SAN FRANCISCO When a dermatopathologist butts heads with a pathologist over a diagnosis, it helps to keep the patient in mind.
"What do you do when your opinion differs radically from that of the contributing pathologist?" asked Dr. Dirk M. Elston, director of dermatology at Geisinger Medical Center, Danville, Pa. "You're getting cases … from all over the country. What you get to look at is sometimes not what the contributor thought. Sometimes it's a sticky situation."
Persistence in the face of diagnostic conflictsespecially when a malignancy is at issuemay be needed to achieve the appropriate treatment. "As long as we keep the patient in mind, we're doing the right thing," said Dr. Elston, who moderated a session at the annual meeting of the American Society of Dermatopathology in which speakers gave examples of cases in which their diagnostic opinions differed from others.
Dr. Ronald P. Rapini described an elderly male patient who had a spindle cell neoplasm on his face in the background of solar elastosis. The biopsy showed relatively bland spindle cells going through the fibrotic sun-damaged dermis. Some areas showed cells that were a little bit atypical, but not strikingly so.
When he looked around the sample more, however, he saw progressively more atypical cells and eventually diagnosed an atypical fibroxanthoma, using the appropriate diagnostic stains, recalled Dr. Rapini, professor and chair of dermatology at the University of Texas M.D. Anderson Cancer Center, Houston.
The patient decided to see a head and neck surgeon at another institution, which requested the biopsy slides for review by their own pathologist. "I'll call him Dr. B, because he diagnosed it as benign," Dr. Rapini said. Dr. B told the head and neck surgeon that the patient had a benign lesion that didn't need excision.
"What would you do?" Dr. Rapini asked. He called a dermatopathologist at the other institution"I'll call him Dr. C"and asked him to talk with Dr. B, the pathologist, to request that he at least put an addendum on his report to acknowledge that there was an alternative opinion saying this might be an atypical fibroxanthoma and that it was not a clear-cut case. "So maybe the head and neck surgeon might actually remove the lesion," Dr. Rapini said.
Dr. C reviewed the case and agreed that the lesion looked like an atypical fibroxanthoma. He did speak with Dr. B, but Dr. B refused to modify his pathology report in any way, insisting that this was a benign lesion. Although both Dr. B and Dr. C worked at the same institution, Dr. C felt it would be inappropriate for Dr. C to make an addendum himself on a colleague's case.
"Now what would you do?" Dr. Rapini asked. He asked Dr. C to talk to the head of his institution's pathology department to see what the chair would say. "The actions of the head of the department are not known to me," Dr. Rapini said. The pathology report basically stayed the same.
"Now what would you do?" he repeated. Dr. Rapini called the head and neck surgeon directly to inform him of the alternative opinion, and that Dr. Rapini had diagnosed the lesion as an atypical fibroxanthoma that should be removed.
The surgeon reexcised the area and sent the surgical specimen to the institution's dermatopathologist, who declared it an atypical fibroxanthoma with clear surgical margins. "So it had a happy ending," Dr. Rapini said.
Dr. Elston praised him for sticking with the case: "You were willing to persist, and kept in mind that there was a patient at the other end who had a malignancy that was not being treated appropriately."
Persistence in the face of diagnostic conflicts may be needed to achieve the appropriate treatment. DR. ELSTON