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Clinicopathological correlation


Dr. Phillip McKee

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Clinicopathological correlation is often the basis of accurate dermatopathological diagnosis. But who should perform this correlation? The dermatologist, the dermatopathologist or both? In my experience, in difficult cases, particularly when no clinical information is given, the pathologist often writes a descriptive report followed by the phrase “clinicopathological correlation is required”. This has major disadvantages. Firstly, no specimen should be sent to the laboratory without a full description of the lesion(s) and a clinical differential diagnosis. This will prevent for example a report of lichenoid keratosis being rendered in a patient with lichen planus which could save acute embarrassment at the next case conference. Secondly, a report should not be issued without a definitive diagnosis where possible. If it is left to the dermatologist to sort things out, the dermatopathologist will have an ever expanding collection of cases with no actual diagnoses. As an illustration, if a specimen is reported as a psoriasiform dermatosis consistent with plaque psoriasis, seborrheic dermatitis, psoriasiform drug reaction etc, then unless the pathologist contacts the dermatologist to obtain full clinical information and his/her opinion on the final diagnosis, the precise nature of the condition will remain a mystery to the pathologist. If then one wants to pull out all psoriasiform drug reactions, how can this be done? I would be interested to hear other’s thoughts on this problem.
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Dr. Mona Abdel-Halim

Posted

I agree Dr McKee, and one of my coming blogs will be dealing with the same problem. I think dermatologists should communicate with the dermatopathologists very efficiently through detailed description of the clinical picture, detailed history as regards onset and relation to drugs.....etc... Clinical picture is said to be the gross pathology of the dermatopathology. Also, I believe dermatopathologists should receive good clinical dermatology training in their programs. I believe both should work in great harmony together. As I am also a clinical dermatologist, I find it easier for me and more informative if the clinician sends me the patient so that I examine him by myself, formulate my differential diagnosis and choose the biopsy site. This is more of importance when it comes to inflammatory conditions where we have lists of pathological differential diagnoses.
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Mark A. Hurt MD

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Phillip, you have hit on a daily problem that usually can be addressed before the report is sent out. I agree with you that a definitive diagnosis should be rendered if at all possible. In about 1/4th of the cases I see, there is no clinical diagnosis offered. My practice has been to have my secretarial staff determine whether a clinical diagnosis was simply left off of the requisition; in most cases, this is what happened. In the few cases where no clinical diagnosis was offered, I call the clinician to make sure about their clinical diagnosis. Oddly enough, "simple" lesions such as "seborrheic keratoses" often are not that clinically. I have been humbled into submission too many times not to resolve these issues beforehand. You are absolutely right about the notion of going in from of colleagues without knowing the clinical information before the diagnosis is rendered; it's easy to look like a fool -- and to actually be one. But it is not necessary.
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Dr. Hafeez Diwan

Posted

I, too, always try to call the dermatologist to get a history or a clinical impression. I have learnt from bitter experience that when I fail to do so, embarrassment and misdiagnoses may follow. I think when it comes to doing the clinicopathologic correlation, both the dermatologist and pathologist should collaborate - in the East we have a saying that it takes two hands to clap. Our role in this collaboration should be, I believe, to try to obtain history and clinical information and then make the best judgment call. Of course, often, the biopsy has been done by a non-dermatologist, in which case the dermatopathologist may be on her/his own. Even so, getting a description of what the lesion(s) looked like, the distribution and so on, can be immensely helpful.
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Dr. Mona Abdel-Halim

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I have once heard a presentation of Dr Helmut Kerl and he said that the clinical picture to the dermatopathologist is like the gross pathology to the general pathologist.
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