Pathology of challenging melanocytic neoplasms. Diagnosis and Management. Christopher R. Shea, Jon A. Reed, Victor G. Prieto (Editors). Springer (2015)
The accurate pathologic staging and reporting of melanocytic lesions is crucial for guiding effective therapy, providing useful prognostic information, and facilitating sound clinicopathologic correlation. Moreover, in our fragmented American healthcare system and mobile workplace, in which many patients change healthcare providers from year to year, a clear and intelligible pathology report may be the best means of ensuring appropriate care through years of follow-up. Also, because some laboratories and hospitals destroy slides and blocks after a number of years (a deplorable practice), the pathology report may survive as the sole reliable documentation of a dangerous melanoma having a risk of recurrence over time. Finally, because melanoma is a leading cause of medicolegal liability, a clearly stated report, carefully documenting pertinent positive and negative findings, is often the pathologist’s best defense, even in cases eventuating in a poor outcome.
There is no single standard for what constitutes an acceptable pathology report, and many pathologists undoubtedly simply follow whatever format they learned during their training. Thus, many pathologists state the diagnosis near the top of their reports, presumably on the principle that busy clinicians may prefer to get to the diagnosis quickly and skip the subsequent details of gross description, prosection, microscopic description, results of special studies, etc. We, on the contrary, prefer a reporting style that more logically replicates the actual flow of information during the course of processing a specimen and reaching a diagnosis. Thus, our reports first state the information received on the requisition sheet regarding patient name and demographics, requests if any from the provider (e.g., reporting on margins, requests for special studies or expedited service), clinical history, and clinical diagnosis. We next provide the gross description, giving details of any gross lesions and their distance from the deep and peripheral margins; describe the scheme, if any, used for inking the margins; and summarize the prosection method, covering the thoroughness of sampling, numbering of blocks, etc.
Next, it is our practice to provide a microscopic description for every specimen, generally proceeding from the epidermal surface down to the deepest tissue represented, and going from low-power (architecture, silhouette) to high-power (cytologic) findings. Admittedly, many very distinguished pathologists do not routinely provide microscopic descriptions, instead inserting a comment on selected cases to make pertinent microscopic observations; such reports often include the simple statement, “Microscopic examination was performed,” which clearly is included merely to meet the minimal reporting standards to justify a gross/microscopic CPT billing code. It is probably true that if one had to sacrifice one component of the report, a good gross description would win out over the microscopic description, at least for larger or more complex specimens. Nonetheless, pathologists whose clientele is mainly composed of surgeons should be aware that most dermatologists have different expectations, and may prefer to receive a microscopic description. All dermatologists receive extensive training in cutaneous histopathology, many actively practice diagnostic dermatopathology, and most find it very useful if not essential to read the microscopic findings so that they may correlate them with what they saw in the clinic—their in vivo gross examination.
Going through the exercise of providing a brief, pointed microscopic description also serves as a very important check for pathologists, forcing them to provide criteria and rationales for their diagnosis rather than relying excessively on intuition or Gestalt psychology (as useful as these also may be). In this regard, the use of macros or “canned” descriptive phrases bears some discussion. We routinely use them, as do most of our colleagues; but there is no doubt that they can be dangerous unless used with care. They can have the undesirable effect of short-circuiting the intellectual process by letting one evade the crucial, explicit step of describing findings. Indeed, one of the more common problems seen in training residents and fellows is their tendency to jump at a diagnosis (often reaching the correct conclusion), and then simply to reach for whichever canned microscopic description corresponds with that diagnosis, thus avoiding a more explicit, lengthy, but ultimately rewarding method of searching for pertinent diagnostic findings, assigning them due weight, and finally arriving at a balanced and deliberate conclusion. Also, in cases of error leading to misdiagnosis, it is very difficult to defend a statement (such as “mitotic figures are not identified”) that can be readily contradicted upon subsequent review with the benefit of hindsight; it is perhaps out of concern for saying too much, as well as a desire for speed and concision, that many pathologists eschew microscopic descriptions altogether. To the contrary, we use our macros as a checklist of essential findings, and we rapidly run through each description in our minds, before deciding whether to apply it. For example, a standard microscopic description of a compound (non-dysplastic/nonatypical) nevus may state, “Nests of melanocytes without significant atypia or mitotic figures are present both at the dermo-epidermal junction and in the dermis. There is no significant architectural disorder or inflammatory response.” That simple description contains a wealth of positive and negative criteria, and a rapid consideration of its elements can usefully prompt the careful pathologist to rethink the diagnosis, in cases where discordant features are present. The best advice is: If you choose to use canned microscopic descriptions, be sure that you know exactly what they say, and that they accurately describe the case at hand; if not, modify them, omit them, or write individual descriptions as needed.
The heart of the report is, of course, the diagnosis. Similar to a clinical progress note, where the subjective evaluation and objective data precedes the final assessment and plan, we prefer to present the final pathologic diagnosis at the end of the report, to complete a logical progression of information that the clinician can easily follow. The diagnosis line should be clear, readily found within the report, and indicate associated data when appropriate. For instance, following the diagnosis line that reads “Melanoma, Invasive”, the histogenetic type, Breslow thickness, mitotic figure count, staging information and other pertinent data are presented.
Other useful information, when appropriate, may be added in comments and notes that follow the diagnosis line. Under comments, one may add details about margin involvement of relevance and suggestions for the clinician, such as management recommendations when appropriate. Areas of uncertainty should be described, and evidence in favor and against the diagnosis presented. Lastly, consultations for collaborative diagnosis with multidisciplinary teams, and pertinent references from the published literature, may also be noted in this section.
More standardized pathology reports may lead to better efficiency, more accurate reporting, and reliability. Regardless of the layout chosen for the report, one of the pathologist’s principal tasks is to include information that will help the clinician and patient decide on appropriate treatment. Reporting out a diagnosis of melanoma can be especially challenging. Some of the features currently understood to influence estimated prognosis may not remain the same in the decades to come. Accordingly, the pathologist may consider including some criteria (i.e., histogenetic type) not currently used for staging or treatment planning, with the expectation that they may become of value for future applications. In addition, the advancement of our understanding of melanocytic lesion behavior depends on research, which often relies on the retrospective evaluation of data obtained from pathology reports. In an attempt to help shed light on some of these important microscopic features of melanocytic lesions, the current chapter highlights data that support the inclusion of selected histopathologic characteristics in the reporting of melanoma.
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