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Merely histological detail? Or something really reportable?


Robledo F. Rocha

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It's not uncommon a tumor appearing in the form of a histological subtype or a microscopic variant, in such a way that makes more difficult the correct diagnosis. There's no remaining alternative for practitioner pathologists but to be aware, as much as possible, about subtypes and variants of tumors, thereby reducing the chances of rare features be misconstrued as evidence of another tumor, or even of no tumor at all. For example, adenoid melanoma can be misconstrued as adenocarcinoma, and desmoplastic melanoma can be misconstrued as scar.

After the correct diagnosis was established, should one write down the subtype, variant or rare features of a tumor in the report? Given the risk of make the report verbose, I prefer not to do that, unless they are important for clinicopathological correlation, therapeutic decision making, or behavior prediction.

In regard to the two melanoma variants cited above, adenoid melanoma does not imply any difference from the most common types of melanoma. As a matter of fact, it's nothing more than a histological detail for microscopic diagnosis purposes only, and the inclusion of the adjective 'adenoid' in the report may be a source of confusion for clinicians.

Conversely, desmoplastic melanoma meets the requirements laid down by me since its typical gross presentation is an amelanotic swelling that hardly is considered clinically a melanoma, hence microscopic diagnosis of melanoma could provoke strangeness without the adjective 'desmoplastic'. Moreover, desmoplastic melanomas are associated with increased recurrences in comparison to non-desmoplastic melanomas.

Maintaining coherence, I use to report basal cell carcinoma as superficial, nodular or infiltrative, despite dozens of subtypes and variants described in the medical literature. I think this simplified reporting system enables appropriate clinicopathological correlation and stratification of patients at low and high-risk for recurrence.

Likewise, when I report common melanocytic nevi, I use to banish those descriptive adjectives 'junctional', 'compound' and 'intradermal'. I prefer to sign them out as flat nevus, Miescher nevus and Unna nevus because I judge them much easier to correlate with clinical attributes of the lesion and its dermatoscopic findings.

I know that some pathologists use to write reports as if they would be revised by other pathologist, but in fact our reports, as a rule, will be read and evaluated by clinicians aiming the benefit of patients.

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Mark A. Hurt MD

Posted

Robledo,

Do you have any specific criticisms for those who prefer to offer detailed microscopic descriptions and subtype classification in reports? Do you think there is any merit at all in doing so? Do you consider it overly defensive?

In the US, we are required to list all of the antibodies used for billing purposes, that is, if we wish to receive payment for our work. Do you list these in your reports in the micro or in a separate section?
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Robledo F. Rocha

Posted

Dr. Hurt,

I apologize for the delay in answering.

About your first query, I don't think reports that are very descriptive and detailed came to being this way pressed by defensive measures. Pathology reports are now standardized by many valuable checklists which are able to provide, to a greater or lesser extent, the required informational content for the most common cases. It would be too much rigorous expecting more than current scientific state can offer.

I believe prolix reports have academic hint since they express more the data recorded in textbooks and in articles than the needed data for patient care.

On the second subject, here pathologists are also demanded to inform, for billing purposes, all the antibodies used for immunohistochemistry in a report that is, as a rule, separated from the first HE-stained report.

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