All that glitters is not gold â€“ the importance of context in the evaluation of atypia
â€œItâ€™s too atypical to be malignant.â€
â€œItâ€™s too atypical and so it has to be malignant.â€
These are too variations on the theme of atypia, and lead the thinker to two contradictory conclusions. I am sure you have either heard or spoken at least one of these two statements. Obviously, atypia doesnâ€™t mean the same in every situation and to every person. Or, as Shakespeare wrote (in his T
Many years ago I saw a biopsy of well-differentiated invasive squamous cell carcinoma. Let me backtrack and say that I thought it was a squamous cell carcinoma. To my eye, what I saw was a markedly atypical and acanthotic proliferation of keratinocytes invading deeply into the dermis.
But I was wrong. This was a patient with fifty such lesions on her legs, and this lesion, which I swore was a well-differentiated invasive squamous cell carcinoma, melted away after a steroid injection.
When I diagnose things a certain way, the likelihood increases that I will diagnose those things in a similar or same way in the future. We are shaped by our training and our actions. This is akin to Shakespeareâ€™s Macbeth getting more comfortable with murder after he had committed the first one.
It is the first murder (or diagnosis) that is often the toughest one. Remember that Macbeth had to be pushed and bullied by Lady Macbeth before he committed his first murder. Lady Macbeth d
Although I am in Houston, Texas, I cannot make any exclusive claims to the Texas Sharpshooter Fallacy. This fallacy is one which I believe we dermatopathologists (as well as others) should be aware of.
What exactly is this fallacy? Where do sharpshooters come into this, and why specifically in Texas? The name, if Wikipedia is to be believed, comes from the story of a Texan who shot holes in the side of a barn and then painted a bullâ€™s eye around a group of them, giving rise to the mistak
Some months ago, a colleague shared a nail biopsy with me. To me it looked like melanoma in situ. It was seen at a consensus conference we have every week with other institutions in the Houston area. Everybody who saw it thought it was melanoma in situ. The problem was that the patient was an eleven-year-old boy.
Given the age of this child, this case was sent in consultation to other experts. One expert opined that it was a junctional nevus with features of pigmented spindle cell nevu
Boris Goldovsky, a man I was unaware of until a few minutes ago, made an important dermatopathologic contribution (without meaning to). He lived from 1908 to 2001, and was a famous conductor and producer of opera. It is reported that he had a piano student who played bar 78 from Brahms Op 76 No.2 incorrectly â€“ or so Goldovsky believed. He asked his student to play it correctly, and the student showed Goldovsky that he had played the notes exactly as they were printed on the score. It was l
Almost every dermatopathologist has had this feeling. You go to a meeting, for example, and hear a talk about the diagnoses which were missed and the often disastrous consequences that ensued â€“ both for the patient and for the dermatopathologist, legally, financially, and morally. Nobody wants to miss important diagnoses. This is never more so than when it comes to melanocytic lesions. I usually return from dermatopathology meetings with that Sixth Sense-esque feeling of I-see-melanomas (t
Imagine you have been given a task as follows: Rearrange the following words to form another word, but do not attempt to unscramble a word further down the list until you have successfully solved the preceding word. Here are the words: â€œwhirl,â€ â€œslapstick,â€ and â€œcinerama.â€ Unless you have a brain disorder that makes you incredibly, even supernaturally smart, I am willing to bet that you will find it difficult, if not impossible to unscramble the words â€œwhirlâ€ and â€œslapstickâ€
The unifying theme behind this series of blogs is as follows: dermatopathologists are humans first and dermatopathologists second, and therefore, are as human as everybody else â€“ including those judges that decide the fate of prisoners presenting to Israeli parole boards. I have created the somewhat cheesy term, â€œskinnectionâ€, to emphasize that some of my blog postings will explore the connection between the mass of psychological data out there and pathologists who focus on the skin.