NZMA Home

Table of contents
Current issue
Search journal
Archived issues
NZMJ Obituaries
Classifieds
Hotline (free ads)
How to subscribe
How to contribute
How to advertise
Contact Us
Copyright
Other journals
The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 05-November-2010, Vol 123 No 1325

Pathology referrals for skin lesions—are we giving the pathologist sufficient clinical information?
Marius Rademaker, Murray Thorburn
Abstract
Aim To assess the quality of data included in the histology request form.
Method We prospectively reviewed the histology request forms of 375 consecutive skin lesions. In addition, the appropriateness of the surgical specimen was determined.
Results There were 196 women and 179 men with a mean age of 58.4 years. The majority of specimens (84.5%) derived from primary care. 233 lesions (62%) were removed by excision, 57 (15%) by shave, three by curettage, with 82 lesions (22%) by punch/incisional biopsy. The clinical diagnosis was either not specified in 56 cases (15%), or simply labelled as ‘lesion’ in 84 (22%) patients. In 140/375 cases (37%), no useful clinical information was available.
The clinical diagnosis matched the histopathological diagnosis in 145 cases (39%). Sixty percent (78/131) of histologically confirmed malignant lesions had not been identified clinically as being malignant: only 2 of 12 (17%) melanomas, 33/74 (45%) BCCs and 18/45 SCCs (57%) were diagnosed clinically. The specimen type was considered inadequate to make a histopathological diagnosis in 25 cases (6.7%).
Conclusion In over a third of histology requests, diagnostic clinical information was absent. In addition, punch biopsy was used in 40% of lesions where a melanoma was being considered clinically.

The pathology request form is a crucial communication document between treating physician and histopathologist.1 The data set should include demographics (age and sex of patient), site and type of specimen, clinical history and preferably the diagnostic query the treating physicians wants answered by the pathologist.
Anecdotal evidence suggests that the information routinely captured on the pathology request form is often minimal, thereby affecting the ability of the histopathologist to correctly report the specimen.2–6
In addition, the recent Australasian / New Zealand Melanoma guidelines recommend that the optimal biopsy approach for a pigmented skin lesion suspicious of melanoma is complete excision with a 2 mm margin, as partial biopsies may not be fully representative of the lesion.6 They do however, go on to comment, “Incisional, punch or shave biopsies may be appropriate in carefully selected clinical circumstances, for example, for large facial or acral lesions, or where the suspicion of melanoma is low.”
This study aimed to assess the quality of information available to the pathologist from the histology request forms, the accuracy of the preliminary clinical diagnosis, and the appropriateness of the biopsy sample provided.

Methods

The histology request forms of skin lesions, read by a single pathologist over a 4-week period, were prospectively assessed for the quality of information. Particulars assessed included demographic data (age and sex of patient), body site of specimen, nature of specimen and all clinical information included on the form.
The histopathologist graded each request form as to whether it contained enough information to determine the purpose of the procedure (was it diagnostic or therapeutic), the type of sample provided (whether curettage, shave, punch or excision), the anatomical site, and whether the specimen was thought to potentially be a melanoma, a pigmented lesion, a non-melanoma skin cancer, or some other skin lesion. The histopathological diagnosis was then compared to the preliminary clinical diagnosis. The suitability of the specimen was also determined according to the clinical and histological diagnosis.

Results

Over a 4-week period during October/November 2009, 375 skin specimens were received. These were from 196 women and 179 men, with a mean age of 58.4 years (SD 16.4 yrs, range 6 - 105 yrs). The majority of the skin specimens had been taken in the primary care setting (317 lesions, 84.5%), with the remainder by plastic surgeons (43 lesions, 11.5%), dermatologists (eight lesions, 2%) and ‘other’ specialist surgeons (seven lesions, 2%).
The face was the most common site (92 lesions) followed by the back (66), trunk (62), legs (59), arms (58) and neck (28). In 10 instances, body site of the specimen was not specified. The majority of specimens were removed by excision (233 lesions, 62%), with 57 (15%) lesions removed by shave and three by curettage (Table 1). Seventy-six (20%) lesions were punch biopsies and six were incisional diagnostic biopsies. Eighty-one specimens (22%) were marked as being diagnostic, 74 (20%) therapeutic, with the majority not specified (220, 59%).
Table 1. Type of biopsy with number of specimens inadequate to make a histological diagnosis
Type of biopsy
Number (%)
Specimen insufficient for diagnosis (%)
Excision
Punch
Shave
Incisional
Curettage
233 (62.1%)
76 (20.3%)
57 (15.2%)
6 (1.6%)
3 (0.8%)
4 (1.7%)
10 (13.2%)
9 (15.8%)
0
2 (67%)
Total
375 (100%)
25 (6.7)
From the request form, the histopathologist concluded that the referring doctor thought 123 (33%) lesions might be a non-melanoma skin cancer, 77 (20.5%) a pigmented lesion, 27 (7%) a melanoma with 42 (11%) other types of skin lesions. In 106 (28%) lesions, it was not possible to determine what the referring practitioners thought the lesion might be.
The most common clinical diagnoses offered were basal cell carcinoma (54 cases), naevus (48), squamous cell carcinoma or keratoacanthoma (47), seborrhoeic keratosis (15), and melanoma (12) (Table 2). The clinical diagnosis was either not specified in 56 cases (15%), or simply labelled as ‘lesion’ in 84 (22%) patients. Therefore in 140/375 cases (37%), no useful clinical information was available to the pathologist.
Table 2. Clinical diagnosis with number (%) confirmed by histology
Variables
Clinical diagnosis
Confirmed by histology
Lesion – (not otherwise specified)
No diagnosis
Basal cell carcinoma
Naevus
Squamous cell carcinoma/keratoacanthoma
Seborrhoeic keratosis
Melanoma
Solar keratosis
Papilloma
Dermatofibroma
Haemangioma
Keratosis
84
56
54
48
47
15
12
10
10
5
5
5


33 (61%)
25 (52%)
20 (42.5%)
13 (87%)
2 (17%)
4 (40%)
2 (20%)
3 (60%)
1 (20%)
1 (20%)
The clinical diagnosis matched the histopathological diagnosis in 145 cases (39%) (Table 3). Of the 230 (61%) cases where the clinical diagnosis (or lack of one) did not match the histological diagnosis, in 136 instances (36%) this was not considered clinically significant. Examples include a histological diagnosed seborrhoeic keratosis having been diagnosed clinically as a benign naevus, or a squamous cell carcinoma having been diagnosed as a basal cell carcinoma. Sixty percent (78/131) of histologically confirmed malignant lesions had not been identified on the request form as being malignant: only two of 12 (17%) melanomas, 33 of 74 (45%) BCCs and 18 of 45 SCCs (57%) were diagnosed clinically.
Table 3. Histological diagnosis with number (%) of patients diagnosed clinically
Variables
Histology diagnosis
Diagnosed clinically
Naevus
Basal cell carcinoma
Seborrhoeic keratosis
Squamous cell carcinoma/keratoacanthoma
Solar keratosis
Keratosis (type not specified)
Papilloma
Melanoma
Dermatofibroma
Haemangioma
74
74
54
45
35
26
12
12
7
5
40 (54%)
33 (44.6%)
13 (24%)
18 (40%)
4 (11%)
2 (8%)
2 (17%)
2 (17%)
3 (43%)
1 (20%)
The specimen and/or request form were considered inadequate to make a histopathological diagnosis in 25 cases (6.7%) (Table 1).
There were 82 punch and incisional biopsies; of these there were no clinical details in 23% and in a further 22%, it was simply labelled ‘lesion’. Despite the 2008 Australian/NZ Melanoma Guidelines, punch biopsy was used in 40% of lesions where a melanoma was being considered clinically. Punch biopsy was used for 32.5% of lesions identified as pigmented and in a third of suspect non-melanoma skin cancer.

Discussion

Dermatosurgery is increasingly being performed by general practitioners. Whilst many GPs have up-skilled themselves technically by attending surgical skills workshops, little attention seems to have been devoted to the communication between doctor and pathologist.
Communication between the medical disciplines is an essential component of quality medical care. Few of us would regard an inter-specialist referral with no clinical information as being either appropriate or adequate. Despite this, practicing clinicians tend not to regard referral to specialist diagnostic services in the same light. This is particularly unfortunate as our colleagues in specialist diagnostic services often have no direct contact with the patient, and are therefore unable to obtain any clinical information independently.
This study has shown that, in a third of cases, the histopathologist is not provided with any clinical information to help in the diagnostic process. There may be a number of reasons for this including both cognitive and procedural. The referring practitioner may be so confident of their clinical diagnosis they do not feel it is necessary to share their opinion. Alternatively they may not know what the lesion is and are embarrassed to show this. The request form may be completed by a surgical assistant, ignorant of the potential diagnoses. It may be pressure of time; most request forms were generated electronically and it requires an extra few minutes to fill the diagnostic/clinical sections. Most likely however, is a simple lack of appreciation of the value the pathologist places on good clinical information.
Skin lesions are removed/biopsied for a variety of concerns including that they are of health, cosmetic, or diagnostic concern (both current or potential), or because they are a nuisance to the patient. The biopsy technique used generally reflects the technical ability of the doctor, but it may also reflect the patient/doctor’s degree of concern about the skin lesion. Unfortunately, in this study, a significant number of lesions were not sampled/removed in the most appropriate manner.
Punch biopsy is generally used for diagnostic purposes. It is simple and heals well, often without sutures. However, it only provides the pathologist with small, 2 to 5 mm tissue samples to work with and therefore, clinical information is essential.7-8 Of the 82 punch and incisional biopsies taken, there were unfortunately no clinical details in 23%, and a further 22% were simply labelled ‘lesion’.
In addition, punch/shave biopsies may not be appropriate in certain circumstances.8 In a study of 2470 patients with melanoma, punch and shave biopsy significantly increased the odds of misdiagnosis by 16.6- and 2.6-fold respectively, compared to excisional biopsy. Moreover, punch biopsy increased the risk of a misdiagnosis with adverse outcome by 20-fold (p < 0.001). The 2008 Australian/New Zealand guidelines recommend complete excision of suspect pigmented lesions with a 2 mm margin.6 This audit showed that 40% of lesions where a melanoma was considered, and 32.5% of lesions identified as pigmented lesions, and therefore potentially a melanoma, were punch biopsied. Some of this may reflect the regional public plastic surgery service’s request for histological confirmation of non-melanoma skin cancer, prior to allocating priority for first specialist assessment.
As surgical techniques go, the shave biopsy appears very simple, although it actually requires a certain degree of understanding of cutaneous pathology to perform correctly. Whilst it may be appropriate for the removal of benign lesions such as papillomatous melanocytic naevi, skin tags and seborrhoeic keratoses, it is not the most appropriate technique for pigmented lesions where there is diagnostic concern. This study shows that 16% of shave specimens were inadequate to make a histopathological diagnosis compared to only 1.7% of lesions that had been sampled by excision.

Conclusion

This audit shows that in over a third of histology requests, diagnostic clinical information was absent. Sixty percent of histologically confirmed malignant lesions had not been identified on the request form as being malignant, including 87% of melanomas, 55% of BCCs and 43% of SCCs. The specimen was inadequate to make a histopathological diagnosis in 6.7% of cases. Finally, 40% of lesions suspected of being a melanoma were sampled by punch biopsy. Clearly there is room for improvement.
Quality medicine requires good communication. Pathologists need good clinical information to interpret subtle histological features. Whilst the size of the tissue sample may never satisfy the pathologist, small incisional punch biopsies of pigmented lesions, particularly if melanoma is being considered, may not be appropriate. Shave excisions, whilst simple, are often suboptimal.
Competing interests: None.
Author information: Marius Rademaker, Hon Associate Professor, Department of Dermatology, Waikato Hospital, Hamilton; Murray Thorburn, Specialist Histopathologist, PathLab, Hamilton
Correspondence: Associate Professor Marius Rademaker, Dermatology Department, Waikato Hospital, Private Bag 3200, Hamilton, New Zealand. Email: Marius.Rademaker@waikatodhb.health.nz
References:
  1. Fleming MG. Pigmented lesion pathology: what you should expect from your pathologist, and what your pathologist should expect from you. Clin Plast Surg. 2010;37:1-20.
  2. Nutt L, Zemlin AE, Erasmus RT. Incomplete laboratory request forms: the extent and impact on critical results at a tertiary hospital in South Africa. Ann Clin Biochem. 2008;45:463-6.
  3. Burnett L, Chesher D, Mudaliar Y. Improving the quality of information on pathology request forms. Ann Clin Biochem. 2004;41:53-6.
  4. Plebani M. Exploring the iceberg of errors in laboratory medicine. Clin Chim Acta. 2009; 404: 16-23. Epub 2009 Mar 18.
  5. Zemlin AE, Nutt L, Burgess LJ, et al. Potential for medical error: incorrectly completed request forms for thyroid function tests limit pathologists' advice to clinicians. S Afr Med J. 2009;99:668-71.
  6. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. The Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group, Wellington, 2008.
  7. Leong AS, Braye S, Bhagwandeen B. Diagnostic 'errors' in anatomical pathology: relevance to Australian laboratories. Pathology. 2006;38:490-7.
  8. Ng JC, Swain S, Dowling JP, et al. The impact of partial biopsy on histopathologic diagnosis of cutaneous melanoma: experience of an Australian tertiary referral service. Arch Dermatol. 2010;146:234-9.
  9. Heal CF, Raasch BA, Buettner PG, Weedon D. Accuracy of clinical diagnosis of skin lesions. Br J Dermatol. 2008;159:661-8. Epub 2008 Jul 4.
  10. Heal CF, Weedon D, Raasch BA, et al. Agreement between histological diagnosis of skin lesions by histopathologists and a dermato-histopathologist. Int J Dermatol. 2009;48:1366-9.
     
Current issue | Search journal | Archived issues | Classifieds | Hotline (free ads)
Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals