Clinician’s Diagnosis vs Pathologist’s Diagnosis

Clinician’s Diagnosis vs Pathologist’s Diagnosis

There are instances in medical practice that the clinician’s diagnosis does not jibe with the pathologist’s diagnosis or vice versa.  What to do then, especially for the clinician who is ultimately the one in charge of the patient’s management.

What the clinician should do is to first initiate discussion with the pathologist.  If after review of the data both clinical and pathologic and discussion, both parties can agree to one similar diagnosis, well and good.  If not, what should the clinician do?

What are the usual factors that the clinician and the pathologist cannot agree to one similar diagnosis? The pathologist usually sticks to his interpretation of what he sees on the microscopic slides. He places secondary importance to the gross appearance of the specimen submitted and to the clinical data.  The clinician, especially the experienced surgeon, usually sticks to his interpretation of the gross appearance of the specimen taken out from operation and submitted to the pathologist supported by the clinical data.

So, if after review of the data both clinical and pathologic and discussion, both parties cannot agree to one similar diagnosis, what should the clinician do?

The clinician has to inform the patient of the differing opinions.  He ends up with formulation of the primary and secondary diagnoses at this time of patient management.  Depending on the conviction of the clinician, the primary and secondary diagnoses will be the clinician’s diagnosis and the pathologist’s diagnosis respectively or vice versa, meaning, the primary diagnosis will be the pathologist’s diagnosis and the secondary diagnosis, the clinician diagnosis.

What to do next after telling the patient of the differing opinions of the clinician and pathologist and the primary and secondary diagnoses?

If the differing diagnoses does not need further treatment, for example, both are non-malignant tumors and whatever be the case, the treatment is the same, such as excision, and it has been done, then clinician will advise monitoring (watch and wait).

If the differing diagnoses needed to be resolved because one diagnosis requires further treatment and different at that and the other diagnosis does not require further treatment or require another type of treatment, the clinician has the following options:

  1. Do further diagnostic tests and act accordingly. The result of the further diagnostic test may either affirm his clinical diagnosis or that of the pathologist.
  2. Especially if there are no more further diagnostic tests that can be done, depending on his conviction on the diagnosis and his analysis of the whole situation, put the pathologist on hold or at the background and proceed with a planned treatment based on his clinical diagnosis. The clinician recommended plan of action has to have a written informed consent.

Below are three examples of differing diagnoses of the clinician and pathologist and what the clinician did afterward.  The third example is a twist on the second example.

Case 1:

Clinician’s diagnosis: Galactocoele with inspissated milk in a 29-year-old female.

Pathologist’s diagnosis: Fibrocystic changes with tubular adenosis

The clinician sticks to his clinical diagnosis based on his operative findings and correlated with the clinical data.  Operative findings shows milky fluid oozing out from the mass and well-encapsulated mass with pasty materials within which may represent inspissated milk.  The clinical data shows well-circumscribed mass, very movable, with history of lactation 2-years ago; and the mass noted one and a half years after lactation.

The pathologist’s description of the gross appearance of the excised mass jibed with that of the clinician except for the additional finding of a 0.5-cm nodule – “cystic tissue with brown external surface, smooth inner cyst lining and a cavity containing white pasty material.  A 0.5 cm. diameter tan nodule is noted in one area. The cyst wall is paper thin.”  The tubular adenosis refers to the 0.5-cm nodule.

The clinician decides to tell the patient the differing diagnoses and recommends GALACTOCOELE with inspissated milk as the primary diagnosis and FIBROCYSTIC CHANGES with TUBULAR ADENOSIS as the secondary diagnosis (after discussion with the pathologist).  Since both are non-malignant conditions and no further treatment is required, the clinician advises monitoring (watch and wait).

histopath_result_galactocoele_vs_fibrocystic_rj_16feb17

IMG_1172

IMG_1175

Case 2:

Clinician’s diagnosis: Thyroid follicular carcinoma

Pathologist’s diagnosis: Thyroid medullar carcinoma (from needle biopsy)

The clinician sticks to his clinical diagnosis based on the clinical findings of a 3-cm movable thyroid nodule with skull metastasis in a 40-year-old Filipino female and based on prevalence, thyroid follicular carcinoma is more common than medullary carcinoma especially in Filipinos.

The clinician decides to tell the patient the differing diagnoses and recommends FOLLICULAR CARCINOMA as the primary diagnosis and MEDULLARY CARCINOMA as the secondary diagnosis (after discussion with the pathologist).  Since both are malignant conditions and surgery is the treatment of choice for both, whatever be the case, the clinician-surgeon advises operation (thyroidectomy).

The final histological diagnosis in this case turns out to be FOLLICULAR CARCINOMA.

 

Case 3: (A twist on Case 2)

Clinician’s diagnosis: Thyroid follicular carcinoma

Pathologist’s diagnosis: Thyroid medullar carcinoma (from needle biopsy)

The clinician sticks to his clinical diagnosis based on the clinical findings of a 3-cm movable thyroid nodule with skull metastasis in a 40-year-old Filipino female and based on prevalence, thyroid follicular carcinoma is more common than medullary carcinoma especially in Filipinos.

The clinician decides to tell the patient the differing diagnoses and recommends FOLLICULAR CARCINOMA as the primary diagnosis and MEDULLARY CARCINOMA as the secondary diagnosis.  Since both are malignant conditions and surgery is the treatment of choice for both, whatever be the case, the clinician-surgeon advises operation (thyroidectomy).

The final histological diagnosis in this case turns out to be FOLLICULAR ADENOMA.

The clinician decides to tell the patient the differing diagnoses and recommends FOLLICULAR CARCINOMA and FOLLICULAR ADENOMA as the secondary diagnosis (after discussion with the pathologist).  Knowing the limitation of the histopathology on distinguishing follicular adenoma from carcinoma and vice versa and in the presence of lytic bone lesion on the skull highly suspicious for metastasis, the clinician decides to put on hold the pathologist diagnosis and treat the patient further with a diagnosis of  FOLLICULAR CARCINOMA with SKULL METASTASIS.

ROJ-TPOR@16feb17

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