Cut it out

Do you insert recommendations regarding need for reexcision in your dermatopathology reports regarding melanocytic lesions? I do – seemingly 24/7. Do you have a well-founded, scientific approach? I do – or more truthfully I rationalize that I do. On some days it seems that deciding if a recommendation is warranted represents the most demanding aspect of diagnostic dermatopathology. I suspect it is highly capricious. Some dermatopathologists and dermatologists report controversy as to whether a recommendation for any therapy, including a suggestion for reexcision, is appropriate fodder for a dermatopathology report. A recent meeting of the California Society of Dermatology involved a panel discussion of the issue. Our colleagues, Bruce Smoller, Scott Binder, and Philip LeBoit served as panelists. A number of dermatologists voiced the perspective that clinical judgment was paramount and that dermatopathology recommendations on paper were out of line. The panel successfully delivered the counterpoint that dermatopathologists see many persistent lesions and develop a better sense of the consequences of not reexcising than any single clinician ever could. Like the panelists, I believe dermatopathologists have the potential to deliver a great deal of added value in this context. The reason for the italicized word in the preceding sentence is that, at least at present, that goal probably eludes us. Thousands of personal recommendations over the years have certainly rarely evoked a complaint. In the last decade or so in particular, if any of my proffered advice has triggered a ruckus in the clinic, the aftershocks have not registered on my voice mail. It seems that most referring physicians in our practice are delighted to have me boss them around, and rarely if ever does a clinician inquire as to the basis for a given recommendation. A number of phone calls come in each week seeking more bossing rather than less. Why do I get to give so many directives? Issuing a report on university letterhead certainly lends credibility that may not be entirely deserved. Perhaps I am merely experiencing a type of selection bias. If the clinicians who would be offended by my instructions have all been chased elsewhere, then certainly no complaints will surface. The situation is not clear. In contrast, what seems clear to me but may not be obvious to referring clinicians is that there is frightfully little if any science backing up advisory report content. Guidelines for reexcision of melanoma are straightforward, of course, but I fret that whimsy rules the day when the diagnosis is something else, be it a dysplastic nevus, a Spitz nevus, an oddball conventional melanocytic nevus, or a descriptive, open-ended interpretation. Many colleagues corral this ambiguity by eschewing recommendations while speaking in code. Are you anxious about a particular diagnosis? Supersize it to moderate dysplasia or diagnose moderate atypia, trigger a reexcision, and put your mind at ease. This approach yields the same endpoint achieved by a specific directive for reexcision, as both eventuate with a second specimen. A converse situation can also occur in which the dermatopathologist can downsize (typically by dropping the word dysplastic) the diagnosis to prevent the appearance of a need for surgery and appease an anxious, reexcision-prone clinician. In our unit at the University of California, a surprising amount of dialog in peer review centers on this issue. I suspect the environment is similar in other laboratories where multiple dermatopathologists are employed. When dermatopathologists close to their training years share cases with more senior colleagues, often the topic is not just couching the diagnosis but spinning the follow-up guidance. As an aside, having a colleague make the call about the need for reexcision is potentially a superior choice as it holds the potential to be utterly nonemotional. I have experienced this in comic fashion in our daily peer review conference. After showing a peculiar melanocytic nevus – the kind of case in which the diagnosis is near-certain but the lesion itself is somehow unconventional – and inquiring of my colleagues if a reexcision recommendation should be included in the final report, a not uncommon rejoinder has been ‘‘it’s not that concerning since it’s not my case.’’ The sheer scope and magnitude of the matter defies a global or quick fix. I long for some data to guide my thinking. I yearn for a methodical,