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Lever's Histopathology of the Skin

Lever's Histopathology of the Skin - Walter F. Lever Intro Meredith's great reviews of law textbooks have inspired me to review some professional books too. It's easy to be cajoled into buying more medical textbooks than you need, especially at conferences and medical meetings. Booksellers draw you in with fancy displays and trinkets, and somehow the sight of your peers drooling over the latest edition of Clout & McSmarty's Principles of Osteomyoneurovascular Disorders of the Left Pinky Toe makes you think to yourself "I might need this someday." So you fork out $450 for a two-volume paperweight that you never open again. Really, you could spend $20,000 on medical textbooks and still feel like you don't have enough, which is absurd because from what I can tell, most pathologists have a few core books that they always use, a few more that they sometimes use, and a much broader contingent that inertly inhabit their offices.About meDo I even have the cred to tell you which skin books to buy? I don't know. I feel reasonably qualified to address the topic of inflammatory skin lesions. I'm not a dermatopathologist. I'm Director of Ancillary Services at a hospital Which I do not care to further identify. It is mostly an administrative job, but I was a general surgical pathologist for ten years, and I still maintain a partial practice (with a partner). Dermatologic cases account for about half of my practice (total workload roughly 5,000 cases/year). I think most pathologists will agree that inflammatory skin lesions are among the most challenging to interpret, and believe me: medical textbook publishers know it! They play on your insecurities, and charge big money for little product. So the focus of this review is comparing the relative merits of three popular Dermatopathology textbooks, and showing how these three should suffice for a general surgical pathologist to diagnose most inflammatory lesions of skin.First: The "also-rans"Essential Skin PathologyPrimer of Dermatopathology Book with CD-ROMRosai and Ackerman's Surgical Pathology 2 Volume Set Rosai Ackerman's Surgical PathologyClues to Diagnosis in DermatopathologyThese books are more like review books or board study aids. They are not overly broad in the entities they cover, and do not examine the process of diagnosis in great detail. Primer of Dermatopathology Book with CD-ROM, for example, lists features of various entities in bullet form, with minimal discussion. I won't review these further, because they don't cover inflammatory lesions in sufficient depth to be a go-to text. That doesn't mean these books have no utility in practice; Essential Skin Pathology in particular has some beautiful photographs (but I read it for the articles). Rosai and Ackerman's Surgical Pathology 2 Volume Set Rosai Ackerman's Surgical Pathology is a massive 3000 page tome which has lovely descriptions and beautiful photos.. but it is very unweildy, and since it attempts to cover every known pathologic diagnosis, it still ends up being too superficial to be a primary text. The entire dermatology section is only 200 pages, of which about half is dedicated to neoplastic disorders. I hardly ever use it, but if I had to pick a pathology book to shoot into space, so that aliens finding it would understand the extent of mankind's knowledge of histopathology, this would for sure be the one. Clues to Diagnosis in Dermatopathology is an odd bird; more of a novelty book than a text. It presents a image of an unknown entity on one page, and then discusses histologic clues on the following pages which reveal the diagnosis. Some of these exercises are quite challenging, and some of the discussion is useful for practice. Unfortunately, the format is not conducive to narrowing a broad differential, and the write-up on each lesion is very superficial, so this is not useful as a primary text. "Clues" is most helpful for finalizing a diagnosis, if you have already got your differential down to one or two entities. I'm told it is also a useful study aid for the Dermatopathology specialty boards.The ContendersI own the following texts which address inflammatory skin lesions:Lever's Histopathology of the Skin HardcoverWeedon's Skin Pathology[b:Histologic Diagnosis of Inflammatory Skin Diseases An Algorithmic Method Based on Pattern Analysis|3089311|Histologic Diagnosis of Inflammatory Skin Diseases An Algorithmic Method Based on Pattern Analysis|A. Bernard Ackerman|http://ecx.images-amazon.com/images/I/51S7V2RD5VL._SL75_.jpg|3120411]Best In ShowIf I could only recommend one of these books, it would be Lever's Histopathology of the Skin Hardcover. The strength of this book is that its histopathologic descriptions and photo plates are superior to the two other texts. In effect, it's my "desert island pick", and if you're a resident thinking about buying a dermpath text, I would say this should be the one (however a newer edition exists). Why are the other two books in the running?Dance to the algorithmIf you're a fan of the algorithmic approach, Bernard Ackerman is your man! He popularized algorithmic diagnosis for inflammatory skin with his very popular series of textbooks, and founded his lucrative Ackerman Academy of Dermatopathology on this approach. In pathology circles, he was one of the big names of the 80's, 90's and up to his passing in 2008. His popularity was due in part to his diagnostic acumen and impressive organizational skills, and in part to his acerbic yet oddly charismatic personality. (i.e. he was fun to watch, if your weren't the target of his wit) I once attended a conference where he was conducting a session of unknowns, and there was an image projected up on the screen, and he asked one of the participants what he thought it was. The poor guy fumbled around for a while, described a few features, and then concluded that he thought it was probably a Schwannoma (a benign tumor of neural origin). Bernie had this real droll look on his face and said "This was supposed to be a warm-up slide. It should be intuitively obvious to even the most casual observer that this is a Schwannoma." Everybody laughed. That's teaching-by-public-humiliation, OldSchool style! But really he was a very nice guy. Aaaanyhow... [b:Histologic Diagnosis of Inflammatory Skin Diseases An Algorithmic Method Based on Pattern Analysis|3089311|Histologic Diagnosis of Inflammatory Skin Diseases An Algorithmic Method Based on Pattern Analysis|A. Bernard Ackerman|http://ecx.images-amazon.com/images/I/51S7V2RD5VL._SL75_.jpg|3120411] instructs on histopathology by asking focused questions to lead you progressively down decision trees until you reach a final diagnosis.Kind of like this (but I couldn't find one related to skin pathology) It's good in theory, but the problem with this approach is that every decision point depends on a definitive answer to a very clearcut question, so there are no allowances for nuance:Is the inflammation nodular or diffuse?That can be a pretty subjective call. What is the character of the intraepidermal dermatitis? Your choices are Spongiotic, Ballooning, Acantholytic, or Cleaving.Wait a sec, what if you see more than one of those features? Which path should you choose?You get the idea. Clinically speakingWeedon's Skin Pathology is almost a text more for dermatologists than for dermatopathologists. It gives lots of descriptions about how the patients present, what the clinical appearance is, what symptoms the patients might suffer from, associations with travel history, familial syndromes, etc. For most cases, when you're sitting at the microscope, you don't dwell too heavily on those issues, but if you're in a quandry, and you call the submitting physician, oftentimes he can provide information along these lines, which is potentially very helpful. Lever's Histopathology of the Skin Hardcover does touch on clinical information a bit, but Weedon's Skin Pathology is the hands-down winner in that category.Rather than focusing on which book is the best, I want to show how the three contenders complement each other, and together are probably all you need.THE DIAGNOSTIC PROCESSSo you put a biopsy slide on your microscope and take a look. There are four possibilities:A) I know exactly what this is.B) I sort-of know what this is. i) I'm pretty sure, but I don't want to sign my name on it. ii) I know the general category, but I need some help.C) I have no fucking clue what this is.If you're in category A, sign the case out. 'Nuff said about that.If you're in category C, look at the clinical information. Nine times out of ten, there will be none offered, but if you call the submitting clinician, he should be able to help you out. Frequently, the clinical information will convert a category C into a category A:Me: I'm looking at a biopsy you submitted on patient X. It's got an awfully strange pattern...Clinician: Oh yes! He's been living the last seven years in Cameroon. He has a well-established case of vonEsoterica's Idiopathic Tropical Artifactosis (VITA). We've been following him with interest.Me: Thank you, doctor!From there, you go to Lever's Histopathology of the Skin Hardcover and look up VITA. If you feel confident the histopathologic features match, you can probably sign out the case, either boldly as "VITA", or meekly as "consistent with VITA" and a comment saying you will send the case to a consultant for confirmation. If there's room for doubt, you can check with Weedon's Skin Pathology to see whether the clinical features match. This might be one of those rare cases where Clues to Diagnosis in Dermatopathology could actually help you. If clinical information doesn't help, and you're still in category C... time to swallow your pride and ask for help. Know your limitations. One thing's for certain: [b:Histologic Diagnosis of Inflammatory Skin Diseases An Algorithmic Method Based on Pattern Analysis|3089311|Histologic Diagnosis of Inflammatory Skin Diseases An Algorithmic Method Based on Pattern Analysis|A. Bernard Ackerman|http://ecx.images-amazon.com/images/I/51S7V2RD5VL._SL75_.jpg|3120411] has no role in a category C case. [b:Histologic Diagnosis of Inflammatory Skin Diseases An Algorithmic Method Based on Pattern Analysis|3089311|Histologic Diagnosis of Inflammatory Skin Diseases An Algorithmic Method Based on Pattern Analysis|A. Bernard Ackerman|http://ecx.images-amazon.com/images/I/51S7V2RD5VL._SL75_.jpg|3120411] really shines in the category B cases. Ackerman at least gets you thinking in the right direction. Okay... it's inflammatory in nature... it is superficial, and perivascular... I see eosinophils.. Hey! I just narrowed my differential down from 10,000 possible choices to just six! Now a few tidbits of clinical information should help me knock it down to just two or three. Naturally it feels a lot better if you can definitively nail a diagnosis, no questions asked. But honestly, if you have the lesion in the correct general category, and you can offer a differential of two or three entities, most of the time you've been a big help to the submitting clincian. I always feel like a loser when I have to sign out something descriptively-"Superficial perivascular lymphocytic dermatitis with scattered eosinophils, and focal vacuolar change; see comments. COMMENTS- The differential includes..."-but the truth is that not every entity declares itself on the first biopsy. You have to communicate well with the contributing clinician, and advise him to rebiopsy if the lesion persists or recurs.Good luck!