What is the gold standard for being able to detect pseudopods? Pseudopods can indicate precancerous problems. What if the histological sectioning of a specimen misses the presence of pseudopods?

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  • "In addition, if a biopsy is performed, it makes the dermoscopy moot."

    Brian, you are a wonderful, kind, knowledgeable teacher that is always appreciated, however

    however I do have a difference of opinion: 

    I learned at the Memorial Sloan Kettering that if a biopsy is performed without dermoscopy, that biopsy is missing valuable horizontal information that is so helpful in sectioning specimens and getting the most accurate diagnosis.  

    The example I gave above "If a pathology lab actually used such dermatopathologic images and sectioned them properly and found irregularly distributed pseudo-pods this just might save lives. Dermoscopy just might save lives."

    An irregular distribution of pseudopods are not the only structures missed on a biopsy specimen without

    horizontal information gotten from dermoscopy.

            Another example might be a misdiagnosis of a blue nevus when a melanoma is actually present. (Without dermoscopy, if a superficial shave biopsy is taken, a blue nevus could be a possible misdiagnosis) Dermoscopy would clearly show such deep blue color absent in sections of the questionable lesion. Such nonuniform presence of a deep blue color would be the additional information needed by the pathologist to ultimately diagnose that melanoma. (In a blue nevus the blue color is horizontally throughout the lesion and likely seen by the dermatopathologist provided with a dermatoscopic image.) 

    Including dematoscopic images sets a new standard in podiatric pathology reporting which I believe is the future gold standard. If dermatoscopes are available and if images can be sent to any lab that has dermatopathologists or podiatry consultants that have experience with dermatoscopic images, patients will likely benefit. Podiatrists who  recieve reports that used such additional information would likely result in a report with a greater possibility for a more accurate diagnosis.  

    If the dermatologists at Sloan Kettering are using dermoscopy with their biopsy specimens, if I have succeeded in having a dermatopathologist add such information to the report I received, then why can't other podiatrists consider doing the same?There are laboratories out there that will include dermatoscopic images in their reports. 

     

    Brian, I believe you have lectured on dermoscopy,  Any podiatric laboratory that has you as a consultant is very fortunate. 

  • Yes Dan, the existence of that article supports my assertion that being a dermatopathologist does not automatically confer expertise in dermoscopy. In addition, if a biopsy is performed, it makes the dermoscopy moot.
  • "What makes you think that a dermatopathologist would know what he or she is looking at when given a dermatoscopic image."


    I went to google and typed in the words "dermatopatholgist and dermoscopy"

    I found this link: https://www.ncbi.nlm.nih.gov/pubmed/18087006

    Ex vivo dermoscopy of melanocytic tumors: time for dermatopathologists to learn dermoscopy.

    Dr. McClain was one of the authors of the article. So is Dr. Marghoob who lectured at Memorial Sloan Kettering during the 2 day intensive seminar 2016.

    McClain Laboratories has Dr. McClain who I believe is a dermatopathologist. 

    There are other dermatopathology labs.  If a dermatopathologist is not familiar with dermoscopy, they can probably ask for help from a podiatry consultant that knows about this modality. Dermatopathologists also can attend future dermoscopy courses such as the intensive 2 day course held at Memorial Sloan Kettering. 

    I was finally successful in having a podiatric pathology report sent back to me with a copy of the dermatoscopic image taken from my Dermlite 4. This sets a new standard in podiatric pathology reporting which I believe will be the future gold standard. 

  • Dan,


    What makes you think that a dermatopathologist would know what he or she is looking at when given a dermatoscopic image.

    Anyway, the discussion is way overdone at this point and it is time to move away from pseudopods.

  • Dan, I am concerned at the volume of your posts and tendency to mix several issues. Back to pseudopods....again even if seen on a slide it is a designation of architecture, geometry or configuration. It is not a cellular level parameter. I applaud your diligence on learning this technique but putting verbiage in these posts that is foreign to most if not all of your colleagues in question form creates confusion.

    Brian, thankyou so much for sharing your opinion.

    1. Dermoscopy is a huge topic and contains a lot of volume.

    2. There are several issues that are mixed into this subject matter.

    3. Foreign verbiage is needed anytime a new topic is brought up.

    4. Even if pseudopods are not a cellular level parameter, their distribution as seen on a dermatoscopic image contributes valuable additional information. This better enables the dermatopathologist to make a more accurate diagnosis.

    5. If a podiatrist is not experienced at interpreting strutures, they still may be performing biopsies of dermatologic lesions. Once a decision is made to biopsy, this is an opportunity for even inexperienced podiatrists to send dermatoscopic pictures to an experienced dermatopathologist with the biopsy specimens. Such additional information can ultimately lead to a more accurate dermatopathology report. 

     

    Brian, you are a wonderful teacher and I appreciate all that you have taught me. Thank you. 

     

  • Jeff, of course you are not wrong but in a typical podiatry day there are not enough instances to look at skin specifically in enough volume to become proficient quickly. However, you have to start somewhere and if one has patience and takes courses and LOOKS AT LESIONS regularly, proficiency will occur.

  • For clarification purposes - in the modern day era of apps and computer there are many self-training apps and so forth that teach you slowly certain characteristics and then teach you by showing and then quiz you. They quiz you by showing you lesions and then you as the clinician have to state what your diagnosis is and why.
    I do believe one can be one proficient using this manner. There was a published study of a resident (non Derm) who studied in this manner and recorded a very high score. ( I don't want to misquote the study but it was greater than 90percent getting same diagnosis as the pathologist with biopsy).
    I do think that with certain areas of study this is the future of studying.
    I remember histology class at NYCPM. None of us knew what the hek we were looking for under those slides.....
    I ran for class president on the basis that I believed we were being taught poorly. I thought the slides should be shown prior to looking under the microscope so that we would know what we were looking for rather than at the end of class as a review.
    I became class president as the whole class agreed. I don't think it's much different here.
    There are many procedures I taught myself to do. Is that wrong? Absolutely not. I think everything should be taken into context.
  • Quote:

    When a medical student or resident listens to the heartbeat with a stethoscope, for the first several hundred times it will be checked by a clinician, and the ability to confer and "bounce off" any questions constitutes a large part of becoming proficient. Dermatology residents have the same training paradigm when it comes to dermoscopy. I cannot imagine becoming proficient in dermoscopy as a non-dermatologist without similar instruction, not to mention studying and attending dermoscopy symposia. There is no medico-legal question; you either know what you are looking at or you don't. A dermoscopy misdiagnosis is no different than an eyeball misdiagnosis if such misdiagnosis causes harm. Having said all that, any seriously interested DPM has the ability to shadow a dermatologist, attend meetings, take online courses and quickly augment his or her clinical skills. Then with a little humility, raise the level of their Podiatric dermatology practice by a ton.

    Thank you. I believe you answered the medico-legal implications of a missed or mis-diagnosis.

  • When a medical student or resident listens to the heartbeat with a stethoscope, for the first several hundred times it will be checked by a clinician, and the ability to confer and "bounce off" any questions constitutes a large part of becoming proficient. Dermatology residents have the same training paradigm when it comes to dermoscopy. I cannot imagine becoming proficient in dermoscopy as a non-dermatologist without similar instruction, not to mention studying and attending dermoscopy symposia. There is no medico-legal question; you either know what you are looking at or you don't. A dermoscopy misdiagnosis is no different than an eyeball misdiagnosis if such misdiagnosis causes harm. Having said all that, any seriously interested DPM has the ability to shadow a dermatologist, attend meetings, take online courses and quickly augment his or her clinical skills. Then with a little humility, raise the level of their Podiatric dermatology practice by a ton.
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