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Nethanel A, Kyprianou C, Barzilai A, Shapira-Frommer R, Shoham Y, Kornhaber R, Cleary M, Avinoam-Dar G, Grynberg S, Haik J, Debby A, Harats M. The Implications of a Dermatopathologist's Report on Melanoma Diagnosis and Treatment. Life (Basel) 2023; 13:1803. [PMID: 37763207 PMCID: PMC10532537 DOI: 10.3390/life13091803] [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: 05/29/2023] [Revised: 08/07/2023] [Accepted: 08/11/2023] [Indexed: 09/29/2023] Open
Abstract
An accurate and comprehensive histopathology report is essential for cutaneous melanoma management, providing critical information for accurate staging and risk estimation and determining the optimal surgical approach. In many institutions, a review of melanoma biopsy specimens by expert dermatopathologists is considered a necessary step. This study examined these reviews to determine the critical primary histopathology Breslow score in which a histopathology review would be most beneficial. Histopathology reports of patients referred to our institute between January 2011 and September 2019 were compared with our in-house review conducted by an expert dermatopathologist. The review focused on assessing fundamental histologic and clinical prognostic features. A total of 177 specimens underwent histopathology review. Significant changes in the Breslow index were identified in 103 cases (58.2%). Notably, in many of these cases (73.2%), the revised Breslow was higher than the initially reported score. Consequently, the T-stage was modified in 51 lesions (28.8%). Substantial discordance rates were observed in Tis (57%), T1b (59%), T3a (67%) and T4a (50%) classifications. The revised histopathology reports resulted in alterations to the surgical plan in 15.3% of the cases. These findings emphasize the importance of having all routine pathologies of pigmented lesions referred to a dedicated cancer center and reviewed by an experienced dermatopathologist. This recommendation is particularly crucial in instances where the histopathology review can potentially alter the diagnosis and treatment plan, such as in melanoma in situ and thinner melanomas measuring 0.6-2.2 mm in thickness. Our study highlights the significant impact of histopathology reviews in cutaneous melanoma cases. The observed changes in Breslow scores and subsequent modifications in T-stage classification underline the need for thorough evaluation by an expert dermatopathologist, especially in cases of melanoma in situ and thin melanomas. Incorporating such reviews into routine practice within dedicated cancer centers can improve diagnostic accuracy and guide appropriate treatment decisions, ultimately leading to better patient outcomes.
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Affiliation(s)
- Asher Nethanel
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (R.S.-F.); (S.G.)
| | - Christofis Kyprianou
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (C.K.); (R.K.); (G.A.-D.); (J.H.); (M.H.)
| | - Aviv Barzilai
- Department of Dermatology, Institute of Pathology, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (A.B.)
| | - Ronnie Shapira-Frommer
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (R.S.-F.); (S.G.)
| | - Yaron Shoham
- Plastic Surgery Department, Burn Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba 84105, Israel;
| | - Rachel Kornhaber
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (C.K.); (R.K.); (G.A.-D.); (J.H.); (M.H.)
- School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, NSW 2795, Australia
| | - Michelle Cleary
- School of Nursing, Midwifery & Social Sciences, Central Queensland University, Sydney, NSW 2000, Australia;
| | - Galit Avinoam-Dar
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (C.K.); (R.K.); (G.A.-D.); (J.H.); (M.H.)
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Shirly Grynberg
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (R.S.-F.); (S.G.)
| | - Josef Haik
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (C.K.); (R.K.); (G.A.-D.); (J.H.); (M.H.)
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel
- Talpiot Leadership Program, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel
- Institute for Health Research, University of Notre Dame, Fremantle, WA 6160, Australia
| | - Assaf Debby
- Department of Dermatology, Institute of Pathology, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (A.B.)
| | - Moti Harats
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel; (C.K.); (R.K.); (G.A.-D.); (J.H.); (M.H.)
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel
- Talpiot Leadership Program, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52621, Israel
- Institute for Health Research, University of Notre Dame, Fremantle, WA 6160, Australia
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Massi D, Szumera-Ciećkiewicz A, Alos L, Simi S, Ugolini F, Palmieri G, Stanganelli I, Cook MG, Mandalà M. Impact of second opinion pathology review in the diagnosis and management of atypical melanocytic lesions: A prospective study of the Italian Melanoma Intergroup (IMI) and EORTC Melanoma Group. Eur J Cancer 2023; 189:112921. [PMID: 37280145 DOI: 10.1016/j.ejca.2023.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/07/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND The clinical value of an expert pathological review in patients with an atypical melanocytic lesion diagnosis remains unclear. Herein, we evaluate its impact in a prospective clinical study. METHODS Patients with newly diagnosed or suspected atypical melanocytic proliferations and challenging skin tumours were reviewed prospectively by a specialised dermatopathologist through the nationwide 'Second Opinion Platform' of the Italian Melanoma Intergroup (IMI) network. The primary aim was the rate of major discrepancies that impacted patient management. Major discrepancies in diagnosis between referral and specialised review were blindly re-analysed by a panel of European Organisation for Research and Treatment (EORTC) Melanoma pathologists. RESULTS The samples submitted to central review included 254 lesions from 230 patients. The most frequent referral diagnoses were atypical melanocytic nevi of different subtypes (74/254, 29.2%), invasive melanomas (61/254, 24.0%), atypical melanocytic proliferations (37/254, 14.6%), AST (21/254, 8.3%) and in situ melanomas (17/254, 6.7%). There was disagreement between referral diagnosis and expert review in 90/254 cases (35.4%). Most importantly, 60/90 (66.7%) were major discordances with a change to the patient's clinical management. Among the 90 discordant cases, the most frequent new diagnosis occurred in World Health Organisation (WHO) Pathway I, followed by WHO Pathway IV (64/90 and 12/90, respectively). In total, 51/60 cases with major discrepancies were blindly re-evaluated by EORTC Melanoma pathologists with a final interobserver agreement in 90% of cases. CONCLUSION The study highlights that a second opinion for atypical melanocytic lesions affects clinical management in a minor, but still significant, proportion of cases. A central expert review supports pathologists and clinicians to limit the risk of both over- and under-treatment.
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Affiliation(s)
- Daniela Massi
- Section of Pathology, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Anna Szumera-Ciećkiewicz
- Maria Sklodowska-Curie National Research Institute of Oncology, Department of Pathology, Warsaw, Poland
| | - Llucia Alos
- Department of Pathology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sara Simi
- Section of Pathology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Filippo Ugolini
- Section of Pathology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giuseppe Palmieri
- Immuno-Oncology & Targeted Cancer Biotherapies, Unit of Cancer Genetics, University of Sassari IRGB-CNR, Sassari, Italy
| | - Ignazio Stanganelli
- Skin Cancer Unit, IRCCS Scientific Institute of Romagna for the Study of Cancer, IRCCS IRST, Meldola, Italy; Dermatology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Martin G Cook
- Unit of Pathology, Royal Surrey County Hospital, Guildford, UK
| | - Mario Mandalà
- University of Perugia, Unit of Medical Oncology, Santa Maria della Misericordia Hospital, Perugia, Italy
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Dillon LD, McPhee M, Davidson RS, Quick AP, Martin B, Covington KR, Zolochevska O, Cook RW, Vetto JT, Jarell AD, Fleming MD. Expanded evidence that the 31-gene expression profile test provides clinical utility for melanoma management in a multicenter study. Curr Med Res Opin 2022; 38:1267-1274. [PMID: 35081854 DOI: 10.1080/03007995.2022.2033560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma (CM) recommend physicians consider increased surveillance for patients who typically have lower melanoma survival rates (stages IIB-IV as determined by the American Joint Committee on Cancer (AJCC), 8th edition). However, up to 15% of patients identified as having a low recurrence risk (stages I-IIA) experience disease recurrence, and some patients identified as having a high recurrence risk will not experience any recurrence. The 31-gene expression profile test (31-GEP) stratifies patient recurrence risk into low (Class 1) and high (Class 2) and has demonstrated risk-appropriate impact on disease management and clinical decisions. METHODS Five-year plans for lab work, frequency of clinical visits, and imaging pre- and post-31-GEP test results were assessed for a cohort of 509 stage I-III patients following an interim subset analysis of 247 patients. RESULTS After receiving 31-GEP results, 50.6% of patients had a change in management plans in at least one of the following categories-clinical visits, lab work, or surveillance imaging. The changes aligned with the risk predicted by the 31-GEP for 76.1% of patients with a Class 1 result and 78.7% of patients with a Class 2 result. A Class 1 31-GEP result was associated with changes toward low-intensity management recommendations, while a Class 2 result was associated with changes toward high-intensity management recommendations. CONCLUSION The 31-GEP can stratify patient recurrence risk in patients with CM, and clinicians understand and apply the prognostic ability of the 31-GEP test to alter patient management in risk-appropriate directions.
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Affiliation(s)
- Larry D Dillon
- Larry D. Dillon Surgical Oncology and General Surgery, Colorado Springs, CO, USA
| | - Michael McPhee
- Breast Cancer Program, Advent Health Cancer Institute, Orlando, FL, USA
| | - Robert S Davidson
- Department of Surgical Oncology, Morton Plant Mease Healthcare, FL, USA
| | - Ann P Quick
- Castle Biosciences, Inc, Friendswood, TX, USA
| | | | | | | | | | - John T Vetto
- Department of Neurology, Surgical Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Abel D Jarell
- Department of Dermatology, Northeast Dermatology Associates, P.C., Portsmouth, NH, USA
| | - Martin D Fleming
- Department of Surgical Oncology, The University of Tennessee Health Science Center, Memphis, TN, USA
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4
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Pulsipher KJ, Harris B, Muse M, Casale J, Presley CL, Dellavalle RP. An update to trends in US dermatology residency and fellowship programs and positions, 2016-2021. J Am Acad Dermatol 2022; 86:e239-e240. [DOI: 10.1016/j.jaad.2021.12.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/14/2021] [Accepted: 12/28/2021] [Indexed: 11/27/2022]
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Alomari AK, Tharp AW, Umphress B, Kowal RP. The utility of PRAME immunohistochemistry in the evaluation of challenging melanocytic tumors. J Cutan Pathol 2021; 48:1115-1123. [PMID: 33660310 DOI: 10.1111/cup.14000] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/11/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND PRAME (PReferentially expressed Antigen in Melanoma) immunohistochemistry has demonstrated high specificity for unequivocal melanomas; however, its utility in ambiguous melanocytic neoplasms has yet to be fully elucidated. METHODS Cases of challenging melanocytic neoplasms were subclassified into one of three categories: challenging, favor benign (FB), challenging, cannot be subclassified (CCS), or challenging, favor malignant (FM). Using a previously published system, whereby cases with diffuse staining (>75%) were considered positive, scoring of PRAME was performed. Additionally, tumors with hotspot staining were also considered positive. RESULTS Sixteen out of 85 tumors showed positive staining representing 5% of FB tumors, 24% of CCS tumors, and 47% of FM. In FB and CCS tumors, positive staining was mainly encountered in atypical intraepidermal melanocytic proliferations and spitzoid neoplasms. The specificity of positive PRAME staining was 95% and its concordance with the final diagnostic interpretation was 75%. CONCLUSIONS PRAME positivity is more common in neoplasms favored to be malignant by histopathologic evaluation. Its clinical utility may include early diagnosis of incipient melanoma in situ. Rarely, benign melanocytic neoplasms could show diffuse expression of PRAME, and additional studies are needed to determine optimal utilization. Lastly, hotspot staining may increase its sensitivity without much compromise in specificity.
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Affiliation(s)
- Ahmed K Alomari
- Department of Pathology, Indiana University, School of Medicine, Indianapolis, Indiana, USA
- Department of Dermatology, Indiana University, School of Medicine, Indianapolis, Indiana, USA
| | - Andrew W Tharp
- Department of Pathology, Indiana University, School of Medicine, Indianapolis, Indiana, USA
| | - Brandon Umphress
- Department of Pathology, Indiana University, School of Medicine, Indianapolis, Indiana, USA
| | - Rachel P Kowal
- Department of Pathology, Indiana University, School of Medicine, Indianapolis, Indiana, USA
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6
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Cho WC, Gill P, Aung PP, Gu J, Nagarajan P, Ivan D, Curry JL, Prieto VG, Torres-Cabala CA. The utility of digital pathology in improving the diagnostic skills of pathology trainees in commonly encountered pigmented cutaneous lesions during the COVID-19 pandemic: A single academic institution experience. Ann Diagn Pathol 2021; 54:151807. [PMID: 34418768 PMCID: PMC8450757 DOI: 10.1016/j.anndiagpath.2021.151807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022]
Abstract
Digital pathology has become an integral part of pathology education in recent years, particularly during the COVID-19 pandemic, for its potential utility as a teaching tool that augments the traditional 1-to-1 sign-out experience. Herein, we evaluate the utility of whole slide imaging (WSI) in reducing diagnostic errors in pigmented cutaneous lesions by pathology fellows without subspecialty training in dermatopathology. Ten cases of 4 pigmented cutaneous lesions commonly encountered by general pathologists were selected. Corresponding whole slide images were distributed to our fellows, along with two sets of online surveys, each composed of 10 multiple-choice questions with 4 answers. Identical cases were used for both surveys to minimize variability in trainees' scores depending on the perceived level of difficulty, with the second set being distributed after random shuffling. Brief image-based teaching slides as self-assessment tool were provided to trainees between each survey. Pre- and post-self-assessment scores were analyzed. 61% (17/28) and 39% (11/28) of fellows completed the first and second surveys, respectively. The mean score in the first survey was 5.2/10. The mean score in the second survey following self-assessment increased to 7.2/10. 64% (7/11) of trainees showed an improvement in their scores, with 1 trainee improving his/her score by 8 points. No fellow scored less post-self-assessment than on the initial assessment. The difference in individual scores between two surveys was statistically significant (p = 0.003). Our study demonstrates the utility of WSI-based self-assessment learning as a source of improving diagnostic skills of pathology trainees in a short period of time.
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Affiliation(s)
- Woo Cheal Cho
- Department of Pathology, University of Texas, MD Anderson Cancer Center, United States of America
| | - Pavandeep Gill
- Department of Pathology, University of Texas, MD Anderson Cancer Center, United States of America
| | - Phyu P Aung
- Department of Pathology, University of Texas, MD Anderson Cancer Center, United States of America
| | - Jun Gu
- School of Health Professions, University of Texas, MD Anderson Cancer Center, United States of America
| | - Priyadharsini Nagarajan
- Department of Pathology, University of Texas, MD Anderson Cancer Center, United States of America
| | - Doina Ivan
- Department of Pathology, University of Texas, MD Anderson Cancer Center, United States of America
| | - Jonathan L Curry
- Department of Pathology, University of Texas, MD Anderson Cancer Center, United States of America
| | - Victor G Prieto
- Department of Pathology, University of Texas, MD Anderson Cancer Center, United States of America
| | - Carlos A Torres-Cabala
- Department of Pathology, University of Texas, MD Anderson Cancer Center, United States of America.
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7
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Al-Rohil RN, Moore JL, Patterson NH, Nicholson S, Verbeeck N, Claesen M, Muhammad JZ, Caprioli RM, Norris JL, Kantrow S, Compton M, Robbins J, Alomari AK. Diagnosis of melanoma by imaging mass spectrometry: Development and validation of a melanoma prediction model. J Cutan Pathol 2021; 48:1455-1462. [PMID: 34151458 DOI: 10.1111/cup.14083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/24/2021] [Accepted: 05/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The definitive diagnosis of melanocytic neoplasia using solely histopathologic evaluation can be challenging. Novel techniques that objectively confirm diagnoses are needed. This study details the development and validation of a melanoma prediction model from spatially resolved multivariate protein expression profiles generated by imaging mass spectrometry (IMS). METHODS Three board-certified dermatopathologists blindly evaluated 333 samples. Samples with triply concordant diagnoses were included in this study, divided into a training set (n = 241) and a test set (n = 92). Both the training and test sets included various representative subclasses of unambiguous nevi and melanomas. A prediction model was developed from the training set using a linear support vector machine classification model. RESULTS We validated the prediction model on the independent test set of 92 specimens (75 classified correctly, 2 misclassified, and 15 indeterminate). IMS detects melanoma with a sensitivity of 97.6% and a specificity of 96.4% when evaluating each unique spot. IMS predicts melanoma at the sample level with a sensitivity of 97.3% and a specificity of 97.5%. Indeterminate results were excluded from sensitivity and specificity calculations. CONCLUSION This study provides evidence that IMS-based proteomics results are highly concordant to diagnostic results obtained by careful histopathologic evaluation from a panel of expert dermatopathologists.
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Affiliation(s)
- Rami N Al-Rohil
- Departments of Pathology and Dermatology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Nathan Heath Patterson
- Frontier Diagnostics, LLC, Nashville, Tennessee, USA.,Mass Spectrometry Research Center, Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | | | - Richard M Caprioli
- Frontier Diagnostics, LLC, Nashville, Tennessee, USA.,Mass Spectrometry Research Center, Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - Jeremy L Norris
- Frontier Diagnostics, LLC, Nashville, Tennessee, USA.,Mass Spectrometry Research Center, Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - Sara Kantrow
- Pathology Associates of Saint Thomas, Nashville, Tennessee, USA
| | - Margaret Compton
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jason Robbins
- Pathology Associates of Saint Thomas, Nashville, Tennessee, USA
| | - Ahmed K Alomari
- Departments of Pathology and Dermatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Ronchi A, Pagliuca F, Zito Marino F, Argenziano G, Brancaccio G, Alfano R, Signoriello G, Moscarella E, Franco R. Second Diagnostic Opinion by Experienced Dermatopathologists in the Setting of a Referral Regional Melanoma Unit Significantly Improves the Clinical Management of Patients With Cutaneous Melanoma. Front Med (Lausanne) 2021; 7:568946. [PMID: 33614670 PMCID: PMC7890120 DOI: 10.3389/fmed.2020.568946] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 12/21/2020] [Indexed: 01/22/2023] Open
Abstract
The diagnosis of cutaneous melanoma and melanocytic neoplasms in general is one of the most challenging fields in pathology, and the reported interobserver diagnostic agreement in the evaluation of melanocytic lesions is poor. Nevertheless, a correct histopathological diagnosis is crucial to ensure a good clinical management of the patients. The institution of multidisciplinary teams has recently modified the approach to the patients with cutaneous melanoma. Patients referred to a multidisciplinary melanoma unit after receiving a diagnosis of melanoma elsewhere are encouraged to have their histopathological diagnosis confirmed by a second opinion from the experienced pathologist of the team before any treatment is initiated. We performed a retrospective analysis on a series of 121 histopathological revisions required for melanocytic neoplasms in the context of a multidisciplinary team, in order to evaluate the effects of second diagnostic opinion (SDO) on the clinical management of the patients. We defined three types of diagnostic discrepancies between the first diagnosis and the second opinion, according to the greatness of their clinical impact. Overall, the incidence of diagnostic discrepancies of any type was quite high in our series (56%). Interestingly, the SDO determined relevant changes in the clinical management of the patients in 33 out of 121 (27.3%) cases. This study confirms that SDO by expert pathologists significantly affects the course of treatment of melanoma patients and helps improving the diagnostic accuracy and clinical outcome.
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Affiliation(s)
- Andrea Ronchi
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Francesca Pagliuca
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Federica Zito Marino
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Giuseppe Argenziano
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Gabriella Brancaccio
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Roberto Alfano
- Department of Anaesthesiology, Surgery and Emergency, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Giuseppe Signoriello
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Elvira Moscarella
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Renato Franco
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
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9
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Lohman ME, Grekin RC, North JP, Neuhaus IM. Impact of second-opinion dermatopathology reviews on surgical management of malignant neoplasms. J Am Acad Dermatol 2021; 84:1385-1392. [PMID: 33333152 DOI: 10.1016/j.jaad.2020.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Second-opinion review is linked to error reduction and treatment changes in anatomic pathology. OBJECTIVE We sought to establish the rate of diagnostic discrepancy identified by second-opinion dermatopathologic review and the effect on surgical treatment. METHODS Cases referred for treatment of a malignant neoplasm diagnosed by an outside pathologist were reviewed. The external and internal second-opinion dermatopathologic reports were compared. Discordance in diagnosis, subtype, and treatment change owing to second-opinion review was recorded. The referring pathologist's level of dermatopathologic training was also documented. RESULTS A total of 358 cases were included. Dermatopathologic second-opinion diagnosis was discordant with the outside diagnosis in 37 of 358 cases (10.3%). In 32 of 358 cases (8.9%), second-opinion review resulted in a change in treatment, with 28 of 32 (87.5%) of these changes resulting in cancelled surgery. Dermatologists without dermatopathologic fellowship training had the highest rate of discordant diagnoses compared with pathologists and dermatopathologists. LIMITATIONS This was a retrospective study at a tertiary care facility. CONCLUSION Second-opinion dermatopathologic review is associated with identification of discordant diagnoses and a substantial influence on treatment, with both cancellation of surgery and augmented management. Secondary pathologic review should be considered in high-volume surgical practices.
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Affiliation(s)
- Mary E Lohman
- Department of Dermatology, University of California-San Francisco, San Francisco, California
| | - Roy C Grekin
- Department of Dermatology, University of California-San Francisco, San Francisco, California
| | - Jeffrey P North
- Department of Dermatology, University of California-San Francisco, San Francisco, California
| | - Isaac M Neuhaus
- Department of Dermatology, University of California-San Francisco, San Francisco, California.
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10
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Torres R, Lang UE, Hejna M, Shelton SJ, Joseph NM, Shain AH, Yeh I, Wei ML, Oldham MC, Bastian BC, Judson-Torres RL. MicroRNA Ratios Distinguish Melanomas from Nevi. J Invest Dermatol 2020; 140:164-173.e7. [PMID: 31580842 PMCID: PMC6926155 DOI: 10.1016/j.jid.2019.06.126] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/27/2019] [Accepted: 06/04/2019] [Indexed: 12/27/2022]
Abstract
The use of microRNAs as biomarkers has been proposed for many diseases, including the diagnosis of melanoma. Although hundreds of microRNAs have been identified as differentially expressed in melanomas as compared to benign melanocytic lesions, a limited consensus has been achieved across studies, constraining the effective use of these potentially useful markers. In this study, we applied a machine learning-based pipeline to a dataset consisting of genetic features, clinical features, and next-generation microRNA sequencing from micro-dissected formalin-fixed paraffin embedded melanomas and their adjacent benign precursor nevi. We identified patient age and tumor cellularity as variables that frequently confound the measured expression of potentially diagnostic microRNAs. By employing the ratios of microRNAs that were either enriched or depleted in melanoma compared to the nevi as a normalization strategy, we developed a model that classified all the available published cohorts with an area under the receiver operating characteristic curve of 0.98. External validation on an independent cohort classified lesions with 81% sensitivity and 88% specificity and was uninfluenced by the tumor content of the sample or patient age.
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Affiliation(s)
- Rodrigo Torres
- Department of Dermatology, University of California, San Francisco, California, USA
| | - Ursula E Lang
- Department of Dermatology, University of California, San Francisco, California, USA; Department of Pathology, University of California, San Francisco, California, USA
| | - Miroslav Hejna
- Department of Physics, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA; Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Samuel J Shelton
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Nancy M Joseph
- Department of Pathology, University of California, San Francisco, California, USA
| | - A Hunter Shain
- Department of Dermatology, University of California, San Francisco, California, USA
| | - Iwei Yeh
- Department of Dermatology, University of California, San Francisco, California, USA; Department of Pathology, University of California, San Francisco, California, USA
| | - Maria L Wei
- Department of Dermatology, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Michael C Oldham
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Boris C Bastian
- Department of Dermatology, University of California, San Francisco, California, USA; Department of Pathology, University of California, San Francisco, California, USA
| | - Robert L Judson-Torres
- Department of Dermatology, University of California, San Francisco, California, USA; Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA; Department of Dermatology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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11
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Lowenstein EJ, Sidlow R, Ko CJ. Visual perception, cognition, and error in dermatologic diagnosis: Diagnosis and error. J Am Acad Dermatol 2019; 81:1237-1245. [DOI: 10.1016/j.jaad.2018.12.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/18/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
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Bhoyrul B, Brent G, Elliott F, McLorinan J, Wilson A, Peach H, Mathew B, Mitra A. Pathological review of primary cutaneous malignant melanoma by a specialist skin cancer multidisciplinary team improves patient care in the UK. J Clin Pathol 2019; 72:482-486. [PMID: 31088937 DOI: 10.1136/jclinpath-2019-205767] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 11/04/2022]
Abstract
AIMS The National Institute for Health and Care Excellence advocated the development of specialist skin cancer multidisciplinary teams (SSMDTs) for the management of higher risk invasive skin cancers in the UK. The interobserver variability in the histopathological assessment of primary cutaneous malignant melanoma (PCMM) is well recognised. METHODS We evaluated the discordance rates in the assessment of the histopathological criteria of PCMM based on the eighth American Joint Committee on Cancer (AJCC) melanoma staging system and subsequent change in prognosis and management following pathology review by an SSMDT. RESULTS 353 cases of PCMM were referred to our SSMDT between April 2015 and May 2016. Cases in which there was a discrepancy in one or more histological parameters following expert review were collected retrospectively. Of 341 eligible cases, there were 94 (27.6%) in which there was an alteration in any parameter. There was interobserver agreement in final diagnosis in 96.8%, Breslow thickness in 86.8%, ulceration in 98.2%, microsatellites in 98.5%, tumour mitotic rate in 88.9%, histological subtype in 92.4%, growth phase in 98.5%, angiolymphatic invasion in 97.7%, perineural invasion in 98.8%, regression in 95.3% and tumour-infiltrating lymphocytes in 95.0%. A corresponding change in AJCC stage occurred in 23 cases (6.7%), with a resulting change in clinical management in 10 cases (2.9%). CONCLUSIONS Disagreements in the pathological assessment of PCMM can have significant clinical implications for a small number of patients. Our findings highlight the value of the SSMDT for high-quality care of patients with melanoma in the UK.
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Affiliation(s)
- Bevin Bhoyrul
- Department of Dermatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Geoffrey Brent
- Department of Dermatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Faye Elliott
- Department of Epidemiology and Biostatistics, Leeds Institute of Cancer and Pathology, Leeds, UK
| | - Joanna McLorinan
- Department of Dermatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Amy Wilson
- Department of Dermatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Howard Peach
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bipin Mathew
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Angana Mitra
- Department of Dermatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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13
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Williams EA, Moy AP, Cipriani NA, Nigwekar SU, Nazarian RM. Factors associated with false-negative pathologic diagnosis of calciphylaxis. J Cutan Pathol 2018; 46:16-25. [DOI: 10.1111/cup.13364] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 08/03/2018] [Accepted: 09/19/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Erik A. Williams
- Massachusetts General Hospital; Dermatopathology Unit, Department of Pathology; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
| | - Andrea P. Moy
- Department of Dermatology; Northwell Health and Zucker School of Medicine at Hofstra/Northwell; Lake Success New York
| | - Nicole A. Cipriani
- The University of Chicago Medicine & Biological Sciences; Chicago Illinois
| | - Sagar U. Nigwekar
- Harvard Medical School; Boston Massachusetts
- Massachusetts General Hospital; Division of Nephrology, Department of Medicine; Boston Massachusetts
| | - Rosalynn M. Nazarian
- Massachusetts General Hospital; Dermatopathology Unit, Department of Pathology; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
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14
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Elder DE, Piepkorn MW, Barnhill RL, Longton GM, Nelson HD, Knezevich SR, Pepe MS, Carney PA, Titus LJ, Onega T, Tosteson ANA, Weinstock MA, Elmore JG. Pathologist characteristics associated with accuracy and reproducibility of melanocytic skin lesion interpretation. J Am Acad Dermatol 2018; 79:52-59.e5. [PMID: 29524584 PMCID: PMC6016831 DOI: 10.1016/j.jaad.2018.02.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/31/2018] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Diagnostic interpretations of melanocytic skin lesions vary widely among pathologists, yet the underlying reasons remain unclear. OBJECTIVE Identify pathologist characteristics associated with rates of accuracy and reproducibility. METHODS Pathologists independently interpreted the same set of biopsy specimens from melanocytic lesions on 2 occasions. Diagnoses were categorized into 1 of 5 classes according to the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis system. Reproducibility was determined by pathologists' concordance of diagnoses across 2 occasions. Accuracy was defined by concordance with a consensus reference standard. Associations of pathologist characteristics with reproducibility and accuracy were assessed individually and in multivariable logistic regression models. RESULTS Rates of diagnostic reproducibility and accuracy were highest among pathologists with board certification and/or fellowship training in dermatopathology and in those with 5 or more years of experience. In addition, accuracy was high among pathologists with a higher proportion of melanocytic lesions in their caseload composition and higher volume of melanocytic lesions. LIMITATIONS Data gathered in a test set situation by using a classification tool not currently in clinical use. CONCLUSION Diagnoses are more accurate among pathologists with specialty training and those with more experience interpreting melanocytic lesions. These findings support the practice of referring difficult cases to more experienced pathologists to improve diagnostic accuracy, although the impact of these referrals on patient outcomes requires additional research.
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Affiliation(s)
- David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Dermatopathology Northwest, Bellevue, Washington
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie, Paris, France; University of Paris Descartes, Paris, France
| | - Gary M Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon; Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | | | - Margaret S Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Linda J Titus
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, Norris Cotton Cancer Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Anna N A Tosteson
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire; Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Martin A Weinstock
- Center for Dermatoepidemiology, VA Medical Center, Providence Department of Dermatology, Rhode Island Hospital, Providence, Rhode Island; Department of Dermatology, Brown University, Providence, Rhode Island; Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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15
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Pathologists' Use of Second Opinions in Interpretation of Melanocytic Cutaneous Lesions: Policies, Practices, and Perceptions. Dermatol Surg 2018; 44:177-185. [PMID: 28858936 DOI: 10.1097/dss.0000000000001256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Research examining the role of second opinions in pathology for diagnosis of melanocytic lesions is limited. OBJECTIVE To assess current laboratory policies, clinical use of second opinions, and pathologists' perceptions of second opinions for melanocytic lesions. MATERIALS AND METHODS Cross-sectional data collected from 207 pathologists in 10 US states who diagnose melanocytic lesions. The web-based survey ascertained pathologists' professional information, laboratory second opinion policy, use of second opinions, and perceptions of second opinion value for melanocytic lesions. RESULTS Laboratory policies required second opinions for 31% of pathologists and most commonly required for melanoma in situ (26%) and invasive melanoma (30%). In practice, most pathologists reported requesting second opinions for melanocytic tumors of uncertain malignant potential (85%) and atypical Spitzoid lesions (88%). Most pathologists perceived that second opinions increased interpretive accuracy (78%) and protected them from malpractice lawsuits (62%). CONCLUSION Use of second opinions in clinical practice is greater than that required by laboratory policies, especially for melanocytic tumors of uncertain malignant potential and atypical Spitzoid lesions. Quality of care in surgical interventions for atypical melanocytic proliferations critically depends on the accuracy of diagnosis in pathology reporting. Future research should examine the extent to which second opinions improve accuracy of melanocytic lesion diagnosis.
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Elmore JG, Barnhill RL, Elder DE, Longton GM, Pepe MS, Reisch LM, Carney PA, Titus LJ, Nelson HD, Onega T, Tosteson ANA, Weinstock MA, Knezevich SR, Piepkorn MW. Pathologists' diagnosis of invasive melanoma and melanocytic proliferations: observer accuracy and reproducibility study. BMJ 2017; 357:j2813. [PMID: 28659278 PMCID: PMC5485913 DOI: 10.1136/bmj.j2813] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 12/22/2022]
Abstract
Objective To quantify the accuracy and reproducibility of pathologists' diagnoses of melanocytic skin lesions.Design Observer accuracy and reproducibility study.Setting 10 US states.Participants Skin biopsy cases (n=240), grouped into sets of 36 or 48. Pathologists from 10 US states were randomized to independently interpret the same set on two occasions (phases 1 and 2), at least eight months apart.Main outcome measures Pathologists' interpretations were condensed into five classes: I (eg, nevus or mild atypia); II (eg, moderate atypia); III (eg, severe atypia or melanoma in situ); IV (eg, pathologic stage T1a (pT1a) early invasive melanoma); and V (eg, ≥pT1b invasive melanoma). Reproducibility was assessed by intraobserver and interobserver concordance rates, and accuracy by concordance with three reference diagnoses.Results In phase 1, 187 pathologists completed 8976 independent case interpretations resulting in an average of 10 (SD 4) different diagnostic terms applied to each case. Among pathologists interpreting the same cases in both phases, when pathologists diagnosed a case as class I or class V during phase 1, they gave the same diagnosis in phase 2 for the majority of cases (class I 76.7%; class V 82.6%). However, the intraobserver reproducibility was lower for cases interpreted as class II (35.2%), class III (59.5%), and class IV (63.2%). Average interobserver concordance rates were lower, but with similar trends. Accuracy using a consensus diagnosis of experienced pathologists as reference varied by class: I, 92% (95% confidence interval 90% to 94%); II, 25% (22% to 28%); III, 40% (37% to 44%); IV, 43% (39% to 46%); and V, 72% (69% to 75%). It is estimated that at a population level, 82.8% (81.0% to 84.5%) of melanocytic skin biopsy diagnoses would have their diagnosis verified if reviewed by a consensus reference panel of experienced pathologists, with 8.0% (6.2% to 9.9%) of cases overinterpreted by the initial pathologist and 9.2% (8.8% to 9.6%) underinterpreted.Conclusion Diagnoses spanning moderately dysplastic nevi to early stage invasive melanoma were neither reproducible nor accurate in this large study of pathologists in the USA. Efforts to improve clinical practice should include using a standardized classification system, acknowledging uncertainty in pathology reports, and developing tools such as molecular markers to support pathologists' visual assessments.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98104, USA
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie Institute Hospital, University of Paris Descartes Faculty of Medicine University, Paris, France
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary M Longton
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Margaret S Pepe
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lisa M Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98104, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Linda J Titus
- Departments of Epidemiology and Pediatrics, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Heidi D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
- Providence Cancer Center, Providence Health and Services, Portland, OR, USA
| | - Tracy Onega
- Geisel School of Medicine at Dartmouth, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Biomedical Data Science, Department of Epidemiology, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Anna N A Tosteson
- Departments of Medicine and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, RI, USA
- Departments of Dermatology and Epidemiology, Brown University, Providence, RI, USA
| | | | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Dermatopathology Northwest, Bellevue, WA, USA
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17
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Vyas NS, Markow M, Prieto-Granada C, Gaudi S, Turner L, Rodriguez-Waitkus P, Messina JL, Jukic DM. Comparing whole slide digital images versus traditional glass slides in the detection of common microscopic features seen in dermatitis. J Pathol Inform 2016; 7:30. [PMID: 27563489 PMCID: PMC4977977 DOI: 10.4103/2153-3539.186909] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 05/30/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The quality and limitations of digital slides are not fully known. We aimed to estimate intrapathologist discrepancy in detecting specific microscopic features on glass slides and digital slides created by scanning at ×20. METHODS Hematoxylin and eosin and periodic acid-Schiff glass slides were digitized using the Mirax Scan (Carl Zeiss Inc., Germany). Six pathologists assessed 50-71 digital slides. We recorded objective magnification, total time, and detection of the following: Mast cells; eosinophils; plasma cells; pigmented macrophages; melanin in the epidermis; fungal bodies; neutrophils; civatte bodies; parakeratosis; and sebocytes. This process was repeated using the corresponding glass slides after 3 weeks. The diagnosis was not required. RESULTS The mean time to assess digital slides was 176.77 s and 137.61 s for glass slides (P < 0.001, 99% confidence interval [CI]). The mean objective magnification used to detect features using digital slides was 18.28 and 14.07 for glass slides (P < 0.001, 99.99% CI). Parakeratosis, civatte bodies, pigmented macrophages, melanin in the epidermis, mast cells, eosinophils, plasma cells, and neutrophils, were identified at lower objectives on glass slides (P = 0.023-0.001, 95% CI). Average intraobserver concordance ranged from κ = 0.30 to κ = 0.78. Features with poor to fair average concordance were: Melanin in the epidermis (κ = 0.15-0.58); plasma cells (κ = 0.15-0.49); and neutrophils (κ = 0.12-0.48). Features with moderate average intrapathologist concordance were: parakeratosis (κ = 0.21-0.61); civatte bodies (κ = 0.21-0.71); pigment-laden macrophages (κ = 0.34-0.66); mast cells (κ = 0.29-0.78); and eosinophils (κ = 0.31-0.79). The average intrapathologist concordance was good for sebocytes (κ = 0.51-1.00) and fungal bodies (κ = 0.47-0.76). CONCLUSIONS Telepathology using digital slides scanned at ×20 is sufficient for detection of histopathologic features routinely encountered in dermatitis cases, though less efficient than glass slides.
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Affiliation(s)
- Nikki S Vyas
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Markow
- Department of Pathology and Cell Biology, University of South Florida, Tampa, USA
| | - Carlos Prieto-Granada
- Department of Pathology and Cell Biology, University of South Florida, Tampa, USA; Department of Dermatology and Cutaneous Surgery, University of South Florida, Tampa, USA; Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Sudeep Gaudi
- Department of Pathology and Laboratory Medicine Service, James A Haley VA Hospital, Tampa, USA
| | - Leslie Turner
- Department of Dermatology and Cutaneous Surgery, University of South Florida, Tampa, USA; Department of Pathology and Laboratory Medicine Service, James A Haley VA Hospital, Tampa, USA
| | - Paul Rodriguez-Waitkus
- Department of Pathology and Cell Biology, University of South Florida, Tampa, USA; Department of Dermatology and Cutaneous Surgery, University of South Florida, Tampa, USA
| | - Jane L Messina
- Department of Pathology and Cell Biology, University of South Florida, Tampa, USA; Department of Dermatology and Cutaneous Surgery, University of South Florida, Tampa, USA; Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA; Center for Infection Research in Cancer, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Drazen M Jukic
- Department of Pathology and Cell Biology, University of South Florida, Tampa, USA; Department of Dermatology and Cutaneous Surgery, University of South Florida, Tampa, USA; Department of Pathology and Laboratory Medicine Service, James A Haley VA Hospital, Tampa, USA; Georgia Dermatopathology, Savannah, GA, USA; Department of Dermatology, University of Florida, Gainesville, FL, USA
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18
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Kuijpers CCHJ, Burger G, Al-Janabi S, Willems SM, van Diest PJ, Jiwa M. Improved quality of patient care through routine second review of histopathology specimens prior to multidisciplinary meetings. J Clin Pathol 2016; 69:866-71. [PMID: 27030307 DOI: 10.1136/jclinpath-2015-203488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 03/07/2016] [Indexed: 11/04/2022]
Abstract
AIM Double reading may be a valuable tool for improving quality of patient care by identifying diagnostic errors before final sign-out, but standard double reading would significantly increase costs of pathology. We assessed the added value of intradepartmental routine double reading of histopathology specimens prior to multidisciplinary meetings. METHODS Diagnoses, treatment plans and prognoses of patients are often discussed at multidisciplinary meetings. As part of the daily routine, all pathology specimens to be discussed at upcoming multidisciplinary meetings undergo prior intradepartmental double reading. We identified all histopathology specimens from 2013 that underwent such double reading and determined major and minor discordance rates based on clinical relevance between the initial and consensus sign-out diagnoses. RESULTS We included 6796 histopathology specimens that underwent double reading, representing approximately 8% of all histopathology cases at our institution in 2013. Double reading diagnoses were concordant in 6566 specimens (96.6%). Major and minor discordances were observed in 60 (0.9%) and 170 (2.5%) specimens, respectively. Urology specimens had significantly more discordances than other tissues of origin, Gleason grading of prostate cancer biopsies being the most frequent diagnostic problem. Furthermore, premalignant and malignant cases showed significantly higher discordance rates than the rest. The vast majority (90%) of discordances represented changes within the same diagnostic category (eg, malignant to malignant). CONCLUSIONS Routine double reading of histopathology specimens prior to multidisciplinary meetings prevents diagnostic errors. It resulted in about 1% discordant diagnoses of potential clinical significance, indicating that second review is worthwhile in terms of patient safety and quality of patient care.
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Affiliation(s)
- Chantal C H J Kuijpers
- Symbiant Pathology Expert Centre, Alkmaar, The Netherlands Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands PALGA, Houten, The Netherlands
| | - Gerard Burger
- Symbiant Pathology Expert Centre, Alkmaar, The Netherlands
| | | | - Stefan M Willems
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mehdi Jiwa
- Symbiant Pathology Expert Centre, Alkmaar, The Netherlands Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Patrawala S, Maley A, Greskovich C, Stuart L, Parker D, Swerlick R, Stoff B. Discordance of histopathologic parameters in cutaneous melanoma: Clinical implications. J Am Acad Dermatol 2016; 74:75-80. [PMID: 26514601 DOI: 10.1016/j.jaad.2015.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/27/2015] [Accepted: 09/06/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Histopathologic analysis remains the gold standard for the diagnosis of melanoma, however previous studies have shown a substantial rate of interobserver variability in the evaluation of melanocytic lesions. OBJECTIVE We sought to evaluate discordance in the histopathological diagnosis and microstaging parameters of melanoma and subsequent impact on clinical management. METHODS This was a retrospective review of 588 cases of cutaneous melanoma and melanoma in situ from January 2009 to December 2014 that were referred to Emory University Hospital, Atlanta, GA, for treatment. Per institutional policy, all outside melanoma biopsy specimens were reviewed internally. Outside and institutional reports were compared. RESULTS Disagreement between outside and internal reports resulted in a change in American Joint Committee on Cancer pathologic stage in 114/588 (19%) cases, resulting in a change in management based on National Comprehensive Cancer Network guidelines in 105/588 (18%) cases. LIMITATIONS Given the retrospective nature of data collection and the bias of a tertiary care referral center, cases in this study may not be representative of all melanoma diagnoses. CONCLUSION These findings confirm consistent subjectivity in the histopathologic interpretation of melanoma. This study emphasizes that a review of the primary biopsy specimen may lead to significant changes in tumor classification, resulting in meaningful changes in clinical management.
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Affiliation(s)
- Samit Patrawala
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander Maley
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Caitlin Greskovich
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Lauren Stuart
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Douglas Parker
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Robert Swerlick
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Benjamin Stoff
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia.
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20
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Nakhleh RE, Nosé V, Colasacco C, Fatheree LA, Lillemoe TJ, McCrory DC, Meier FA, Otis CN, Owens SR, Raab SS, Turner RR, Ventura CB, Renshaw AA. Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology: Guideline From the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med 2016; 140:29-40. [PMID: 25965939 DOI: 10.5858/arpa.2014-0511-sa] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT Additional reviews of diagnostic surgical and cytology cases have been shown to detect diagnostic discrepancies. OBJECTIVE To develop, through a systematic review of the literature, recommendations for the review of pathology cases to detect or prevent interpretive diagnostic errors. DESIGN The College of American Pathologists Pathology and Laboratory Quality Center in association with the Association of Directors of Anatomic and Surgical Pathology convened an expert panel to develop an evidence-based guideline to help define the role of case reviews in surgical pathology and cytology. A literature search was conducted to gather data on the review of cases in surgical pathology and cytology. RESULTS The panel drafted 5 recommendations, with strong agreement from open comment period participants ranging from 87% to 93%. The recommendations are: (1) anatomic pathologists should develop procedures for the review of selected pathology cases to detect disagreements and potential interpretive errors; (2) anatomic pathologists should perform case reviews in a timely manner to avoid having a negative impact on patient care; (3) anatomic pathologists should have documented case review procedures that are relevant to their practice setting; (4) anatomic pathologists should continuously monitor and document the results of case reviews; and (5) if pathology case reviews show poor agreement within a defined case type, anatomic pathologists should take steps to improve agreement. CONCLUSIONS Evidence exists that case reviews detect errors; therefore, the expert panel recommends that anatomic pathologists develop procedures for the review of pathology cases to detect disagreements and potential interpretive errors, in order to improve the quality of patient care.
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Affiliation(s)
- Raouf E Nakhleh
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida (Dr Nakhleh); the Department of Pathology, Massachusetts General Hospital, Boston (Dr Nosé); Governance (Ms Colasacco) and the Pathology and Laboratory Quality Center (Mss Fatheree and Ventura), College of American Pathologists, Northfield, Illinois; Hospital Pathology Associates, Abbott Northwestern Hospital, Minneapolis, Minnesota (Dr Lillemoe); the Department of Medicine, Duke University, Durham, North Carolina (Dr McCrory); the Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, Michigan (Dr Meier); the Department of Pathology, Baystate Medical Center, Springfield, Massachusetts (Dr Otis); the Department of Pathology, University of Michigan Medical School, Ann Arbor (Dr Owens); the Department of Pathology, Memorial University of Newfoundland/Eastern Health Authority, St John's, Newfoundland, Canada (Dr Raab); the Department of Pathology, St John's Health Center, Santa Monica, California (Dr Turner); and the Department of Pathology, Homestead Hospital, Homestead, Florida (Dr Renshaw). Dr Meier is currently with the Department of Pathology, Massachusetts General Hospital, Boston
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21
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Longo C, Piana S, Lallas A, Moscarella E, Lombardi M, Raucci M, Pellacani G, Argenziano G. Routine Clinical-Pathologic Correlation of Pigmented Skin Tumors Can Influence Patient Management. PLoS One 2015; 10:e0136031. [PMID: 26325678 PMCID: PMC4556521 DOI: 10.1371/journal.pone.0136031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 07/29/2015] [Indexed: 01/16/2023] Open
Abstract
Background Several studies have demonstrated the benefit of integrating clinical with pathologic information, to obtain a confident diagnosis for melanocytic tumors. However, all those studies were conducted retrospectively and no data are currently available about the role of a clinical-pathologic correlation approach on a daily basis in clinical practice. Aim of the Study In our study, we evaluated the impact of a routine clinical-pathologic correlation approach for difficult skin tumors seen over 3 years in a tertiary referral center. Results Interestingly, a re-appraisal was requested for 158 out of 2015 (7.7%) excised lesions because clinical-pathologic correlation was missing. Of note, in 0.6% of them (13 out of 2045) the first histologic diagnosis was revised in the light of clinical information that assisted the Pathologist to re-evaluate the histopathologic findings that might be bland or inconspicuous per se. Conclusion In conclusion, our study demonstrated that an integrated approach involving clinicians and pathologists allows improving management of selected patients by shifting from a simply disease-focused management (melanoma versus nevus) to a patient-centered approach.
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Affiliation(s)
- Caterina Longo
- Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
- * E-mail:
| | - Simonetta Piana
- Pathology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Aimilios Lallas
- Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Elvira Moscarella
- Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Mara Lombardi
- Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Margherita Raucci
- Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | - Giuseppe Argenziano
- Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
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22
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Improved cytodiagnostics and quality of patient care through double reading of selected cases by an expert cytopathologist. Virchows Arch 2015; 466:617-24. [PMID: 25775953 PMCID: PMC4460278 DOI: 10.1007/s00428-015-1738-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/02/2015] [Accepted: 02/04/2015] [Indexed: 11/23/2022]
Abstract
Double reading may be a valuable tool for improving the quality of patient care by restoring diagnostic errors before final sign-out, but standard double reading would significantly increase costs of pathology. The aim of this study was to assess the added value of routine double reading of defined categories of clinical cytology specimens by specialized cytopathologists. Specialized cytopathologists routinely re-diagnosed blinded defined categories of clinical cytology specimens that had been signed out by routine pathologists from January 2012 up to December 2013. Major and minor discordance rates between initial and expert diagnoses were determined, and both diagnoses were validated by comparison with same-site histological follow-up. Initial and expert diagnoses were concordant in 131/218 specimens (60.1 %). Major and minor discordances were present in 28 (12.8 %) and 59 (27.1 %) specimens, respectively. Pleural fluid, thyroid and urine specimens showed the highest major discordance rates (19.4, 19.2 and 16.7 %, respectively). Histological follow-up (where possible) supported the expert diagnosis in 95.5 % of specimens. Our implemented double reading strategy of defined categories of cytology specimens showed major discordance in 12.8 % of specimens. The expert diagnosis was supported in 95.5 % of discordant cases where histological follow-up was available. This indicates that this double reading strategy is worthwhile and contributes to better cytodiagnostics and quality of patient care, especially for suspicious pleural fluid, thyroid and urine specimens. Our results emphasize that cytopathology is a subspecialization of pathology and requires specialized cytopathologists.
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23
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Geller BM, Nelson HD, Carney PA, Weaver DL, Onega T, Allison KH, Frederick PD, Tosteson ANA, Elmore JG. Second opinion in breast pathology: policy, practice and perception. J Clin Pathol 2014; 67:955-60. [PMID: 25053542 DOI: 10.1136/jclinpath-2014-202290] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIMS To assess the laboratory policies, pathologists' clinical practice and perceptions about the value of second opinions for breast pathology cases among pathologists practising in the USA. METHODS Cross-sectional data were collected from 252 pathologists who interpret breast specimens in eight states using a web-based survey. Descriptive statistics were used to characterise findings. RESULTS Most participants had >10 years of experience interpreting breast specimens (64%), were not affiliated with academic centres (73%) and were not considered experts by their peers (79%). Laboratory policies mandating second opinions varied by diagnosis: invasive cancer 65%; ductal carcinoma in situ (DCIS) 56%; atypical ductal hyperplasia 36% and other benign cases 33%. 81% obtained second opinions in the absence of policies. Participants believed they improve diagnostic accuracy (96%) and protect from malpractice suits (83%), and were easy to obtain, did not take too much time and did not make them look less adequate. The most common (60%) approach to resolving differences between the first and second opinion is to ask for a third opinion, followed by reaching a consensus. CONCLUSIONS Laboratory-based second opinion policies vary for breast pathology but are most common for invasive cancer and DCIS cases. Pathologists have favourable attitudes towards second opinions, adhere to policies and obtain them even when policies are absent. Those without a formal policy may benefit from supportive clinical practices and systems that help obtain second opinions.
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Affiliation(s)
- Berta M Geller
- Department of Family Medicine, OHPR, University of Vermont, Burlington, Vermont, USA
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Donald L Weaver
- Department of Pathology, University of Vermont and Vermont Cancer Center, Burlington, Vermont, USA
| | - Tracy Onega
- Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Anna N A Tosteson
- Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington, Seattle, Washington, USA
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24
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Neil DAH, Roberts ISD, Bellamy COC, Wigmore SJ, Neuberger JM. Improved access to histopathology using a digital system could increase the organ donor pool and improve allocation. Transpl Int 2014; 27:759-64. [PMID: 24629110 DOI: 10.1111/tri.12320] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/13/2014] [Accepted: 03/11/2014] [Indexed: 11/30/2022]
Abstract
Improvements in digital slide scanners have reached a stage that digital whole slide images (WSIs) can be used for diagnostic purposes. A digital system for histopathology, analogous to the systems used in radiology, would allow the establishment of networks of subspecialist histopathologists to provide a regional, national or even international rota to support out of hours histopathology for emergency frozen sections, urgent paraffin sections and to generally improve efficiencies with the provision of histopathology services. Such a system would promote appropriate organ utilization by allowing rapid characterization of unexpected lesions in the donor to determine whether donation should occur and further characterization of the organ, such as the degree of fibrosis in the kidney or steatosis in the liver, to determine whether the organ should be used. If introduced across Europe, this would promote safe and effective exchange of organs and support a cost efficient use of pathologist expertise. This review article outlines current issues with the provision of an urgent out of hours histopathology service and focuses on how such a service has the potential to increase organ donors, improve allocation, sharing and the use of available donor organs.
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Affiliation(s)
- Desley A H Neil
- Department of Histopathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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25
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Piepkorn MW, Barnhill RL, Elder DE, Knezevich SR, Carney PA, Reisch LM, Elmore JG. The MPATH-Dx reporting schema for melanocytic proliferations and melanoma. J Am Acad Dermatol 2013; 70:131-41. [PMID: 24176521 DOI: 10.1016/j.jaad.2013.07.027] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 07/12/2013] [Accepted: 07/18/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The histologic diagnosis of melanoma and nevi can be subject to discordance and errors, potentially leading to inappropriate treatment and harm. Diagnostic terminology is not standardized, creating confusion for providers and patients and challenges for investigators. OBJECTIVE We sought to describe the development of a pathology reporting form for more precise research on melanoma and a diagnostic-treatment mapping tool for improved patient care and consistency in treatment. METHODS Three dermatopathologists independently reviewed melanocytic lesions randomly selected from a dermatopathology database. Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) reporting schema evolved from iterative case review and form revision. RESULTS Differences in diagnostic thresholds, interpretation, and nomenclature contributed to development of the MPATH-Dx histology reporting form, which groups lesions by similarities in histogenesis and degrees of atypia. Because preliminary results indicate greater agreement regarding suggested treatments than for specific diagnoses, the diverse terminologies of the MPATH-Dx histology reporting form were stratified by commonalities of treatments in the MPATH-Dx diagnostic-treatment mapping scheme. LIMITATIONS Without transformative advances in diagnostic paradigms, the interpretation of melanocytic lesions frequently remains subjective. CONCLUSIONS The MPATH-Dx diagnostic-treatment mapping scheme could diminish confusion for those receiving reports by categorizing diverse nomenclature into a hierarchy stratified by suggested management interventions.
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Affiliation(s)
- Michael W Piepkorn
- Division of Dermatology, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Dermatopathology Northwest, Bellevue, Washington.
| | - Raymond L Barnhill
- Department of Pathology and Laboratory Medicine, University of California at Los Angeles, Los Angeles, California
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Patricia A Carney
- Department of Family Medicine, Oregon Health Sciences University, Portland, Oregon
| | - Lisa M Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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