Diagnosis In Dermatopathology Research Articles

Adding "Unlikely" as a Clinical Qualifier Is Unlikely to Be of Help: A Retrospective, Single-Center, Cross-Sectional Cohort Study.

Clinical correlation is essential to accurate and efficient diagnosis and differential diagnosis in dermatopathology. Poor-quality clinical information can lead to failures and delays in patient care. Some clinicians use the term "unlikely" when submitting a specimen. How frequently the "unlikely" clinical diagnosis correlates with the final pathologic diagnosis is unknown. We studied 203 dermatopathology reports from December 8, 2020, to July 1, 2021, that included the qualifier "unlikely" on the requisition sheet. Samples were stratified into either an inflammatory or neoplastic cohort based on final histopathologic diagnosis, with the neoplastic cohort being further stratified into pigmented and nonpigmented cohorts. Statistical analyses were conducted. The "unlikely" diagnosis in the clinical differential diagnosis and the final histologic diagnosis were the same in 7.9% of the 203 samples studied. This occurred in 8.5% of the inflammatory cohort and 7.6% of the neoplastic cohort. We concluded that the use of the qualifier "unlikely" is not helpful. We acknowledge the limitations of our study because of a small sample.

Atretic cephalocele and encephalocele: A single-institution clinicopathological study.

Encephaloceles are neural tube defects characterized by herniation of meninges, neural tissue and cerebrospinal fluid, while atretic cephaloceles denote a rudimentary connection to the intracranial space with absence of herniated neural tissue and represent an infrequent dermatopathologic diagnosis. Limited reports of these entities confound the challenge in their histopathologic distinction. Accurate classification is important given associated anomalies and neurologic manifestations that impact prognosis. We describe the clinicopathological and immunohistochemical [glial fibrillary acidic protein (GFAP), S100, epithelial membrane antigen (EMA), and somatostatin receptor subtype 2A (SSTR2A)] features in a retrospective series encountered at a single institution between 1994 and 2020. We identified 13 cases classified as atretic cephalocele (n=11) and encephalocele (n=2). Hamartomatous changes and multinucleated cells were unique to atretic cephaloceles while myxoid areas were unique to encephaloceles. At least focal staining for SSTRA was seen in all atretic cephaloceles with the majority (87.5%) staining for EMA; negative staining for GFAP and S100 confirmed absence of neural tissue. Encephaloceles were GFAP and S100 positive, and negative for SSTR2 and EMA. Atretic cephaloceles had a favorable prognosis compared to encephaloceles, with severe morbidity present in both encephalocele cases. Our study raises awareness of atretic cephalocele and encephalocele among dermatopathologists and reveals a mutually exclusive immunophenotype that facilitates their distinction for prognostication and management.

33407 Accuracy of clinical-dermatoscopic versus dermatopathologic diagnosis of melanoma and nonmelanoma skin cancer

Results from a retrospective, quantitative, cross-sectional study to assess the agreement and accuracy of the clinical dermatoscopic diagnosis of melanoma and nonmelanoma SC in comparison with dermatopathologic examinations. In total, 3205 patients were evaluated, with a 67-year mean age. Of these patients, 1603 (50.1%) had a clinical-dermatoscopic hypothesis of AC, with 859 (53.4%) being female and 744 (46.6%) being male patients. Of the suspected cases, 1300 had a clinical-dermatoscopic diagnosis of BCC; 230, SCC; 34, MM; and 39, keratoacanthoma (KA), with a dermatopathologic confirmation of 90.85%; 67.39%; 93.5%; and 85.64%, respectively. The clinical dermatoscopic versus dermatopathologic agrement for all the SC was statistically significant, according to Kappa coefficient and chi-square test. For KA, our accuracy was 85.64%, and these data are the first publication that correlate the clinical dermatoscopic suspect of KA with dermatopathologic confirmation. Our findings show our BCC clinical accuracy (90.85%) is in accordance with the literature. However, for SCC and MM, we had an accuracy greater than what had been published until then, respectively, 67.39 and 93.5%. In conclusion, an exact diagnosis of SCC depends on clinical, dermatoscopic, and histopathologic criteria. Likewise, MM, in which clinical diagnosis’ assertiveness is only 76%, SCC’s clinical diagnosis may be considered a fragile issue because KA is often confused with SCC. In these cases, dermatoscopy has the ability to speed up the therapeutic management of SC which needs more immediate management, even more so when the dermatopathologic diagnosis, the gold-standard tool for diagnosing SC, may be delayed or not available.

Clinicopathological Correlation in Dermatopathology

Introduction and aim: Getting an accurate diagnosis in dermatopathology requires a combination of clinical and pathological information. Our aim was to assess the importance of the correlation between clinical and histopathological diagnosis in various cutaneous diseases. Materials and Methods: One-hundred cases of variable skin diseases were studied clinically by dermatologist and histopathologically by general pathologists. Cliniopathological correlation was done by direct communication between the dermatologist and the pathologist. Results: Concordance between pathological and clinical diagnoses was seen in 84%, a new pathological diagnosis was issued in 3% and non-diagnostic report in 13 %. After clinicopathological correlation; out of 84%, we accept only 65% as final diagnosis. In addition, the correlation was helpful and provide a diagnosis in another 20% of cases. One new pathological diagnosis was accepted whereas in the remaining cases (14%) further workup were required. Conclusions: Accurate diagnosis of cutaneous disorders depends on clinical skills as well as careful histopathological assessment and best results can be obtained if the patient and biopsy sections are viewed together. Electron microscopy, immunofluorescence assay, immunohistochemistry techniques and molecular pathology are important adjuncts for definite diagnosis of many skin diseases.

A clinico-histopathological study of cutaneous appendageal tumours

The cutaneous appendageal tumors are an ideal subject for study from clinical and morphological point of view and so ubiquitous that they can affect people of all age group A histopathological study of 100 cases of cutaneous appendageal tumors was carried out at tertiary care hospital over 18 months. A Total 95 cases were benign and 5 cases were malignant tumors, constituting 95.0 % p0.01 respectively. Sweat gland tumors were the most common manifestation (79.0% ) p follicle tumors (20%) and eccrine duct tumors 1(1%). Male and female ratio was 27:73. The commonest affected body site was head and neck region . The mean age was 36.58 1.22 years . Out of 95 cases of benign tumors, syringoma accounted for 48% (48), trichoepithelioma12 p (11) p0.01. Total (39) p clinically and histopathologically. Summing of the results concludes that ,the diagnosis of skin tumors presenting with unique difficulties in correlation with wide variety of tumors . Histopathological study is one of the most valuable means of diagnosis in dermatopathology and the diagnosis of skin tumors can be done by correlating clinical features, gross and histological appearances.

Analysis of the Most Commonly Encountered Diagnoses in Academic Dermatopathology

: The number of skin biopsies has increased over the last three decades, but benchmarks based on the number of biopsies required to capture skin cancers are lacking. To determine the most common dermatopathology diagnoses, reports of all 85,785 dermatopathology specimens examined in the Department of Dermatology at the University of Florida from January 2017 to December 2017 were reviewed. 78,353 non-excisional specimens were evaluated for diagnosis. 7,432 excisional specimens consisting of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), melanoma, and dysplastic nevi were evaluated for residual tumor and marginal status. The fifteen most common diagnoses accounted for 84% of all biopsies, and an additional 30 entities accounted for 12% of all biopsies. The remaining 4% of cases were composed of only 206 diagnoses. This pattern reflects current dermatology practice in the United States, wherein the 20 most commonly encountered diseases account for 85.4% of all diagnoses made by dermatologists. Among the total number of biopsies, 90.7% of specimens were neoplasms and 9.3% were inflammatory or infectious disorders. Uncommon (4%) and inflammatory or infectious (9.3%) disorders comprise a small minority of academic dermatopathology, with implications for resident and fellowship training.

Common traps/pitfalls and emergency diagnosis in dermatopathology.

Although all diagnoses in dermatopathology are important, three main groups may be highlighted. One group includes diagnoses that need to be communicated to the treating physician as soon as possible(this review includes infectious process while erythema multiforme and related diseases are discussed elsewhere in this series). A second group has diagnoses significant for their association with syndromes or internal malignancies. And a third group includes malignant lesions that can be confused histologically with benign ones or lesions that have an aggressive behavior unexpected for their apparently low-grade histology. This manuscript describes some of these important diseases and the method we use to reach the diagnosis, and as such it may be considered to be a "survival" guide for the dermatopathologist.

‘Why don't they ever call?’ Expectations of clinicians and pathologists regarding the communication of critical diagnoses in dermatopathology

Certain diagnoses in dermatopathology have significant implications for patient management and on occasion appropriate clinical care may be facilitated by a phone call from the reporting dermatopathologist to the referring doctor. Whether this is appropriate depends on a number of factors. The concept of 'critical diagnoses' is now well established in surgical pathology, having evolved from critical value policies in clinical pathology and haematology. However, only limited attempts have been made to assess perceptions among different clinical groups. We designed a survey to assess the attitudes of pathologists, dermatologists, surgeons and general practitioners as to what circumstances warrant telephone contact in addition to a standard written report, as well as their approaches to routine histology follow-up. The survey was distributed Australia-wide via a combination of specialist colleges, medical forums and collegiate contacts. A total of 262 responses were received, encompassing representations from all of the targeted specialties. Approximately 20% of respondents were aware of adverse outcomes or 'near misses' which they felt had been due in some part to inadequate communication of histopathology results. While most practitioners have formal systems in place to review histopathology reports, this practice is not universal. There were a number clinical situations where there was a discrepancy between the expectations of clinicians and those of pathologists, in particular with regard to a diagnosis of cutaneous melanoma as well as cutaneous lesions which might be associated with inherited cancer syndromes. It is our hope that the results of this study will facilitate discussion between pathologists and referring clinicians at a local level to minimise the potential for miscommunication.

Collagen Anomalies as Clues for Diagnosis: Part 1.

Collagen is the most abundant protein in the body and the main structural component of the skin. To provide a review of the histopathology of collagen alterations and to propose a classification with the most important types of collagen anomalies in dermatopathology. The authors describe some of the main morphological clues of collagen anomalies for specific diagnosis of some cutaneous inflammatory and neoplastic conditions. The authors review histopathologic collagen anomalies, concerning both morphology and disposition in some inflammatory and neoplastic cutaneous conditions, and they review previous terminology and proposed a classification of the most important types of collagen anomalies that can be seen in dermatopathological practice. Collagen anomalies in skin can be classified into lamellar fibrosis, sclerosis, and "balls" and "rings" of collagen. Lamellar fibrosis presents as long and thin collagen bundles forming a delicate network, which can be disposed in a parallel pattern, onion-bulb-like pattern, and storiform pattern. Sclerosis is characterized by large, thick, and eosinophilic bundles of collagen, which may present as a homogenous-diffuse pattern or as individual thick bundles of collagen with few or abundant number of fibroblasts between them. Finally, the authors propose the terms "balls" and "rings" of collagen. The term "balls" of collagen stands for thick, homogenous, eosinophilic, globular collagen bundles, with no distinguishable individual composing fibers, which include the floating sign and the free-floating sign. The term "rings" of collagen is characterized by sclerotic collagen arranged in a homogenous rimming pattern around vessels without independent fibers in its composition. Collagen anomalies may be important clues to establish specific clues for specific diagnoses in dermatopathology.

Diagnostic Performance of Deep Learning Algorithms Applied to Three Common Diagnoses in Dermatopathology

Background: Artificial intelligence is advancing at an accelerated pace into clinical applications, providing opportunities for increased efficiency, improved accuracy, and cost savings through computer-aided diagnostics. Dermatopathology, with emphasis on pattern recognition, offers a unique opportunity for testing deep learning algorithms. Aims: This study aims to determine the accuracy of deep learning algorithms to diagnose three common dermatopathology diagnoses. Methods: Whole slide images (WSI) of previously diagnosed nodular basal cell carcinomas (BCCs), dermal nevi, and seborrheic keratoses were annotated for areas of distinct morphology. Unannotated WSIs, consisting of five distractor diagnoses of common neoplastic and inflammatory diagnoses, were included in each training set. A proprietary fully convolutional neural network was developed to train algorithms to classify test images as positive or negative relative to ground truth diagnosis. Results: Artificial intelligence system accurately classified 123/124 (99.45%) BCCs (nodular), 113/114 (99.4%) dermal nevi, and 123/123 (100%) seborrheic keratoses. Conclusions: Artificial intelligence using deep learning algorithms is a potential adjunct to diagnosis and may result in improved workflow efficiencies for dermatopathologists and laboratories.

Validation of Digital Pathology for Primary Histopathological Diagnosis of Routine, Inflammatory Dermatopathology Cases.

Digital pathology (DP) systems have been validated for routine, histopathological diagnosis by several investigators. The diagnostic matter in previous studies is composed mostly of neoplasms. However, in dermatopathology, inflammatory diseases constitute a greater proportion of cases and have been under-represented in this literature. Herein, we report the results of a prospective, DP side-by-side validation study comparing the histologic assessment of routine, clinical inflammatory dermatopathology cases by whole slide imaging (WSI) and traditional light microscopy (LM). Glass slides were digitized at ×40 magnification. Two dermatopathologists rendered diagnoses digitally and immediately thereafter by light microscopy. Additional recuts, special, and immunohistochemical stains obtained during workup were scanned and evaluated similarly. Morphological features used to make diagnoses and appreciable differences in histology were recorded. A total of 332 slides representing 93 cases were examined, including 157 hematoxylin & eosin sections, 132 special stains, and 43 immunohistochemical slides. In total, 333 microscopic features important for rendering inflammatory diagnoses were identified. Two discrepant instances were noted wherein Gram-positive cocci were identified using traditional microscopy but not by DP (×40 scan). Eosinophils, melanin granules, and mucin were identified on both modalities but were noted to have different appearances. Our findings indicate that DP is sufficient for primary diagnosis in inflammatory dermatopathology. Higher magnification scanning may be required to identify submicron features, such as microorganisms. Subtle differences in image quality between these 2 modalities may contribute to varied histologic interpretations of which pathologists should be aware when validating clinical DP systems.

Histologic Mimics of Basal Cell Carcinoma.

- Basal cell carcinoma (BCC) is the most common human malignant neoplasm and is a frequently encountered diagnosis in dermatopathology. Although BCC may be locally destructive, it rarely metastasizes. Many diagnostic entities display morphologic and immunophenotypic overlap with BCC, including nonneoplastic processes, such as follicular induction over dermatofibroma; benign follicular tumors, such as trichoblastoma, trichoepithelioma, or basaloid follicular hamartoma; and malignant tumors, such as sebaceous carcinoma or Merkel cell carcinoma. Thus, misdiagnosis has significant potential to result in overtreatment or undertreatment. - To review key features distinguishing BCC from histologic mimics, including current evidence regarding immunohistochemical markers useful for that distinction. - Review of pertinent literature on BCC immunohistochemistry and differential diagnosis. - In most cases, BCC can be reliably diagnosed by histopathologic features. Immunohistochemistry may provide useful ancillary data in certain cases. Awareness of potential mimics is critical to avoid misdiagnosis and resulting inappropriate management.

Pediatric dermatopathology: an overview.

Dermatopathology is a subspecialty of pathology and dermatology involving correlation of clinical information with microscopic observations of skin biopsies to provide diagnostic information. Pediatric dermatology is a subspecialty of dermatology for which specific points need to be known for evaluating and managing skin disorders in children. The histopathological approach and other important factors for definitive diagnoses in pediatric dermatopathology are reviewed. Skin diseases in children are not necessarily smaller versions of those that develop in adults and some diaseases may be confined to pediatric age group. An experienced team of dermatology and pathology increases the success of skin biopsies in pediatric dermatology besides the excellent technical skills. The histopathologic findings of skin lesions in children should be evaluated by pediatric pathologists, who have a specific interest for pediatric dermatopathology, in close collaboration with pediatric dermatologists.

Risk Factors for Invasive Fungal Infection among Thai Oncologic Patients with Febrile Neutropenia and Cutaneous Presentation: A 5-Year Retrospective Study in Southern Thailand

Background:Febrile neutropenia (FNP) is a condition defined by fever and neutropenia. There are current only limited data on related cutaneous manifestations. This study aimed to assess cutaneous lesions and their etiologies in a Thai group of FNP patients.Methods:A retrospective analysis was conducted on 43 non-transplant febrile neutropenic patients with concurrent cutaneous lesions, as determined by dermatopathologic studies at Songklanagarind Hospital in Thailand over a five-year period.Results:The mean age was 39 years (SD: 18.8). Approximately 60% were male. The most common underlying disease was a hematologic neoplasm. Twenty-one of the participants had developed FNP within 7.5±8.7 days after presenting with skin lesions. Twenty-two participants had skin lesions 9.0±11.1 days after FNP diagnosis. Cutaneous manifestations were mostly in the form of multiple lesions (67.4%), of which the most common were nodular skin lesions (37.2%) presenting on the lower extremities of the body (58.1%). The dermatopathologic diagnoses included infections which were almost all fungal and leukemia cutis. The development of skin lesions after FNP proved to be a statistically significant risk factor for fungal infection (OR 8.13, P = 0.009), whereas age (over 40 years) proved to be a statistically significant protective factor (OR 0.20, P = 0.04).Conclusions:There are a variety of cutaneous manifestations in FNP, of which the most common were cutaneous nodular skin lesions in the lower extremities. The most frequent infection was fungal in patients under 40 who had developed skin lesions after FNP.

Measures of Completeness and Accuracy of Clinical Information in Skin Biopsy Requisition Forms: An Analysis of 249 Cases.

To define indices of completeness and accuracy of clinical information in the skin biopsy requisition form (RF) and correlate them with health care delivery outcomes and pathology service utilization. RFs in our pathology information system were reviewed and assessed for the presence of 10 clinical elements considered critical for dermatopathologic diagnosis. Accuracy was determined by reviewing corresponding clinical notes. In total, 249 RFs were reviewed. In inflammatory dermatoses, provision of a clinical impression, provision of more than two elements, and achieving more than 75% accuracy were associated with improved outcomes and decreased utilization. For all nonlymphoproliferative cases, higher quality clinical information was associated with decreased turnaround time (P < .001). More clinical information was associated with increased utilization and turnaround time (P = .0235) for lymphoproliferative cases and higher resampling rates for melanocytic lesions (P = .0066). In inflammatory dermatoses, providing high-quality clinical information on the RF promotes optimal histopathologic diagnostic performance and appropriate pathology service utilization.

Seasonal variations in dermatologic and dermatopathologic diagnoses: a retrospective 15-year analysis of dermatopathologic data.

Certain dermatologic conditions are known to show seasonal variations in frequency, the reasons for which are unclear but in some cases may be attributable to changes in ambient weather conditions. The current study was conducted to determine whether seasonal trends might exist for dermatologic conditions including erythema multiforme, guttate psoriasis, erythema dyschromicum perstans (ashy dermatosis), pityriasis lichenoides, and pityriasis rosea. Data were derived from a 15-year retrospective review of electronic records from a large dermatopathology laboratory located in the mid-Atlantic region of the USA. Numbers of diagnoses per month and "per season" were determined. Pairwise comparisons of seasonal data were made using two-sample t-tests with significance set at P ≤ 0.05. Perniosis (chilblains) was significantly more common in winter and spring (P = 0.001). Hand, foot, and mouth disease was statistically more prevalent in summer and autumn (P = 0.028). Erythema multiforme was most common in spring and summer (P = 0.004). Grover's disease was most common in winter and spring (P = 0.000039). Guttate psoriasis was non-significantly more common in winter and spring (P = 0.076). No statistically significant seasonal variation was found for erythema dyschromicum perstans (P = 0.899), pityriasis rosea (P = 0.727), or pityriasis lichenoides (P = 0.366). This study found statistically significant seasonal trends for several dermatologic conditions. The study was primarily epidemiologic and was not intended to address histopathologic differences that might underlie the seasonal variations observed. However, further investigation of seasonal differences in the histopathology of erythema multiforme may prove interesting.

Rates of provision of clinical information in the skin biopsy requisition form and corresponding encounter visit note

Background: The skin biopsy requisition form (RF) serves as a key communication tool for transfer of relevant information related to skin biopsy between clinicians and pathologists. Clinical information in the skin biopsy RF is frequently missing or incomplete. Objective: To determine the rates of provision of critical clinical information necessary for histopathologic interpretation in the skin biopsy RF and encounter visit note (EVN). Methods: A retrospective review of 300 RFs and corresponding EVNs from May 1 to 7, 2012, in a tertiary care dermatology practice. Results: Age (100%), lesion location (100%), and clinical impression (93%) were the most commonly supplied elements in the RF and EVN. Clinical elements that were commonly not provided in the RF but present in the EVN included sampling method – partial versus complete (46%), duration of lesion (54%), morphology of lesion (97%), clinical symptoms (63%), clinical photos (63%), previous clinical (97%), and dermatopathologic diagnoses (82%). Limitations: Retrospective study design. Conclusions: These data suggest that while missing critical clinical information in the RF is often present in the EVN, some information is still not present in either source.

Primary Cutaneous Carcinosarcomas

To present and define diagnostic criteria for primary cutaneous carcinosarcomas (CSs). Neoplasms of 6 patients with primary cutaneous CSs were retrospectively analyzed. A panel of histopathologic parameters and immunophenotypic expression of distinct markers of differentiation were investigated. All cases had medium-to-poorly differentiated squamous cell carcinoma representing the epithelial component intermingled with a variable amount of malignant sarcomatous tissue proliferation. The authors identified 3 distinct morphological criteria for the diagnosis of primary cutaneous CSs with features of (1) a clearly defined dual neoplasm with explicit morphological characterization using histology and immunohistochemistry with distinct marker panels while, (2) metastases from distant sites and true collision neoplasms must be excluded, and (3) recognition of the neoplasm as a solid coherent proliferation with careful exclusion of sarcomatous stromal changes in the surrounding neoplasm stroma has to be assured. The low incidence of this entity and a plethora of different synonymous terms in the dermatopathologic literature often cause diagnostic problems and hamper the accurate comparative analysis of cases published previously. Herein, the authors propose defining criteria and a clearly defined morphological approach to contribute to more accurate dermatopathologic diagnoses and provide an unprecedented summary on this neoplastic entity.

Dermatopathology Practice in Ethiopia

Dermatologic diseases are extremely common among the Ethiopian population and are a significant cause of morbidity. However, few studies exist in the literature that describe the incidence and clinical and histologic features of biopsied cutaneous lesions. To categorize the cutaneous diseases observed in skin biopsies at the All African Leprosy Rehabilitation and Training Center (ALERT) in Addis Ababa, Ethiopia, and to describe the clinical and histologic features of dermatopathologic diagnoses most frequently encountered in this practice setting. Pathology reports of 2342 cutaneous specimens received at ALERT in Addis Ababa, Ethiopia, were reviewed to determine the range and frequency of cutaneous diseases and dermatoses diagnosed from January 2007 through December 2010. The range of cutaneous diseases observed in skin biopsies at ALERT was varied and included inflammatory dermatoses (27%), infectious diseases (24%), and malignant and benign cutaneous neoplasms (22% and 20%, respectively). The most common conditions observed in this study were squamous cell carcinoma (8% of total cases), eczema (6% of total cases), leishmaniasis (6% of total cases), tuberculosis (6% of total cases), and benign nevi (4% of total cases).

Cutaneous Complications in Hematopoietic Cell Transplant Recipients: Impact of Biopsy on Patient Management

The utility of cutaneous biopsies in directing the management of posthematopoietic cell transplantation (HCT) eruptions remains uncertain. We retrospectively analyzed 439 consecutive HCT procedures for malignant hematologic disorders performed at our institution between January 2005 and December 2012; 192 patients underwent 430 cutaneous biopsies. The clinical and dermatopathologic diagnosis differed in 240 cases (56%). Biopsy results led to a change in therapy in 69 (16%) episodes. Seventeen of 69 management changes occurred in response to a clinical diagnosis of graft-versus-host disease and resulted in augmentation of systemic immunosuppression. The management was modified with similar frequencies with respect to concordance or discordance between the clinical and histopathologic diagnosis (P = .51). We used classification and regression tree (CART) analysis, a decision-modeling technique, to predict the biopsy yield as expressed by impact on clinical management in the allogeneic and autologous setting. The models were cross-validated and then tested against a validation subset, and they maintained a high negative predictive value and high specificity. Although skin biopsies may not be mandatory for either diagnostic or therapeutic reasons, in carefully chosen circumstances, this procedure can yield extremely important data. We believe a prospective study should be undertaken to evaluate current practice data and to validate our decision tree models.