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Solorzano L, Robertson S, Acs B, Hartman J, Rantalainen M. Ensemble-based deep learning improves detection of invasive breast cancer in routine histopathology images. Heliyon 2024; 10:e32892. [PMID: 39022088 PMCID: PMC11252882 DOI: 10.1016/j.heliyon.2024.e32892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 06/11/2024] [Accepted: 06/11/2024] [Indexed: 07/20/2024] Open
Abstract
Accurate detection of invasive breast cancer (IC) can provide decision support to pathologists as well as improve downstream computational analyses, where detection of IC is a first step. Tissue containing IC is characterized by the presence of specific morphological features, which can be learned by convolutional neural networks (CNN). Here, we compare the use of a single CNN model versus an ensemble of several base models with the same CNN architecture, and we evaluate prediction performance as well as variability across ensemble based model predictions. Two in-house datasets comprising 587 whole slide images (WSI) are used to train an ensemble of ten InceptionV3 models whose consensus is used to determine the presence of IC. A novel visualisation strategy was developed to communicate ensemble agreement spatially. Performance was evaluated in an internal test set with 118 WSIs, and in an additional external dataset (TCGA breast cancer) with 157 WSI. We observed that the ensemble-based strategy outperformed the single CNN-model alternative with respect to accuracy on tile level in 89 % of all WSIs in the test set. The overall accuracy was 0.92 (DICE coefficient, 0.90) for the ensemble model, and 0.85 (DICE coefficient, 0.83) for the single CNN alternative in the internal test set. For TCGA the ensemble outperformed the single CNN in 96.8 % of the WSI, with an accuracy of 0.87 (DICE coefficient 0.89), the single model provides an accuracy of 0.75 (DICE coefficient 0.78). The results suggest that an ensemble-based modeling strategy for breast cancer invasive cancer detection consistently outperforms the conventional single model alternative. Furthermore, visualisation of the ensemble agreement and confusion areas provide direct visual interpretation of the results. High performing cancer detection can provide decision support in the routine pathology setting as well as facilitate downstream computational analyses.
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Affiliation(s)
- Leslie Solorzano
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Balazs Acs
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Hartman
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Rantalainen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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2
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Schulmeyer CE, Beckmann MW, Fasching PA, Häberle L, Golcher H, Kunath F, Wullich B, Emons J. Improving the Quality of Care for Cancer Patients through Oncological Second Opinions in a Comprehensive Cancer Center: Feasibility of Patient-Initiated Second Opinions through a Health-Insurance Service Point. Diagnostics (Basel) 2023; 13:3300. [PMID: 37958196 PMCID: PMC10647700 DOI: 10.3390/diagnostics13213300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND To improve the quality and cost-effectiveness of care, cancer patients can obtain a second medical opinion on their treatment. Validation of the diagnostic procedure (e.g., imaging), diagnosis, and treatment recommendation allows oncological therapy to be applied in a more targeted way, optimizing interdisciplinary care. This study describes patients who received second opinions at the Comprehensive Cancer Center for Erlangen-Nuremberg metropolitan area in Germany over a 6-year period, as well as the amount of time spent on second-opinion counseling. METHODS This prospective, descriptive, single-center observational study included 584 male and female cancer patients undergoing gynecological, urologic, or general surgery who sought a second medical opinion. The extent to which the first opinion complied with standard guidelines was assessed solely descriptively. RESULTS The first opinion was in accordance with the guidelines and complete in 54.5% of the patients, and guideline compliant but incomplete in 13.2%. The median time taken to form a second opinion was 225 min, and the cancer information service was contacted by patients an average of eight times. CONCLUSIONS The initial opinion was guideline compliant and complete in every second case. Without a second opinion, the remaining patients would have been denied a guideline-compliant treatment recommendation. Obtaining a second opinion gives patients an opportunity to receive a guideline-compliant treatment recommendation and enables them to benefit from newer, individualized therapeutic approaches in clinical trials. Establishing patient-initiated second opinions via central contact points appears to be a feasible option for improving guideline compliance.
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Affiliation(s)
- Carla E. Schulmeyer
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University of Erlangen–Nuremberg, 91054 Erlangen, Germany
| | - Matthias W. Beckmann
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University of Erlangen–Nuremberg, 91054 Erlangen, Germany
| | - Peter A. Fasching
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University of Erlangen–Nuremberg, 91054 Erlangen, Germany
| | - Lothar Häberle
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University of Erlangen–Nuremberg, 91054 Erlangen, Germany
- Biostatistics Unit, Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University of Erlangen–Nuremberg, 91054 Erlangen, Germany
| | - Henriette Golcher
- Department of Surgery, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University of Erlangen–Nuremberg, 91054 Erlangen, Germany
| | - Frank Kunath
- Department of Urology, Klinikum Bayreuth GmbH, 95445 Bayreuth, Germany
| | - Bernd Wullich
- Department of Urology and Pediatric Urology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University of Erlangen–Nuremberg, 91054 Erlangen, Germany;
| | - Julius Emons
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University of Erlangen–Nuremberg, 91054 Erlangen, Germany
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Rakha EA, Adebayo LA, Abbas A, Hodi Z, Lee AHS, Ellis IO. Second opinion (external specialist referral) practice of breast pathology: the Nottingham experience. Histopathology 2023; 83:394-405. [PMID: 37356966 DOI: 10.1111/his.14993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/23/2023] [Accepted: 06/01/2023] [Indexed: 06/27/2023]
Abstract
AIMS Breast pathology is a challenging field, and discrepancies in diagnoses exist and can affect patient management. This study aims to review a breast referral practice and assess the pattern and frequency of breast lesions sent for an external expert review and evaluate potential impacts on patients' care. METHODS AND RESULTS Seven hundred and forty cases that were referred to Nottingham City Hospital for a second opinion between 2019 and 2022 which have slides and reports were retrieved and reviewed. Reasons for referral, initial diagnosis, proffered specialist opinion and any discrepancy or potential impacts of management were assessed. The most frequent entities were papillary lesions (19%), fibroepithelial lesions (17%), invasive carcinomas that were sent for confirmation of the invasive diagnosis or subtyping of the invasive tumour (17%), intraductal epithelial proliferation with atypia (9%) and spindle cell lesions (8%). Other entities included biphasic tumours such as adenomyoepithelioma, as well as vascular and nipple lesions. Few cases were sent for prognostic classification or comments on the management, and in occasional cases no initial diagnosis was offered. After reviewing the cases by the expert pathologists, the initial diagnosis was confirmed or one of the suggested diagnoses was preferred in 79% of cases, including 129 cases (17%) in which the opinion resulted minor changes in the management. Significant changes in the classification of lesions were made in 132 cases (18%) which resulted in significant change in the patient management recommendation. In 14 cases (2%) a final classification was not possible, and further specialist opinion was obtained. Comments on the differential diagnosis and advice on further patient management were provided in most cases. CONCLUSIONS This study demonstrates the value of external referral of challenging, rare and difficult to classify breast lesions. It also highlights the most common breast lesions that are likely to be challenging, and specialist opinion can refine their classification to improve patient care.
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Affiliation(s)
- Emad A Rakha
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
- Academic Unit for Translational Medical Sciences, School of Medicine, The University of Nottingham, Nottingham, UK
- Pathology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Luqman Adedotun Adebayo
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Areeg Abbas
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Zsolt Hodi
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Andrew H S Lee
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Ian O Ellis
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
- Academic Unit for Translational Medical Sciences, School of Medicine, The University of Nottingham, Nottingham, UK
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4
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Miceli R, Mercado CL, Hernandez O, Chhor C. Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ. JOURNAL OF BREAST IMAGING 2023; 5:396-415. [PMID: 38416903 DOI: 10.1093/jbi/wbad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 03/01/2024]
Abstract
Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are relatively common breast lesions on the same spectrum of disease. Atypical ductal hyperblasia is a nonmalignant, high-risk lesion, and DCIS is a noninvasive malignancy. While a benefit of screening mammography is early cancer detection, it also leads to increased biopsy diagnosis of noninvasive lesions. Previously, treatment guidelines for both entities included surgical excision because of the risk of upgrade to invasive cancer after surgery and risk of progression to invasive cancer for DCIS. However, this universal management approach is not optimal for all patients because most lesions are not upgraded after surgery. Furthermore, some DCIS lesions do not progress to clinically significant invasive cancer. Overtreatment of high-risk lesions and DCIS is considered a burden on patients and clinicians and is a strain on the health care system. Extensive research has identified many potential histologic, clinical, and imaging factors that may predict ADH and DCIS upgrade and thereby help clinicians select which patients should undergo surgery and which may be appropriate for active surveillance (AS) with imaging. Additionally, multiple clinical trials are currently underway to evaluate whether AS for DCIS is feasible for a select group of patients. Recent advances in MRI, artificial intelligence, and molecular markers may also have an important role to play in stratifying patients and delineating best management guidelines. This review article discusses the available evidence regarding the feasibility and limitations of AS for ADH and DCIS, as well as recent advances in patient risk stratification.
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Affiliation(s)
- Rachel Miceli
- NYU Langone Health, Department of Radiology, New York, NY, USA
| | | | | | - Chloe Chhor
- NYU Langone Health, Department of Radiology, New York, NY, USA
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5
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Clayton DA, Eguchi MM, Kerr KF, Miyoshi K, Brunyé TT, Drew T, Weaver DL, Elmore JG. Are Pathologists Self-Aware of Their Diagnostic Accuracy? Metacognition and the Diagnostic Process in Pathology. Med Decis Making 2023; 43:164-174. [PMID: 36124966 PMCID: PMC9825636 DOI: 10.1177/0272989x221126528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Metacognition is a cognitive process that involves self-awareness of thinking, understanding, and performance. This study assesses pathologists' metacognition by examining the association between their diagnostic accuracy and self-reported confidence levels while interpreting skin and breast biopsies. DESIGN We studied 187 pathologists from the Melanoma Pathology Study (M-Path) and 115 pathologists from the Breast Pathology Study (B-Path). We measured pathologists' metacognitive ability by examining the area under the curve (AUC), the area under each pathologist's receiver operating characteristic (ROC) curve summarizing the association between confidence and diagnostic accuracy. We investigated possible relationships between this AUC measure, referred to as metacognitive sensitivity, and pathologist attributes. We also assessed whether higher metacognitive sensitivity affected the association between diagnostic accuracy and a secondary diagnostic action such as requesting a second opinion. RESULTS We found no significant associations between pathologist clinical attributes and metacognitive AUC. However, we found that pathologists with higher AUC showed a stronger trend to request secondary diagnostic action for inaccurate diagnoses and not for accurate diagnoses compared with pathologists with lower AUC. LIMITATIONS Pathologists reported confidence in specific diagnostic terms, rather than the broader classes into which the diagnostic terms were later grouped to determine accuracy. In addition, while there is no gold standard for the correct diagnosis to determine the accuracy of pathologists' interpretations, our studies achieved a high-quality reference diagnosis by using the consensus diagnosis of 3 experienced pathologists. CONCLUSIONS Metacognition can affect clinical decisions. If pathologists have self-awareness that their diagnosis may be inaccurate, they can request additional tests or second opinions, providing the opportunity to correct inaccurate diagnoses. HIGHLIGHTS Metacognitive sensitivity varied across pathologists, with most showing higher sensitivity than expected by chance.None of the demographic or clinical characteristics we examined was significantly associated with metacognitive sensitivity.Pathologists with higher metacognitive sensitivity were more likely to request additional tests or second opinions for their inaccurate diagnoses.
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Affiliation(s)
- Dayna A. Clayton
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Megan M. Eguchi
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Kathleen F. Kerr
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Kiyofumi Miyoshi
- Department of Psychology, University of California, Los Angeles, CA, United States of America
| | - Tad T. Brunyé
- Center for Applied Brain and Cognitive Sciences, Tufts University, Medford, MA, United States of America
| | - Trafton Drew
- Department of Psychology, University of Utah, Salt Lake City, UT, United States of America
| | - Donald L. Weaver
- Department of Pathology & Laboratory Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
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6
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Woeste MR, Jacob K, Duff MB, Donaldson M, Sanders MAG, McMasters KM, Ajkay N. Impact of routine expert breast pathology consultation and factors predicting discordant diagnosis. Surg Oncol 2022; 45:101860. [DOI: 10.1016/j.suronc.2022.101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/10/2022] [Accepted: 10/02/2022] [Indexed: 12/05/2022]
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Girardi V, Guaragni M, Ruzzenenti N, Palmieri F, Fogazzi G, Cozzi A, Lucchini D, Buffoli A, Schiaffino S, Sardanelli F. B3 Lesions at Vacuum-Assisted Breast Biopsy under Ultrasound or Mammography Guidance: A Single-Center Experience on 3634 Consecutive Biopsies. Cancers (Basel) 2021; 13:5443. [PMID: 34771606 PMCID: PMC8582448 DOI: 10.3390/cancers13215443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022] Open
Abstract
The rate of upgrade to cancer for breast lesions with uncertain malignant potential (B3 lesions) diagnosed at needle biopsy is highly influenced by several factors, but large series are seldom available. We retrospectively assessed the upgrade rates of a consecutive series of B3 lesions diagnosed at ultrasound- or mammography-guided vacuum-assisted biopsy (VAB) at an EUSOMA-certified Breast Unit over a 7-year timeframe. The upgrade rate was defined as the number of ductal carcinoma in situ (DCIS) or invasive cancer at pathology after excision or during follow-up divided by the total number of B3 lesions. All lesions were reviewed by one of four pathologists with a second opinion for discordant assessments of borderline cases. Excision or surveillance were defined by the multidisciplinary tumor board, with 6- and 12-month follow-up. Out of 3634 VABs (63% ultrasound-guided), 604 (17%) yielded a B3 lesion. After excision, 17/604 B3 lesions were finally upgraded to malignancy (2.8%, 95% confidence interval [CI] 1.8-4.5%), 10/17 (59%) being upgraded to DCIS and 7/17 (41%) to invasive carcinoma. No cases were upgraded during follow-up. B3a lesions showed a significantly lower upgrade rate (0.4%, 95% CI 0.1-2.1%) than B3b lesions (4.7%, 95% CI 2.9-7.5%, p = 0.001), that had a 22.0 adjusted odds ratio for upgrade (95% CI 2.1-232.3). No significant difference was found in upgrade rates according to imaging guidance or needle caliper. Surveillance-oriented management can be considered for B3a lesions, while surgical excision should be pursued for B3b lesions.
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Affiliation(s)
- Veronica Girardi
- Breast Radiology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Monica Guaragni
- Breast Pathology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy; (M.G.); (N.R.)
| | - Nella Ruzzenenti
- Breast Pathology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy; (M.G.); (N.R.)
| | - Fabrizio Palmieri
- Breast Surgery, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Gianluca Fogazzi
- Breast Medical Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Andrea Cozzi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy;
| | - Diana Lucchini
- Breast Psycho-Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Alberto Buffoli
- Radiation Oncology, EUSOMA-Certified Breast Unit, Istituto Clinico Sant’Anna, Via del Franzone 31, 25127 Brescia, Italy;
| | - Simone Schiaffino
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy;
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy;
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy;
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8
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Johnson SM, Samulski TD, O’Connor SM, Smith SV, Funkhouser WK, Broaddus RR, Calhoun BC. Clinical and Financial Implications of Second-Opinion Surgical Pathology Review. Am J Clin Pathol 2021; 156:559-568. [PMID: 33769453 DOI: 10.1093/ajcp/aqaa263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Second-opinion pathology review identifies clinically significant diagnostic discrepancies for some patients. Discrepancy rates and laboratory-specific costs in a single health care system for patients referred from regional affiliates to a comprehensive cancer center ("main campus") have not been reported. METHODS Main campus second-opinion pathology cases for 740 patients from eight affiliated hospitals during 2016 to 2018 were reviewed. Chart review was performed to identify changes in care due to pathology review. To assess costs of pathology interpretation, reimbursement rates for consultation Current Procedural Terminology billing codes were compared with codes that would have been used had the cases originated at the main campus. RESULTS Diagnostic discrepancies were identified in 104 (14.1%) patients, 30 (4.1%) of which resulted in a change in care. In aggregate, reimbursement for affiliate cases was 65.6% of the reimbursement for the same cases had they originated at the main campus. High-volume organ systems with low relative consultation reimbursement included gynecologic, breast, and thoracic. CONCLUSIONS Preventable diagnostic errors are reduced by pathology review for patients referred within a single health care system. Although the resulting changes in care potentially lead to overall cost savings, the financial value of referral pathology review could be improved.
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Affiliation(s)
- Steven M Johnson
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Teresa D Samulski
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Siobhan M O’Connor
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Scott V Smith
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - William K Funkhouser
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Russell R Broaddus
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Benjamin C Calhoun
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
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Sanchez S, Adamowicz I, Chrusciel J, Denormandie P, Denys P, Degos L. Predictive factors of diagnostic and therapeutic divergence in a nationwide cohort of patients seeking second medical opinion. BMC Health Serv Res 2021; 21:902. [PMID: 34470642 PMCID: PMC8408960 DOI: 10.1186/s12913-021-06936-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/24/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe the profile of patients who sought a second medical opinion (SMO) on their therapeutic or diagnostic strategy using nationwide data from a French physician network dedicated to SMOs. METHODS An observational cohort study was conducted and the study population consisted of patients residing in France or in the French overseas territories who submitted a request for an SMO through a dedicated platform between January 2016 and October 2020. Patient characteristics were compared between convergent and divergent SMOs. The divergent rate for all patients excluding those with mental diseases were described. Logistic regression was used to estimate the probability of a divergent SMO according to patient characteristics. RESULTS AND DISCUSSION In total, 1,552 adult patients over several French regions were included. The divergence rate was 32.3 % (n = 502 patients). Gynecological [Odds Ratio (OR) and 95 % CI: 5.176 (3.154 to 8.494)], urological [OR 4.246 (2.053 to 8.782)] and respiratory diseases [OR 3.639 (1.357 to 9.758)] had the highest probability of a divergent SMO. Complex cases were also associated with a significantly higher risk of a divergent opinion [OR 2.78 (2.16 to 3.59)]. Age, sex, region and profession were not found to be predictive of a divergent second opinion. CONCLUSIONS Policymakers should encourage new research on patient outcomes such as mortality and hospitalization rates after a SMO. When proven effective, SMO networks will have the potential to benefit from specific public funding or even play a key role in national healthcare quality improvement programs.
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Affiliation(s)
- Stéphane Sanchez
- Public Health and Performance Department, Champagne Sud Hospitals, 101 avenue Anatole France, 10000, Troyes, France.
| | | | - Jan Chrusciel
- Public Health and Performance Department, Champagne Sud Hospitals, 101 avenue Anatole France, 10000, Troyes, France
| | | | - Pierre Denys
- Urology and Neurology Rehabilitation Department, Raimond Poincaré Hospital, APHP, Garches, France
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10
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Tosteson ANA, Tapp S, Titus LJ, Nelson HD, Longton GM, Bronson M, Pepe M, Carney PA, Onega T, Piepkorn MW, Knezevich SR, Barnhill R, Weinstock MA, Elder DE, Elmore JG. Association of Second-Opinion Strategies in the Histopathologic Diagnosis of Cutaneous Melanocytic Lesions With Diagnostic Accuracy and Population-Level Costs. JAMA Dermatol 2021; 157:1102-1106. [PMID: 34076664 PMCID: PMC8173465 DOI: 10.1001/jamadermatol.2021.1779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/14/2021] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Diagnostic variation among pathologists interpreting cutaneous melanocytic lesions could lead to suboptimal care. OBJECTIVE To estimate the potential association of second-opinion strategies in the histopathologic diagnosis of cutaneous melanocytic lesions with diagnostic accuracy and 1-year population-level costs in the US. DESIGN, SETTING, AND PARTICIPANTS Decision analysis with 1-year time horizon including melanocytic lesion diagnoses available from US pathologists participating in the Melanoma Pathology Study (M-Path) and from the study panel of reference pathologists who classified cases using the MPATH-Dx classification tool. M-Path data collection occurred from July 2013 through March 2015; analyses for the present study were performed between April 2015 and January 2021. EXPOSURES Various second-opinion strategies for interpretation of melanocytic cutaneous lesions. MAIN OUTCOMES AND MEASURES Estimated accuracy of pathologists' diagnoses, defined as concordance with the reference panel diagnoses, and 1-year postbiopsy medical costs under various second-opinion strategies. Expected percentage of concordant diagnoses, including percentages of overinterpretation and underinterpretation, and 1-year costs of medical care per 100 000 in the US population. RESULTS Decision-analytic model parameters were based on diagnostic interpretations for 240 cases by 187 pathologists compared with reference panel diagnoses. Without second opinions, 83.2% of diagnoses in the US were estimated to be accurate-ie, concordant with the reference diagnosis; with overinterpretation (8.0%) or underinterpretation (8.8%), and 16 850 misclassified diagnoses per 100 000 biopsies. Accuracy increased under all second-opinion strategies. Accuracy (87.4% concordance with 3.6% overinterpretation and 9.1% underinterpretation) and cost (an increase of more than $10 million per 100 000 biopsies per year) were highest when second opinions were universal (eg, performed on all biopsies), relative to no second opinions. A selective second-opinion strategy based on pathologists' desire or institutional requirements for a second opinion was most accurate (86.5% concordance; 4.4% overinterpretation; 9.1% underinterpretation) and would reduce costs by more than $1.9 million per 100 000 skin biopsies relative to no second opinions. Improvements in diagnostic accuracy with all second-opinion strategies were associated with reductions in overinterpretation but not underinterpretation. CONCLUSIONS AND RELEVANCE In this decision-analytic model, selective second-opinion strategies for interpretation of melanocytic skin lesions showed the potential to improve diagnostic accuracy and decrease costs relative to no second opinions or universal second opinions.
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Affiliation(s)
- Anna N. A. Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Stephanie Tapp
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Linda J. Titus
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | | | - Gary M. Longton
- Program in Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mackenzie Bronson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Margaret Pepe
- Program in Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Tracy Onega
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Michael W. Piepkorn
- Division of Dermatology, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | | | - Raymond Barnhill
- Departments of Pathology and Translational Research, Institut Curie, Paris, France
- Paris Sciences and Letters Research University, Paris, France
| | | | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Joann G. Elmore
- David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles
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11
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Laliberté SM, Poirier VJ, Pinard CJ, Hocker SE, Foster RA. A retrospective comparison of first and second opinion histopathology with patient outcomes in veterinary oncology cases (2011-2019). Vet Comp Oncol 2021; 20:198-206. [PMID: 34399003 DOI: 10.1111/vco.12762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/13/2021] [Indexed: 11/29/2022]
Abstract
Mandatory second opinion histopathology is common practice in human surgical pathology. It is intended to confirm the original diagnosis or identify clinically significant discrepancies, which could alter the course of disease, cost of treatment, patient management or prognosis. This retrospective analysis aimed to evaluate agreement between first and second opinion histopathology cases, examine their correlation with natural history of disease and investigate the rationale for pursuing this test. Medical records from 2011 to 2019 were reviewed, identifying 109 cases where second opinion histopathology was sought. Reasons for seeking second opinion and clinical disease course were also reviewed to determine whether case progression favoured first or second opinion findings in cases of diagnostic disagreement. Diagnostic disagreement was found in 49.5% of cases. Complete diagnostic disagreement (a change in degree of malignancy or tumour type) occurred in 15.6% cases and partial disagreement (a change in tumour subtype, grade, margins and mitotic count) occurred in 33.9%. Major disagreement (a change in diagnosis resulting in alteration of treatment recommendations) occurred in 38.5% of cases. The most common reasons for seeking second opinion were an atypical/poorly differentiated tumour (31.2%; 34/109) or a discordant clinical picture (24.8%; 27/109). Among cases with any form of disagreement, natural history of disease favoured second opinion findings in 33.3%. The first opinion was favoured over the second in a single case. These findings reinforce previous literature supporting a role for second opinion histopathology in optimizing therapy and predicting outcomes in veterinary oncology, particularly in cases where diagnosis is in question based on the overall clinical picture.
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Affiliation(s)
- Sarah M Laliberté
- Mona Campbell Animal Cancer Center, Ontario Veterinary College, University of Guelph, Guelph, Canada
| | - Valerie J Poirier
- Mona Campbell Animal Cancer Center, Ontario Veterinary College, University of Guelph, Guelph, Canada
| | - Christopher J Pinard
- Mona Campbell Animal Cancer Center, Ontario Veterinary College, University of Guelph, Guelph, Canada
| | - Samuel E Hocker
- Mona Campbell Animal Cancer Center, Ontario Veterinary College, University of Guelph, Guelph, Canada.,Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas, USA
| | - Robert A Foster
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, Canada
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12
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Hohnen H, Dessauvagie B, Hardie M, McCallum D, Oehmen R, Latham B. Diagnostic concordance among pathologists interpreting breast core biopsies on secondary review over a 1-year period at an Australian tertiary hospital. Breast J 2021; 27:664-670. [PMID: 34196447 DOI: 10.1111/tbj.14267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/26/2022]
Abstract
This study provides data on the diagnostic concordance between initial and review diagnoses of all breast core biopsy cases at a single tertiary hospital in Western Australia over a 1-year period. A retrospective review of all breast core biopsy cases between January 1 and December 31, 2016, was carried out at PathWest, Fiona Stanley Hospital in Perth, Western Australia. Each biopsy is reported by a single pathologist and then reviewed within 1 week by a panel of intradepartmental subspecialist breast pathologists, who either agree with the original diagnosis, have a minor discordant diagnosis, or a major discordant diagnosis. Records for 2036 core biopsies were available between January 1 and December 31, 2016. Of these, 56.0% (n = 1141) were classified as benign, 34.3% (n = 699) as malignant, 7.2% (n = 147) as indeterminate, 2.3% (n = 46) as nondiagnostic, and 0.1% (n = 3) as suspicious for malignancy. In 99.1% (n = 2018) of cases, there was agreement between initial and review diagnoses. In total, 0.9% (n = 18) were disagreements: 0.49% (n = 10) were major discordant disagreements and 0.39% (n = 8) were minor discordant disagreements. All cases of major discordant disagreements would have resulted in significant changes to clinical management. This study demonstrates that an Australian institution is providing a high-quality pathology service with a low error rate between initial and review diagnoses of breast core biopsies. It reinforces the importance of secondary review of biopsies in a timely fashion for detecting potentially serious misdiagnoses that could lead to inappropriate management.
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Affiliation(s)
| | - Benjamin Dessauvagie
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia.,School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Mireille Hardie
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia.,Pathology and Laboratory Medicine, University of Western Australia, Perth, WA, Australia
| | - Dugald McCallum
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Raoul Oehmen
- School of Medicine, University of Notre Dame Fremantle, Perth, WA, Australia
| | - Bruce Latham
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia.,School of Medicine, University of Notre Dame Fremantle, Perth, WA, Australia
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13
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Merola E, Zandee W, de Mestier L, Klümpen HJ, Makulik K, Geboes K, van Velthuysen ML, Couvelard A, Cros J, van Eeden S, Hoorens A, Stephenson T, Zajęcki W, de Herder W, Munir A. Histopathological Revision for Gastroenteropancreatic Neuroendocrine Neoplasms in Expert Centers: Does It Make the Difference? Neuroendocrinology 2021; 111:170-177. [PMID: 32155627 DOI: 10.1159/000507082] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/09/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The correct histopathological diagnosis of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) is crucial for treatment selection and prognostication. It is also very challenging due to limited experience in nonexpert centers. Revision of pathology is standard of care for most patients who are referred to NEN expert centers. OBJECTIVES To describe the clinical impact of histopathological revision for GEP-NEN patients referred to an expert center. METHODS Retrospective multicenter analysis of all GEP-NENs receiving a histopathological revision in 6 European NEN expert centers (January 2016 to December 2016) to evaluate the impact on patient management. RESULTS 175 patients were included and 14.7% referred for a second opinion. Histological samples were 69.1% biopsies, 23.4% surgical specimens, and 7.5% endoscopic resections. Histopathological changes due to revision included first assessment of Ki67 in 8.6% of cases, change in grading in 11.4% (3.4% G1 to G2; 5.7% G2 to G1; 0.6% G2 to G3; 1.7% G3 to G2), definition of tumor invasion in 10.8%, additional immunohistochemical staining in 2.3%, diagnosis of mixed adenoneuroendocrine carcinoma in 3.4%, exclusion of NEN in 3.4%, first diagnosis of NEN in 2.3%, and tumor differentiation for G3 in 1.7%. The revision had a clinical impact in 36.0% of patients, leading to a new therapeutic indication in 26.3%. The indication to then perform a new imaging test occurred in 21.1% and recommendation to follow-up with no further treatment in 6.3%. CONCLUSIONS Histopathological revision in expert centers for NENs can change the diagnosis, with a significant clinical impact in about one third of patients.
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Affiliation(s)
- Elettra Merola
- Department of Gastroenterology, Azienda Provinciale Servizi Sanitari (APSS), Trento, Italy,
| | - Wouter Zandee
- Department of Internal Medicine, Sector of Endocrinology, Erasmus MC, Rotterdam, The Netherlands
| | - Louis de Mestier
- Department of Gastroenterology and Pancreatology, Beaujon Hospital (APHP) and Paris 7 University, Clichy, France
| | - Heinz Josef Klümpen
- Department of Medical Oncology, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Karolina Makulik
- Department of Endocrinology and Neuroendocrine Tumors, Medical University of Silesia, Katowice, Poland
| | - Karen Geboes
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | | | - Anne Couvelard
- Department of Pathology, Beaujon/Bichat Hospital (APHP) and Université de Paris, Clichy, France
| | - Jérôme Cros
- Department of Pathology, Beaujon/Bichat Hospital (APHP) and Université de Paris, Clichy, France
| | - Susanne van Eeden
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Anne Hoorens
- Department of Pathology, University Hospital Ghent, Ghent, Belgium
| | - Timothy Stephenson
- Department of Pathology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - W Zajęcki
- Department of Endocrinology and Neuroendocrine Tumors, Medical University of Silesia, Katowice, Poland
| | - Wouter de Herder
- Department of Internal Medicine, Sector of Endocrinology, Erasmus MC, Rotterdam, The Netherlands
| | - Alia Munir
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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14
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Schiaffino S, Cozzi A, Sardanelli F. An update on the management of breast atypical ductal hyperplasia. Br J Radiol 2020; 93:20200117. [PMID: 32207989 PMCID: PMC10993217 DOI: 10.1259/bjr.20200117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/13/2020] [Accepted: 03/20/2020] [Indexed: 11/05/2022] Open
Abstract
Among lesions with uncertain malignant potential found at percutaneous breast biopsy, atypical ductal hyperplasia (ADH) carries both the highest risk of underestimation and the closest and most pathologist-dependent differential diagnosis with ductal carcinoma in situ (DCIS), matching the latter's features save for size only. ADH is therefore routinely surgically excised, but single-centre studies with limited sample size found low rates of upgrade to invasive cancer or DCIS. This suggests the possibility of surveillance over surgery in selected subgroups, considering the 2% threshold allowing for follow-up according to the Breast Imaging Reporting and Data System. A recent meta-analysis on 6458 lesions counters this approach, confirming that, surgically excised or managed with surveillance, ADH carries a 29% and 5% upgrade rate, respectively, invariably higher than 2% even in subgroups considering biopsy guidance and technique, needle calibre, apparent complete lesion removal. The high heterogeneity (I2 = 80%) found in this meta-analysis reaffirmed the need to synthesise evidence from systematic reviews to achieve generalisable results, fit for guidelines development. Limited tissue sampling at percutaneous biopsy intrinsically hampers the prediction of ADH-associated malignancy. This prediction could be improved by using contrast-enhanced breast imaging and applying artificial intelligence on both pathology and imaging results, allowing for overtreatment reduction.
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Affiliation(s)
- Simone Schiaffino
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi
30, 20097 San Donato Milanese,
Italy
| | - Andrea Cozzi
- Department of Biomedical Sciences for Health, Università
degli Studi di Milano, Via Mangiagalli 31,
20133 Milano, Italy
| | - Francesco Sardanelli
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi
30, 20097 San Donato Milanese,
Italy
- Department of Biomedical Sciences for Health, Università
degli Studi di Milano, Via Mangiagalli 31,
20133 Milano, Italy
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15
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Allison KH, Hammond MEH, Dowsett M, McKernin SE, Carey LA, Fitzgibbons PL, Hayes DF, Lakhani SR, Chavez-MacGregor M, Perlmutter J, Perou CM, Regan MM, Rimm DL, Symmans WF, Torlakovic EE, Varella L, Viale G, Weisberg TF, McShane LM, Wolff AC. Estrogen and Progesterone Receptor Testing in Breast Cancer: American Society of Clinical Oncology/College of American Pathologists Guideline Update. Arch Pathol Lab Med 2020; 144:545-563. [PMID: 31928354 DOI: 10.5858/arpa.2019-0904-sa] [Citation(s) in RCA: 177] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE.— To update key recommendations of the American Society of Clinical Oncology/College of American Pathologists estrogen receptor (ER) and progesterone receptor (PgR) testing in breast cancer guideline. METHODS.— A multidisciplinary international Expert Panel was convened to update the clinical practice guideline recommendations informed by a systematic review of the medical literature. RECOMMENDATIONS.— The Expert Panel continues to recommend ER testing of invasive breast cancers by validated immunohistochemistry as the standard for predicting which patients may benefit from endocrine therapy, and no other assays are recommended for this purpose. Breast cancer samples with 1% to 100% of tumor nuclei positive should be interpreted as ER positive. However, the Expert Panel acknowledges that there are limited data on endocrine therapy benefit for cancers with 1% to 10% of cells staining ER positive. Samples with these results should be reported using a new reporting category, ER Low Positive, with a recommended comment. A sample is considered ER negative if < 1% or 0% of tumor cell nuclei are immunoreactive. Additional strategies recommended to promote optimal performance, interpretation, and reporting of cases with an initial low to no ER staining result include establishing a laboratory-specific standard operating procedure describing additional steps used by the laboratory to confirm/adjudicate results. The status of controls should be reported for cases with 0% to 10% staining. Similar principles apply to PgR testing, which is used primarily for prognostic purposes in the setting of an ER-positive cancer. Testing of ductal carcinoma in situ (DCIS) for ER is recommended to determine potential benefit of endocrine therapies to reduce risk of future breast cancer, while testing DCIS for PgR is considered optional. Additional information can be found at www.asco.org/breast-cancer-guidelines .
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Affiliation(s)
| | | | | | | | | | | | | | - Sunil R Lakhani
- University of Queensland, Brisbane, Queensland, Australia
- Pathology Queensland, Brisbane, Queensland, Australia
| | | | | | | | - Meredith M Regan
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Emina E Torlakovic
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Giuseppe Viale
- IEO, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- University of Milan, Milan, Italy
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16
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Allison KH, Hammond MEH, Dowsett M, McKernin SE, Carey LA, Fitzgibbons PL, Hayes DF, Lakhani SR, Chavez-MacGregor M, Perlmutter J, Perou CM, Regan MM, Rimm DL, Symmans WF, Torlakovic EE, Varella L, Viale G, Weisberg TF, McShane LM, Wolff AC. Estrogen and Progesterone Receptor Testing in Breast Cancer: ASCO/CAP Guideline Update. J Clin Oncol 2020; 38:1346-1366. [PMID: 31928404 DOI: 10.1200/jco.19.02309] [Citation(s) in RCA: 640] [Impact Index Per Article: 160.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To update key recommendations of the American Society of Clinical Oncology/College of American Pathologists estrogen (ER) and progesterone receptor (PgR) testing in breast cancer guideline. METHODS A multidisciplinary international Expert Panel was convened to update the clinical practice guideline recommendations informed by a systematic review of the medical literature. RECOMMENDATIONS The Expert Panel continues to recommend ER testing of invasive breast cancers by validated immunohistochemistry as the standard for predicting which patients may benefit from endocrine therapy, and no other assays are recommended for this purpose. Breast cancer samples with 1% to 100% of tumor nuclei positive should be interpreted as ER positive. However, the Expert Panel acknowledges that there are limited data on endocrine therapy benefit for cancers with 1% to 10% of cells staining ER positive. Samples with these results should be reported using a new reporting category, ER Low Positive, with a recommended comment. A sample is considered ER negative if < 1% or 0% of tumor cell nuclei are immunoreactive. Additional strategies recommended to promote optimal performance, interpretation, and reporting of cases with an initial low to no ER staining result include establishing a laboratory-specific standard operating procedure describing additional steps used by the laboratory to confirm/adjudicate results. The status of controls should be reported for cases with 0% to 10% staining. Similar principles apply to PgR testing, which is used primarily for prognostic purposes in the setting of an ER-positive cancer. Testing of ductal carcinoma in situ (DCIS) for ER is recommended to determine potential benefit of endocrine therapies to reduce risk of future breast cancer, while testing DCIS for PgR is considered optional. Additional information can be found at www.asco.org/breast-cancer-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | - Sunil R Lakhani
- University of Queensland, Brisbane, Queensland, Australia
- Pathology Queensland, Brisbane, Queensland, Australia
| | | | | | | | - Meredith M Regan
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Emina E Torlakovic
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Giuseppe Viale
- IEO, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- University of Milan, Milan, Italy
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17
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Schiaffino S, Calabrese M, Melani EF, Trimboli RM, Cozzi A, Carbonaro LA, Di Leo G, Sardanelli F. Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions. Radiology 2019; 294:76-86. [PMID: 31660803 DOI: 10.1148/radiol.2019190748] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Management of percutaneously diagnosed pure atypical ductal hyperplasia (ADH) is an unresolved clinical issue. Purpose To calculate the pooled upgrade rate of percutaneously diagnosed pure ADH. Materials and Methods A search of MEDLINE and EMBASE databases was performed in October 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines were followed. A fixed- or random-effects model was used, along with subgroup and meta-regression analyses. The Newcastle-Ottawa scale was used for study quality, and the Egger test was used for publication bias. Results Of 521 articles, 93 were analyzed, providing data for 6458 ADHs (5911 were managed with surgical excision and 547 with follow-up). Twenty-four studies used core-needle biopsy; 44, vacuum-assisted biopsy; 21, both core-needle and vacuum-assisted biopsy; and four, unspecified techniques. Biopsy was performed with stereotactic guidance in 29 studies; with US guidance in nine, with MRI guidance in nine, and with mixed guidance in eight. Overall heterogeneity was high (I2 = 80%). Subgroup analysis according to management yielded a pooled upgrade rate of 29% (95% confidence interval [CI]: 26%, 32%) for surgically excised lesions and 5% (95% CI: 4%, 8%) for lesions managed with follow-up (P < .001). Heterogeneity was entirely associated with surgically excised lesions (I2 = 78%) rather than those managed with follow-up (I2 = 0%). Most variability was explained by guidance and needle caliper (P = .15). At subgroup analysis of surgically excised lesions, the pooled upgrade rate was 42% (95% CI: 31%, 53%) for US guidance, 23% (95% CI: 19%, 27%) for stereotactic biopsy, and 32% (95% CI: 22%, 43%) for MRI guidance, with heterogeneity (52%, 63%, and 56%, respectively) still showing the effect of needle caliper. When the authors considered patients with apparent complete lesion removal after biopsy (subgroups in 14 studies), the pooled upgrade rate was 14% (95% CI: 8%, 23%). Study quality was low to medium; the risk of publication bias was low (P = .10). Conclusion Because of a pooled upgrade rate higher than 2% (independent of biopsy technique, needle size, imaging guidance, and apparent complete lesion removal), atypical ductal hyperplasia diagnosed with percutaneous needle biopsy should be managed with surgical excision. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Brem in this issue.
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Affiliation(s)
- Simone Schiaffino
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Massimo Calabrese
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Enrico Francesco Melani
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Rubina Manuela Trimboli
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Andrea Cozzi
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Luca Alessandro Carbonaro
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Giovanni Di Leo
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
| | - Francesco Sardanelli
- From the Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy (S.S., L.A.C., G.D.L., F.S.); Unit of Radiology, IRCCS Policlinico San Martino, Genoa, Italy (M.C.); Unit of Radiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.F.M.); and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy (R.M.T., A.C., F.S.)
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18
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Spreafico F, Quarello P, Alaggio R, Collini P, Haupt R, Mastronuzzi A, Prete A, Rabusin M, Rizzari C, Schumacher F, Zecca M, Pession A, Fagioli F. Nationwide central diagnosis review for childhood solid tumors: From concept to realization of an Associazione Italiana Ematologia Oncologia Pediatrica (AIEOP) integrated project. Pediatr Blood Cancer 2019; 66:e27749. [PMID: 30997709 DOI: 10.1002/pbc.27749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/11/2019] [Accepted: 03/26/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Filippo Spreafico
- Pediatric Oncology Unit, Department of Medical Oncology and Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Paola Quarello
- Pediatric Onco-Haematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Rita Alaggio
- Department of Pathology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.,Department of Medicine-DIMED, Padova University Hospital, Padova, Italy
| | - Paola Collini
- Soft Tissue and Bone Pathology, Histopathology and Pediatric Pathology Unit, Department of Diagnostic Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Riccardo Haupt
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Angela Mastronuzzi
- Neuro-Oncology Unit, Department of Pediatric Hematology/Oncology and Cellular and Gene Therapy, Bambino Gesù Children's Hospital, Roma, Italy
| | - Arcangelo Prete
- Hematology-Oncology Unit, Department of Pediatrics, University of Bologna, Bologna, Italy
| | - Marco Rabusin
- Hematology-Oncology Unit, Department of Pediatrics, Institute of Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Carmelo Rizzari
- Pediatric Hematology Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - Fabian Schumacher
- Department of Pediatric Hematology Oncology, University Children's Hospital "Ospedale dei Bambini", ASST Spedali Civili, Brescia, Italy
| | - Marco Zecca
- Department of Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Pession
- Hematology-Oncology Unit, Department of Pediatrics, University of Bologna, Bologna, Italy
| | - Franca Fagioli
- Pediatric Onco-Haematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Torino, Italy.,Università di Torino, Torino, Italy
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19
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Lilleborge M, Falk RS, Russnes H, Sauer T, Ursin G, Hofvind S. Risk of breast cancer by prior screening results among women participating in BreastScreen Norway. Cancer 2019; 125:3330-3337. [DOI: 10.1002/cncr.32330] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/05/2019] [Accepted: 05/13/2019] [Indexed: 11/11/2022]
Affiliation(s)
| | - Ragnhild S. Falk
- Oslo Centre for Biostatistics and Epidemiology Oslo University Hospital Oslo Norway
| | - Hege Russnes
- Institute for Cancer Research Oslo University Hospital Oslo Norway
| | - Torill Sauer
- Department of Pathology Akershus University Hospital Lorenskog Norway
- Institute of Clinical Medicine University of Oslo Lorenskog Norway
| | - Giske Ursin
- Cancer Registry of Norway, Oslo University Hospital Oslo Norway
- Institute for Basic Medical Sciences University of Oslo Oslo Norway
- Department of Preventive Medicine, Keck School of Medicine University of Southern California Los Angeles California
| | - Solveig Hofvind
- Cancer Registry of Norway, Oslo University Hospital Oslo Norway
- Department of Life Sciences and Health Oslo Metropolitan University Oslo Norway
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Benbassat J. Obtaining a second opinion is a neglected source of health care inequalities. Isr J Health Policy Res 2019; 8:12. [PMID: 30651143 PMCID: PMC6335699 DOI: 10.1186/s13584-019-0289-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/10/2019] [Indexed: 11/25/2022] Open
Abstract
Observational studies have detected discrepancies between two expert interpreters of imaging and histopathological studies. Furthermore, in a substantial proportion of patients, an independent second opinion disagreed with the first one. Therefore, it is widely accepted that patients have a right to obtain a second opinion and, in case of divergent opinions, to deliberate and choose the option that they believe is most consistent with their individual circumstances. However, doctors are less likely to inform old and poorly educated patients about the possibility of seeking a second opinion, and this may contribute to healthcare inequalities. Hence the importance of (a) promoting doctors’ self-awareness of a possible tendency to discriminate against old and poorly educated patients, and (b) creating programs within the healthcare system that would help patients in seeking a second opinion, suggest specialists for the specific problem of the patient, and provide tools to reconcile between discrepant opinions.
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Affiliation(s)
- Jochanan Benbassat
- Myers-JDC-Brookdale Institute, Department of Health Policy Research, PO Box 3886, 91037, Jerusalem, Israel.
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Sardanelli F, Trimboli RM, Tot T. Expert Review of Breast Pathology in Borderline Lesions. JAMA Oncol 2018; 4:1325-1326. [DOI: 10.1001/jamaoncol.2018.1953] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Rubina M. Trimboli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
- PhD Program in Integrative Biomedical Research, Università degli Studi di Milano, Milan, Italy
| | - Tibor Tot
- Pathology & Cytology Dalarna, Falun, Sweden
- Uppsala University, Uppsala, Sweden
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