How informative are dermatopathology requisition forms completed by dermatologists? A review of the clinical information provided for 100 consecutive melanocytic lesions

Influence of submission form characteristics on clinical information received in biopsy accession

“…Key case information regarding the signalment of the patient, clinical history, gross appearance of the specimen submitted, and/or physical location of the specimen (tissue or organ and anatomic site) is frequently omitted or ambiguous. Furthermore, in direct contradiction to the conjectures put forward for human dermatopathology requisitions, 23 the authors have circumstantially observed that open-type biopsy submission forms utilized in veterinary biopsy tend to provide more thorough clinical information than closed-type forms and are, thus, more useful for the purposes of diagnosis and clinical correlation in the accompanying specimen.…”

“…In cases where multiple specimens were submitted using a single form, scoring was based upon the information provided for the first sample listed, as it has previously been determined in human biopsy that clinicians tend to submit equivalent information across samples in a multi-tissue submission, either reporting an element for all tissues submitted or for none. 23 To determine total length of response, a word count was tallied that included all words written or typed in response to prompts. Patient signalment were excluded in order to prevent bias against those forms using checkboxes to solicit signalment information.…”

“…10,11 There is ample evidence that both clinicians and pathologists are aware of the necessity of presenting clinical information with specimens through laboratory submission forms. 2,7,9,16,[18][19][20]23,25 By one estimate in human biopsy requisition, however, "deficiencies related to missing or incorrect information account for approximately 80% of all deficiencies" 17 encountered in biopsy specimen acquisition. Furthermore, missing and inaccurate clinical information in biopsy submission has been shown to contribute to significant time delays, increased costs related to additional staining procedures or sectioning to reach a diagnosis, misdiagnosis leading to poor patient outcomes, and legal action related to the aforementioned issues.…”

Combined Use of Ex Vivo Dermoscopy and Histopathology for the Diagnosis of Melanocytic Tumors

“…4,5 However, important clinical information is often not provided to the dermatopathologist. 6 Dermoscopy is presently a valuable aid in the clinical diagnosis of pigmented skin lesions. This imaging technique improves sensitivity in the early diagnosis of melanoma, [7][8][9] providing the clinician with an interface between naked eye and histopathological examinations.…”

“…[13][14][15] Submission of dermoscopic images for the dermatopathologist to analyze is in general uncommon. 6 In this context, ex vivo dermoscopy has been proposed as an auxiliary method of gross pathology accessible to the dermatopathologist. It allows guided tissue sectioning and serves as a surrogate when clinical information is incomplete.…”