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Clinicopathological Correlation is as or More Powerful Than a Special Stain


Mark A. Hurt MD

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How many times have you been looking at a tumor on the H&E sections and said to yourself: "The differential diagnosis is …. I need a clinical differential diagnosis."

You have done this probably hundreds of times.

You have also encountered tumors in which you wondered the following: "I need to determine lineage so that I can narrow the differential diagnosis."

It occurs on a daily basis.

Have you ever considered the difference between the two examples? Probably, I suspect -- but what is the difference?


A clinicopathological context occurs when one knows the clinical differential diagnosis and considers it in light of the histopathological findings. It is the basic tool of the dermatopathologist, but one often ignored when beginning a practice in dermatopathology mainly from lack of experience. Surprisingly, however, clinical information is not always obtained as a matter of course. Special stains, in contrast, provide specific information in the context of a clinicopathological differential diagnosis. Neither is necessarily more important than the other, but the clinicopathological context is more fundamental in the diagnostic process than a special stain, which comes later in the decision point analysis.

In 2007, a question was posed to dermatopathologists practicing throughout the world (1). The question was as follows: "Please estimate the percentage of skin biopsies in which you render a diagnosis with uncertainty because of insufficient clinical information." The answers varied, but most dermatopathologists in that survey went to some length to obtain the necessary information before signing off on the case. In some examples, however, up to 20% of the cases resulted in a diagnosis with uncertainty because of inadequate clinical information.


If one were to consider clinicopathological information as though it were a special stain, I suspect it might be the most important special stain obtained on every case -- one for which there is no CPT code. Without it, however, one cannot differentiate a seborrheic keratosis from an epidermal nevus, the context of a pigmented purpuric dermatitis, or many of the adnexal tumor presentations. In some cases, one cannot differentiate melanoma in situ from physiological hyperplasia of melanocytes.

Given the nature of clinicopathological correlation, it probably should be considered the most powerful "special stain" of all.


Reference

1. Question to Colleagues: Should skin biopsies come together with clinical photographs? Dermatopathol Pract Concept 2007; 13(4):article 17.
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Robledo F. Rocha

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[font="Palatino Linotype, serif"][size="4"]I believe all of us have experienced of dealing with a difficult case that remained unresolved even after special stains, but became clear following submition of clinical information.[/size][/font]
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