Oral epithelial dysplasia with lymphocytic immune response: clinicopathological characterisation of 44 cases

AIMS

Oral epithelial dysplasia (OED) often exhibits a lymphocytic/lichenoid immune response (LIR), imparting histological resemblance to lichenoid mucositis and rendering diagnosis challenging. The clinical appearances of OED and lichenoid inflammatory processes are generally divergent, presenting as well-demarcated hyperkeratotic plaques and diffuse white and/or red mucosal change with variably prominent Wickham striae, respectively. To date, clinicopathological characterisation of OED with LIR, including clinical/gross appearance, has not been depicted.

METHODS AND RESULTS

Cases of solitary OED with LIR for which a clinical photograph was available were identified in the authors' institutional files. Clinical and histological features were documented. In 44 identified cases, dysplasia was mild (19 of 44, 43.2%), moderate (19 of 44, 43.2%) and severe (six of 44, 13.6%). Clinically/grossly, all 44 cases (100.0%), presented as well-demarcated hyperkeratotic plaques lacking diffuse white-and-red mucosal change or Wickham striae. Histologically, OED with LIR exhibited numerous 'lichenoid' features beyond the lymphocytic band in the superficial lamina propria, including: leucocyte transmigration (38 of 44, 86.4%), spongiosis (37 of 44, 84.1%), Civatte/colloid bodies (36 of 44, 81.8%), basal cell degeneration (29 of 45, 65.9%), sawtooth rete ridges (11 of 44, 25.0%) and subepithelial clefting (7 of 44, 15.9%).

CONCLUSIONS

Virtually any lichenoid histological feature may be seen in OED with LIR, representing a significant diagnostic pitfall. The typical clinical appearance of OED with LIR is of a well-demarcated hyperkeratotic plaque, characteristic of keratinising dysplasia and devoid of lichenoid features. This suggests that pathologist access to clinical photographs during diagnostic interpretation of biopsied white lesions, which represents opportunity to perform gross examination of the disease process, may reduce interobserver variability and improve diagnostic accuracy in this challenging differential diagnosis.

High-Yield Vulvar Histopathology for the Clinician

Certain adjustable factors may influence how helpful a pathology report is to the clinician. Different biopsy techniques may be preferable based on the type of lesion being biopsied and the background epithelial surface. Key observations from the history and physical examination, possibly with a clinical photograph, are helpful to the pathologist. When reading the pathology report, realize the difficulties arising from definitively classifying some diseases and how treatment can affect the tissue. Finally, avoid miscommunication with the pathologist by understanding current nomenclature of vulvar disease.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

In inflammatory dermatoses, providing high-quality clinical information on the RF promotes optimal histopathologic diagnostic performance and appropriate pathology service utilization.

Dermatopathologists' concerns and challenges with clinical information in the skin biopsy requisition form: a mixed-methods study

BACKGROUND

Communication failures between clinicians and dermatopathologists are prevalent. Our primary objective was to characterize the concerns and challenges of dermatopathologists posed by incomplete or inaccurate clinical information in the skin biopsy requisition form.

METHODS

An explanatory sequential, mixed-methods study design comprised of a survey sent to 1103 members of the American Society of Dermatopathology (ASDP), followed by two focus group sessions.

RESULTS

A total of 54% (598/1103) of dermatopathologists completed the questionnaire. Most dermatopathologists (80%; 436/548) viewed their roles to be providers of histopathological diagnosis and a report that is clinically meaningful. Paper or electronic requisition forms were the most common communication method (85%; 458/541) and were associated with the highest rates of dissatisfaction in 36% (193/537) of respondents. Inadequacy of specimens emerged as an important factor influencing judgment of the quality of provided clinical information. 44.7% (261/584) of dermatopathologists spent 30 minutes or more on average every day searching for relevant clinical information to assist with their histopathologic interpretation.

CONCLUSION

ASDP dermatopathologists expressed significant dissatisfaction with the quality of clinical information in the requisition form and the time spent gathering information necessary for accurate, timely and clinically meaningful diagnosis. These findings have implications for the quality, safety and efficiency of dermatologic care.

Dermatopathologists' opinions about the quality of clinical information in the skin biopsy requisition form and the skin biopsy care process: a semiqualitative assessment

OBJECTIVES

The skin biopsy care process is prone to communication failures. We sought to solicit dermatopathologists about their opinions on the quality of clinical information provided in the requisition form (RF) that accompanies skin specimens and their suggestions on how to improve the process.

METHODS

A self-administered survey of the membership of the American Society of Dermatopathology was performed. Qualitative methods were used to analyze free-text comments.

RESULTS

Of 1,102 participants, 153 completed the final question in the survey (response rate 14%). Respondent opinions fell into four critical themes: (1) quality of clinical information in the RF and adequacy of biopsy specimens, (2) training of residents and nondermatologist providers, (3) information transfer via electronic medical records, and (4) practice constraints.

CONCLUSIONS

Dermatopathologists communicated that missing clinical information in the RF and inadequate specimens are common and adversely affect the quality of care. Multiple provider- and practice-related factors contribute to communication failures and deserve further investigation.