Oops We Did it Again--Another Research Paper Tells Us Pathologists Sometimes Have it Tough, This Time With Melanoma

the-big-c

Laura Linney starred as a melanoma patient in "the big C".

I keep saying it. Pathology is hard. I know that it is convenient to believe that when your surgeon does a biopsy and "sends it to the lab," someone you have never met will look down the tube of a microscope, make a definite diagnosis, call your doctor immediately with all the answers and then send you a bill. After all, they call us the "The Doctors Doctor."

Unfortunately, another scientific article says life isn't so rosy. As the study tells us (you can also read about it in the Tribune), we don't always know all the answers. The current study looks at the diagnosis of melanoma, the potentially fatal skin cancer that has also affected my wife Barb. The lead author, Dr. Joann Elmore of the University of Washington, was spurred to do some research after conflicting diagnoses on her own skin biopsy. Working with a pathologist, she arranged for a set of microscopic slides showing a variety of pigmented skin lesions to be sent to a group of volunteer pathologists around the country for their diagnosis. A few months later, the same slides were sent out again to the same pathologists, garnering a second round of opinions.

A "reference diagnosis" on each case was obtained from three expert pathologists and this was used to measure the accuracy of the volunteer's diagnoses. The volunteer diagnoses were also compared to their peers, and to their own conclusions from 6 months earlier. The results? Some cases were easily and consistently diagnosed as benign, some were clearly malignant. And in the middle was a big gray zone without much agreement. Maybe malignant, maybe not.

This may have come as a surprise to the author, but not to those of us in the pathology trenches.  A similar gray zone exists throughout diagnostic pathology. It is there in lesions of the breast. It is there in my field, urologic pathology. We even have a term to describe it in prostate biopsies, atypical small acinar proliferation, or ASAP. (A good rule of thumb is that the longer the diagnosis, the more uncertain the pathologist.) No matter how many sections we cut, how many special stains we do, we just can't reach a definite diagnosis. Maybe the cells just aren't atypical enough, or maybe there just aren't enough nasty looking glands, for us to say the word "cancer." One mentor's lesson still rings in my ear--"don't call a prostate biopsy malignant if you wouldn't want that patient's prostate gland in your hand the next day." Our methods of treating prostate cancer have changed since then, with small tumors often not resulting in prostatectomy, but the mental image is still a potent one.

So what is a patient to do in an ambiguous situation? You can ask for a second opinion, but be prepared that you may not get a resolution. Ask if there are any new tests, particularly in the molecular biology spectrum, that might help make a definitive diagnosis. That field is exploding exponentially with new tests being released almost daily. Yet sometimes it may take patience, careful follow-up, or even an additional biopsy before you have an answer.

In the meantime, we pathologists try to get better, via continuing education, increasing our experience with a variety of lesions, and interaction with our experts and our peers.The goal one day is to see the headline "Pathologists Get It Right."

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Recent Blog Follow-Ups:

IKEA provided us with a refund for the reclaimed wall units! I still begrudge them the 90 minutes on hold.

I jumped the gun with my Game of Thrones post. Now that the season 7 premier is truly upon us, read the GOT life lessons here.

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The above blog is the opinion of the author and does not reflect the opinion of UroPartners LLC .
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