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Pathology’s little secret


Uma Sundram

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When asked to contribute something to the Dermpath pro blog site, I thought I would ruminate on a topic close to my heart. When we speak to our non-pathology clinical colleagues, they often think of pathologists as the ‘final say’ in diagnosis. “We can only guess at the diagnosis but you guys tell us EXACTLY what the diagnosis is”. While it’s great to feel omniscient, as pathologists we know how slippery this slope really is. Arriving at the appropriate diagnosis is very tricky, especially for dermatopathologists, for whom the clinical scenario is everything.

Let’s talk about melanocytic lesions, for example. We often receive a biopsy from the clinician labeled “lesion”. We need to know the size, the site, and the clinical characteristics to determine if the melanocytic proliferation is benign or malignant. In some cases, we are still making an educated guess, and crossing our fingers that we are making the correct call. We show it to our colleagues and, if it’s really difficult and there is no internal consensus, we ask for an “expert’s” opinion.

What’s important to remember here is that even experts have differing opinions. One person may say ‘melanoma’ to a lesion that someone else thinks is a low grade Clark’s nevus. The site is important—a periumbilical melanocytic lesion may have atypia similar to a low grade melanoma and yet have a good clinical outcome.

So what should the ordinary dermatopathologist do in these types of difficult situations? Of course, one must render the most educated diagnosis they can, ask for opinions within their department, and perhaps send the case to an expert for consultation. It’s equivalently important, however, to have good relationships with clinicians, so that they can communicate the uncertainty inherent in a difficult diagnosis to the patient, and thus arrive at appropriate management, even if the final diagnosis is not a clear-cut benign-or-malignant one.
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