Under the microscope: doctors, lawyers, and melanocytic neoplasms

Dermatopathological Correlation of Clinically Challenging Cutaneous Lesions: a Single Center Experience of 2184 Cases

INTRODUCTION

Although a trained eye can easily identify typical skin lesions, histopathological examination and clinicopathological correlation are critical in challenging cases.

OBJECTIVES

The primary objective is to organize the final diagnoses reached following clinicopathological consensus in clinically challenging cutaneous lesions, identifying the most common diagnostic scenarios encountered by dermatopathologists and discussing their diverse differentials submitted by clinicians. The secondary objective is to investigate how the case profile and clinician decision-making processes evolved during the COVID-19 pandemic.

METHODS

Skin and mucosa samples collected by the dermatology department between 2016 and 2020 were classified based on pathology reports. For frequent diagnoses, preliminary diagnoses stated by clinicians on pathology requisition forms were reviewed. The years preceding and following the first nationally reported COVID-19 case were compared to investigate the pandemic's impact on the distribution of dermatology and dermatopathology cases.

RESULTS

One thousand nine hundred and eighty-nine reports were classified into 4 major categories: inflammatory (49.8%), neoplastic (30.1%), other diseases (7.1%), and non-diagnostic (12.8%). We further classified inflammatory diseases based on major tissue reaction patterns and neoplasms based on cell origin. We analyzed the leading diagnoses in each category, discussed their differential diagnoses, and provided clinicians with clues to reduce errors in practice. Following the pandemic, the overall number of pathology reports and patient admissions dropped dramatically, with significant changes in case profiles.

CONCLUSIONS

We presented and discussed the frequently encountered confounding cases to sketch the diagnostic landscape. In the authors' experience, clinicopathological correlation can increase the rate of reaching the diagnosis by up to 75.3%.

Reforms, Errors, and Dermatopathology Malpractice: Then and Now: A Comprehensive Retrospective

Medical malpractice occurs when a hospital, doctor, or other health care professional, through a negligent act or omission, causes an injury to a patient. The negligence might be the result of errors in diagnosis, treatment, aftercare, or health management. To be considered medical malpractice under the law, the claim must violate the standard of care, the injury must be caused by the negligence and, last but most certainly not least, the injury must result in significant damages. This review is an overview of medicolegal issues specific to the practice of Dermatopathology with the caveat that most are likely pertinent to other specialties of pathology as well. The safety of patients remains the priority in pathology as it does in any medical undertaking, and this is no different in the practice of Dermatopathology. The review is broadly divided in 2 parts-we begin with an overview of tort reforms, advocated by physicians to reduce costs associated with malpractice defense. In the second part we address practical issues specific to the practice of pathology and dermatopathology. These include among others, errors-related to the biopsy type, inadequacy of clinical information regarding the lesion that is biopsied, role of interstate dermatopathology as well as examples of select entities commonly misdiagnosed in dermatopathology. In the last decade, artificial intelligence (AI) has moved to the forefront of technology. While research into the uses of AI in pathology is promising, the use of AI in diagnostic practice is still somewhat uncommon. Given that AI is not fully integrated routinely as a diagnostic adjunct, its' impact on pathology-specific medicolegal issues cannot, as yet at least, be defined. Restriction of medical malpractice is of particular relevance in the COVID-19 era, a period that is anything but normal. The response of states with specific pandemic-related guidelines is addressed with the caveat that this particular issue is only covered in select states. Furthermore, given that the COVID pandemic is only a year old, while it does not appear to have had an immediate impact on pathology-specific medicolegal matters, it is possible that the role of COVID on this issue, if any at all, will and can only be fully defined a few years down the line.

Medical Malpractice in Dermatology-Part I: Reducing the Risks of a Lawsuit

Malpractice risk is a common source of concern for the practicing physician. Dermatologists experience fewer lawsuits than most other specialists in medicine, but the risk is not negligible. All physicians should familiarize themselves with areas of potential risk and avoid medico-legal pitfalls. We present Part I of a two-part series addressing medico-legal questions common to most practitioners that cause a great deal of anxiety. Part I will focus upon risk management and prevention of future malpractice lawsuits, and Part II deals with suggestions and guidance once a lawsuit occurs. Herein, we discuss the primary sources of malpractice lawsuits delivered against healthcare practitioners including issues with informed consent, patient noncompliance, medical negligence, and inappropriate documentation, including use of electronic medical records. The overall goal is to effectively avoid these common sources of litigation. The risk management strategies discussed in this paper are relevant to the everyday practitioner and may offer physicians some degree of protection from potential liability.

Main clues in the pathologic diagnosis of melanoma: is molecular genetics helping?

Although conventional histopathologic examination is still the undisputable mainstay for the diagnosis of melanocytic skin neoplasms, application of molecular testing has experienced tremendous growth and will continue to expand in the future as the need for more specific diagnoses and new targeted therapies evolve. Ancillary molecular methods, including comparative genomic hybridization and fluorescence in situ hybridization, have the potential to provide important new information to challenging cases, and will help improve diagnostic accuracy, particularly in cases in which morphology is not conclusive. Pathologists are increasingly involved in the prospective genotyping of melanoma, which leads to patient stratification in light of the novel personalized therapeutic approaches in the advanced setting.

The melanoma 'epidemic': lessons from prostate cancer

The rise in malignant melanoma incidence has been termed "epidemic". Closer scrutiny of epidemiologic data suggests overdiagnosis as the true cause of the dramatic rise in melanoma incidence. In epidemiologic terms, "overdiagnosis" describes lesions that are histologically malignant but biologically benign. Overdiagnosis is not unique to melanoma screening but is prevalent in screening for cancers of other organs, including the thyroid and prostate glands.

Ethical considerations in alleged dermatologic malpractice

Although dermatology does not lead the list of specialties most commonly sued for malpractice, anyone who has been the recipient of a malpractice claim is often traumatized both personally and professionally. Every day dermatologists must address various ethical concerns that have legal implications. Herein, we chose to discuss the following such issues: (1) the ethical and legal necessity of submitting a clinically benign appearing lesion for dermatopathologic review; (2) the ethical and legal considerations regarding frequency of screening after a patient has been diagnosed with melanoma; (3) the multiple ethical and legal considerations involved with the misdiagnosis of a melanoma; (4) the complex ethical and legal considerations of a dermatologist making a clinical diagnosis in a nonprofessional social and public setting; and (5) the ethical and legal implications of sharing care of patients with other dermatologists and specialists.

A comprehensive analysis of a web-based dermatopathology second opinion consultation practice

CONTEXT

Sharing cases and seeking second opinion consultations is an important part of everyday pathology practice. Internet-based communications and upcoming digital slide technologies have the potential to decrease barriers and open access to the best expertise. We recently developed a dedicated Web-based process for communication with outside practices seeking second opinion consultations. The software allowed us to collect data about the current needs and use of a second opinion consultation practice, a topic that has not been addressed in research studies thus far.

OBJECTIVE

To analyze the needs for and performance of a Web-based second opinion consultation practice in dermatopathology.

DESIGN

We performed a retrospective analysis on paper and digital records.

RESULTS

The average turn-around time from the time of biopsy to the time the report was issued was 7-days. Eighty-two percent of cases were reported the same day they were received. Biopsies of melanocytic lesions, inflammatory dermatoses, and squamous lesions comprised 82% of consultations. Among the remaining cases, soft tissue tumors, adnexal neoplasms, alopecia, and nonmelanoma nonsquamous lesions were the most common diagnoses. In 69% of cases, the outside report contained information about the diagnosis favored by the submitting pathologists. In 5%, there was a significant change in the diagnosis.

CONCLUSIONS

Web-based communication facilitates rapid turn-around time and reduces costs and barriers to second opinion consultation.

[Skin biopsy with histopathologic analysis: why? what for? how? part II]

Skin biopsy is a common procedure in dermatology practice. The cost-benefit ratio, though, can be unfavorable if attention is not paid to specific details in performing a skin biopsy. For example, proper selection of anatomical site and best lesion to perform a biopsy are very important. The present article discusses those and other variables that directly influence the satisfaction level of the dermatologist who undertakes it, the pathologist who analysis it and the patient of whom the biopsy is taken.

Histopathological characterization of primary cutaneous melanoma using infrared microimaging: a proof-of-concept study

BACKGROUND

The diagnosis of malignant melanoma is based upon the histological evaluation of the lesion. As such, the morphological interpretation relies on the expertise of a dermatopathologist. Infrared microimaging is emerging as a new powerful tool to investigate tissue biochemistry. Infrared spectra probe the biochemical constitution of the sample and are real tissue-specific spectroscopic fingerprints.

OBJECTIVES

To assess the potential of infrared microimaging to aid in the analysis of tissue sections from primary cutaneous melanomas.

METHODS

Ten samples of melanoma sections from the main histological subtypes were investigated using infrared microimaging combined with multivariate statistical analyses.

RESULTS

This methodology yielded highly contrasted colour-coded images that permitted to highlight tissue architecture without any staining. It was possible to discriminate tumour areas from normal epidermis automatically, and intratumoral heterogeneity as revealed by our approach was correlated with the aggressiveness of the tumour.

CONCLUSIONS

This proof-of-concept study shows that infrared microimaging could help in the diagnosis of primary cutaneous melanoma.

Pigmented lesion pathology: what you should expect from your pathologist, and what your pathologist should expect from you

The first part of this review examines the reliability of histologic diagnosis in pigmented lesions, as measured by concordance studies and medicolegal analysis. It emphasizes the role of clinicians in maximizing that reliability, by providing adequate clinical descriptions, using appropriate biopsy technique, and critically interpreting pathology reports. It identifies those entities that are especially problematic, either because they cannot be reliably recognized by the histopathologist or because their histology is a poor guide to their biologic behavior. The second part of the review is a guide to some of the more difficult and controversial pigmented lesions, including dysplastic nevus, spitzoid nevi and melanomas, cellular blue nevus, animal-type melanoma, and deep penetrating nevus.

Medicolegal liability in surgical pathology: a consideration of underlying causes and selected pertinent concepts

Malpractice actions against surgical pathologists are still relatively uncommon, but they have increased in frequency over time and are associated with sizable indemnity figures. This discussion categorizes areas of liability in surgical pathology into three groups: those that represent health system flaws (problems with specimen identification, or transportation, or both; lack of clinical information or erroneous information; sampling effects and defects; and poorly reproducible or poorly defined diagnostic or prognostic criteria), others that exist at the interface between the system and individuals (allowing clinicians to bypass pathologic review of referred specimens; acceding to clinical demands for inadvisable procedures; and working in a disruptive environment), and truly individual errors by pathologists (lapses in reasoning; deficiencies concerning continuity in the laboratory; invalid assumptions regarding recipients of surgical pathology reports; over-reliance on the results of "special" tests; and problems with peer consultation). Finally, two important topic areas are discussed that commonly enter into lawsuits filed against surgical pathologists; namely, "delay in diagnosis" of malignant neoplasms and "failure to provide adequate prognostic information." Based on a review of the pertinent literature, we conclude that the clinical courses of most common malignancies are not affected in a significant manner by delays in diagnosis. Moreover, the practice of using "personalized external validity" for supposedly prognostic tests is examined, with the resulting opinion that prognostication of tumor behavior in individual patients is not reliable using anything but anatomic staging systems.

Medicolegal aspects of neoplastic dermatology

Medical malpractice litigation is rising at an explosive rate in the US and, to a lesser extent, in Canada. The impact of medical malpractice litigation on health care costs and the cost of insurance is dramatic. Certain specialist categories are becoming uninsurable in some parts of the US, while in others, clinicians are retiring early, restricting or changing practice or changing states of residence in consequence of medical malpractice claims and of the cost and availability of insurance. This, in turn, has had the real effect of denying care to patients in some communities in the US. Some 13% of all medical malpractice claims relate to one area of neoplastic dermatopathology, specifically, melanocytic neoplasia. Certain steps can be taken by pathology laboratories to reduce, but never completely eliminate, the risk of medical malpractice claims. In this review, attention is paid to the source of medical malpractice claims and an abbreviated approach to specific strategies for risk management is presented.

Interobserver reproducibility of histological features in cutaneous malignant melanoma

AIMS

To assess the interobserver reproducibility of certain histological features proposed for the diagnosis of melanoma.

METHODS

In a series of melanomas, 13 histological parameters were analysed: dimension > 6 mm, asymmetry, poor circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, asymmetrical melanin, melanin in deep cells, cytological atypia, mitoses, dermal lymphocytic infiltrate, and necrosis.

RESULTS

The agreement (reproducibility) between the nine observers was excellent (kappa > 0.75) for 10 of the 13 examined features (dimension > 6 mm, poor circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, asymmetrical melanin, melanin in deep cells, mitoses, and necrosis). The agreement for asymmetry was very close to excellence (kappa = 0.74), and that for cytological atypia (kappa = 0.65) and dermal lymphocytic infiltrate (kappa = 0.47) was slightly lower, but in the fair to good agreement range. The kappa values obtained by comparison with the majority diagnosis were generally high (> or = 0.85); the mean value of kappa was lower (0.70) for only one parameter (dermal lymphocytic infiltrate).

CONCLUSIONS

The parameters investigated showed an overall good reproducibility.

Childhood melanoma: update and treatment

Childhood melanoma is a rare but potentially fatal disease that is important to include in the differential diagnosis of any pigmented lesion in a child. The best prognosis is achieved with early diagnosis and definitive surgical excision. Adjuvant chemotherapy and immunotherapy are options for those with more advanced tumors. Melanoma in children must be treated as aggressively as in adults because childhood melanoma may be equally devastating.

Dermatology's malpractice experience: Clinical settings for risk management

BACKGROUND

Dermatologists need objective information that will help them make rational risk management decisions.

OBJECTIVE

We asked, "What can be learned from the limited sources available regarding the clinical situations associated with malpractice litigation against dermatologists?"

METHODS

We searched 2 legal databases, one jury verdict and settlement reporter, and reviewed and analyzed a major report from an association of physician insurers.

RESULTS

A wide variety of clinical circumstances give rise to malpractice claims. Melanoma is still associated with high risk, and common conditions are associated with relative claim frequency. The clinical details currently available do not encourage optimal responses to reports of malpractice cases.

CONCLUSION

Information that clinicians can use in their own risk management efforts can be derived from available sources, but more reliable objective data is needed.

Heat shock protein 27 is expressed in normal and malignant human melanocytes in vivo

BACKGROUND

Heat shock proteins (HSPs) are a family of highly conserved proteins found ubiquitously in mammalian cells, believed to be regulators of normal cell physiology and the cellular stress response. In addition, the small 27-kDa heat shock protein (HSP27) has previously been found to be a differentiation marker for keratinocytes and a prognostic marker associated with increased survival in certain cancerous tumors.

METHODS

Using immunohistochemistry on routinely processed paraffin sections, we examined skin biopsies from 15 invasive melanomas, 13 intradermal nevi, and two compound nevi immunostained with a mouse monoclonal antibody to HSP27. In addition, cultured melanocytes were heat stressed at 45 degrees C for 1 h and then fixed and immunostained in order to localize HSP27 expression intracellularly.

RESULTS

We found cytoplasmic and strong perinuclear staining of HSP27 in melanocytes in normal skin, in melanomas, and in nevi. Nuclear reactivity was absent. In addition, in cultured non-malignant melanocytes, HSP27 expression relocated from the cytoplasm to the nucleus with heat stress.

CONCLUSIONS

To our knowledge, this investigation is the first to demonstrate that HSP27 is expressed in melanocytes in normal skin, in nevi, and in non-malignant cultured melanocytes.