American Society of Dermatopathology

Five Things Physicians and Patients Should Question

October 17, 2018

  1. 1

    Do not perform T-cell receptor (beta and gamma) gene rearrangement studies on inflammatory/reactive lesions or papular / papulonecrotic eruptions when there is clinical and histologic concordance for a diagnosis of pityriasis lichenoides or lymphomatoid papulosis.

    Although clonality assays such as T-cell receptor beta and gamma studies can be useful in the detection of monoclonality in lymphoproliferative disorders, there are limitations in the sensitivity and specificity of the test. In addition, the test has a high false positive rate making it unreliable in differentiating between benign inflammatory dermatoses and T-cell lymphoproliferative disorders.

  2. 2

    Do not perform diagnostic cytogenetic analysis on a lesion from an adult patient when the histopathology is definitive for a melanoma.

    Histologic examination is currently the gold standard in the diagnosis of melanocytic lesions. Cytogenetic analysis can serve as an adjunct test when a definitive diagnosis cannot be rendered on histologic grounds, but should not be used when a diagnosis can be made unequivocally by histologic examination.

  3. 3

    Do not perform diagnostic cytogenetic analysis on a lesion from an adult patient when the histopathology is definitive for a melanocytic nevus.

    Histologic examination is currently the gold standard in the diagnosis of melanocytic lesions. Cytogenetic analysis can serve as an adjunct test when a definitive diagnosis cannot be rendered on histologic grounds, but should not be used when a diagnosis can be made by histologic examination.

  4. 4

    Do not perform the t(17;22) fluorescence in situ hybridization (FISH) assay on cases of dermatofibrosarcoma protuberans in situations where the translocation has already been detected by another testing modality.

    Various testing modalities can be used to detect the t(17;22) translocation in dermatofibrosarcoma protuberans, with each being able to provide confirmation of the presence of the translocation.

  5. 5

    Do not perform the EWSR1 fluorescence in situ hybridization (FISH) assay on cases of clear cell sarcoma in situations where the translocation has already been detected by another testing modality.

    Various testing modalities can be used to detect the translocation involving EWSR1 gene in clear cell sarcoma, with each being able to confirm the presence or absence of the translocation.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Society of Dermatopathology (AAD) is honored to be a partner in the Choosing Wisely Campaign. The society is committed to improving the quality of lives by continually advancing the theory and practice of dermatopathology. The society was founded in 1962 and serves as the hub of knowledge in the practice of dermatopathology and has a membership of over 1400 individuals. With the increase in new technologies and diagnostic tests available along with the call by health care agencies and patients for safer, more efficient and cost-conscious care, ASDP’s participation in the campaign allows for a more meaningful dialogue between dermatopathologists, pathologists, dermatologists and patients.

How This List Was Created

The American Society of Dermatopathology (ASDP) is committed to improving the quality of lives by continually advancing the theory and practice of dermatopathology. In 2015, under the vision of the then Society President, Dr. Dirk Elston, the Appropriate Use Criteria (AUC) Task Force was created to help guide dermatopathologists and inform their clinical colleagues in their use of ancillary studies performed in dermatopathology in specific clinical scenarios with overarching goal of producing high quality care, lowering costs and ensuring efficient use of laboratory resources. The Task Force identified ancillary studies performed in dermatopathology encompassing four broad areas in which AUC could be developed. These include: lymphoproliferative, melanocytic, soft tissue, and other, which includes entities that do not fit into one of the aforementioned groups. Using the methodology developed by RAND/ UCLA, which combines best scientific evidence with expert opinion to develop patient-centered guidelines (appropriateness ratings), the Task Force explored 12 ancillary studies used in dermatopathology and 211 clinical scenarios that are commonly encountered in dermatopathology. The Task Force was transitioned to a standing Committee in 2017, and along with working on dissemination of the developed AUC, the committee identified areas, which have a potential for misuse and are supported by evidence, which could be converted into recommendations for the Choosing Wisely Campaign. The recommended list was reviewed and approved by the ASDP Ethics Committee and Board of Directors.

Sources

  1. Comfere N, Sundram U, Yadira Hurley M, Swick B. Views of Dermatopathologists about Clonality Assays in the Diagnosis of Cutaneous T cell and B cell Lymphoproliferative Disorders. J Cutan Pathol. 2018 Jan;45(1):39-47.

    Vidal CI, Armbrect EA, Andea AA, et al. Appropriate Use Criteria in Dermatopathology: Initial Recommendations from the American Society of Dermatopathology. J Cutan Pathol. 2018 Aug;45(8):563-580 (full version) and J Am Acad Dermatol. 2018 Apr 21. [Epub ahead of print] (abbreviated version) [co-published].

    Zhang B, Beck AH, Taube JM, et al. Combined use of PCR-based TCRG and TCRB clonality tests on paraffin embedded skin tissue in the differential diagnosis of mycosis fungoides and inflammatory dermatoses. J Mol Diagn 2010 May; 12(3): 320-7.

  2. Emanuel PO, Andea AA, Vidal CI, et al. Evidence behind the use of molecular tests in melanocytic lesions and practice patterns of these tests by dermatopathologists. J Cutan Pathol. 2018 Jul 24. [Epub ahead of print]

    Lang UE, Yeh I, McCalmont TH. Molecular Melanoma Diagnosis Update: Gene Fusion, Genomic Hybridization, and Massively Parallel Short-Read Sequencing. Clin Lab Med. 2017 Sep;37(3):473-484.

    Vidal CI, Armbrect EA, Andea AA, et al. Appropriate Use Criteria in Dermatopathology: Initial Recommendations from the American Society of Dermatopathology. J Cutan Pathol. 2018 Aug;45(8):563-580 (full version) and J Am Acad Dermatol. 2018 Apr 21. [Epub ahead of print] (abbreviated version) [co-published].

  3. Emanuel PO, Andea AA, Vidal CI, et al. Evidence behind the use of molecular tests in melanocytic lesions and practice patterns of these tests by dermatopathologists. J Cutan Pathol. 2018 Jul 24. [Epub ahead of print]

    Lang UE, Yeh I, McCalmont TH. Molecular Melanoma Diagnosis Update: Gene Fusion, Genomic Hybridization, and Massively Parallel Short-Read Sequencing. Clin Lab Med. 2017 Sep;37(3):473-484.

    Vidal CI, Armbrect EA, Andea AA, et al. Appropriate Use Criteria in Dermatopathology: Initial Recommendations from the American Society of Dermatopathology. J Cutan Pathol. 2018 Aug;45(8):563-580 (full version) and J Am Acad Dermatol. 2018 Apr 21. [Epub ahead of print (abbreviated version) [co-published].

  4. Linos K, Kozel JA, Yadira Hurley M, Andea AA. Review of the medical literature and assessment of current utilization patterns regarding the use two common fluorescence in situ hybridization assays in the diagnosis of dermatofibrosarcomaprotuberans and clear cell sarcoma. J Cutan Pathol. 2018 Aug 28. [Epub ahead of print]

    Vidal CI, Armbrect EA, Andea AA, et al. Appropriate Use Criteria in Dermatopathology: Initial Recommendations from the American Society of Dermatopathology. J Cutan Pathol. 2018 Aug;45(8):563-580 (full version) and J Am Acad Dermatol. 2018 Apr 21. [Epub ahead of print] (abbreviated version) [co-published].

  5. Linos K, Kozel JA, Yadira Hurley M, Andea AA. Review of the medical literature and assessment of current utilization patterns regarding the use two common fluorescence in situ hybridization assays in the diagnosis of dermatofibrosarcomaprotuberans and clear cell sarcoma. J Cutan Pathol. 2018 Aug 28. [Epub ahead of print]

    Vidal CI, Armbrect EA, Andea AA, et al. Appropriate Use Criteria in Dermatopathology: Initial Recommendations from the American Society of Dermatopathology. J Cutan Pathol. 2018 Aug;45(8):563-580 (full version) and J Am Acad Dermatol. 2018 Apr 21. [Epub ahead of print] (abbreviated version) [co-published].