Clinicopathological consistency in skin disorders:A retrospective study of 3949 pathological reports

Canan Aslan, MD,a Fatih G€oktay, MD,a Ayse T€ulin Mansur, MD,a _Ikbal Esen Aydıng€oz, MD,a

Pembeg€ul G€unes, MD,b and Tu�gba Rezan Ekmekci, MDa

_Istanbul, Turkey

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Background: Although the clinicopathological approach plays an important role in skin disorderdiagnoses, few studies have evaluated the consistency between clinical and histopathological diagnosesof skin disorders.

Objective: We sought to investigate the consistency, and factors affecting consistency, between clinicaldiagnoses and pathological diagnoses in patients with skin disorders referred for biopsy by dermatologists.

Methods: We retrospectively examined 3949 pathological reports of biopsy specimens, between 1999 and2008. The relationships between clinical and pathological diagnoses were studied in 4 groups, namely: (1)definite pathological diagnoses consistent with the clinical diagnoses, (2) descriptive pathologicaldiagnoses consistent with the clinical diagnoses, (3) definite pathological diagnoses inconsistent withthe clinical diagnoses, and (4) descriptive pathological diagnoses inconsistent with the clinical diagnoses.The first two groups show consistency, whereas the latter two groups show inconsistency between thediagnoses.

Results: The pathological diagnoses were consistent with the clinical diagnoses in 3034 biopsy reports(76.8%), and they were inconsistent in 915 reports (23.2%). In all types of skin disorders, clinicopatho-logical consistency was higher in patients with sufficient clinical descriptive information. No correlationwas observed between clinicopathological consistency and biopsy type, number of clinical diagnoses, orspecifying the location of disease. Disease duration was shorter in the biopsy reports showing clinico-pathological consistency. Moreover, a statistically significant increase was found in clinicopathologicalconsistency for inflammatory dermatoses, when pathologists evaluated the specimens with clinicaldiagnoses, in comparison with blind evaluation.

Limitations: The retrospective nature of the study might have resulted in a loss of data.

Conclusion: In a dermatology clinic setting, providing sufficient clinical descriptive information forpathology requisition forms increases the probability of making an accurate diagnosis. ( J Am AcadDermatol 2012;66:393-400.)

Key words: biopsy; clinicopathological correlation; dermatology; diagnosis; pathology; skin.

kin biopsy is one of the most commonly used communication between the clinician and the pa-

S diagnostic tests in dermatology.1 To achieveaccurate and rapid diagnosis, it is important to

incorporate clinical information during evaluationtogether with clinical knowledge during histopath-ological examinations.2 Therefore, it is essential that

theDepartments ofDermatologya and Pathology,b Haydarpasa

umune Training and Research Hospital, _Istanbul, Turkey.

ing sources: None.

licts of interest: None declared.

pted for publication December 28, 2010.

int requests: Canan Aslan, MD, Dermatoloji Klini�gi,aydarpasa Numune E�gitim ve Arastırma Hastanesi, 34668

sk€udar/_Istanbul/Turkey. E-mail: drcananaslan@yahoo.com.

thologist is complete and orderly, particularly whenpathology requisition forms are completed.2

Previous research on clinicopathological consis-tency has compared the diagnoses of dermatologistswith those of physicians in other disciplines, such as

Published online December 6, 2011.

0190-9622/$36.00

� 2011 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2010.12.031

393

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MARCH 2012394 Aslan et al

plastic surgeons, orthopedists, internal medicinedoctors, pediatricians, ophthalmologists, generalsurgeons, otorhinolaryngologists, gynecologists,urologists, and family practice physicians.3-6 Thesestudies observed that the clinical diagnostic accuracyrates of dermatologists were significantly higher thanthose of physicians in the other disciplines. These

CAPSULE SUMMARY

d Previous research on clinicopathologicalconsistency suggests that the accuracyof clinical diagnosis of dermatologists issignificantly higher than that ofphysicians in other disciplines.

d In this study, conducted at adermatology clinic and involving manydifferent skin disorders, theclinicopathological consistency was76.8%.

d Providing adequate clinical descriptiveinformation on pathology requisitionforms is a critical tool for increasingdiagnostic accuracy.

studies mainly addressed sol-itary lesions, skin malignan-cies, and common skindiseases.3-6

To our knowledge, nostudy to date in the English-language literature hasinvestigated the diagnosticaccuracy rates of skin dis-eases by dermatologists. Inthis study, we aimed to inves-tigate the consistency of clini-cal diagnoseswith subsequentpathological diagnoses of skindiseases, especially in inflam-matory dermatoses, and thefactors that affected consis-tency. We studied all biopsyreports for skin diseases be-tween 1999 and 2008 at the

dermatology clinic of Haydarpasa Numune Trainingand Research Hospital, _Istanbul, Turkey.

METHODSOur study was conducted at a tertiary-care refer-

ence hospital that provides residency training.Biopsy reports received between January 1999 andDecember 2008 were included in the study. Werecorded the available parameters from the biopsyreports, and unavailable data were considered miss-ing. Each patient’s age and gender were recorded.Each biopsy was classified as punch, shave, inci-sional, or excisional. The biopsied regions weredivided into 8 categories: head/neck, hair/scalp,oral mucosa/lip, trunk, upper extremity, lower ex-tremity, genital region, and nails.

Clinical and demographic characteristicsThe clinic information in the reports was evalu-

ated in 3 categories, namely: disease duration, clin-ical descriptive knowledge, and location of skindisease. The clinical descriptive knowledge wasread irrespective of the written clinical diagnoses inthe report. If the clinical descriptive knowledgeconnoted clinical diagnoses, then it was consideredsufficient. If the description did not connote clinicaldiagnoses, then it was considered insufficient. Lastly,if there was no description of clinical diagnoses in

the report, it was considered absent. The number ofclinical diagnoses and length of the reports wererecorded.

Pathological knowledgePathological diagnoses were classified as descrip-

tive or definite. If any additional evaluations, such as

histochemistry, immunohis-tochemistry, or immunofluo-rescence, were performedduring the pathological ex-amination, this informationwas recorded. In addition,we evaluated all cases of re-peated biopsies performedbecause the pathologistcould not make a diagnosisor based on the insistence ofthe clinicians at clinical diag-nosis. In these biopsies, di-agnostic accuracy rates andthe reports with and withoutchanging diagnoses wereassessed.

Correlation betweenclinical diagnoses and

pathological diagnosesThe relationships between clinical and patholog-

ical diagnoses were studied in 4 groups, namely:

1. Definite pathological diagnosis consistentwith the clinical diagnosis. If the pathologistdiagnosed a disease that was listed among theclinical diagnoses, then the correlation was con-sidered to be a definite pathological diagnosisconsistent with the clinical diagnosis.

2. Descriptive pathological diagnosis consis-tent with the clinical diagnosis. If the pathol-ogist made a descriptive diagnosis of a diseasebased on his or her histopathological findings,and that disease was listed among the clinicaldiagnoses, then the correlation was categorizedas a descriptive pathological diagnosis consistentwith the clinical diagnosis.

3. Definite pathological diagnosis inconsistentwith the clinical diagnosis. If the pathologistdiagnosed a disease not listed among the clinicaldiagnoses, then the correlation was categorizedas a definite pathological diagnosis inconsistentwith the clinical diagnosis.

4. Descriptive pathological diagnosis inconsis-tent with the clinical diagnosis. If the

Table I. Descriptive diagnoses inconsistent withclinical diagnoses

NormalNonspecific epidermal changesNonspecific dermal changesNonspecific epidermal and dermal changesVascular changesIntraepidermal vesicular and pustular dermatitisNodular and diffuse dermatitisFolliculitis and perifolliculitisSubepidermal vesicular dermatitisSuperficial perivascular dermatitisSuperficial and deep perivascular dermatitisOthers

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descriptive report written by the pathologist didnot indicate a disease name and was not consis-tent with the histopathology reported in anyclinical diagnoses, then the correlation was cat-egorized as a descriptive pathological diagnosisinconsistent with the clinical diagnosis.

When the correlation between the clinical diag-nosis and the pathological diagnoses was classifiedwithin one of the first two categories, it was taken asevidence of clinicopathological consistency. In con-trast, when the correlation between the clinicaldiagnoses and the pathological diagnoses was clas-sified in either of the latter two categories, it wastaken as evidence of clinicopathological inconsis-tency. In each case of clinicopathological consis-tency, we recorded the clinical diagnosis andpathological diagnosis pair that showed consistency.

Disease classificationDiseases receiving definite or consistent diagno-

ses were classified into the groups listed inBraun-Falco’s Dermatology textbook.7 Descriptivediagnoses that were inconsistent with the clinicaldiagnoses were classified using the HistologicalDiagnosis of Inflammatory Skin Diseases: AnAlgorithmic Method Based on Pattern Analysis text-book,8 as shown in Table I. The consistencies ofclinical diagnoses with pathological diagnoses wereevaluated separately for each group.

Clinicopathological consistency ininflammatory dermatoses

We randomly selected 154 of 807 biopsy reportsthat were classified as inflammatory dermatosesfor further study. Specimen slides from these caseswere taken from the pathology department archivesand re-examined by a single pathologist withoutany knowledge of clinical diagnoses. The clinico-pathological correlation between these latest

pathological diagnoses and the pre-existing clinicaldiagnoses was then re-evaluated. In addition, thenumber of pathological diagnoses established withclinical diagnoses was compared with those estab-lished without clinical diagnoses.

Factors that may affect clinicopathologicalconsistency

We analyzed factors that may affect clinicopatho-logical consistency, including biopsy type, clinicalknowledge (ie, disease duration, clinical descriptiveknowledge, disease location), number of clinicaldiagnoses, report duration, and use of additionalevaluations.

Statistical analysisData analyses were performed using statistical

software programs: SPSS 11.0 (SPSS Inc, Chicago, IL),NCSS 2007 (Number Cruncher Statistical Systems,Kaysville, UT), and PASS 2008 (Number CruncherStatistical Systems). The study data were evaluatedusing the Mann-Whitney U test for intergroup com-parisons of descriptive statistics (mean, SD, fre-quency) and quantitative data. The x2 test wasused to compare qualitative data. Values wererepresented as means 6 SD. A P value less than .05was considered statistically significant in all cases.

LimitationsThe study has the following limitations:

1. The patients’ clinical and demographic informa-tion was obtained through reports filed by thepathology secretary from the pathology requisi-tion forms filled out in our clinic. This might haveresulted in some losses of data.

2. Verbal communication between the clinician andpathologist could not be evaluated.

3. Although the clinical and pathological evalua-tions were performed by specialists, changes instaff and medical approaches during the periodstudied may have influenced clinicopathologicalconsistency; however, these effects were notevaluated.

RESULTSOf the 3949 biopsy reports investigated, 2220

(56.2%) were for female patients and 1729 (43.8%)were for male patients. Patient ages were recorded in3900 reports, with a mean patient age of 46 6 20years.

The biopsies were categorized by type as follows:84.1% punch, 11.6% excisional, 3.4% incisional, and

Table II. Consistency between clinical diagnosesand pathological diagnoses

n %

Clinicopathological consistency 3034 76.8Definite pathological diagnosisconsistent with clinical diagnosis

2422 61.3

Descriptive pathological diagnosisconsistent with clinical diagnosis

612 15.5

Clinicopathological inconsistency 915 23.2Definite pathological diagnosis in-consistent with clinical diagnosis

510 12.9

Descriptive pathological diagnosisinconsistent with clinicaldiagnosis

405 10.3

Table III. Disease groups and rates ofclinicopathological consistencies

Clinicopathological

consistencies

Clinicopathological

inconsistencies

n (%) n (%)

Infectious diseases 140 (68.0) 66 (32.0)Intolerance reactions 283 (4.9) 15 (5.0)Inflammatorydermatoses

758 (93.9) 49 (5.9)

Environmentaldiseases

20 (67.9) 9 (32.1)

Bullous diseases 148 (94.6) 9 (5.7)Connective tissuediseases

351 (96.8) 19 (5.1)

Hereditary disorders 86 (92.5) 7 (7.5)Vascular diseases 177 (87.6) 25 (12.4)Pigmentary diseases 60 (52.6) 54 (47.4)Diseases of adnexalstructures

65 (89.0) 8 (11.0)

Regional and specialdisorders

82 (86.3) 12 (12.8)

Metabolic diseases 58 (95.1) 3 (4.9)Benign tumors 432 (74.8) 145 (25.1)Malignant tumors 374 (88.5) 49 (11.6)Normal 0 (0) 41 (100)Descriptivediagnoses forpatients

0 (0) 405 (100)

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0.9% shave. The type of biopsy was not reported in11 cases (0.3%). Of the 3190 reports (80.8%) in whichthe biopsy region was indicated, the most frequentregion was the trunk (27.1%), followed by a lowerextremity (25%), head/neck (22%), upper extremity(15.5%), and hair/scalp (5.6%).

Disease duration was indicated in 2412 of thereports (61.1%). The average disease duration was1124 6 1992 days. There was no clinical descriptiveknowledge in 9.9% of the reports. There was insuf-ficient knowledge in 13.3% of the reports, andsufficient descriptive knowledge in 76.8% of thereports. The location of skin disease was recorded in3472 of the case reports (87.9%). The number ofclinical diagnoses varied between 1 and 7 (mean 2.36 0.96). Report length could be calculated for 3402reports (86.1%). The average report length was 1268 days. Additional testing was performed in 613 ofthe cases (15.5%). The additional tests reportedincluded histochemical tests in 349 cases (8.8%),immunofluorescence tests in 172 cases (4.4%), im-munohistochemical tests in 80 cases (2.0%), and bothhistochemical and immunohistochemical tests in 12of the total cases (0.3%). Definite diagnoses wererecorded in 74.2% of the reports, and descriptivediagnoses in 25.8% of the reports. Two or morebiopsy specimens were taken in 36 patients (0.9%).

Of the 3949 cases examined, 61.3% were given adefinite pathological diagnosis consistent with theclinical diagnosis, whereas 15.5% had a descriptivepathological diagnosis consistent with the clinicaldiagnosis, 12.9% had a definite pathological diagno-sis inconsistent with the clinical diagnosis, and 10.3%had a descriptive pathological diagnosis that wasinconsistent with the clinical diagnosis. From thesefindings, we determined that clinicopathologicalconsistency occurred in 76.8% of the cases andclinicopathological inconsistency occurred in 23.2%of the cases (Table II). After classifying the patients

into groups according to clinicopathological consis-tency or inconsistency, the patient diagnoses wereranked. Within the group of patients receiving clin-icopathologically consistent diagnoses, 20.4% weregiven a diagnosis of inflammatory dermatosis, 14.6%of benign tumor, and 10.7% of malignant tumor. Inthe patient group that received clinicopathologicallyinconsistent diagnoses, the most frequent diagnosiswas superficial perivascular dermatitis (5.9% of thetotal cases).

In the reports with clinicopathological consis-tency, the pathological diagnosis was consistentwith the first clinical diagnosis in 68.8% of cases,consistent with the second clinical diagnosis in 22.0%of cases, and consistent with the third clinicaldiagnosis in 7.3% of cases. Our investigation of therelationship between clinicopathological consis-tency and disease group revealed a high level ofconsistency between clinical diagnosis and patho-logical diagnosis for inflammatory dermatoses, bul-lous diseases, connective tissue diseases, malignanttumors, and benign tumors (Table III). When thesubgroups of these diseases were investigated,clinicopathological consistency was high for psoria-sis vulgaris (96.8%), pityriasis rubra pilaris (95.2%),lichen planus (94.6%), bullous pemphigoid (95.1%),

Table IV. Distribution of clinicopathologicalconsistency in randomly selected inflammatorydermatoses examined with clinical diagnoses orblindly

Pathology slides

examined

with clinical

diagnoses, n (%)

Pathology

slides examined

blindly,

n (%)

Clinicopathologicalconsistency

145 (94.1) 114 (74.0)

Definite pathologicaldiagnosis consistentwith clinical diagnosis

109 (70.8) 87 (56.5)

Descriptive pathologicaldiagnosis consistentwith clinical diagnosis

36 (23.4) 27 (17.5)

Clinicopathologicalinconsistency

9 (5.9) 40 (26)

Definite pathologicaldiagnosis inconsistentwith clinical diagnosis

9 (5.8) 14 (9.1)

Descriptive pathologicaldiagnosis inconsistentwith clinical diagnosis

0 (0) 26 (16.9)

Total 154 (100) 154 (100)

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pemphigus vulgaris (92.5%), morphea (98.3%), dis-coid lupus erythematosus (93.6%), basal cell carci-noma (93.2%), squamous cell carcinoma (SCC)(80.9%), malignant melanoma (87.5%), dermatofi-broma (97.1%), and seborrheic keratosis (72.6%).Clinicopathological consistencywas low for pigmen-tation diseases (52.6%), environmental diseases(67.9%), and infectious diseases (68%).

Of the 807 biopsy reports classified as inflamma-tory dermatoses, 599 (74.2%) were given a definitepathological diagnosis that was consistent with theclinical diagnosis, 159 (19.7%) had a descriptivepathological diagnosis that was consistent with theclinical diagnosis, and 49 (5.9%) had a definitepathological diagnosis that was inconsistent withthe clinical diagnosis. None of the reports had adescriptive pathological diagnosis that was inconsis-tent with the clinical diagnosis. Clinicopathologicalconsistency was 93.9%. In the 154/807 specimensthat were randomly selected for further investigation,clinicopathological consistency was 94.1%. Whenthese specimens were evaluatedwithout clinical dataand clinical diagnoses, the clinicopathological con-sistency of the pathologic diagnoses with the previ-ous clinical diagnoses declined to 74.0%. Thedifference between these two figures of clinicopath-ological consistency was statistically significant (P =.001). Two or more pathological diagnoses werefound in 5 of the 154 cases with clinical diagnoses(3.2%) and in 21 of the 154 cases evaluated withoutclinical diagnoses (13.6%) (Table IV).

Clinicopathological consistency was higher inthose patients with sufficient descriptive clinicalknowledge. Specifying the location of skin diseasehad no effect on clinicopathological consistency. Inthe reports with clinicopathological consistency, dis-ease duration and the reports were shorter in accor-dance with the fact that there were fewer additionalinvestigations performed. No correlation was ob-served between clinicopathological consistency andbiopsy type or number of clinical diagnosis (Table V).

A total of 74 biopsies were performed in 36patients. Of these 36 patients, 23 (63.0%) had achanged pathological diagnoses after a repeatedbiopsy, and 13 (37.0%) had no change in theirpathological diagnosis on repeated biopsies. Theclinicopathological consistency was 58.3% for firstbiopsies and 80.6% for second biopsies. In 9 patients(25.0%), the first biopsy resulted in a descriptivediagnosis, and the second biopsy was used to form adefinite diagnosis.

DISCUSSIONOur results demonstrated a clinicopathological

consistency in diagnosing dermatologic diseases of

76.8%. The diagnostic accuracy rate in prior clinico-pathological consistency studies has varied between44% and 96.5%.3-6,9-12 These studies were performedmainly in solitary lesions, benign tumors, and suspi-cious pigmented lesions,3-6,9-12 whereas our studyinvestigated all types of dermatologic diseases.

The results of our study yielded an accuracy ofclinical diagnosis for inflammatory dermatosis of93.9%. In previous reports by Sellheyer andBergfeld3 and Rajaratnam et al,13 the diagnosticaccuracy rates for inflammatory dermatoses were71.0% and 75.8%, respectively. Although our diag-nostic accuracy rate was higher than these, it is notappropriate to directly compare it with the rates inthese studies as several factors could account for thedifference in accuracy, including differences in thenumber of cases studied and possible differences inthe classification of diseases as inflammatorydermatoses.

We did observe a significant decrease in theclinicopathological consistency rate when biopsyspecimens from inflammatory dermatoses were re-examined without clinical diagnoses. In addition, incases of inflammatory dermatoses, the pathologisttended to suggest more than one pathological diag-nosis in the absence of clinical diagnoses. Diagnosesfrom cliniciansmay reduce the number of differentialdiagnoses by pathologists. In previous reports,13,14

the diagnostic accuracy rate has been shown to be

Table V. Distribution of factors influencing clinicopathological consistency

Biopsy reports showing

clinicopathological consistency

Biopsy reports showing

clinicopathological inconsistency Total

Pn (%) n (%) n

Type of skin biopsyPunch 2567 (77.5) 746 (22.5) 3313 .052*Excision 336 (73.7) 120 (26.3) 456Shave 30 (83.3) 6 (16.7) 36Incision 93 (69.9) 40 (30.1) 133

Mean of disease duration (mean day) 1077 6 1932 1298 6 2190 .001y

Diseases localizationMentioned 2682 (77.3) 790 (22.7) 3472 .094*Not mentioned 352 (73.8) 125 (26.2) 477

Clinical informationSufficient 2358 (77.8) 673 (22.2) 3031 \.032*Insufficient 387 (73.4) 140 (26.6) 527Absent 289 (73.9) 102 (26.1) 391

No. of clinical diagnoses 2.29 6 0.96 2.28 6 0.96 .840y

Mean length of reporting (mean day) 11.52 6 7.15 12.47 6 8.50 .007y

Additional investigationPerformed 448 (14.8) 165 (18.0) 613 .017*

*x2.yMann-Whitney U.

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increased when the clinical pictures or clinicalinformation are provided to pathologists.

In our study, the clinicopathological consistencywas 72.6% for seborrheic keratosis and 88% forbenign melanocytic nevus. In previous studies, di-agnostic accuracy rates were in the range of 55% to89.2% for seborrheic keratosis and 89% to 94% forbenign melanocytic nevus.3,4,6,9 Most seborrheickeratosis lesions diagnosed clinically by dermatolo-gists are treated with cryotherapy or cauterizationwithout pathological examinations. Therefore, thevariation in the diagnostic accuracy rates for sebor-rheic keratosis could be a result of variations in thereferral rates of patients sent to pathology. The rangeof diagnostic accuracy rates for melanocytic lesionsis more narrow, perhaps because all patients withmelanocytic lesions who were referred to pathologyunderwent excision either at their dermatologists’recommendations or for cosmetic purposes.

Previously reported diagnostic accuracy rateswere 67.1% for dermatofibroma, 76.9% for vascularlesions, 64.2% and 83.2% for verruca vulgaris, 77.5%and 81.2% for fibroepithelial polyp, and 88.5% fortrichilemmal and epidermal cysts.3,9 In our study, theclinicopathological consistencies for the above dis-eases were 91.6%, 73.6%, 78.8%, 67.5%, and 44.4%,respectively. Our lower diagnostic accuracy rate fortrichilemmal/epidermal cyst lesions is striking. In ourstudy, 18 cases had this diagnosis, indicating thatthere is a low referral rate for histopathologicalexaminations of trichilemmal/epidermal cyst lesions

in our department, although these cysts are encoun-tered frequently and treated excisionally. The casesreferred for histopathological examinations did nothave clinical diagnoses of trichilemmal/epidermalcysts, suggesting that patients with these lesionswere sent to pathology with different clinical diag-noses as a result of secondary changes.

The diagnostic accuracy rate ranges for basal cellcarcinoma and SCC in previous studies were 70% to95% and 60.3% to 77%, respectively.3,5,6,10 In ourstudy, the clinicopathological consistency rates forbasal cell carcinoma and SCC (93.2% and 81.6%,respectively) were relatively close to those in theseprevious studies.

Sellheyer and Bergfeld3 measured diagnostic ac-curacy rates of 35.9% for actinic keratosis and 96.5%for cutaneous lymphomas. In our study, the clinico-pathological consistency was 70.4% for actinic ker-atosis and 93% for cutaneous lymphomas. In ourclinic we usually performed biopsy for papular,hyperkeratotic lesions of actinic keratosis to excludeSCC. The findings of these biopsy specimens weremainly actinic keratosis, whereas most of the restwere microinvasive SCC. In the study by Sellheyerand Bergfeld,3 dysplastic nevi, lentigo maligna, andSCC were the clinical misdiagnoses of pigmentedactinic keratosis, which may account for the lowdiagnostic accuracy.

Diagnostic accuracy rates for malignant melano-mas in the range of 44% to 80% have been reportedpreviously.3,6,11,12 In our report, there were only 8

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patients who were given a diagnosis histopatholog-ically, and the clinicopathological consistency was92.8% for these cases. Our study was conducted onlyon biopsy specimens collected at the dermatologyclinic. Lesions given clinical diagnoses of melanomaduring our study were generally referred to surgicalclinics for excision. Therefore, although we have ahigher diagnostic accuracy rate, the small number ofcases limits comparisons with the other studies.

Patients with pigmentation diseases were mostcommonly given definite pathological diagnoses thatwere inconsistent with the clinical diagnoses. Most ofthese patients had postinflammatory hyperpigmen-tation. In the reports we investigated, superficialperivascular dermatitis was present most often(5.85%) in patients who received descriptive diag-noses inconsistent with their clinical diagnoses. Themost commonly observed pattern in inflammatorydermatoses is superficial perivascular dermatitis.15

Many dermatoses, such as erythema annulare cen-trifugum, drug eruption, and early period lupuserythematosus, may display superficial perivasculardermatitis.15 The pathologist must establish a specificdiagnosis by evaluating findings, such as perivascu-lar lymphocyte infiltration, atrophy, spongiosis, andbasal layer vacuolization.15 If these findings are notenough to make a definitive diagnosis, then thepathologist must give a descriptive diagnosis. Suchdescriptions are often used for biopsy specimenstaken from the lesion, especially early in the courseof the disease when the clinical picture is not yet fullyestablished. Some of these patients may be given adiagnosis with repeated biopsies. In the group thatunderwent repeated biopsies with diagnoses similarto their prior diagnoses in our study, the pathologistsought clinicopathological consistency with the sec-ondary biopsies. Moreover, although the first biopsyresults were descriptive for 9 patients (25%), thediagnoses after the secondary biopsies were definitediagnoses. These results indicate that repeated biop-sies are useful for establishing accurate and definitediagnoses. The shift toward definite diagnoses aftersecondary biopsies may be a result of a number offactors. Most notably, secondary biopsy specimensmay be taken when the disease has a more typicalclinical and histopathological picture. Alternatively, amore appropriate lesion may have been biopsied, orpathologists may more carefully examine secondarybiopsy specimens to form the diagnoses.

The majority (68.8%) of the diagnoses showingclinicopathological consistency were consistent withthe first clinical diagnosis listed, indicating that theclinical diagnoses on the pathology requisition formare arranged in order of importance. We investigatedfactors that could affect clinicopathological

consistency and observed that disease duration wasshorter in the group with consistency. With moreprolonged disease duration, specific primary lesionslose their specificity and secondary changes, such ascrust, ulceration, and lichenification, may occur.1 Inaddition, typical featuresmay not be observable if thedisease enters a regression phase.1 Writing all clinicaldescriptive knowledge on the pathology requisitionforms in an orderly manner increases the diagnosticaccuracy rate.2,16 In a study performed by Rajaratnamet al,13 accurate diagnoses weremade at a rate of 55%without clinic knowledge of the patients, and accu-rate diagnoses were made at a rate of 78% afterobtaining clinic knowledge. Likewise, in our study,the rate of clinicopathological consistencywas higherin the patients for whom there was sufficient clinicaldescriptive knowledge. Disease duration was signif-icantly shorter and fewer additional investigationswereperformed in the groupwith clinicopathologicalconsistency versus those in the group with inconsis-tency. When pathological diagnoses are inconsistentwith the clinical diagnosis, the pathologist can applyadditional procedures to establish a definite diagno-sis, such as histochemistry, immunohistochemistry,and serial sections. Therefore, the duration of thereports may be prolonged in such cases.

In our study, we demonstrated that biopsy typeand the location of skin disease had no effect onclinicopathological consistency. Biopsy type is gen-erally not related to diagnostic accuracy, except fordiseases involving fatty tissue.17 In these cases,punch biopsy specimens are useful, because theyallow for histopathological examination of the entirelayer of skin. Although typical locations for thedisease are described for many diseases, inflamma-tory dermatoses and even tumors can be observed inmany locations in addition to the classic locations.Our study demonstrates that clinicians or patholo-gists should establish diagnoses by studying lesionfeatures, rather than based on region, because clin-ical descriptive knowledge provides more accuratediagnoses than disease locations.

In conclusion, the rate of clinicopathologicalconsistency in our study was 76.8%. Providing suf-ficient clinical descriptive knowledge increases theprobability of making an accurate diagnosis. Arepeated biopsy is helpful for establishing accuratediagnoses in certain cases. The type of biopsy,specifying the location of diseases, and number ofclinical diagnoses seem not to affect clinicopatho-logical consistency.

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