Clinical Vignettes for Dermatology The following dermatopathology clinical vignettes highlight patient cases where the Inform Diagnostics diagnosis made a difference.Clinical Vignettes Lesion is Benign, Yet Microscopically Similar to Malignant Tumor 23-year-old man presented to his clinician with a forehead lesion. Upon biopsy, another laboratory diagnosed the forehead lesion as a dermatofibromasarcoma protuberans (DFSP), a type of malignant soft tissue tumor. The clinician was planning Mohs surgery and requested a second opinion from Inform Diagnostics. Our Diagnosis Nodular fasciitis, a benign soft tissue lesion The Inform Diagnostics Difference In our daily consensus conference, Inform Diagnostics dermatopathologists differentiated between two microscopically similar conditions. Patient avoided surgery on his face. (DFSP requires wide excision, while nodular fasciitis, a benign condition, resolves on its own.) The Inform Diagnostics dermatopathologist spoke to the clinician, who stated that the patient’s lesion had arisen very quickly, which further supported the diagnosis of nodular fasciitis Unusual Mole Shown to be Malignant Melanoma 27-year-old woman presented with a lesion on the posterior ear that the patient remembers having since childhood. The lesion was excised and sent to Inform Diagnostics. Microscopically, the lesion largely resembled a benign nevus, but an atypical nodule was present, and the case was reviewed at Inform Diagnostics’s daily consensus conference of dermatopathologists, where melanoma was suspected, but the diagnosis was not conclusive. The case was sent to UCSF for consultation, where it was agreed that the lesion was very unusual and difficult to classify. After discussing with the Inform Diagnostics dermatopathologist, the need for comparative genomic hybridization, an expensive molecular test, was recommended, despite the fact that the clinician was convinced it was benign. Consistent with Inform Diagnostics’s indigent patient policy, the cost of the test was covered, and several mutations were found in a pattern indicative of malignant melanoma. Our Diagnosis Melanoma The Inform Diagnostics Difference Unusual case that was thought to be benign (due to its indolent course), was nevertheless recognized as suspicious by the Inform Diagnostics dermatopathology faculty. The Inform Diagnostics dermatopathologist advocated for the indigent patient to receive necessary testing at Inform Diagnostics’s expense. The melanoma was recognized in a young woman who would have otherwise gone untreated. Wide Margin Surgery Cancelled After Inform Diagnostics Diagnosis A woman in her fifties presented with a pigmented lesion. Her dermatologist performed a biopsy, reviewed the slides herself, and diagnosed “invasive melanoma.” The surgeon who was planning to perform a removal of the tumor with a wide margin sent the original biopsy slides to Inform Diagnostics. Our dermatopathologist determined that the lesion was actually a type of benign mole (dysplastic nevus). Our Diagnosis Dysplastic nevus with moderate atypia The Inform Diagnostics Difference A dysplastic nevus does not require a wide excision, and surgery was cancelled. Inform Diagnostics’s expert dermatopathologist rendered a definitive diagnosis. Inform Diagnostics Dermatopathologists See Far More Cases, Recognize Basal Cell Carcinoma A woman in her fifties had a biopsy which her dermatologist diagnosed as melanoma. This physician has her own in-office lab and interprets her own biopsies. When the entire tumor was later removed, the large re-excision was sent to Inform Diagnostics. Our dermatopathologists did not find residual melanoma in the patient’s tumor; rather, they diagnosed residual basal cell carcinoma, a much less dangerous tumor type. Subsequently, the Inform Diagnostics dermatopathologist reviewed the patient’s original biopsy, which in fact showed basal cell carcinoma, not melanoma. Our Diagnosis Basal cell carcinoma The Inform Diagnostics Difference Patient is diagnosed with and treated for a much less dangerous tumor type. Definitive diagnosis is rendered by Inform Diagnostics subspecialist dermatopathologist, who reads far more cases than a dermatologist in clinical practice. Definitive diagnosis rendered by Inform Diagnostics dermatopathologist who subspecializes in alopecia 23-year-old woman with a prior clinical history (not biopsy-proven) of both psoriasis and alopecia areata. Other pertinent medical history is current Crohn’s disease. Chief complaint of visit was “now having scalp pustules.” The patient’s dermatologist performed a scalp biopsy, which was sent to Inform Diagnostics. Our dermatopathologist used the Headington grossing protocol for alopecia, which showed histologic features overlapping those seen in psoriatic alopecia, with the additional findings of peribulbar plasma cells and follicular pustules. Our dermatopathologist reviewed the patient’s medication list, which was provided through Inform Diagnostics’ interface with the clinician’s EMA software. The patient’s medication included an anti-TNF (tumor necrosis factor) medication Cimzia (certolizumab pergola) for her Crohn’s disease. The combination of clinical information and histologic features helped to make a definitive diagnosis. Our Diagnosis TNF-alpha inhibitor-associated psoriasiform alopecia The Inform Diagnostics Difference A definitive diagnosis was rendered by the Inform Diagnostics dermatopathologist who subspecializes in alopecia (and who sees a greater number of alopecia cases compared to the average dermatopathologist). The clinician, now with a definitive diagnosis, can give the appropriate treatment with the consideration of withholding, discontinuing, or changing anti-TNF therapy based upon the degree of scalp pustular eruptions (and alopecia) and clinical control of the Crohn’s disease.