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LIVE BLOG: Communicating With Your Dermatopathologist

In this live blog Clay J. Cockerell, M.D. lectures at the Fall SDPA 2013 Conference on the “secrets” of dermatopathology that he’s acquired through his years of practice. From lost biopsies to refuting diagnosis, Dr. Cockerell covered the pearls and things you are expected to know without being told.

 

Secret #1: Clinical Path Correlation

The Cornerstone of Diagnosis

1. Some histologic diagnoses are unquestionable but many pathologists think that ALL are and that what is on the slide is all that matters.
2. In dermatology, clinical correlation is essential as many diseases give similar histologic reaction patterns.
3. One study showed that accuracy of diagnosis improved 23% when patients are evaluated at a clinical conference where histology and clinical features are correlated.

How to Get Better CPC for Your Patients

1. Include as much information as possible on path request form.
2. Write legibly!

      – If pigmented lesion, describe and put the diameter.
      – If an eruption, describe the extent, distribution, color, duration, etc.

3. Avoid “cryptic” allusions: i.e., r/o leukemia cutis—There’s obviously more to that story!
4. Don’t expect your pathologist to be a “mind reader.”

      – Tell them when you want margins:
      – Example: “I only want margins on ‘dysplastic’ nevi” or malignant lesions,: this is hard to do “after the fact.” It’s better to check off on the requisition slip.
      – Remind your pathologist: “Call us before you do any special stains.”

5. Don’t underestimate the value of your impression!
6. If there is a prior biopsy, put down the prior number and diagnosis.
7. Take pictures.
8. Fill out all demographic information such as sex, race, age and other important information (pregnancy status, medication history, underlying condition or neoplasm etc.)

      – Different conditions affect different populations.

9. Note: We are often “set up to lose” when dealing with inflammatory diseases.

      – Give as much information as possible here. 
      – Remeber they typically won’t look text-book.
      – Biopsy at different stages and from different parts of the body.

In the realm of Dermatopathology, Murphy’s law is paramount! “Whatever can go wrong, will go wrong”

Secret #2: Biopsy Technique

1. Always harvest a good piece of tissue and place it into the proper medium.
2. Diseased tissue may be degenerating or crusted.
3. Make sure you see your specimen floating in the liquid!

      – Specimens may stick to side of bottle, lid, or get crushed in lid.
      – Watch out for specimen remaining on scalpel blade or within barrel of punch

4. Put all the information on the bottle.

      – A lost bottle can make its way back home if properly labeled.
      – Don’t write on lid—it can pop off.

5. Don’t put more than one specimen in the same bottle, especially if you are dealing with two different neoplasms.
6. Extremely small specimens may not survive processing. The smaller the specimen, the higher the chance that it will get lost.

Keep Track of Your Biopsies

1. Keep a Biopsy Log Book or other record.
2. Review Path Reports.
3. Call laboratory to check on the status of your biopsy.

      – If you haven’t heard back, definitely give a call.
      – Delayed treatment or notification can result in legal action if your patient isn’t notified.
      – For legal purposes, get a certified letter if patient doesn’t follow-up in timely fashion.

Things You Are Expected to Know Without Being Told

1. Margins on shave biopsies = margins on elliptical specimens or Mohs surgery.
2. Should say it only “seems to be removed in these sections” because it is not for certain that lesion has been totally removed.
3. Elliptical specimens, while much better, are not as good as Mohs sections.

Trust Your Instinct

1. If you clinically are concerned about a diagnosis, especially melanoma and histologic diagnosis comes back benign, EXCISE IT ANYWAY!

      – A “final” diagnosis depends on several elements: clinical, histological, historical, genetic, etc.
      – Sometimes the clinical diagnosis trumps the histologic diagnosis.

2. Feel free to call, ask questions, refute diagnosis, etc.
3. The goal of your dermopathologist is to come up with best diagnosis, not to be “right.”

Remember the Traveler!

1. Patients travel to unusual areas more commonly today and may bring back unusual diseases like leishmaniasis, Hansen’s disease.
2. Most common infections in travelers are common conditions such as staph and tinea.

Secrets About Alopecia Biopsies

1. A number of these may appear similar. Clinical correlation will be required.

      – Late stage AA, subtle androgenetic alopecia, “involutional” alopecia of the elderly and telogen effluvium will look similar.
      – Late stage LPP and follicular degeneration syndrome; DLE and LPP will look similar.

2. Biopsy early lesion and fully developed lesion – Late lesions often not diagnostic.
3. Submit 2, 3 or 4 mm punches so that we can do horizontal and vertical sectioning.

Conclusions

1. PAs can better serve their patients by expanding their knowledge on what who dermatopathologists are and what they do.
2. Use the dermatopathologist and the lab as a tool: ask questions!
3. Always feel free to contact your dermatopathologist or Dr. Cockerell at any time if you have any questions about a diagnosis or about any other issue in general.

 

Image: Ed Uthman




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