THE NEW ZEALAND MEDICAL JOURNAL        NZMJ 5 November 2010, Vol 123 No 1325; ISSN 1175 8716 Page 53 URL: http://www.nzma.org.nz/journal/123-1325/4420/ ©NZMA Pathology referrals for skin lesions—are we giving the pathologist sufficient clinical information? Marius Rademaker, Murray Thorburn Abstract Aim To assess the quality of data included in the histology request form. Method We prospectively reviewed the histology request forms of 375 consecutive skin lesions. In addition, the appropriateness of the surgical specimen was determined. Results There were 196 women and 179 men with a mean age of 58.4 years. The majority of specimens (84.5%) derived from primary care. 233 lesions (62%) were removed by excision, 57 (15%) by shave, three by curettage, with 82 lesions (22%) by punch/incisional biopsy. The clinical diagnosis was either not specified in 56 cases (15%), or simply labelled as ‘lesion’ in 84 (22%) patients. In 140/375 cases (37%), no useful clinical information was available. The clinical diagnosis matched the histopathological diagnosis in 145 cases (39%). Sixty percent (78/131) of histologically confirmed malignant lesions had not been identified clinically as being malignant: only 2 of 12 (17%) melanomas, 33/74 (45%) BCCs and 18/45 SCCs (57%) were diagnosed clinically. The specimen type was considered inadequate to make a histopathological diagnosis in 25 cases (6.7%). Conclusion In over a third of histology requests, diagnostic clinical information was absent. In addition, punch biopsy was used in 40% of lesions where a melanoma was being considered clinically. The pathology request form is a crucial communication document between treating physician and histopathologist. 1 The data set should include demographics (age and sex of patient), site and type of specimen, clinical history and preferably the diagnostic query the treating physicians wants answered by the pathologist. Anecdotal evidence suggests that the information routinely captured on the pathology request form is often minimal, thereby affecting the ability of the histopathologist to correctly report the specimen. 2–6 In addition, the recent Australasian / New Zealand Melanoma guidelines recommend that the optimal biopsy approach for a pigmented skin lesion suspicious of melanoma is complete excision with a 2 mm margin, as partial biopsies may not be fully representative of the lesion. 6 They do however, go on to comment, “Incisional, punch or shave biopsies may be appropriate in carefully selected clinical circumstances, for example, for large facial or acral lesions, or where the suspicion of melanoma is low.” This study aimed to assess the quality of information available to the pathologist from the histology request forms, the accuracy of the preliminary clinical diagnosis, and the appropriateness of the biopsy sample provided.