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Dr. Mona Abdel Halim's Blog

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When clinicians make me irritated !!!!


Dr. Mona Abdel-Halim

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It happened a couple of times this month that I have received insufficient specimens from clinicians!!

A keratotic lesion on the forehead was referred to me and my colleague ,Dr Eman El-Nabarawy, as a lesion suspicious to be BCC. The specimen was a punch biopsy that revealed only masses of keratin!!!!! We signed out the report as insufficient specimen, excisional biopsy is required. The excisional biopsy revealed bowenoid actinic keratosis.

A punch biopsy was referred to us from a lesion described by the clinician as an irregular pigmented lesion with a nodular component. The clinician was suspecting melanoma. Is it supposed that I will diagnose a melanoma from a punch biopsy?!!! The punch biopsy was taken from the flat part of the lesion. It was so suspicious with atypical junctional component, small atypical dermal nests, Pagetoid spread and brisk inflammatory reaction. We signed out the report as melanocytic lesion with worrisome histological features which in view of the clinical presentation necessitates complete excision with a safety margin for further histopathological assessment. The complete excision revealed invasive melanoma, Clark level III.

Clinicians sometimes think that dermatopathologists have falcon eyes and are able to know everything about a lesion from tiny pieces given to them!!!!! I am fighting this concept hardly. I have managed to teach younger generations of dermatologists the importance of excisional biopsies but I am still struggling with older generations!!!!!
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One other thing that I find irritating is when fellow Dermatologists take a mish-mashed curetting of a well demarcated lesion. Assessment and orientation of specimen becomes extremely difficult and further excision is invariably needed as the pathologist cannot guarantee the absence of an invasive component. Worse- the lesion turns out to be a melanoma, as has happened recently with a case in our dept.!
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Robledo F. Rocha

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I deal often with inadequate sampling. As I’ve written elsewhere, my mobile phone has been a working tool as essential as my microscope. Thereby I get a chance to enlighten clinicians about better sampling methods.
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Dr. Richard Carr

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Wise not to commit on a punch biopsy (other than for ?PG / nodular melanoma or ?lentigo maligna in expert hands I would say punch biopsy of pigmented lesions other than typical SEBK is contra-indicated). I well remember a very worrisome punch my experienced colleague wanted to call melanoma. I spotted Kamino bodies and despite being a very disturbing pattern advised holding back on a diagnosis. The excision we interpreted as a thin compound Spitz naevus.
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