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Dr. Hafeez Diwan's Blog

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Looking into the seeds of time…the importance of the clinical outcome

Dr. Hafeez Diwan


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.

Clinically, the lesion was one of prurigo. This lady was studded with prurigos.

This is not to say that a lesion that comes labeled as prurigo can’t be a squamous cell carcinoma. Of course it can. But in this case, it is hard to justify a diagnosis of carcinoma because of the complete clinical picture and especially the outcome.

The importance of the clinical outcome and follow-up is also relevant to melanocytic lesions, as we all know when it comes to the notorious atypical Spitzoid neoplasms.

Or take unilesional mycosis fungoides and pagetoid reticulosis. Are these really mycosis fungoides? Lesions of “mycosis fungoides” that go away and never come back – were they really mycosis fungoides to begin?

I think it is unreasonable to expect dermatopathologists, who are not psychic or prescient, to be able to look into the seeds of time, like the witches in Shakespeare’s Macbeth could. We can only look at the slide before us, and make the best call. It is a pity that this information, about our inability to be psychic dermatopathologists is not widely known to the general population. It makes us vulnerable.

In this connection, have you seen ads from lawyers? They always make a statement that they are not suggesting that they are the best or infallible. Should we make some such statement on our reports? Should we, for example, have a disclaimer on our reports that clarifies that we are giving an opinion and that we could be wrong? I don’t think this is wimping out – it is a fair statement of the true state of affairs (I think). Time and again psychological, sociological and anthropological studies have shown that humans make perceptual errors all the time and even (or sometimes perhaps especially) experts can be totally wrong.


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