INTRODUCTION
Other than visual inspection with the naked eye, the dermatologist’s
microscope represents the single most
important tool in diagnosing and curing skin diseases.
A large number of microscopic techniques are used to improve
specimen contrast and highlight specific structures. Of particular
importance is the utility of bright field microscopy in the diagnosis
and treatment of cutaneous tumors. Bright field microscopy
is the simplest of all light microscopy techniques. In this method,
a sample of tissue is illuminated by transmitted white light generally
from below and viewed from above. Simple microscopes
date back to the 1600s, and Robert Hooke invented the first simple
microscope in the 1660s. Extensive research and improvements
during the eighteenth and nineteenth century along with
advances in the twentieth century created the advanced microscopes
of current time.1 Relatively recent enhancements, often
unrecognized by most dermatologists, can dramatically enhance
current microscopes and their utility.
Mohs micrographic surgery (MMS) represents a method of excision
that provides microscopic control of tumor margins. In order
to achieve cure rates superior to all other forms of excision, MMS
requires precise interpretation of frozen section tissue specimens
to ensure complete tumor extirpation. The synergy afforded by
the surgeon also serving as the pathologist, results in unparalleled
cure rates in cutaneous oncology. In order to achieve these
high cure rates, bright field microscopy is critically important for
eradication of cutaneous tumors. Although appropriate training
proves paramount in minimizing interpretation errors in Mohs
histopathology sections other factors may influence the ability
of the Mohs surgeon to appropriately interpret frozen section pathology.
2 While slide quality is commonly highlighted as an area
in which to improve accuracy and efficiency in Mohs surgery,
other methods such as slide interpretation may likewise improve
accuracy and efficiency.
A trivial but common reason for misdiagnosis of pathologic
specimens is simply a failure to examine a relevant tissue fragment
or levels. The visual fatigue and information overload that
occur after examining many cases also contributes to perceptual
mistakes.3 As recently highlighted by Liang, et al, dermatologic
surgeons are at high risk of fatigue, musculoskeletal disorders
and eyestrain especially when multiple procedures are being
performed in a single day. The posture assumed when using a
microscope while reading slides is one situation that puts the
surgeon in a static posture and at risk of neck strain.4 Additionally,
improper wrist angles were noted in Mohs surgeons during
microscope use in a recent observational study.5
As has been previously reported, ultra-wide (UW) view field
(also known as super wide [SW] view field) microscopy provides
multiple advantages.6 Namely, ultra-wide field microscopy allows
for a large viewing area thus decreasing scanning time of
tissue. In the diagnostic realm for cutaneous tumors, the low-power
pattern is often more important than the high-power
cellular characteristics. This in turn minimizes eyestrain on the
pathologist, decreases the potential time for improper wrist
angles and static posture during microscope use and improves
efficiency. Improved efficiency has become increasingly important
given the current status of healthcare reimbursement.
Additionally, newer techniques allow for rapid preparation of
large high-quality frozen sections.7 Orienting tissue and mapping
remaining tumor while scanning large sections presents a
challenge in interpretation of these specimens.
DISCUSSION
Recent advances in microscope technology provide additional
opportunity for improved efficiency and minimize strain on
the pathologist. In order to more fully appreciate this technology,
one must understand some of the basic principles of
