An Update on Super Wide Field Microscopy in Dermatologic Surgery

June 2013 | Volume 12 | Issue 6 | Original Article | 668 | Copyright © 2013

Nicholas B. Countryman MD MBA,a* Ross M. Levy MD,b, C.William Hanke MDa

aThe Laser and Skin Surgery Center of Indiana, Carmel, IN
bDermatologic Surgery Unit, Division of Dermatology, Skokie, IL

Abstract

Microscopic interpretation represents the central tenet for diagnosis and eradication of cutaneous tumors. Standard microscopes are limited by relatively high-powered objectives and smaller viewable diameter. Newer equipment offers optional lower powered objectives including 1X and 2X objectives and can be combined with super widefield eyepieces to greatly enhance the viewable area during pathologic interpretation of slides. Mohs micrographic surgery represents one of the most useful areas in which the dermatologic surgeon gleans multiple efficiencies from these microscope systems. One such system that was recently trialed, the Nikon 80i microscope, proved to be incredibly easy to use and multiple efficiencies were quickly realized.

J Drugs Dermatol. 2013;12(6):668-671.

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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

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