1
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Scope A, Liopyris K, Weber J, Barnhill RL, Braun RP, Curiel-Lewandrowski CN, Elder DE, Ferrara G, Grant-Kels JM, Jeunon T, Lallas A, Lin JY, Marchetti MA, Marghoob AA, Navarrete-Dechent C, Pellacani G, Soyer HP, Stratigos A, Thomas L, Kittler H, Rotemberg V, Halpern AC. International Skin Imaging Collaboration-Designated Diagnoses (ISIC-DX): Consensus terminology for lesion diagnostic labeling. J Eur Acad Dermatol Venereol 2024. [PMID: 38733254 DOI: 10.1111/jdv.20055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/16/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND A common terminology for diagnosis is critically important for clinical communication, education, research and artificial intelligence. Prevailing lexicons are limited in fully representing skin neoplasms. OBJECTIVES To achieve expert consensus on diagnostic terms for skin neoplasms and their hierarchical mapping. METHODS Diagnostic terms were extracted from textbooks, publications and extant diagnostic codes. Terms were hierarchically mapped to super-categories (e.g. 'benign') and cellular/tissue-differentiation categories (e.g. 'melanocytic'), and appended with pertinent-modifiers and synonyms. These terms were evaluated using a modified-Delphi consensus approach. Experts from the International-Skin-Imaging-Collaboration (ISIC) were surveyed on agreement with terms and their hierarchical mapping; they could suggest modifying, deleting or adding terms. Consensus threshold was >75% for the initial rounds and >50% for the final round. RESULTS Eighteen experts completed all Delphi rounds. Of 379 terms, 356 (94%) reached consensus in round one. Eleven of 226 (5%) benign-category terms, 6/140 (4%) malignant-category terms and 6/13 (46%) indeterminate-category terms did not reach initial agreement. Following three rounds, final consensus consisted of 362 terms mapped to 3 super-categories and 41 cellular/tissue-differentiation categories. CONCLUSIONS We have created, agreed upon, and made public a taxonomy for skin neoplasms and their hierarchical mapping. Further study will be needed to evaluate the utility and completeness of the lexicon.
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Affiliation(s)
- Alon Scope
- The Kittner Skin Cancer Screening & Research Institute, Sheba Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Konstantinos Liopyris
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Dermatology-Venereology, University of Athens Medical School, Athens, Greece
| | - Jochen Weber
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Raymond L Barnhill
- Department of Translational Research, Institut Curie, and UFR de Médecine, Université de Paris, Paris, France
| | - Ralph P Braun
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Clara N Curiel-Lewandrowski
- Department of Dermatology, University of Arizona College of Medicine, and the University of Arizona Cancer Center Skin Cancer Institute, Tucson, Arizona, USA
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gerardo Ferrara
- Anatomic Pathology and Cytopathology Unit, Istituto Nazionale Tumori IRCCS Fondazione 'G. Pascale', Naples, Italy
| | - Jane M Grant-Kels
- Department of Dermatology, UConn Health, Farmington, Connecticut, USA
- Department of Dermatology, University of Florida, Gainesville, Florida, USA
| | - Thiago Jeunon
- Departments of Dermatology and Pathology, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Aimilios Lallas
- First Department of Dermatology, Aristotle University, Thessaloniki, Greece
| | - Jennifer Y Lin
- Department of Dermatology, Brigham and Women's Hospital and Melanoma Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael A Marchetti
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ashfaq A Marghoob
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Cristian Navarrete-Dechent
- Melanoma and Skin Cancer Unit and Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Giovanni Pellacani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena and Dermatology Clinic, University of Rome, Rome, Italy
| | - Hans Peter Soyer
- The University of Queensland Diamantina Institute, University of Queensland, Dermatology Research Centre, Brisbane, Queensland, Australia
| | - Alexander Stratigos
- 1st Department of Dermatology-Venereology, Andreas Sygros Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Luc Thomas
- Dermatology Department, Hôpital Universitaire Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Harald Kittler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Veronica Rotemberg
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Allan C Halpern
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Kose K, Rotemberg V. The Promise and Drawbacks of Federated Learning for Dermatology AI. JAMA Dermatol 2024; 160:269-270. [PMID: 38324308 DOI: 10.1001/jamadermatol.2023.5410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Kivanc Kose
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Veronica Rotemberg
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
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3
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Green AR, Moshiri A, Hippe DS, Raymundo C, Piepkorn M, Shinohara MM. Differences in nomenclature usage and preference among dermatopathologists for "dysplastic" nevi: A national survey. J Cutan Pathol 2023; 50:530-535. [PMID: 36239041 DOI: 10.1111/cup.14341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Ongoing controversy exists regarding terminology used to describe atypical melanocytic nevi. Efforts to standardize nomenclature, including the 1992 NIH consensus conference, have been largely unsuccessful. Significant advances have revealed an increasingly detailed genetic picture of melanocytic neoplasms, including strong evidence for the existence of those with "intermediate" behavior. METHODS We sent an electronic survey to dermatopathologists (n = 846) to assess trends in nomenclature usage and attitudes toward developing new consensus nomenclature for atypical melanocytic nevi. RESULTS There were 229 complete responses (27.1% response rate). The most used/preferred nomenclature was "dysplastic nevus" (43%/39%, respectively), followed by the NIH-recommended terminology (28%/26%). Three-tier grading systems were most heavily used/preferred (79%/63%). Dermatopathologists based in New England were most likely to use the NIH terminology; on the other hand, "dysplastic nevus" or "other" were most used elsewhere (p = 0.029). Most (76%) expressed at least "moderate" enthusiasm for developing consensus nomenclature, with 47% "very" or "extremely" enthusiastic. CONCLUSION Little has changed with the wide variation in terminology for atypical melanocytic nevi. There continues to be no one dominant terminology in use. However, there is enthusiasm for standardization. A new attempt at updated consensus nomenclature may be fruitful.
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Affiliation(s)
- Austin R Green
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Ata Moshiri
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Daniel S Hippe
- Cancer Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Caroline Raymundo
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | | | - Michi M Shinohara
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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4
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Gjersvik P, Veierød MB, Thompson A, Grzyb K, Liland KH, Vazov N, Roscher I, Bassarova AV. Histopathologic reassessment of melanoma and other melanocytic skin lesions excised in 2009 and 2018–2019. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2022; 142:22-0204. [PMID: 36286556 DOI: 10.4045/tidsskr.22.0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Histopathological assessment of melanoma and other melanocytic skin lesions can be difficult and can vary between pathologists. MATERIAL AND METHOD Histopathological slides of 196 melanocytic skin lesions from 2009 and 2018-2019 were obtained from the archive of the Department of Pathology at Oslo University Hospital and classified into six diagnostic categories: 1) benign nevus, 2) irregular/dysplastic nevus, i.e. dysplastic nevus with moderate atypia, 3) nevus with severe atypia, i.e. dysplastic nevus with severe atypia, 4) melanoma in situ, 5) superficial spreading or lentiginous melanoma and 6) nodular melanoma. The slides were then examined independently and blindly by three experienced pathologists and categorised in the same way. Interobserver agreement was assessed with Cohen's kappa, and agreement with the original diagnosis was assessed by the proportion of assessments in the same diagnostic category. RESULTS The kappa values for the assessments from the three pathologists ranged from 0.45 to 0.50. The proportion of reassessments in agreement with the original diagnostic category was 85.7 % (95 % CI 75.7 to 92.1), 29.2 % (19.9 to 40.5), 27.8 % (20.9 to 36.0), 78.3 % (70.4 to 84.5), 81.2 % (73.7 to 86.9) and 93.3 % (82.1 to 97.7), respectively, i.e. highest for nodular melanoma. The proportion of reassessments in which the diagnosis was more serious or less serious than the original diagnosis was higher and lower, respectively, for slides from 2009 than for slides from 2018-2019. INTERPRETATION The differences between the pathologists' assessments and deviations from the original diagnoses can be explained by poorly reproducible diagnostic criteria, diagnostic entities with overlapping morphology and increasing awareness of early signs of malignancy. Some evolution in diagnostic practice cannot be ruled out.
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Affiliation(s)
- Petter Gjersvik
- Institutt for klinisk medisin, Universitetet i Oslo, og, Seksjon for hudsykdommer, Oslo universitetssykehus
| | - Marit B Veierød
- Oslo senter for biostatistikk og epidemiologi, og, Avdeling for biostatistikk, Institutt for medisinske basalfag, Universitetet i Oslo
| | - Alec Thompson
- Avdeling for patologi, Oslo universitetssykehus, Ullevål sykehus
| | - Krzysztof Grzyb
- Avdeling for patologi, Oslo universitetssykehus, Rikshospitalet
| | | | - Nikolay Vazov
- Seksjon for forskningsinfrastruktur, Universitetet i Oslo
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5
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Kerr KF, Longton GM, Reisch LM, Radick AC, Eguchi MM, Shucard HL, Pepe MS, Piepkorn MW, Elder DE, Barnhill RL, Elmore JG. Histopathological diagnosis of cutaneous melanocytic lesions: blinded and nonblinded second opinions offer similar improvement in diagnostic accuracy. Clin Exp Dermatol 2022; 47:1658-1665. [PMID: 35426450 PMCID: PMC9391266 DOI: 10.1111/ced.15219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous studies of second opinions in the diagnosis of melanocytic skin lesions have examined blinded second opinions, which do not reflect usual clinical practice. The current study, conducted in the USA, investigated both blinded and nonblinded second opinions for their impact on diagnostic accuracy. METHODS In total, 100 melanocytic skin biopsy cases, ranging from benign to invasive melanoma, were interpreted by 74 dermatopathologists. Subsequently, 151 dermatopathologists performed nonblinded second and third reviews. We compared the accuracy of single reviewers, second opinions obtained from independent, blinded reviewers and second opinions obtained from sequential, nonblinded reviewers. Accuracy was defined with respect to a consensus reference diagnosis. RESULTS The mean case-level diagnostic accuracy of single reviewers was 65.3% (95% CI 63.4-67.2%). Second opinions arising from sequential, nonblinded reviewers significantly improved accuracy to 69.9% (95% CI 68.0-71.7%; P < 0.001). Similarly, second opinions arising from blinded reviewers improved upon the accuracy of single reviewers (69.2%; 95% CI 68.0-71.7%). Nonblinded reviewers were more likely than blinded reviewers to give diagnoses in the same diagnostic classes as the first diagnosis. Nonblinded reviewers tended to be more confident when they agreed with previous reviewers, even with inaccurate diagnoses. CONCLUSION We found that both blinded and nonblinded second reviewers offered a similar modest improvement in diagnostic accuracy compared with single reviewers. Obtaining second opinions with knowledge of previous reviews tends to generate agreement among reviews, and may generate unwarranted confidence in an inaccurate diagnosis. Combining aspects of both blinded and nonblinded review in practice may leverage the advantages while mitigating the disadvantages of each approach. Specifically, a second pathologist could give an initial diagnosis blinded to the results of the first pathologist, with subsequent nonblinded discussion between the two pathologists if their diagnoses differ.
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Affiliation(s)
- Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Gary M Longton
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lisa M Reisch
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Andrea C Radick
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Megan M Eguchi
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Hannah L Shucard
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Margaret S Pepe
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Dermatopathology Northwest, Bellevue, WA, USA
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Raymond L Barnhill
- Department of Translational Research, Institut Curie, Paris, France
- UFR of Medicine, University of Paris, Paris, France
| | - Joann G Elmore
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
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6
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Elmore JG, Eguchi MM, Barnhill RL, Reisch LM, Elder DE, Piepkorn MW, Brunyé TT, Radick AC, Shucard HL, Knezevich SR, Kerr KF. Effect of Prior Diagnoses on Dermatopathologists' Interpretations of Melanocytic Lesions: A Randomized Controlled Trial. JAMA Dermatol 2022; 158:1040-1047. [PMID: 35947391 PMCID: PMC9366662 DOI: 10.1001/jamadermatol.2022.2932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/29/2022] [Indexed: 11/14/2022]
Abstract
Importance Medical second opinions are common, although little is known about the best processes for obtaining them. This study assesses whether knowledge of a prior physician's diagnosis influences consulting physicians' diagnoses. Objective To measure the extent to which dermatopathologists' diagnoses are influenced by prior diagnostic information from another dermatopathologist. Design, Setting, and Participants Dermatopathologists were randomly assigned to interpret 1 slide set of 18 melanocytic skin biopsy specimens in 2 phases (5 slide sets totaling 90 cases). Phase 1 interpretations were conducted without prior diagnostic information. After a washout period of 12 or more months, dermatopathologists' phase 2 interpretations were conducted with their identical slide set; for a random subset of cases in phase 2, participants were shown prior diagnoses by other dermatopathologists that were either more or less severe than their own phase 1 diagnosis of the case. Using the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis tool, cases ranged from class I (benign) to class V (≥pT1b invasive melanoma). Data collection took place from August 2018 to March 2021, and data analysis was performed from March to December 2021. Intervention Prior diagnoses were actual diagnoses from board-certified and/or fellowship-trained dermatopathologists. A prior diagnosis was always in a more severe or less severe diagnostic class than the participant's phase 1 interpretation; more or less severe was determined by the randomization scheme. In the control condition of no prior diagnostic information, the participants were told that a prior diagnosis was not available. Main Outcomes and Measures When exposure was to a prior diagnosis in a higher diagnostic class, the primary study outcome was whether a participant's diagnosis in phase 2 was in a higher diagnostic class than the participant's diagnosis in phase 1. When exposure was to a prior diagnosis in a lower diagnostic class, the primary study outcome was whether a participant's diagnosis in phase 2 was in a lower diagnostic class than the participant's diagnosis in phase 1. The effect of prior diagnostic information was measured using the relative risk (RR) of each outcome relative to the control condition of no prior diagnostic information, adjusted for the diagnostic class of the phase 1 diagnosis. Prior to data collection, it was hypothesized that participants would be swayed in the direction of prior diagnostic information. Results A total of 149 dermatopathologists (median [range] age, 47 years [34-76] years; 101 [68%] were male) provided 5322 interpretations of study cases. Participants were more likely to increase the severity of their diagnosis when the prior diagnosis was of greater severity compared with when no prior diagnosis was provided (RR, 1.52; 95% CI, 1.34-1.73); likewise, participants gave less severe diagnoses when prior diagnoses were of lesser severity (RR, 1.38; 95% CI, 1.19-1.59). Trends were similar among dermatopathologists who had previously stated they were "not at all influenced" by prior diagnoses. Prior diagnoses also swayed dermatopathologists away from correct diagnoses. Conclusions and Relevance In this randomized controlled trial, despite the preference of most dermatopathologists to receive prior diagnoses when providing second opinions, this information swayed them away from a correct diagnosis to an incorrect diagnosis.
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Affiliation(s)
- Joann G. Elmore
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine
| | - Megan M. Eguchi
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine
| | - Raymond L. Barnhill
- Department of Translational Research, Institut Curie, Paris Sciences and Lettres Research University, and Faculty of Medicine University of Paris Descartes, Paris, France
| | - Lisa M. Reisch
- Department of Biostatistics, University of Washington, Seattle
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | - Tad T. Brunyé
- Center for Applied Brain and Cognitive Sciences, Tufts University, Medford, Massachusetts
| | - Andrea C. Radick
- Department of Medicine, University of Washington School of Medicine, Seattle
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7
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Katz I, O’Brien B, Clark S, Thompson CT, Schapiro B, Azzi A, Lilleyman A, Boyle T, Espartero LJL, Yamada M, Prow TW. Assessment of a Diagnostic Classification System for Management of Lesions to Exclude Melanoma. JAMA Netw Open 2021; 4:e2134614. [PMID: 34889949 PMCID: PMC8665368 DOI: 10.1001/jamanetworkopen.2021.34614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
Importance The proposed MOLEM (Management of Lesion to Exclude Melanoma) schema is more clinically relevant than Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MATH-Dx) for the management classification of melanocytic and nonmelanocytic lesions excised to exclude melanoma. A more standardized way of establishing diagnostic criteria will be crucial in the training of artificial intelligence (AI) algorithms. Objective To examine pathologists' variability, reliability, and confidence in reporting melanocytic and nonmelanocytic lesions excised to exclude melanoma using the MOLEM schema in a population of higher-risk patients. Design, Setting, and Participants This cohort study enrolled higher-risk patients referred to a primary care skin clinic in New South Wales, Australia, between April 2019 and December 2019. Baseline demographic characteristics including age, sex, and related clinical details (eg, history of melanoma) were collected. Patients with lesions suspicious for melanoma assessed by a primary care physician underwent clinical evaluation, dermoscopy imaging, and subsequent excision biopsy of the suspected lesion(s). A total of 217 lesions removed and prepared by conventional histologic method and stained with hematoxylin-eosin were reviewed by up to 9 independent pathologists for diagnosis using the MOLEM reporting schema. Pathologists evaluating for MOLEM schema were masked to the original histopathologic diagnosis. Main Outcomes and Measures Characteristics of the lesions were described and the concordance of cases per MOLEM class was assessed. Interrater agreement and the agreement between pathologists' ratings and the majority MOLEM diagnosis were calculated by Gwet AC1 with quadratic weighting applied. The diagnostic confidence of pathologists was then assessed. Results A total of 197 patients were included in the study (102 [51.8%] male; 95 [48.2%] female); mean (SD) age was 64.2 (15.8) years (range, 24-93 years). Overall, 217 index lesions were assessed with a total of 1516 histological diagnoses. Of 1516 diagnoses, 677 (44.7%) were classified as MOLEM class I; 120 (7.9%) as MOLEM class II; 564 (37.2%) as MOLEM class III; 114 (7.5%) as MOLEM class IV; and 55 (3.6%) as MOLEM class V. Concordance rates per MOLEM class were 88.6% (class I), 50.8% (class II), 76.2% (class III), 77.2% (class IV), and 74.2% (class V). The quadratic weighted interrater agreement was 91.3%, with a Gwet AC1 coefficient of 0.76 (95% CI, 0.72-0.81). The quadratic weighted agreement between pathologists' ratings and majority MOLEM was 94.7%, with a Gwet AC1 coefficient of 0.86 (95% CI, 0.84-0.88). The confidence in diagnosis data showed a relatively high level of confidence (between 1.0 and 1.5) when diagnosing classes I (mean [SD], 1.3 [0.3]), IV (1.3 [0.3]) and V (1.1 [0.1]); while classes II (1.8 [0.2]) and III (1.5 [0.4]) were diagnosed with a lower level of pathologist confidence (≥1.5). The quadratic weighted interrater confidence rating agreement was 95.2%, with a Gwet AC1 coefficient of 0.92 (95% CI, 0.90-0.94) for the 1314 confidence ratings collected. The confidence agreement for each MOLEM class was 95.0% (class I), 93.5% (class II), 95.3% (class III), 96.5% (class IV), and 97.5% (class V). Conclusions and Relevance The proposed MOLEM schema better reflects clinical practice than the MPATH-Dx schema in lesions excised to exclude melanoma by combining diagnoses with similar prognostic outcomes for melanocytic and nonmelanocytic lesions into standardized classification categories. Pathologists' level of confidence appeared to follow the MOLEM schema diagnostic concordance trend, ie, atypical naevi and melanoma in situ diagnoses were the least agreed upon and the most challenging for pathologists to confidently diagnose.
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Affiliation(s)
- Ian Katz
- Southern Sun Pathology, Sydney, New South Wales, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Blake O’Brien
- Sullivan Nicolaides Pathology, Brisbane, Queensland, Australia
| | - Simon Clark
- Douglass Hanly Moir Pathology, Sydney, New South Wales, Australia
| | | | | | - Anthony Azzi
- Newcastle Skin Check, Charlestown, New South Wales, Australia
| | | | - Terry Boyle
- Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Lore Jane L. Espartero
- Future Industries Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Miko Yamada
- Future Industries Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Tarl W. Prow
- Future Industries Institute, University of South Australia, Adelaide, South Australia, Australia
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8
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Crompton JG, Busam KJ, Bartlett EK. Interpretation of the Complex Melanoma Pathology Report. Surg Oncol Clin N Am 2021; 29:327-338. [PMID: 32482311 DOI: 10.1016/j.soc.2020.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An ambiguous pathologic report can present a clinical dilemma to the treating surgeon. We describe lesions ranging from the potentially benign to the likely malignant. Correctly identifying features associated with higher-risk lesions has proven challenging given the overall good prognosis and low rate of events. An appropriate treatment plan generally requires discussion between the surgeon and an experienced dermatopathologist. When clinically indicated, additional testing may be used to further support or refute a diagnosis of melanoma. The indications for these techniques, the data to support their use, and the strengths and weakness of each are reviewed.
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Affiliation(s)
- Joseph G Crompton
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Klaus J Busam
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Edmund K Bartlett
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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9
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Deacon DC, Smith EA, Judson-Torres RL. Molecular Biomarkers for Melanoma Screening, Diagnosis and Prognosis: Current State and Future Prospects. Front Med (Lausanne) 2021; 8:642380. [PMID: 33937286 PMCID: PMC8085270 DOI: 10.3389/fmed.2021.642380] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/17/2021] [Indexed: 12/22/2022] Open
Abstract
Despite significant progress in the development of treatment options, melanoma remains a leading cause of death due to skin cancer. Advances in our understanding of the genetic, transcriptomic, and morphologic spectrum of benign and malignant melanocytic neoplasia have enabled the field to propose biomarkers with potential diagnostic, prognostic, and predictive value. While these proposed biomarkers have the potential to improve clinical decision making at multiple critical intervention points, most remain unvalidated. Clinical validation of even the most commonly assessed biomarkers will require substantial resources, including limited clinical specimens. It is therefore important to consider the properties that constitute a relevant and clinically-useful biomarker-based test prior to engaging in large validation studies. In this review article we adapt an established framework for determining minimally-useful biomarker test characteristics, and apply this framework to a discussion of currently used and proposed biomarkers designed to aid melanoma detection, staging, prognosis, and choice of treatment.
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Affiliation(s)
- Dekker C. Deacon
- Department of Dermatology, University of Utah, Salt Lake City, UT, United States
| | - Eric A. Smith
- Department of Pathology, University of Utah, Salt Lake City, UT, United States
| | - Robert L. Judson-Torres
- Department of Dermatology, University of Utah, Salt Lake City, UT, United States
- Huntsman Cancer Institute, Salt Lake City, UT, United States
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10
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Rotemberg V, Kurtansky N, Betz-Stablein B, Caffery L, Chousakos E, Codella N, Combalia M, Dusza S, Guitera P, Gutman D, Halpern A, Helba B, Kittler H, Kose K, Langer S, Lioprys K, Malvehy J, Musthaq S, Nanda J, Reiter O, Shih G, Stratigos A, Tschandl P, Weber J, Soyer HP. A patient-centric dataset of images and metadata for identifying melanomas using clinical context. Sci Data 2021; 8:34. [PMID: 33510154 PMCID: PMC7843971 DOI: 10.1038/s41597-021-00815-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/18/2020] [Indexed: 11/09/2022] Open
Abstract
Prior skin image datasets have not addressed patient-level information obtained from multiple skin lesions from the same patient. Though artificial intelligence classification algorithms have achieved expert-level performance in controlled studies examining single images, in practice dermatologists base their judgment holistically from multiple lesions on the same patient. The 2020 SIIM-ISIC Melanoma Classification challenge dataset described herein was constructed to address this discrepancy between prior challenges and clinical practice, providing for each image in the dataset an identifier allowing lesions from the same patient to be mapped to one another. This patient-level contextual information is frequently used by clinicians to diagnose melanoma and is especially useful in ruling out false positives in patients with many atypical nevi. The dataset represents 2,056 patients (20.8% with at least one melanoma, 79.2% with zero melanomas) from three continents with an average of 16 lesions per patient, consisting of 33,126 dermoscopic images and 584 (1.8%) histopathologically confirmed melanomas compared with benign melanoma mimickers.
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Affiliation(s)
- Veronica Rotemberg
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Nicholas Kurtansky
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brigid Betz-Stablein
- The University of Queensland Diamantina Institute, The University of Queensland, Dermatology Research Centre, Brisbane, Australia
| | - Liam Caffery
- The University of Queensland Diamantina Institute, The University of Queensland, Dermatology Research Centre, Brisbane, Australia
| | - Emmanouil Chousakos
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,University of Athens Medical School, Athens, Greece
| | | | - Marc Combalia
- Melanoma Unit, Dermatology Department, Hospital Cĺınic Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Stephen Dusza
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pascale Guitera
- Melanoma Institute Australia and Sydney Melanoma Diagnostic Center, Sydney, Australia
| | - David Gutman
- Emory University School of Medicine, Department of Biomedical Informatics, Atlanta, GA, USA
| | - Allan Halpern
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Harald Kittler
- Medical University of Vienna, Department of Dermatology, Vienna, Austria
| | - Kivanc Kose
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Steve Langer
- Division of Radiology Informatics, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Josep Malvehy
- Melanoma Unit, Dermatology Department, Hospital Cĺınic Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Shenara Musthaq
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,SUNY Downstate Medical School, New York, NY, USA
| | - Jabpani Nanda
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Stony Brook Medical School, Stony Brook, NY, USA
| | - Ofer Reiter
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Rabin Medical Center, Tel Aviv, Israel
| | - George Shih
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA
| | | | - Philipp Tschandl
- Medical University of Vienna, Department of Dermatology, Vienna, Austria
| | - Jochen Weber
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - H Peter Soyer
- The University of Queensland Diamantina Institute, The University of Queensland, Dermatology Research Centre, Brisbane, Australia
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11
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Radick AC, Reisch LM, Shucard HL, Piepkorn MW, Kerr KF, Elder DE, Barnhill RL, Knezevich SR, Oster N, Elmore JG. Terminology for melanocytic skin lesions and the MPATH-Dx classification schema: A survey of dermatopathologists. J Cutan Pathol 2020; 48:733-738. [PMID: 32935869 DOI: 10.1111/cup.13873] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Diagnostic terms used in histopathology reports of cutaneous melanocytic lesions are not standardized. We describe dermatopathologists' views regarding diverse diagnostic terminology and the utility of the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) for categorizing melanocytic lesions. METHODS July 2018-2019 survey of board-certified and/or fellowship-trained dermatopathologists with experience interpreting melanocytic lesions. RESULTS Among 160 participants, 99% reported witnessing different terminology being used for the same melanocytic lesion. Most viewed diverse terminology as confusing to primary care physicians (98%), frustrating to pathologists (83%), requiring more of their time as a consultant (64%), and providing necessary clinical information (52%). Most perceived that adoption of the MPATH-Dx would: improve communication with other pathologists and treating physicians (87%), generally be a change for the better (80%), improve patient care (79%), be acceptable to clinical colleagues (68%), save time in pathology report documentation (53%), and protect from malpractice (51%). CONCLUSIONS Most dermatopathologists view diverse terminology as contributing to miscommunication with clinicians and patients, adversely impacting patient care. They view the MPATH-Dx as a promising tool to standardize terminology and improve communication. The MPATH-Dx may be a useful supplement to conventional pathology reports. Further revision and refinement are necessary for widespread clinical use.
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Affiliation(s)
- Andrea C Radick
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Lisa M Reisch
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Hannah L Shucard
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Dermatopathology Northwest, Bellevue, Washington, USA
| | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Division of Anatomic Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie, Paris Sciences and Letters Research University, Paris, France.,Department of Translational Research, Institut Curie, Paris Sciences and Letters Research University, Paris, France.,Faculty of Medicine, University of Paris Descartes, Paris, France
| | | | - Natalia Oster
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Joann G Elmore
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
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12
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May CJ, Piepkorn MW, Knezevich SR, Elder DE, Barnhill RL, Lee AC, Flores MJ, Kerr KF, Reisch LM, Elmore JG. Factors associated with use of immunohistochemical markers in the histopathological diagnosis of cutaneous melanocytic lesions. J Cutan Pathol 2020; 47:896-902. [PMID: 32383301 DOI: 10.1111/cup.13736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 04/06/2020] [Accepted: 04/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Melanocytic tumors are often challenging and constitute almost one in four skin biopsies. Immunohistochemical (IHC) studies may assist diagnosis; however, indications for their use are not standardized. METHODS A test set of 240 skin biopsies of melanocytic tumors was examined by 187 pathologists from 10 US states, interpreting 48 cases in Phase I and either 36 or 48 cases in Phase II. Participant and diagnosis characteristics were compared between those who reported they would have ordered, or who would have not ordered IHC on individual cases. Intraobserver analysis examined consistency in the intent to order when pathologists interpreted the same cases on two occasions. RESULTS Of 187 participants interpreting 48 cases each, 21 (11%) did not request IHC tests for any case, 85 (45%) requested testing for 1 to 6 cases, and 81 (43%) requested testing for ≥6 cases. Of 240 cases, 229 had at least one participant requesting testing. Only 2 out of 240 cases had more than 50% of participants requesting testing. Increased utilization of testing was associated with younger age of pathologist, board-certification in dermatopathology, low confidence in diagnosis, and lesions in intermediate MPATH-Dx classes 2 to 4. The median intraobserver concordance for requesting tests among 72 participants interpreting the same 48 cases in Phases I and II was 81% (IQR 73%-90%) and the median Kappa statistic was 0.20 (IQR 0.00, 0.39). CONCLUSION Substantial variability exists among pathologists in utilizing IHC.
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Affiliation(s)
- Caitlin J May
- Dermatopathology Northwest, Bellevue, Washington, USA.,Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael W Piepkorn
- Dermatopathology Northwest, Bellevue, Washington, USA.,Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond L Barnhill
- Department of Translational Research Institut Curie, Paris Sciences and Lettres Research University; Faculty of Medicine, University of Paris Descartes, Paris, France
| | - Annie C Lee
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Kathleen F Kerr
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA
| | - Lisa M Reisch
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA
| | - Joann G Elmore
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California, USA.,Division of Dermatology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
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13
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Clarke LE, Mabey B, Flake Ii DD, Meek S, Cassarino DS, Duncan LM, High WA, Napekoski KM, Prieto VG, Tetzlaff MT, Vitale P, Elder DE. Clinical validity of a gene expression signature in diagnostically uncertain neoplasms. Per Med 2020; 17:361-371. [PMID: 32915688 DOI: 10.2217/pme-2020-0048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Aim: Evaluate the accuracy of a 23-gene expression signature in differentiating benign nevi from melanoma by comparing test results with clinical outcomes. Materials & methods: Seven dermatopathologists blinded to gene expression test results and clinical outcomes examined 181 lesions to identify diagnostically uncertain cases. Participants independently recorded diagnoses and responses to questions quantifying diagnostic certainty. Test accuracy was determined through comparison with clinical outcomes (sensitivity and percent negative agreement). Results: Overall, 125 cases fulfilled criteria for diagnostic uncertainty (69.1%; 95% CI: 61.8-75.7%). Test sensitivity and percent negative agreement in these cases were 90.4% (95% CI: 79.0-96.8%) and 95.5% (95% CI: 87.3-99.1%), respectively. Conclusion: The 23-gene expression signature has high diagnostic accuracy in diagnostically uncertain cases when evaluated against clinical outcomes.
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Affiliation(s)
- Loren E Clarke
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Brent Mabey
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Darl D Flake Ii
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Stephanie Meek
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - David S Cassarino
- Kaiser Permanente, Los Angeles Medical Center Bldg., Los Angeles, CA 90027, USA
| | - Lyn M Duncan
- Pathology Associates, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Whitney A High
- Department of Dermatology, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | | | - Victor G Prieto
- Departments of Pathology & Translational & Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Michael T Tetzlaff
- Departments of Pathology & Translational & Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Patricia Vitale
- Departments of Dermatology and Pathology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - David E Elder
- Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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14
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Fraga-Braghiroli N, Grant-Kels JM, Oliviero M, Rabinovitz H, Ferenczi K, Scope A. The role of reflectance confocal microscopy in differentiating melanoma in situ from dysplastic nevi with severe atypia: A cross-sectional study. J Am Acad Dermatol 2020; 83:1035-1043. [PMID: 32442695 DOI: 10.1016/j.jaad.2020.05.071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/23/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Melanoma in situ and dysplastic nevi with severe atypia present overlapping histopathologic features. Reflectance confocal microscopy findings can be integrated with the dermatopathology report to improve differentiation between melanoma and dysplastic nevi with severe atypia. OBJECTIVE To compare prevalence of reflectance confocal microscopy findings between melanoma in situ and dysplastic nevi with severe atypia. METHODS This retrospective observational study compared reflectance confocal microscopy findings in dermatopathologically diagnosed dysplastic nevi with severe atypia and melanoma in situ, collected between 2007 and 2017 at a private pigmented-lesion clinic. Concordant pathologic diagnosis was defined as unanimous agreement between 3 dermatopathologists who independently reviewed all cases; all other cases were classified as discordant. RESULTS The study included 112 lesions, 62 concordant melanomas in situ, 28 concordant dysplastic nevi with severe atypia, and 22 discordant lesions. In comparing reflectance confocal microscopy findings in concordant cases, melanoma in situ showed more frequently than dysplastic nevi with severe atypia the presence of epidermal atypical melanocytes as round cells (19/62 vs 0/28; P < .001) and dendritic cells (50/62 vs 6/28; P < .001), as well as a diffuse distribution of epidermal atypical melanocytes (50/54 vs 3/6; P = .002). In contrast, dysplastic nevi with severe atypia showed the presence of dense melanocytic nests more frequently than melanoma in situ did (15/28 vs 14/62; P = .003). LIMITATIONS The study was based on a limited number of lesions originating from a single clinic. CONCLUSIONS Reflectance confocal microscopy findings may help differentiate a subset of dysplastic nevi with severe atypia from melanoma in situ.
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Affiliation(s)
| | - Jane M Grant-Kels
- University of CT Dermatology Department, Farmington, Connecticut; University of Florida Dermatology Department, Gainesville, Florida
| | | | | | - Katalin Ferenczi
- University of CT Dermatology Department, Farmington, Connecticut
| | - Alon Scope
- The Kittner Skin Cancer Screening & Research Institute, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Géraud C, Griewank KG. Re: Deep learning outperformed 11 pathologists in the classification of histopathological melanoma images. Eur J Cancer 2020; 130:259-261. [PMID: 31668521 DOI: 10.1016/j.ejca.2019.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/10/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Cyrill Géraud
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg, Mannheim, Germany; Section of Clinical and Molecular Dermatology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Klaus G Griewank
- Department of Dermatology, University Hospital Essen, West German Cancer Center, University Duisburg-Essen and the German Cancer Consortium (DKTK), Essen, Germany; Dermatopathologie bei Mainz, Nieder-Olm, Germany.
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16
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Pathologists' agreement on treatment suggestions for melanocytic skin lesions. J Am Acad Dermatol 2019; 82:1435-1444. [PMID: 31862403 DOI: 10.1016/j.jaad.2019.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 11/08/2019] [Accepted: 12/11/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although treatment guidelines exist for melanoma in situ and invasive melanoma, guidelines for other melanocytic skin lesions do not exist. OBJECTIVE To examine pathologists' treatment suggestions for a broad spectrum of melanocytic skin lesions and compare them with existing guidelines. METHODS Pathologists (N = 187) completed a survey and then provided diagnoses and treatment suggestions for 240 melanocytic skin lesions. Physician characteristics associated with treatment suggestions were evaluated with multivariable modeling. RESULTS Treatment suggestions were concordant with National Comprehensive Cancer Network guidelines for the majority of cases interpreted as melanoma in situ (73%) and invasive melanoma (86%). Greater variability of treatment suggestions was seen for other lesion types without existing treatment guidelines. Characteristics associated with provision of treatment suggestions discordant with National Comprehensive Cancer Network guidelines were low caseloads (invasive melanoma), lack of fellowship training or board certification (melanoma in situ), and more than 10 years of experience (invasive melanoma and melanoma in situ). LIMITATIONS Pathologists could not perform immunohistochemical staining or other diagnostic tests; only 1 glass side was provided per biopsy case. CONCLUSIONS Pathologists' treatment suggestions vary significantly for melanocytic lesions, with lower variability for lesion types with national guidelines. Results suggest the need for standardization of treatment guidelines for all melanocytic lesion types.
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17
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Mancera N, Smalley KSM, Margo CE. Melanoma of the eyelid and periocular skin: Histopathologic classification and molecular pathology. Surv Ophthalmol 2019; 64:272-288. [PMID: 30578807 DOI: 10.1016/j.survophthal.2018.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 12/29/2022]
Abstract
Cutaneous melanoma, a potentially lethal malignancy of the periocular skin, represents only a small proportion of the roughly 87,000 new cases of cutaneous melanoma diagnosed annually in the United States. Most of our understanding of melanoma of the eyelid skin is extrapolated from studies of cutaneous melanoma located elsewhere. Recent years have witnessed major breakthroughs in molecular biology and genomics of cutaneous melanoma, some of which have led to the development of targeted therapies. The molecular insights have also kindled interest in rethinking how cutaneous melanomas are classified and assessed for risk. We provide a synopsis of the epidemiology, histopathologic classification, and clinical experience of eyelid melanoma since 1990 and then review major advances in the molecular biology of cutaneous melanoma, exploring how this impacts our understanding of classification and predicting risk.
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Affiliation(s)
- Norberto Mancera
- Department of Ophthalmology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.
| | - Keiran S M Smalley
- Departments of Tumor Biology, The Moffitt Cancer Center & Research Institute, Tampa, Florida, USA; Cutaneous Oncology The Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Curtis E Margo
- Department of Ophthalmology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA; Department of Pathology and Cell Biology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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18
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Sturm B, Creytens D, Cook MG, Smits J, van Dijk MCRF, Eijken E, Kurpershoek E, Küsters-Vandevelde HVN, Ooms AHAG, Wauters C, Blokx WAM, van der Laak JAWM. Validation of Whole-slide Digitally Imaged Melanocytic Lesions: Does Z-Stack Scanning Improve Diagnostic Accuracy? J Pathol Inform 2019; 10:6. [PMID: 30972225 PMCID: PMC6415522 DOI: 10.4103/jpi.jpi_46_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/17/2018] [Indexed: 01/21/2023] Open
Abstract
Background Accurate diagnosis of melanocytic lesions is challenging, even for expert pathologists. Nowadays, whole-slide imaging (WSI) is used for routine clinical pathology diagnosis in several laboratories. One of the limitations of WSI, as it is most often used, is the lack of a multiplanar focusing option. In this study, we aim to establish the diagnostic accuracy of WSI for melanocytic lesions and investigate the potential accuracy increase of z-stack scanning. Z-stack enables pathologists to use a software focus adjustment, comparable to the fine-focus knob of a conventional light microscope. Materials and Methods Melanocytic lesions (n = 102) were selected from our pathology archives: 35 nevi, 5 spitzoid tumors of unknown malignant potential, and 62 malignant melanomas, including 10 nevoid melanomas. All slides were scanned at a magnification comparable to use of a ×40 objective, in z-stack mode. A ground truth diagnosis was established on the glass slides by four academic dermatopathologists with a special interest in the diagnosis of melanoma. Six nonacademic surgical pathologists subspecialized in dermatopathology examined the cases by WSI. Results An expert consensus diagnosis was achieved in 99 (97%) of cases. Concordance rates between surgical pathologists and the ground truth varied between 75% and 90%, excluding nevoid melanoma cases. Concordance rates of nevoid melanoma varied between 10% and 80%. Pathologists used the software focusing option in 7%-28% of cases, which in 1 case of nevoid melanoma resulted in correcting a misdiagnosis after finding a dermal mitosis. Conclusion Diagnostic accuracy of melanocytic lesions based on glass slides and WSI is comparable with previous publications. A large variability in diagnostic accuracy of nevoid melanoma does exist. Our results show that z-stack scanning, in general, does not increase the diagnostic accuracy of melanocytic.
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Affiliation(s)
- Bart Sturm
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David Creytens
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Martin G Cook
- Department of Histopathology, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Jan Smits
- Pathan B.V., Rotterdam, The Netherlands
| | | | - Erik Eijken
- Laboratory for Pathology East Netherlands (LabPON), Hengelo, The Netherlands
| | | | | | | | - Carla Wauters
- Department of Pathology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Willeke A M Blokx
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
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19
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Scope A, Dusza SW, Pellacani G, Gill M, Gonzalez S, Marchetti MA, Rabinovitz HS, Marghoob AA, Alessi-Fox C, Halpern AC. Accuracy of tele-consultation on management decisions of lesions suspect for melanoma using reflectance confocal microscopy as a stand-alone diagnostic tool. J Eur Acad Dermatol Venereol 2018; 33:439-446. [PMID: 30242916 DOI: 10.1111/jdv.15257] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/26/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Diagnostic accuracy of reflectance confocal microscopy (RCM) as a stand-alone diagnostic tool for suspect skin lesions has not been extensively studied. OBJECTIVE Primary aim was to measure experts' accuracy in RCM-based management decisions. Secondary aim was to identify melanoma-specific RCM features. METHODS The study enrolled patients ≥18 years that underwent biopsy of skin lesions clinically suspected to be melanoma. One hundred lesions imaged by RCM were randomly selected from 439 lesions prospectively collected at four pigmented lesion clinics. The study data set included 23 melanomas, three basal cell and two squamous cell carcinomas, 11 indeterminate melanocytic lesions and 61 benign lesions including 50 nevi. Three expert RCM evaluators were blinded to clinical or dermoscopic images, and to the final histopathological diagnosis. Evaluators independently issued a binary RCM-based management decision, 'biopsy' vs. 'observation'; these decisions were scored against histopathological diagnosis, with 'biopsy' as the correct management decision for malignant and indeterminate lesions. A subset analysis of 23 melanomas and 50 nevi with unequivocal histopathological diagnosis was performed to identify melanoma-specific RCM features. RESULTS Sensitivity, specificity and diagnostic accuracy were 74%, 67% and 70% for reader 1, 46%, 84% and 69% for reader 2, and 72%, 46% and 56% for reader 3, respectively. The overall kappa for management decisions was 0.34. Readers had unanimous agreement on management for 50 of the 100 lesions. Non-specific architecture, non-visible papillae, streaming of nuclei, coarse collagen fibres and abnormal vasculature showed a significant association with melanoma in the evaluation of at least two readers. CONCLUSIONS Reflectance confocal microscopy tele-consultation of especially challenging lesions, based on image review without benefit of clinical or dermoscopy images, may be associated with limited diagnostic accuracy and interobserver agreement. Architectural and stromal criteria may emerge as potentially useful and reproducible criteria for melanoma diagnosis.
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Affiliation(s)
- A Scope
- Medical Screening Institute, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S W Dusza
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - G Pellacani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - M Gill
- SkinMedical Research and Diagnostics, Dobbs Ferry, NY, USA.,SUNY Downstate, Brooklyn, NY, USA
| | - S Gonzalez
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine and Medical Specialties, University de Alcalà, Madrid, Spain
| | - M A Marchetti
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - A A Marghoob
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - C Alessi-Fox
- Caliber Imaging and Diagnostics, Rochester, NY, USA
| | - A C Halpern
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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20
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Harvey NT, Wood BA. A Practical Approach to the Diagnosis of Melanocytic Lesions. Arch Pathol Lab Med 2018; 143:789-810. [PMID: 30059258 DOI: 10.5858/arpa.2017-0547-ra] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Melanocytic lesions are common in routine surgical pathology. Although the majority of these lesions can be confidently diagnosed using well-established morphologic criteria, there is a significant subset of lesions that can be diagnostically difficult. These can be a source of anxiety for patients, clinicians, and pathologists, and the potential consequences of a missed diagnosis of melanoma are serious. OBJECTIVE.— To provide a practical approach to the diagnosis of melanocytic lesions, including classic problem areas as well as suggestions for common challenges and appropriate incorporation of ancillary molecular techniques. DATA SOURCES.— Literature search using PubMed and Google Scholar, incorporating numerous search terms relevant to the particular section, combined with contemporaneous texts and lessons from personal experience. CONCLUSIONS.— Although a subset of melanocytic lesions can be diagnostically challenging, the combination of a methodical approach to histologic assessment, knowledge of potential diagnostic pitfalls, opinions from trusted colleagues, and judicious use of ancillary techniques can help the pathologist navigate this difficult area.
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Affiliation(s)
- Nathan T Harvey
- From the Dermatopathology Group, Department of Anatomical Pathology, PathWest Laboratory Medicine, Perth, Australia; and the Division of Pathology and Laboratory Medicine, Medical School, University of Western Australia, Perth, Australia
| | - Benjamin A Wood
- From the Dermatopathology Group, Department of Anatomical Pathology, PathWest Laboratory Medicine, Perth, Australia; and the Division of Pathology and Laboratory Medicine, Medical School, University of Western Australia, Perth, Australia
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21
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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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[Dermatoscopic-pathological correlation of melanocytic skin lesions]. Hautarzt 2018; 69:528-535. [PMID: 29876611 DOI: 10.1007/s00105-018-4204-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There is no doubt that dermatopathology is the most important method to decide if a melanocytic lesion is benign or malignant; however, like most morphologic examinations, dermatopathology is subjective. A recent study demonstrated that the pathologic diagnosis of melanocytic skin lesions has a high variability. Reports with false-positive or false-negative diagnoses are relatively common. The pathologic examination of melanocytic lesions also has observer-independent limitations and one has to accept that some melanocytic lesions cannot be classified as benign or malignant with confidence by dermatopathology alone. If a confident diagnosis is not possible a dermatoscopic-pathologic correlation may be helpful. This, however, is only possible if dermatoscopic images are available and if the dermatopathologist knows how to interpret dermatoscopic structures. A dermatoscopic-pathologic correlation is not useful in all difficult melanocytic lesions but it should be considered in difficult flat pigmented lesions. In these cases dermatoscopy may provide even more important additional information than molecular findings.
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Abstract
BACKGROUND Ambiguous histopathologic diagnoses represent a challenge for clinicians because of a lack of definitive diagnosis and related uncertainty about management. OBJECTIVE To review the literature on atypical melanocytic proliferations and detail synonymous terms, epidemiology, diagnostic work-up, histopathology, treatment, and prognosis. METHODS Databases from PubMed and Web of Science were searched for articles related to atypical melanocytic proliferations. RESULTS Intraepidermal melanocytic proliferations with features worrisome for possible melanoma in situ (MIS) are generally excised as for MIS. Reported rates of upstaging of such cases to invasive melanoma on review of the excision are very low. Because invasion, lymph node spread, and metastasis can occur in atypical melanocytic lesions with a thick intradermal component, these are often treated as for malignant melanoma. CONCLUSION Because the diagnosis dictates treatment, it is incumbent to establish a diagnosis as definitive as possible, obtaining second or third opinions and using ancillary studies when appropriate. When the diagnosis remains uncertain, it is difficult to provide guidelines for treatment. Clinical care decisions for patients with an uncertain diagnosis are best done on a case-by-case basis weighing probabilities of adverse outcomes against potential benefits and risks from various treatment options.
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Lott JP, Boudreau DM, Barnhill RL, Weinstock MA, Knopp E, Piepkorn MW, Elder DE, Knezevich SR, Baer A, Tosteson ANA, Elmore JG. Population-Based Analysis of Histologically Confirmed Melanocytic Proliferations Using Natural Language Processing. JAMA Dermatol 2018; 154:24-29. [PMID: 29094145 PMCID: PMC5833584 DOI: 10.1001/jamadermatol.2017.4060] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/06/2017] [Indexed: 11/14/2022]
Abstract
Importance Population-based information on the distribution of histologic diagnoses associated with skin biopsies is unknown. Electronic medical records (EMRs) enable automated extraction of pathology report data to improve our epidemiologic understanding of skin biopsy outcomes, specifically those of melanocytic origin. Objective To determine population-based frequencies and distribution of histologically confirmed melanocytic lesions. Design, Setting, and Participants A natural language processing (NLP)-based analysis of EMR pathology reports of adult patients who underwent skin biopsies at a large integrated health care delivery system in the US Pacific Northwest from January 1, 2007, through December 31, 2012. Exposures Skin biopsy procedure. Main Outcomes and Measures The primary outcome was histopathologic diagnosis, obtained using an NLP-based system to process EMR pathology reports. We determined the percentage of diagnoses classified as melanocytic vs nonmelanocytic lesions. Diagnoses classified as melanocytic were further subclassified using the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) reporting schema into the following categories: class I (nevi and other benign proliferations such as mildly dysplastic lesions typically requiring no further treatment), class II (moderately dysplastic and other low-risk lesions that may merit narrow reexcision with <5-mm margins), class III (eg, melanoma in situ and other higher-risk lesions warranting reexcision with 5-mm to 1-cm margins), and class IV/V (invasive melanoma requiring wide reexcision with ≥1-cm margins and potential adjunctive therapy). Health system cancer registry data were used to define the percentage of invasive melanoma cases within MPATH-Dx class IV (stage T1a) vs V (≥stage T1b). Results A total of 80 368 skin biopsies, performed on 47 529 patients, were examined. Nearly 1 in 4 skin biopsies were of melanocytic lesions (23%; n = 18 715), which were distributed according to MPATH-Dx categories as follows: class I, 83.1% (n = 15 558); class II, 8.3% (n = 1548); class III, 4.5% (n = 842); class IV, 2.2% (n = 405); and class V, 1.9% (n = 362). Conclusions and Relevance Approximately one-quarter of skin biopsies resulted in diagnoses of melanocytic proliferations. These data provide the first population-based estimates across the spectrum of melanocytic lesions ranging from benign through dysplastic to malignant. These results may serve as a foundation for future research seeking to understand the epidemiology of melanocytic proliferations and optimization of skin biopsy utilization.
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Affiliation(s)
- Jason P. Lott
- Cornell Scott-Hill Health Center, New Haven, Connecticut
| | - Denise M. Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle
- Departments of Pharmacy and Epidemiology, University of Washington, Seattle
| | - Ray L. Barnhill
- Department of Pathology, Institut Curie, and Faculty of Medicine, University of Paris Descartes, Paris, France
| | - Martin A. Weinstock
- Departments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island
- Center for Dermatoepidemiology, Department of Veterans Affairs Medical Center, Providence, Rhode Island
- Department of Dermatology, Rhode Island Hospital, Providence, Rhode Island
| | - Eleanor Knopp
- Division of Dermatology, Department of Medicine, University of Washington, Seattle
- Group Health Capitol Hill Campus, Seattle, Washington
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | | | - Andrew Baer
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Anna N. A. Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Medicine Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Joann G. Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle
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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: 242] [Impact Index Per Article: 34.6] [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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Lee KC, Peacock S, Weinstock MA, Zhao GA, Knezevich SR, Elder DE, Barnhill RL, Piepkorn MW, Reisch LM, Carney PA, Onega T, Lott JP, Elmore JG. Variation among pathologists' treatment suggestions for melanocytic lesions: A survey of pathologists. J Am Acad Dermatol 2016; 76:121-128. [PMID: 27692732 DOI: 10.1016/j.jaad.2016.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/21/2016] [Accepted: 07/12/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND The extent of variability in treatment suggestions for melanocytic lesions made by pathologists is unknown. OBJECTIVE We investigated how often pathologists rendered suggestions, reasons for providing suggestions, and concordance with national guidelines. METHODS We conducted a cross-sectional survey of pathologists. Data included physician characteristics, experience, and treatment recommendation practices. RESULTS Of 301 pathologists, 207 (69%) from 10 states (California, Connecticut, Hawaii, Iowa, Kentucky, Louisiana, New Jersey, New Mexico, Utah, and Washington) enrolled. In all, 15% and 7% reported never and always including suggestions, respectively. Reasons for offering suggestions included improved care (79%), clarification (68%), and legal liability (39%). Reasons for not offering suggestions included referring physician preference (48%), lack of clinical information (44%), and expertise (29%). Training and caseload were associated with offering suggestions (P < .05). Physician suggestions were most consistent for mild/moderate dysplastic nevi and melanoma. For melanoma in situ, 18 (9%) and 32 (15%) pathologists made suggestions that undertreated or overtreated lesions based on National Comprehensive Cancer Network (NCCN) guidelines, respectively. For invasive melanoma, 14 (7%) pathologists made treatment suggestions that undertreated lesions based on NCCN guidelines. LIMITATIONS Treatment suggestions were self-reported. CONCLUSIONS Pathologists made recommendations ranging in consistency. These findings may inform efforts to reduce treatment variability and optimize patterns of care delivery for patients.
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Affiliation(s)
- Kachiu C Lee
- Department of Dermatology, Brown University, Providence, Rhode Island
| | - Sue Peacock
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Martin A Weinstock
- Department of Dermatology, Brown University, Providence, Rhode Island; Department of Epidemiology, Brown University, Providence, Rhode Island; Dermatoepidemiology Unit, Department of Veterans Affairs Medical Center, Providence, Rhode Island; Department of Dermatology, Rhode Island Hospital, Providence, Rhode Island
| | - Ge Alice Zhao
- Division of Dermatology, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | | | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raymond L Barnhill
- Departments of Pathology, Institut Curie, and Faculty of Medicine, University of Paris Descartes, Paris, France
| | - 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
| | - Lisa M Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tracy Onega
- Departments of Biomedical Data Science and Epidemiology, Norris Cotton Cancer Center, and Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jason P Lott
- Cornell Scott-Hill Health Center, New Haven, Connecticut
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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