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Dr. Mark Hurt's Blog

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Is Cancer Cancer?

[color=#000000][font=Arial, sans-serif][size=3]“What's in a name? that which we call a rose by any other name would smell as sweet;” -- Shakespeare (Romeo and Juliet, Act II, Scene 2. Published 1597) Is Cancer [i]Cancer[/i]? What is cancer? Those reading this blog are in the cancer “business.” Cancer is a neoplasm (a stimulus independent cellular proliferation) that, untreated, has the capacity to kill the patient. As a rule, this is the meaning of malignancy when applied

Mark A. Hurt MD

Mark A. Hurt MD

An error with a question.

I have a question. What is the legal status of the following error? The patient had a series of three biopsies under a single case number. Parts “B” and “C” were small, of similar size, and with the differential of “rule out basal cell carcinoma.” Part “B” contained a basal cell carcinoma in the initial section; part “C” was a cell-poor lichenoid infiltrate. Recuts to deplete block “C” were ordered. When received, there was a basal cell carcinoma, and the diagnosi

Mark A. Hurt MD

Mark A. Hurt MD

Is it proper to comment in reports on another's diagnosis?

Here is the situation: I received a telephone call from a dermatology colleague who wanted my opinion, a second opinion, on a patient's specimen. It was, I was told, a melanocytic proliferation and that my opinion of it was needed so that a definitive surgery could be planned. I reviewed the specimen, and my opinion was similar to the first dermatopathologist. Now my question: Is it proper to comment in reports on another's diagnosis? As a rule, when one agrees with the prior report, it

Mark A. Hurt MD

Mark A. Hurt MD

Have you ever been fired?

Have you ever been fired? I have, on 4 occasions. I suspect, in the course of a practice, that it's impossible to please everyone. That has certainly been my experience in the past 30 years of practice. In this blog, I'll describe four dermatologists who fired me and why (if I know why) they did so. ---------- One dermatologist fired me for no particular reason that I could tell. I still, to this day, don't know why. Another dermatologist fired me because my reports were "too

Mark A. Hurt MD

Mark A. Hurt MD

How do you consult each other?

How do you consult each other? There are two basic kinds of consults. The first is an internal consult; the second is an external consult. [u][i][b]Internal consults take 3 basic forms:[/b][/i][/u] 1. A colleague within your practice group comes to your office with a slide and asks your opinion of it, then leaves to write his report. 2. The colleague leaves the slide and paperwork with you and wants your written comments, then he writes his report, incorporating your comments, v

Mark A. Hurt MD

Mark A. Hurt MD

Atypia - a different perspective

"Atypia" is a word applied commonly in pathology and dermatopathology. It has two principal forms of usage. The first of these refers to structural, cellular, or nuclear abnormalities identified in sections of tissue when observed under a microscope. The second usage refers to the lack of certainty about a diagnosis. If you have ever read or heard the following statement that "this is an atypical nucleus," then you have been presented an example of the first usage. If, however, you

Mark A. Hurt MD

Mark A. Hurt MD

"Dysplastic Nevus" as a legitimate phrase?

It has often been said of melanocytic nevi, which many designate as “dysplastic,” that such nevi are “intermediate” between the so-called “common” or “ordinary” melanocytic nevus and melanoma. Clark wrote, famously, that they (i.e., dysplastic nevi) were the “formal histogenetic precursors” of melanoma if “the pathway of differentiation was not followed” that is usually present in the “common acquired melanocytic nevus.” But what of control skin, and what of oth

Mark A. Hurt MD

Mark A. Hurt MD

Persistence, Recurrence, and Metastasis: Similar or Fundamentally Different?

I'm certain that you read about persistence and recurrence all of the time. Here are the dictionary definitions of these words: [b]Persistence[/b]: continued existence -- or the fact that the lesion of an attempted excision was not removed completely. [b]Recurrence[/b]: to occur again. In such a case, the lesion is apparently removed both clinically and histopathologically. In such a case, there is no histopathological evidence of any remaining lesion. Practically, the differen

Mark A. Hurt MD

Mark A. Hurt MD

Mitoses in melanoma: Is there really a meaning?

Just this month there are two interesting articles published on the issue of mitosis in melanoma and whether they confer diagnostic or prognostic meaning. The first is by Gori et al. (1), who make the argument that the presence of greater than 1 mitosis/mm[sup]2[/sup] should not necessarily result in sentinel node biopsy in pregnant women. Their reasoning, based on a single case, was: [indent=1]"to minimize the risk to the fetus, especially with respect to potential risks to the growing b

Mark A. Hurt MD

Mark A. Hurt MD

How do you file articles? The YPA method.

It is now some 24 years ago that I discovered a way to file articles from the literature. You might say, or think, so what? What's the big deal about filling articles from the literature? Here's the big deal: you are, and will continue be, confronted with the problem of how to find and store literature articles you have copied or downloaded as PDF's. How do you go about that task? When I trained in pathology in the early 1980's, everything -- I mean everything -- was in hard copy. If yo

Mark A. Hurt MD

Mark A. Hurt MD

How much should we push clinicians for molecular testing of melanocytic lesions?

In my practice, I and my colleagues confront a problem almost on a weekly basis. I'm sure many of you confront the same problem. It happens this way: there is an unusual melanocytic lesion that presents the differential diagnosis of melanoma [i]versus[/i] melanocytic nevus, but there is enough similarity of the lesion to a melanocytic nevus, and there is enough depth (often 1 mm or more), that if the lesion is melanoma, most dermatologists (at least in the USA) will pursue a sentinel lymph no

Mark A. Hurt MD

Mark A. Hurt MD

Consulting with Colleagues about Quandaries

I have never met anyone who knows everything, including me (perhaps [i]especially[/i] me). Thus, there is a real need for consultations. In my practice, the most common kind of consultation is the [u][i]internal[/i][/u] consultation. It usually takes the following form:[list] [*]I have a quandary that I cannot solve easily from experience or by reading books or the literature. [*]I write on my worksheet what I believe is the differential diagnosis. [*]I circulate the case with my questio

Mark A. Hurt MD

Mark A. Hurt MD

Working with Music in the Background -- What Kind, if Any?

I have experimented over the years about what, if anything, to listen to in the background while I'm working on cases. I'm curious to learn what, if anything [i]others [/i]do and what they like. Music connects to one's soul on an emotional level, as one does not translate it conceptually directly from words. So, what one finds enjoyable, another might not. In my case, in the setting of work, I have been looking for some time to find music that allows my mind to focus on the work and not

Mark A. Hurt MD

Mark A. Hurt MD

Filling Big Shoes

When Dr. McKee asked me to succeed him as the chief editor of this site, my first thought was: "I'm not [i]qualified[/i] to fill such a role." He assured me I [i]was[/i] -- in his subtle and steady manner. Yet, such a transition raises a deep question: What do we owe our teachers and mentors? -- if anything. My answer to this question is personal and even selfish. We owe our teachers and mentors the same respect we owe ourselves -- to take our work seriously, to always try to do our best

Mark A. Hurt MD

Mark A. Hurt MD

Is metastatic melanoma really metastatic melanoma?

I recently encountered a biopsy from a man in his forties. The lesion was composed of melanocytes in the epidermis and dermis. It's was relatively symmetrical, and it had a minor degree of maturation of melanocytes on progressive descent. There was greater than 1 mitotic figure per square millimeter, and, with Sox-10, there was a pagetoid pattern of melanocytes in the epidermis. Additionally, with Melan-A, the staining of melanocytes was not uniform. The depth was 0.95 mm. Based on these para

Mark A. Hurt MD

Mark A. Hurt MD

Using the Literature

I “grew up” in medicine from 1978 to 1982, graduating from the University of Missouri-Columbia. During my medical school years, learning consisted of long days of lectures followed by hours of study in the evening; it almost never consisted of using the literature directly. In my experience then, laboratories were also more-or-less “cooked”; it was a lot of work mentally, but it was composed of mostly lecture, demonstration, and textbook-based presentations not on using the literature di

Mark A. Hurt MD

Mark A. Hurt MD

The form of perception and the object of perception

Let's visit a thorny subject in pathology (that has wider implications in philosophy in general). Perhaps the easiest way to state it is that it is the problem of understanding the difference between the form of perception and the object of perception. At the risk of appearing to lapse into subjectivity, here is a common example: you and your colleague are looking through a multi-headed microscope at a melanocytic lesion stained in one section with H&E and another with Melan-A. You o

Mark A. Hurt MD

Mark A. Hurt MD

Diagnosis versus Prognosis

Dermatopathologists are in the business of diagnosis, not prognosis. Consider that we observe findings under a microscope and formulate those findings, with clinical information, into a concept of a disease -- a diagnosis. It is true that many times we use special stains to gather more information about the findings in the tissue. Some of us, in specialized practices, take it as far as learning detailed genetic information on specimens from patients. Yet, this does not tell us prognosis; i

Mark A. Hurt MD

Mark A. Hurt MD

Clinicopathological Correlation is as or More Powerful Than a Special Stain

How many times have you been looking at a tumor on the H&E sections and said to yourself: "The differential diagnosis is …. I need a clinical differential diagnosis." You have done this probably hundreds of times. You have also encountered tumors in which you wondered the following: "I need to determine lineage so that I can narrow the differential diagnosis." It occurs on a daily basis. Have you ever considered the difference between the two examples? Probably, I suspect -

Mark A. Hurt MD

Mark A. Hurt MD

What are the limits of dermatopathology?

A “limit” is defined as “the utmost extent: a point beyond which it is impossible to go.” Where is that point in dermatopathology? My answer might surprise the reader, so I will state it outright. The limit of dermatopathology is the diagnosis. The entire point of the discipline, the “why” we exist as dermatopathologists is because of the diagnosis. Let's not kid ourselves. Looking at changes in cutaneous tissue under the microscope is often a beautiful and stimulating ex

Mark A. Hurt MD

Mark A. Hurt MD

The Importance of Negatives

Although it is true that a positive is more important than a negative, a negative is not unimportant. A positive will tell you what a thing [i]is[/i], and it is true that a negative will not do this. What a negative [i]does[/i] do is provide context. Here is an example I see commonly in my practice: I receive a shave biopsy with a clinical diagnosis of basal cell carcinoma. In the initial sections, I see no basal cell carcinoma, only solar elastosis with telangiectasia. Based on the clini

Mark A. Hurt MD

Mark A. Hurt MD

What is Historical Perspective?

[i]History[/i] is an account of events that have occurred in the past. [i]Perspective[/i] refers to a point of view of a thing or a group of things or a point of view about body of knowledge concerning a thing or group of things. Thus, [i]historical perspective[/i] refers to a point of view about a body of knowledge of a thing or group of things over a period of time. Usually, it takes the form of a chronological presentation of concrete examples that have been conceptualized one way in the

Mark A. Hurt MD

Mark A. Hurt MD

Redundancy in reports as a double check

Recently, I experienced the horror of an error on a report. The diagnosis was that of melanoma with a depth of 0.2 mm. My report stated, however, a depth of 2.0 mm! I learned of this error when a very friendly oncologist called me and asked me about the Breslow measurement in relation to the T1a staging statement. Fortunately, from my report, I could tell what had happened. In the microscopic description, I stated that most of the melanoma was in mostly situ. I went as far as saying

Mark A. Hurt MD

Mark A. Hurt MD

Quality Improvement?

What do you think is the best way ensure diagnostic quality in a dermatopathology laboratory? This is a question we have been grappling with and addressing in our laboratory. Of course, all laboratories have to deal with this problem. There are common sense ways to approach this question. Here are a few that we perform currently: 1. Any case that is reviewed by anyone other than the dermatopathologist of record is referred to in the report, and it is documented so that a report of "mul

Mark A. Hurt MD

Mark A. Hurt MD

Difficult Conversations About Errors

Error: an act involving an unintentional deviation from truth or accuracy ("error." Webster's Third New International Dictionary, Unabridged. Merriam-Webster, 2002. [url="http://unabridged.merriam-webster.com/"]http://unabridged.merriam-webster.com[/url] (14 Oct. 2012)). How do you approach a colleague when you discover he has made an error in diagnosis? How do you initiate the conversation with a clinician colleague when you have made an error in diagnosis? These are not small matters

Mark A. Hurt MD

Mark A. Hurt MD

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