Q&A: Balancing clinical findings with dermatopathology

Clinical findings do not always correlate with the histology on a biopsy. An important element in arriving at a correct diagnosis is recognizing when to give weight to clinical findings and when to rely heavily on the dermatopathology report. M. Yadira Hurley, MD, director of Friday’s session “AAD Derby: Clinical or Dermatopathology — Which Hat Wins?” (U024), talked with Dermatology World Meeting News about the relative strength of clinical and dermatopathological outcomes in everyday practice.

How important is clinicopathologic correlation in daily dermatology practice?

Dr. Hurley: Agreement, or lack of agreement, between clinical and dermatopathological findings is a conundrum that happens to all of us in everyday practice. Sometimes biopsy results can lead you astray, and other times the clinical findings can be misleading or have an extensive differential diagnosis so a biopsy is really needed to arrive at the correct diagnosis.

Give an example of how to balance clinical and dermatopathological findings.

Mycosis fungoides is an entity where the histopathology can be subtle, and the characteristic findings are not always present on biopsies. If your clinical suspicion is high and the biopsy shows worrisome or suggestive findings, you should go on your clinical suspicion and put less weight on the biopsy. However, when you are dealing with panniculitis, where the clinical presentation of various entities is very similar, a subcutaneous nodule biopsy can provide valuable insight by delineating the inflammatory infiltrate (neutrophils, lymphocytes, or histiocytes) and help guide your treatment and additional workup.

Are there broad principles that can guide decision-making when clinical and pathologic findings diverge?

If your clinical suspicion is high, the first step is to pick up the phone and talk with your dermatopathologist. Often, discussing the clinical picture can help expand the pathologic differential diagnosis or aide in looking for more subtle pathology. Second, it often helps to rebiopsy or do multiple biopsies, especially when there are several morphologies present on the clinical exam. One biopsy may not be representative of the entire pathological process.

Dr. Hurley is professor of dermatology and pathology and director of dermatopathology at Saint Louis University.


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