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Why and When a Dermatopathologist Should Tell a Clinician to Excise


Mark A. Hurt MD

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Unlike the human mind, a neoplasm has no free will. It cannot choose to think or evade thinking; it cannot choose between alternatives; it cannot decide to allow some to live and others to die. Because it cannot do these things, humans must acquire knowledge about the nature of neoplasms in order, if possible, to effect an appropriate clinical outcome.

This knowledge is a heavy burden for the patient, the clinician, and the dermatopathologist. The knowledge is difficult to obtain, as it is forged through practice by trial and observation of outcomes as well as by practice and by historical precedent as established objectively (or as objectively as possible) in the literature.

Thus, the interaction of the dermatologist (or clinician as such) and the dermatopathologist (whether from a pathology or dermatology background) is paramount in the decision point for excision of any neoplasm.

In the mind of a dermatopathologist, the diagnosis is always "what is it?" Without that knowledge, it becomes more difficult to effect a treatment strategy. With inflammatory diseases, one can at least describe the constituents of the infiltrate and its location in the skin; with neoplasms one must ultimately decide whether the lesion is benign or malignant. Any decision that is uncertain always prompts additional consultation or excision (or both).

Since I began the practice of anatomic pathology (some 30 years ago), and, later, dermatopathology (25 years ago), the issue of when to tell a clinician to excise has always been a point of controversy. Why is this so? Does it need to be a problem? My conclusion is -- no (despite the uncommon protests of some of my clinician colleagues), it doesn't have to be problematic. Here are some guidelines that have helped me assist the surgeon’s scalpel:

1. If you know the diagnosis definitely, there is nothing more that needs to be said. If you are certain about the diagnosis of melanoma, for instance, the clinician knows what to do next. Sure, you might have to include a Breslow measurement, information about mitoses in the dermal component (in thin melanoma), and whether the lesion is ulcerated -- but then the surgeon rarely needs to know more. This lesion is going to be excised, and the clinical standards will take over from there.

2. If you don't know the diagnosis with certainty, even if you have a bias one way or another, there is everything right about suggesting excision of the lesion, provided that the clinical context allows for it. The implied meaning of uncertainty is that malignancy cannot be excluded -- meaning that malignancy is in the differential diagnosis. In reality, it means that the lesion in question is one or the other: malignant or benign. In the mind, however, there is a conflict of criteria, thus the dilemma. This is why some truly benign lesions will be excised -- and should be excised.

3. Then, there is the case of certain types of benign neoplasms. Spitz’s nevus is probably the most important example because of the persistent nevus problem. Should a dermatopathologist tell a clinician to excise a benign neoplasm? In selected cases, I say -- yes! Why? Principally it is because of mimicry. When melanocytic nevi persist at the site of prior biopsies, they can present as dramatic lesions that can mimic melanomas. I think that every dermatopathologist who has been practicing for 5 or more years has seen at least one example, and it has left an indelible memory. Thus, in a given case of a certain [i]kind[/i] of benign neoplasm, tell the surgeon to excise the lesional field. The patient will benefit, and you will have a clear conscience.
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Dr. Phillip McKee

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I like this blog as it covers such an important topic.
I think that the real problem however in many cases is the increasingly smaller sized samples that we are given on which to make a diagnosis. When I started in dermatopathology, tumors (other than very large lesions) were excised completely) making it much easier to come to a definive diagnosis particularly in the realm of melanocytic pathology. Nowadays with the advent of the punch and shave biopsies we are almost invariably looking at only part of the lesion and hence re-excision becomes an almost daily necessity so that one can see what was left behind. I can think of the numerous dysplastic nevi which harbored a melanoma in the re-excision specimen. I think that our society has allowed cosmetic results to take precidence over diagnostic accuracy.

Mind to the contrary, we should not recomend a re-excision just to be safe if the whole lesion is present in the specimen. The important thing with tumors is to decide whether it is benign or malignant and if it is the latter, whether it is a primary cutaneous lesion or a metastasis. Giving it a precise name for example in malignant appendage tumors although valuable cannot be done in many cases despite the use of immunohistochemistry or consultations opinions. There is no shame in making the diagnosis of malignant appendage tumor NOS and then determining if it does or does not require a re-excision (although nowadays in almost always does).
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