My Most Memorable Mistakes: Cautionary Tales by Pathologists, Take 2

Dear readers of AJSP: Reviews and Reports,

I am thrilled to present a second issue on the subject of “My most memorable diagnostic mistake.” We all hope to never make them, and yet it happens to all of us, regardless of experience. The most important thing is that we learn from these mistakes, which is what inspired us to start publishing reports of real-life diagnostic errors, accompanied by an honest assessment of their causes and consequences and recommendations on how to prevent others from repeating them. We believe this will serve as a powerful teaching tool for the readers of our Journal, regardless of where in their pathology career they are.

In this issue you will find a collection of notoriously hard diagnoses to make—common and rare—and honest discussions about ways to avoid making a mistake when dealing with them. It is not surprising therefore that the first 3 articles are devoted to mesothelial lesions in all their treacherous perturbations. Burke and colleagues start this issue with a detailed and practical review of an exquisitely difficult dilemma for any surgical pathologist: sarcomatoid mesothelioma and its distinction from a reactive process. Immunohistochemistry is an extremely valuable tool in the workup of possible mesothelioma and its differential diagnosis; however, it can also become a pitfall, as shown in the wonderfully thorough and helpful review by Stashek et al. Another example of a diagnostic issue regarding peritoneal mesothelial proliferations is provided by Burke and Legesse. Their report illustrates the difficulty in distinguishing reactive and neoplastic peritoneal mesothelial processes and offers very helpful guidance for this differential diagnosis.

Elishaev et al deliver a great example of the often frustratingly difficult differential diagnosis of mucinous tumors of gynecologic and gastrointestinal origin. The thorough summary of helpful features will be no doubt useful to practicing pathologists faced with this common dilemma of separating metastatic spread from primary ovarian tumors. Another difficult instance of metastatic malignancy mimicking a primary tumor is described by Fanaroff and Burke in a beautifully illustrated report.

It is well established that pitfalls in hematopathology abound. The next 3 articles showcase these difficulties really well. The first, by Kallen and colleagues, describes a situation where flow cytometry may hinder the diagnosis instead of facilitating it. The authors perform a root-cause analysis of the error and address the need to carefully review all available information, as well as to pay constant attention to quality assurance efforts in the laboratory. The article that follows expands further on the dangers of using ancillary studies, such as flow cytometry, in separation from clinical data and morphologic examination. The authors, Aqil and Ramos, make a compelling case for integrating all available information when making such complex diagnoses as hematologic malignancies. This section is concluded by a very interesting report of an ALK-positive anaplastic large cell lymphoma, which presented with a leukemic picture and was initially diagnosed as T-cell prolymphocytic leukemia. The differential diagnosis of these entities is masterfully presented by Vadasz et al.

Every pathologist knows how treacherous thyroid carcinoma metastases are due to their benign appearance and presence in unexpected locations. The report or, rather, cautionary tale by Wiles and Sayeedi is that of a diagnostic error of an opposite direction: an unusual, distorted shape of a benign thyroid gland interpreted as a lymph node with metastatic papillary thyroid carcinoma, which led to total thyroidectomy. The authors carefully dissect factors that caused the mistake and provide ample advice on how to avoid similar errors.

Nonneoplastic liver pathology is notoriously difficult, and the case reported by Alkahash et al is no exception. The authors describe a case of end-stage liver disease necessitating liver transplant that was presumed to be secondary to cirrhosis; the cause, however, was discovered to be vascular in nature: the culprit was portosinusoidal vascular disease or idiopathic noncirrhotic portal hypertension—an exceedingly difficult diagnosis, for which the authors provide a very helpful diagnostic algorithm.

Mimickers in our field are numerous; many of them are well known, some are uncommon. The first of the following 2 articles describes a very rare mimicker—all the more dangerous because of its rarity: renal cell carcinoma seen in a urine cytology specimen and mistaken for high-grade urothelial carcinoma. The next case report in this issue concerns 2 common and infamous mimickers: melanoma and angiosarcoma. Both are known to mimic other tumors, and we are trained to always consider them in the differential diagnosis of almost any tumor in any location. This case, however, illustrates a doubly dangerous scenario: poorly differentiated angiosarcoma that was initially interpreted as melanoma, both clinically and pathologically. Truly, a warning to all of us!

To conclude, I promise more issues in the future devoted to an honest and open discussion of memorable diagnostic mistakes; may we all learn from these so as not to make them ourselves!

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