The Importance of Reviewing Pathology Specimens Before Mohs Surgery

Using Initial Biopsies and Vertical Sections to Improve Trainees' Confidence in Performing Mohs Surgery

BACKGROUND

Tissue preservation and tumor clearance are hallmarks of Mohs micrographic surgery, but no standardized method currently exists to guide trainees on how to balance the two.

OBJECTIVE

The authors provided residents and fellows with additional histologic information to enhance their surgical decision-making without changing the standard methodology of Mohs surgery.

METHODS AND MATERIALS

Trainees were provided initial biopsy slides (IS) and frozen vertical sections (VS) of the first Mohs layer. All Mohs layers were excised in standard fashion, and vertically oriented sections were taken from the layer without disturbing the surgical margins to obtain VS. Surveys were used to assess trainees' confidence in performing Mohs surgery with and without these tools.

RESULTS

Trainees reported increased confidence in performing Mohs surgery when they reviewed IS before surgery and viewed VS of the first layer.

CONCLUSION

Reviewing IS and VS improved trainees' confidence in performing Mohs surgery. This additional histological information was obtained while maintaining the usual steps of Mohs surgery. Objective information obtained from IS and VS may explain why trainees' confidence increased using this technique. Both IS and VS can be valuable teaching tools that may enhance trainees' ability to perform Mohs surgery.

Impact of second-opinion dermatopathology reviews on surgical management of malignant neoplasms

BACKGROUND

Second-opinion review is linked to error reduction and treatment changes in anatomic pathology.

OBJECTIVE

We sought to establish the rate of diagnostic discrepancy identified by second-opinion dermatopathologic review and the effect on surgical treatment.

METHODS

Cases referred for treatment of a malignant neoplasm diagnosed by an outside pathologist were reviewed. The external and internal second-opinion dermatopathologic reports were compared. Discordance in diagnosis, subtype, and treatment change owing to second-opinion review was recorded. The referring pathologist's level of dermatopathologic training was also documented.

RESULTS

A total of 358 cases were included. Dermatopathologic second-opinion diagnosis was discordant with the outside diagnosis in 37 of 358 cases (10.3%). In 32 of 358 cases (8.9%), second-opinion review resulted in a change in treatment, with 28 of 32 (87.5%) of these changes resulting in cancelled surgery. Dermatologists without dermatopathologic fellowship training had the highest rate of discordant diagnoses compared with pathologists and dermatopathologists.

LIMITATIONS

This was a retrospective study at a tertiary care facility.

CONCLUSION

Second-opinion dermatopathologic review is associated with identification of discordant diagnoses and a substantial influence on treatment, with both cancellation of surgery and augmented management. Secondary pathologic review should be considered in high-volume surgical practices.

Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology: Guideline From the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology

CONTEXT

Additional reviews of diagnostic surgical and cytology cases have been shown to detect diagnostic discrepancies.

OBJECTIVE

To develop, through a systematic review of the literature, recommendations for the review of pathology cases to detect or prevent interpretive diagnostic errors.

DESIGN

The College of American Pathologists Pathology and Laboratory Quality Center in association with the Association of Directors of Anatomic and Surgical Pathology convened an expert panel to develop an evidence-based guideline to help define the role of case reviews in surgical pathology and cytology. A literature search was conducted to gather data on the review of cases in surgical pathology and cytology.

RESULTS

The panel drafted 5 recommendations, with strong agreement from open comment period participants ranging from 87% to 93%. The recommendations are: (1) anatomic pathologists should develop procedures for the review of selected pathology cases to detect disagreements and potential interpretive errors; (2) anatomic pathologists should perform case reviews in a timely manner to avoid having a negative impact on patient care; (3) anatomic pathologists should have documented case review procedures that are relevant to their practice setting; (4) anatomic pathologists should continuously monitor and document the results of case reviews; and (5) if pathology case reviews show poor agreement within a defined case type, anatomic pathologists should take steps to improve agreement.

CONCLUSIONS

Evidence exists that case reviews detect errors; therefore, the expert panel recommends that anatomic pathologists develop procedures for the review of pathology cases to detect disagreements and potential interpretive errors, in order to improve the quality of patient care.

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.