Washington University School of Medicine, St. Louis, Missouri, USA.
Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
J Cutan Pathol. 2023 Dec;50(12):1048-1051. doi: 10.1111/cup.14532. Epub 2023 Sep 4.
Heuristics are cognitive strategies used to facilitate decision-making. They can be helpful tools for expediting pathologic diagnoses, however, they can also affect judgment and lead to biases that guide the pathologist astray. We report the case of a 52-year-old female who presented with two unusual pigmented lesions on the wrist and thigh that clinically and histopathologically resembled an atypical melanocytic proliferation. A biopsy of the thigh revealed a broad proliferation of large, atypical cells forming nests within a heavily pigmented epidermis. The lesion was initially misdiagnosed as melanoma in situ, despite equivocal staining for melanocytic markers, likely due to anchoring and adjustment as well as availability biases, which restricted the differential diagnosis and limited the selection of immunohistochemical stains. It was later discovered through chart review that the patient had a prior history of a cutaneous CD30+ lymphoproliferative disorder, which eventually led to the appropriate diagnosis in this case. Herein, we highlight a rare and unusual presentation of a pigmented epidermotropic CD30+ lymphoproliferative disorder, along with the biases leading to its misdiagnosis and the steps leading to the revelation of the actual diagnosis.
启发式是用于促进决策制定的认知策略。它们可以作为加快病理诊断的有用工具，但是它们也可能影响判断并导致偏见，从而使病理学家误入歧途。我们报告了一名 52 岁女性的病例，她的手腕和大腿上出现了两个不寻常的色素沉着病变，临床上和组织病理学上都类似于非典型黑素细胞增生。大腿的活检显示出广泛的大而异常的细胞增生，在色素沉着的表皮内形成巢。尽管黑素细胞标志物的染色结果不确定，但最初仍误诊为原位黑色素瘤，这可能是由于锚定和调整以及可用性偏见所致，这些偏见限制了鉴别诊断并限制了免疫组织化学染色的选择。后来通过图表审查发现，该患者曾有过皮肤 CD30+淋巴增生性疾病的病史，这最终导致了该病例的正确诊断。在此，我们强调了一种罕见且不寻常的色素性表皮内 CD30+淋巴增生性疾病的表现，以及导致误诊的偏见以及揭示实际诊断的步骤。
