new skin cells to replace the dead ones that are regularly sloughed off.  With enough UV damage, these cells produce skin cells at an abnormal, uncontrolled rate.

BCCs often look like open sores, red patches, pearly pink growths, or scars.  Since they can take on such a variety of appearances, a biopsy is the only reliable way to make a definitive diagnosis.

Nodular:  The most common type of BCC.  Usually presents as a round, pearly growth with rolled edges that may be pigmented (brown) or have small blood vessels on the surface.

Superficial: A less common form of BCC.  Looks like a crusty red patch with a threadlike waxy border.  Is often mistaken for other skin conditions such as eczema or psoriasis. 

Fibrosing or Sclerotic:  A fairly uncommon type of BCC.  Appears ivory-white, is flat or slightly depressed like a scar, and feels firm to the touch.  Difficult to excise because it is often infiltrative and has indistinct margins.   

Squamous Cell Carcinoma

Squamous cell carcinoma (SCC) is the second most common form of skin cancer (BCC > SCC > Melanoma).  An estimated 700,000 cases of SCC are diagnosed each year in the US, resulting in approximately 2,500 deaths.  Like BCC, SCC is mainly caused by cumulative UV exposure; however, it is more dangerous than BCC because it can spread to the lymph nodes or other organs, and in some cases be fatal.

Whereas basal cells are only found in the epidermis, squamous cells are found in both the epidermis and mucosal membranes.  Thus, SCCs can also occur on the genitals and inside the mouth, nostrils, and eyelids.

SCCs often look like scaly red patches, open sores, elevated growths with a central depression, or warts.  They may also crust or bleed.

SCC in situ (also known as Bowen’s disease):  An early form of cancer that has yet to penetrate the basement membrane and is still confined to site of the original cancer cell.  Often appears as a thick scaly red rash.

Well differentiated SCC:  The cancer has penetrated the basement membrane and is now spreading through the dermis and adjacent tissues.  It is now able to metastasize (spread to other organs and form secondary tumors there)  These often appear as very thick, crusty lesions with tops that may fall off but invariably grow back.

Aggressive, poorly differentiated SCC:  The most dangerous type of SCC because it grows very quickly and has a greater tendency to metastasize.  They have a wide variety of appearances (soft, hard, open sores, etc.)


Actinic keratosis:  Common sunspots, the least dangerous type of SCC (more of a pre-cancer).  The surrounding skin often looks sun damaged (blotchy, freckled, and wrinkled).

Melanoma

Melanoma is less common than other skin cancers but is by far the most dangerous if not found early, causing the majority (75%) of deaths related to skin cancer.  More than 76,000 cases of melanoma are diagnosed in the US every year.  If the cancer is found in the early stages, it can usually be removed with surgery.  If the melanoma has spread, it will need to be treated with chemo- and immunotherapy, or radiation therapy.

 

Melanomas begin in the melanocytes (pigment-producing cells) and are caused by UV damage and genetic factors.  They may appear suddenly on the skin or develop from an existing mole.  Early signs of melanoma are summarized by the mnemonic “ABCDE”:

Asymmetry

Borders (irregular edges that are notched, uneven, or blurred)

Color (different shades of brown, black, or tan)

Diameter (>6mm, the size of a pencil eraser)

Evolving over time