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Doing Too Much?


Mark A. Hurt MD

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Mark A. Hurt, MD
I have been accused by some of ”doing too much” to complete a report. This has happened to me a number of times over the years. In wonder, and, to some degree, astonishment, I have listened to the criticisms, usually dismissing them -- losing clients, rarely, in the process.
What are some arguments that one is doing too much to complete a case? Although probably not a complete list, they are, in my experience, as follows:
- Obtaining too many recuts
How many times have you experienced, in the evaluation of a biopsy or an excision, missing epidermis, an edge without ink showing, solar elastosis only in a small biopsy when the differential diagnosis is basal cell carcinoma, or a tip with tumor? If you have experienced any of these situations (and I know you have), you probably obtained recuts (serials or levels) to attempt to resolve the diagnostic quandary.
Recuts help solve problems in two ways: one positive, one negative. In the positive, the simplest example is that one attempts to identify a tumor -- one doesn't see the tumor in the initial sections -- one obtains recuts and finds the tumor -- dilemma solved. In the negative, one attempts to identify a tumor -- one doesn't see the tumor in the initial sections -- sections are made to deplete all the tissue in the block -- no tumor is identified.
The positive case is obvious and self-evident: the tumor is identified. The negative case is somewhat more difficult because the expected lesion is not identified even after sectioning to deplete; colleagues have told me often it is a waste of time and money. Yet, the negative case is valuable because it often leads often to the identification of the fact of another lesion that explains the differential or that the biopsy simply missed the lesion. In either example, by depleting the block, one has more knowledge then if, say, no recuts or only one set of them was made.
- Obtaining too many special stains
Special stains have a particular place in the evaluation of cutaneous specimens. Although not considered "special," the H&E is, in fact, a stain, and probably the most special one of all because it provides structural contrast so that dermatopathologists can evaluate the form of a lesion.
Yet, by "special stains" one refers usually to histochemical stains other than H&E, and one refers to immunohistochemical stains and even genetic "stains" and ultrastructural "stains." Histochemical stains target specific structural components of or specific kinds of materials in the skin (or both), whereas immunohistochemical stains target lineages as well as certain proteins or even segments of DNA that aid in narrowing the differential.

In essence the usage of such stains has a single purpose: decision point testing. A decision point occurs when one observes the histopathological changes under a microscope and realizes that there is a differential diagnosis that can be settled or narrowed by employing a stain or a panel of them. For neurofibroma the number of stains is usually fewer than for lymphoma. For melanoma, it is often a lineage issue: epithelial versus melanocytic, for instance. There are dozens of examples that one encounters in a single day of sign-out.
There are myriad uses of such stains, and it is not always easy to explain to a client (usually a dermatologist in my case) why I had to use S100 protein, p75, and CD34 to come to the conclusion that the lesion was just a scar! After all, can't you just know that by looking? Well, no, not always -- and that is the whole point of using them.
- Quoting the literature too much
From time to time, I quote key articles when I produce a report. The point of it is to document the fact that I am not making up the diagnosis and that it is grounded in some empirical or systematic study of similar cases (or both). Most of my clients like this; a few do not; most are indifferent.
As a rule, I think the literature should be quoted with some degree of caution. It should be reserved for cases that are sufficiently unusual that the client might want to have a reference, or that I want the reference in the report for my own purpose to remind me of relevant literature if there is any follow-up on a given patient's case.
- Producing long comments
Why produce a comment at all much less a long one? Comments have a place in reports, but clinicians vary in how they evaluate comments. Some clinicians have told me that a comment is a crutch for when you don't know the diagnosis; this is partly true -- but it is not the whole truth. Comments serve for exposition of a diagnosis, for indication of the status of surgical margins, and, most importantly, they serve to explain a differential diagnosis when a definitive diagnosis is not possible in a given specimen.
I have had experience with many clinicians about how to use comments and whether to use them; some have even fired me for using comments. Despite this unfortunate situation, my philosophy is that comments should be as short and pithy as possible. This, however, is not always possible or desirable. My most common use of comments centers on the evaluation of melanocytic proliferations, specifically in explaining why I cannot exclude melanoma from the differential diagnosis in a given case. Even though I can weigh the facts of a case and even be biased toward nevus or melanoma in a given case, when uncertainty arises, it should be explained. It is at least an honest way to communicate.
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In essence, "doing too much" should be reframed as "doing what is necessary and sufficient" to evaluate a specimen. If, after this is done, someone complains, then let them make the most of it. I, for one, have a clean conscience.
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Dr. Phillip McKee

Posted

You have made yor point prefectly. I couldn't agree with you more. There is nothing to add other than at the end of the day the patient needs to know that no stone has been left unturned by the pathologist in an effort to get to the correct diagnosis. If the dermatologist doesn't like it, too bad!!!!!!
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Dr. Mona Abdel-Halim

Posted

I agree with every single word. Recuts are very important and I have practiced what you have said about lesions that did not show themselves clearly except with multiple sectioning, it is crucial...I loved the part of quoting the literature, I usually do not include it in the report but I send it to the clinician when I send him his copy of the report by email but I guess including it in the report is an excellent idea especially if the client is educated and is used to checking everything on the internet!!!!!! Doing too much to ensure patient's well being is our job.. We have to do too much...
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Mark A. Hurt MD

Posted

Thank you for these comments. I will add that part of the reason to include the literature is so that I will remember it, too!
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Dr. Hafeez Diwan

Posted

I completely agree with your points in this superb post. Yes, as you say, "it is not doing too much", "it is doing what is necessary and sufficient." Sometimes doing what is necessary and sufficient can evoke not gratitude, but censure, in the spirit of "no good deed goes unpunished". I believe we are responsible for whatever remains in the block, and so if we unearth no obvious pathology, then maybe it is a clue for the dermatologist to go back and re-biopsy. The few instances where a tumor pops up on deepers justify the practice of getting as many levels as are needed for the diagnosis to be made.
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As everybody else, I agree completely. For lazy clinicians or pathologist would be "too much" but for those who do their jobs the best they can it is never enough to have a clean conscience.
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Dr. Richard Carr

Posted

I cannot dissagree with Mark but some days when I send back 30% of the cases for recuts, specials, immunos etc. I feel am I the only dermatopathologist incapable of making a diagnosis? Admittedly this does not happen every day but some days there is a dissproportionate number of these frustratating cases that just won't sign out easily. On the other side of the coin I find it equally frustrating when a colleague shows you a case with ample pathology in the first section to make a perfect clinical pathological diagnosis of a rare (but often relatively common!) condition that you only see once in a blue moon and would love to use for teaching or that national meeting or exam etc and they have cut the block through to nothing hoping somehow inspiration will come before finally showing the case to their specialist colleague or referring the case for a second opinion. Sometimes it is best to leave something in the block so that someone else can have a crack at the case!! Usually in those cases that same diagnosis is present in all 9 levels through the block! This often applies to difficult / borderline melanocytic lesions - I think (for a non-expert dermatopathologist or an expert with close colleagues to ask) my advice would be if you can't be sure in the first 3 levels (when there is clear-cut pathology but you can't put a name to it) it is time to ask a friend for help! We actually started an informal policy (to try to reduce IHC requests) of showing the difficult cases to colleagues before making the request and to rationalise the panel. If you are lucky to have respectful and fore-bearing colleagues then close team working can be very time and labour saving for all concerned. We try to team sign out all the "difficult" melanocytic cases. It may be folie a deux but one sleeps better at night!
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