Agreement of dermatopathologists in the evaluation of clinically difficult melanocytic lesions: how golden is the 'gold standard'?

BACKGROUND

The 'gold standard' for the diagnosis of melanocytic lesions is dermatopathology. Although most of the diagnostic criteria are clearly defined, the interpretation of histopathology slides may be subject to interobserver variability.

OBJECTIVES

The aim of this study was to determine the variability among dermatopathologists in the interpretation of clinically difficult melanocytic lesions.

METHODS

This study used the database of MelaFind®, a computer-vision system for the diagnosis of melanoma. All lesions were surgically removed and sent for independent evaluation by four dermatopathologists. Agreement was calculated using kappa statistics.

RESULTS

A total of 1,249 pigmented melanocytic lesions were included. There was a substantial agreement among expert dermatopathologists: two-category kappa was 0.80 (melanoma vs. non-melanoma) and three-category kappa was 0.62 (malignant vs. borderline vs. benign melanocytic lesions). The agreement was significantly greater for patients ≥40 years (three-category kappa = 0.67) than for younger patients (kappa = 0.49). In addition, the agreement was significantly lower for patients with atypical mole syndrome (AMS) (kappa = 0.31) than for patients without AMS (kappa = 0.76).

LIMITATIONS

The data were limited by the inclusion/exclusion criteria of the MelaFind® study. This might represent a selection bias. The agreement was evaluated using kappa statistics. This is a standard method for evaluating agreement among pathologists, but might be considered controversial by some statisticians.

CONCLUSIONS

Expert dermatopathologists have a high level of agreement when diagnosing clinically difficult melanocytic lesions. However, even among expert dermatopathologists, the current 'gold standard' is not perfect. Our results indicate that lesions from younger patients and patients with AMS may be more problematic for the dermatopathologists, suggesting that improved diagnostic criteria are needed for such patients.

The follow-up of radioiodine-treated hyperthyroid patients: should thyroid function be monitored more frequently?

BACKGROUND

There is a lack of data regarding the timing and particularly the severity of hypothyroidism post radioiodine (RI).

AIM

To investigate the timing and severity of hypothyroidism in RI-treated hyperthyroid patients.

METHODS

Retrospective examination of the records of 183 RI-treated hyperthyroid patients (79 autoimmune hyperthyroidism, 46 toxic multinodular goiter, and 58 hyperthyroidism of indeterminate etiology).

RESULTS

One hundred and fifty-nine patients requiring a single dose of RI (435 MBq), 107 (67%) developed hypothyroidism. Hypothyroidism detected in: 16% of patients at <8 weeks, 46% at 8 to <16 weeks, 24% at 16 to <24 weeks, 9% at 24 to <36 weeks, 3% at 36 to <52 weeks, and 2% at >52 weeks. One hundred and eighty-three patients had follow-up after one or more doses of RI and 124 (68%) patients developed hypothyroidism; of these, 44 (36%) had TSH>50 mU/l and 34 (27%) had free T4<5 pmol/l when hypothyroidism was first detected. Of those patients with a delayed outpatient visit (no.=77) and those with an outpatient visit within the recommended target interval (no.=47), median TSH was 23 (0.05-152) mU/l and 32 (0.05-150) mU/l, respectively (p=0.75) and median free T4 was 7.1 (1.3-16.7) pmol/l and 6.6 (1.3-15.4) pmol/l, respectively (p=0.21) at first detection of hypothyroidism.

CONCLUSIONS

The severity of hypothyroidism when first detected during follow-up is of concern and suggests that closer monitoring of thyroid function is required, particularly during the first 6 months post- RI therapy.

Sensor positioning for activity recognition using wearable accelerometers

Activities of daily living are important for assessing changes in physical and behavioral profiles of the general population over time, particularly for the elderly and patients with chronic diseases. Although accelerometers have been used widely in wearable devices for activity classification, the positioning of the sensors and the selection of relevant features for different activity groups still pose significant research challenges. This paper investigates wearable sensor placement at different body positions and aims to provide a systematic framework that can answer the following questions: 1) What is the ideal sensor location for a given group of activities? and 2) Of the different time-frequency features that can be extracted from wearable accelerometers, which ones are the most relevant for discriminating different activity types?

Regulation of HSH2 adaptor protein expression in the B lineage regulates the qualitative and quantitative nature of the humoral response (109.2)

Endogenous expression of the adaptor protein HSH2 is regulated in a dynamic manner during B cell maturation and differentiation. Developing B cells lack detectable HSH2, whereas T1 and T2 B cells in the periphery exhibit increasing levels of expression. Mature follicular B cells exhibit decreased expression of HSH2 compared to T2 cells and expression is further downregulated in germinal center B cells. In contrast, marginal zone B cells and B1a/b B cells exhibit high-level HSH2 expression. Regulation of HSH2 expression plays a critical role in determining the outcome of the humoral immune response as demonstrated using HSH2 transgenic mice. Constitutive expression of HSH2 in B cells results in decreased serum Ig titers for all subclasses with the exception of IgA. HSH2 Tg mice immunized with T-dependent or T-independent antigens exhibit a moderate decrease in the production of antigen-specific IgM, whereas class switched isotypes are decreased by approximately 80-90% compared to control mice. In contrast, HSH2 hypomorphic mice exhibit accelerated and enhanced class switching in response to challenge with T-dependent antigen. Analysis of HSH2 Tg B cell activation in vitro demonstrated that HSH2 selectively regulates the B cell response to TNF family receptors (i.e. CD40 and BAFF-R), but not BCR- or TLR-dependent signals. These data demonstrate that changes in HSH2 expression have profound effects on the humoral immune response.

Human TLT2 is expressed on and potentiates chemotaxis of cells of both myeloid and lymphoid lineage (158.6)

The TREM locus encodes a family of innate immune receptors, which play diverse roles in modulating the immune response. Trem-like transcript 2, or TLT2, is the only family member expressed on both myeloid and lymphoid cells, and is conserved among mouse and man, with 60% sequence homology between murine (m) and human (h) TLT2. Previous work by our lab defined the expression pattern for mTLT2 on cells of the immune system: granulocytes, macrophages, and B cells all express mTLT2, whereas monocytes and T cells do not. When mTLT2 is ligated with αTLT2 1C5 mAb, neutrophil chemotaxis is enhanced in a dose dependent manner in response to chemokines. To further understand the biological function of TLT2, our lab has characterized hTLT2 expression on peripheral leukocytes and studied its role in potentiating chemotaxis. Human granulocytes, monocytes, macrophages, NK cells, and B cells all express hTLT2 on their surface. Furthermore, interaction with antigen and differentiation downregulates surface expression of hTLT2 on B cells. In contrast, activation of granulocytes or monocytes with PMA upregulates hTLT2 expression. Lastly, naive, memory, and in vitro activated T cells do not express hTLT2, opposed to results from other groups. Functionally, ligation of hTLT2 augments B cell chemotaxis towards CXCL13, and neutrophil migration towards IL-8. In this regard, we observe hTLT2 and mTLT2 to have conserved phenotypic expression and function throughout the immune compartment.

Lentiginous Melanoma

Context.—Atypical lentiginous melanocytic lesions, particularly in older individuals, continue to pose a diagnostic challenge. Such lesions often show features intermediate between lentiginous nevus and melanoma in situ. We have recently defined within this group of lesions a histologic pattern of lentiginous melanoma, a slowly progressing variant of melanoma typically found on the trunk and proximal extremities of middle-aged and older individuals.

Objective.—To review the clinical and histologic features of lentiginous melanoma and its histologic differential diagnosis.

Data Sources.—Review of pertinent published literature and work in our laboratory.

Conclusions.—Lentiginous melanoma defines a subset of slowly progressing melanoma occurring in middle-aged and older patients. It is histologically characterized by a broad atypical lentiginous growth pattern of moderately atypical melanocytes showing focal nesting and pagetoid spread without significant dermal fibroplasia or alteration of the rete ridges. Lentiginous melanoma shows significant overlap in clinical and histologic features with atypical lentiginous nevus (of the elderly). Relationship between these entities requires further investigations. Given the risk of progression to invasive melanoma, all lesions showing features of lentiginous melanoma should be treated with adequately wide excision.

Reintroducing the Persian fallow deer Dama mesopotamica in Israel - a chronology

The Persian fallow deer (Dama mesopotamica) reintroduction project of the Israel Nature and Parks Authority is based on a permanent breeding core (Hai-Bar Carmel) established in Israel in 1976 from 2 males and 5 females, before the formulation of the guidelines for reinstruction by the IUCN, with no strategic long-term planning, and little consideration of conservation principles and monetary consequences. By the mid 1990s the breeding core had nearly 50 adult females and it became evident that a reintroduction program should be prepared. The existence of a permanent breeding core offered flexibility in protocol and the possibility of a long-term approach based on multiple releases. Using a maximum sustained yield approach, IUCN criteria, and simulations of population performance we formulated a release strategy and a time frame for the project, based on repeated releases carried out sequentially in three reserves in northern Israel with good corridors connecting them. The project began with releases in the Kziv reserve with continuous post-release monitoring and an adaptive management approach. Reproductive success was dampened during the initial years after release, but increased to expected levels thereafter. Survival was higher than expected. Animals from later releases used formerly released animals as cue and established a home range faster. Annual home-range dynamics and social structure were comparable to other similar deer species. The deer transported viable seeds of many species by ingestion (endozoochory) and thinned the forest canopy allowing for better understory growth. Simulations based on empirical data indicated that pre-project demographic simulation offered reliable projections. A growth model incorporating the empirical data on dynamics, habitat preferences, and social structure during the first 2.5 years enabled the construction of a spatially realistic individual-based population model that reliably projected the numerical and spatial growth of the population over a 5-year period. This model was then used to assess future risks due to human sprawl. Due to agricultural damage, the project was forced in 2003 to select a new less favourable site in the Judean hills (central Israel) with no habitat linkage to the former location. Release in this area was based on individuals from the Hai Bar Carmel and from a second breeding core established in the Jerusalem Biblical Zoo. The less favourable site and behavioural problems of the zoo animals hampered the success of the reintroduction. In 2010 the northern region of the Israel Nature and Parks Authority approved a second release site in the Galilee. Using the spatially realistic model described above we reassessed the multiple-site approach, considering options of releases in 1–10 sites carried out in parallel or sequentially. These simulations indicated that the best results, in terms of numerical growth and spatial expansion, would be obtained by repeated releases in two sites carried out sequentially. Computer simulations combined with a permanent breeding core enabled robust planning and an adaptive management approach. Post-release monitoring provided important data for assessing reintroduction procedures and for future management of the species. This reintroduction has greatly enhanced the survival prospects of the Persian fallow deer, and their reintroduction has reestablished important ecosystem processes.

The performance of MelaFind: a prospective multicenter study

OBJECTIVE

To demonstrate the safety and effectiveness of MelaFind, a noninvasive and objective computer-vision system designed to aid in detection of early pigmented cutaneous melanoma.

DESIGN

A prospective, multicenter, blinded study. The diagnostic performance of MelaFind and of study clinicians was evaluated using the histologic reference standard. Standard images and patient information for a subset of 50 randomly selected lesions (25 melanomas) were used in a reader study of 39 independent dermatologists to estimate clinicians' biopsy sensitivity to melanoma.

SETTING

Three academic and 4 community practices in the United States with expertise in management of pigmented skin lesions.

PATIENTS

A total of 1383 patients with 1831 lesions enrolled from January 2007 to July 2008; 1632 lesions (including 127 melanomas-45% in situ-with median Breslow thickness of invasive lesions, 0.36 mm) were eligible and evaluable for the study end points.

MAIN OUTCOME MEASURES

Sensitivity of MelaFind; specificities and biopsy ratios for MelaFind and the study investigators; and biopsy sensitivities of independent dermatologists in the reader study.

RESULTS

The measured sensitivity of MelaFind was 98.4% (125 of 127 melanomas) with a 95% lower confidence bound at 95.6% and a biopsy ratio of 10.8:1; the average biopsy sensitivity of dermatologists was 78% in the reader study. Including borderline lesions (high-grade dysplastic nevi, atypical melanocytic proliferations, or hyperplasias), MelaFind's sensitivity was 98.3% (172 of 175), with a biopsy ratio of 7.6:1. On lesions biopsied mostly to rule out melanoma, MelaFind's average specificity (9.9%) was superior to that of clinicians (3.7%) (P=.02).

CONCLUSION

MelaFind is a safe and effective tool to assist in the evaluation of pigmented skin lesions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00434057.

Postmenopausal hormone therapy and cognition: effects of timing and treatment type

SETTING

Hormone therapy used for the management of postmenopausal symptoms in older women appears to result in variable effects on cognitive function, depending on study design, subjects, tests used, and types of therapy.

OBJECTIVE

To determine the effects of estrogen-only and estrogen plus progestogen preparations on cognitive performance (cognitive status, general and working memory) when taken 'early' and 'late' from the onset of menopause.

METHOD

The study consisted of 410 women who were participants in a longitudinal study, first recruited at age 40-80 years. They were tested for change over 5 years as an observational cohort by the Mini-Mental State Examination, National Adult Reading Test and the Wechsler Memory Scale Version 3. Cognitive decline, measured by age-adjusted scores, was defined as >or=10% negative change in each individual woman.

RESULTS

Controlling for age and lifestyle factors, and using the criterion of decrease in score >or=10% over 5 years for 'cognitive decline', 'early start' of hormone therapy (<3 years from menopause) was strongly associated with reduction in risk by the Mini-Mental State Examination (estrogen-only preparation, p = 0.005) but with increase in risk for general memory (with estrogen plus progestogen preparation, p = 0.02). Overall, there were no major effects on subgroups with type/timing of hormone therapy in relation to testing for a negative change in cognitive function.

CONCLUSION

'Early start' of estrogen-only hormone therapy was associated with reduced risk of global cognitive decline, and 'early start' estrogen-only and estrogen/progestogen hormone therapies showed increased risks of general memory decline. Even though this study did not have the power to discriminate between minor and mixed effects, it suggests that cognitive effects of hormone therapies may be mixed, depending on cognitive domain and timing of use/type of preparation.