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An evasive diagnosis is not a diagnosis at all!


Robledo F. Rocha

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Melanocytic lesions always represent diagnostic challenge. Some nevi might display features disquieting enough to be unskillfully misdiagnosed as melanoma. And some melanomas have too subtle malignant characteristics that can pass unnoticed if a careful scrutiny is not accomplished. Not surprisingly, some melanocytic lesions are so difficult to be rendered as benign or malignant that even worldwide recognized experts in the field fail in achieve a reproducible diagnosis.

During a recent practical discussion on a small-sized melanocytic lesion, some non-expert pathologists, admittedly frightened of an onerous litigation, thought it would be more prudent to label the case as an atypical melanocytic proliferation, or anything of the sort. Others, avoiding being compromised to a specific diagnosis and its implications, sheltered themselves under the sophisticated acronym SAMPUS (superficial atypical melanocytic proliferation of uncertain significance).

In fact, the presented lesion was originally signed out as SAMPUS, and was managed watching and waiting until a metastasis at last proved it was a thin melanoma.

As seen, both suggested evasive pathways may offer a short-term solution to the pathologist, but an uncomfortable feeling of unfulfilled mission will remain because those gray zones do not provide to the clinician and to the patient any alternative other than an expectant approach, praying that a metastasis never happens.

An evasive diagnosis is not a diagnosis at all! A lesion must be benign or malignant, never something intermediary!

So, what should a pathologist do when feel himself / herself not completely confident to make a diagnosis with surety of a problematic melanocytic lesion?

It does not seem to be the best option acting as a cytopathologist in doubt, who reports a cervical cytology as ASCUS (atypical squamous cells of undetermined significance) and recommends pap test repetition six months later.

So, what about making clear that you don't know the correct diagnosis and referring the case to a renowned expert? It's not different of making an evasive diagnosis since an evasive diagnosis really means an I-don't-know diagnosis.

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As evident from my previous discussions, I have no problem with Meltump/ SAMPUS etc as i see no difference between these terms, which to me imply 'I don't know'. I don't see it as putting the burden on the tumor, as it is the pathologist that is saying that he/ she is uncertain of the significance. It is not that the pathologist is saying that the tumor is uncertain of its own significance!!!

I agree that if one isn't sure about the diagnosis., it is very important to take the opinion of someone else who you respect. However, it is still an opinion and in difficult cases SAMPUS or 'I don't know' (which I consider synonyms) are perfectly alright to summarise one's report, AS LONG AS, one doesn't consider them as diseases in themselves!!

Diagnosis is an opinion of the expert. Disease is a distinct entity!
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Dr. Hurt. Nowhere in the article did they say that the neoplasm itself is ambiguous. The authors clearly imply that the interpretation of the histological findings is ambiguous because the features are neither definitely benign nor malignant. In fact in my humble opinion you have falsely accused the authors when[url="http://www.archivesofpathology.org/doi/pdf/10.1043/2009-0612-RAR.1"] even in their abstract[/url], they have clearly explained their what they mean by the title.


I think it is just a question of perspective & interpretation. That is what I mentioned earlier- [u]as long as one understands how to interpret the diagnosis made by the pathologist, the term can be used[/u]. I think most dermatologists know what the pathologist means by MELTUMP or SAMPUS etc i.e. that the pathologist isn't sure about the diagnosis. I am unaware of a single dermatologist who interprets the diagnosis to mean that the tumour itself does not know! Certainly not in the UK!

Therefore I do not believe it is worth journal/ mind-space to debate on this topic, as it does not really matter in clinical terms.
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