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Ojukwu K, Eguchi MM, Adamson AS, Kerr KF, Piepkorn MW, Murdoch S, Barnhill RL, Elder DE, Knezevich SR, Elmore JG. Immunohistochemistry for Diagnosing Melanoma in Older Adults. JAMA Dermatol 2024; 160:434-440. [PMID: 38446470 PMCID: PMC10918577 DOI: 10.1001/jamadermatol.2023.6417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/23/2023] [Indexed: 03/07/2024]
Abstract
Importance Pathologic assessment to diagnose skin biopsies, especially for cutaneous melanoma, can be challenging, and immunohistochemistry (IHC) staining has the potential to aid decision-making. Currently, the temporal trends regarding the use of IHC for the examination of skin biopsies on a national level have not been described. Objective To illustrate trends in the use of IHC for the examination of skin biopsies in melanoma diagnoses. Design, Setting, and Participants A retrospective cross-sectional study was conducted to examine incident cases of melanoma diagnosed between January 2000 and December 2017. The analysis used the SEER-Medicare linked database, incorporating data from 17 population-based registries. The study focused on incident cases of in situ or malignant melanoma of the skin diagnosed in patients 65 years or older. Data were analyzed between August 2022 and November 2023. Main Outcomes and Measures The main outcomes encompassed the identification of claims for IHC within the month of melanoma diagnoses and extending up to 14 days into the month following diagnosis. The SEER data on patients with melanoma comprised demographic, tumor, and area-level characteristics. Results The final sample comprised 132 547 melanoma tumors in 116 117 distinct patients. Of the 132 547 melanoma diagnoses meeting inclusion criteria from 2000 to 2017, 43 396 cases had accompanying IHC claims (33%). Among these cases, 28 298 (65%) were diagnosed in male patients, 19 019 (44%) were diagnosed in patients aged 65 years to 74 years, 16 444 (38%) in patients aged 75 years to 84 years, and 7933 (18%) in patients aged 85 years and older. In 2000, 11% of melanoma cases had claims for IHC at or near the time of diagnosis. This proportion increased yearly, with 51% of melanoma cases having associated IHC claims in 2017. Increasing IHC use is observed for all stages of melanoma, including in situ melanoma. Claims for IHC in melanomas increased in all 17 SEER registries but at different rates. In 2017, the use of IHC for melanoma diagnosis ranged from 39% to 68% across registries. Conclusions and Relevance Considering the dramatically rising and variable use of IHC in diagnosing melanoma by pathologists demonstrated in this retrospective cross-sectional study, further investigation is warranted to understand the clinical utility and discern when IHC most improves diagnostic accuracy or helps patients.
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Affiliation(s)
- Kenechukwu Ojukwu
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Megan M. Eguchi
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Adewole S. Adamson
- Division of Dermatology, Department of Medicine, Dell Medical School, The University of Texas at Austin
- Deputy Editor and Web Editor, JAMA Dermatology
| | | | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | | | - 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
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | | | - Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
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Kerr KF, Elder DE, Piepkorn MW, Knezevich SR, Eguchi MM, Shucard HL, Reisch LM, Elmore JG, Barnhill RL. Pathologist Characteristics Associated With Rendering Higher-Grade Diagnoses for Melanocytic Lesions. JAMA Dermatol 2023; 159:1315-1322. [PMID: 37938821 PMCID: PMC10633399 DOI: 10.1001/jamadermatol.2023.4334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/10/2023] [Indexed: 11/10/2023]
Abstract
Importance The incidence of melanoma diagnoses has been increasing in recent decades, and controlled studies have indicated high histopathologic discordance across the intermediate range of melanocytic lesions. The respective causes for these phenomena remain incompletely understood. Objective To identify pathologist characteristics associated with tendencies to diagnose melanocytic lesions as higher grade vs lower grade or to diagnose invasive melanoma vs any less severe diagnosis. Design, Setting, and Participants This exploratory study used data from 2 nationwide studies (the Melanoma Pathology [M-Path] study, conducted from July 2013 to May 2016, and the Reducing Errors in Melanocytic Interpretations [REMI] study, conducted from August 2018 to March 2021) in which participating pathologists who interpreted melanocytic lesions in their clinical practices interpreted study cases in glass slide format. Each pathologist was randomly assigned to interpret a set of study cases from a repository of skin biopsy samples of melanocytic lesions; each case was independently interpreted by multiple pathologists. Data were analyzed from July 2022 to February 2023. Main Outcomes and Measures The association of pathologist characteristics with diagnosis of a study case as higher grade (including severely dysplastic and melanoma in situ) vs lower grade (including mild to moderately dysplastic nevi) and diagnosis of invasive melanoma vs any less severe diagnosis was assessed using logistic regression. Characteristics included demographics (age, gender, and geographic region), years of experience, academic affiliation, caseload of melanocytic lesions in their practice, specialty training, and history of malpractice suits. Results A total of 338 pathologists were included: 113 general pathologists and 74 dermatopathologists from M-Path and 151 dermatopathologists from REMI. The predominant factor associated with rendering more severe diagnoses was specialist training in dermatopathology (board certification and/or fellowship training). Pathologists with this training were more likely to render higher-grade diagnoses (odds ratio [OR], 2.63; 95% CI, 2.10-3.30; P < .001) and to diagnose invasive melanoma (OR, 1.95; 95% CI, 1.53-2.49; P < .001) than pathologists without this training interpreting the same case. Nonmitogenic pT1a diagnoses (stage pT1a melanomas with no mitotic activity) accounted for the observed difference in diagnosis of invasive melanoma; when these lesions, which carry a low risk of metastasis, were grouped with the less severe diagnoses, there was no observed association (OR, 0.95; 95% CI, 0.74-1.23; P = .71). Among dermatopathologists, those with a higher caseload of melanocytic lesions in their practice were more likely to assign higher-grade diagnoses (OR for trend, 1.27; 95% CI, 1.04-1.56; P = .02). Conclusions and Relevance The findings suggest that specialty training in dermatopathology is associated with a greater tendency to diagnose atypical melanocytic proliferations as pT1a melanomas. These low-risk melanomas constitute a growing proportion of melanomas diagnosed in the US.
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Affiliation(s)
| | - 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
| | | | - Megan M. Eguchi
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Lisa M. Reisch
- Department of Biostatistics, University of Washington, Seattle
| | - Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Raymond L. Barnhill
- Department of Translational Research, Institut Curie, Paris, France
- UFR of Medicine, University of Paris Cité, Paris, France
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Reisch LM, Shucard H, Radick AC, Eguchi MM, Elder DE, Barnhill RL, Piepkorn MW, Knezevich SR, Kerr KF, Elmore JG. Implementing the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx): Long Term Effect of a Simple Educational Intervention. JAAD Int 2023; 11:211-219. [PMID: 37144178 PMCID: PMC10151420 DOI: 10.1016/j.jdin.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 03/14/2023] Open
Abstract
Background A standardized pathology management tool for melanocytic skin lesions may improve patient care by simplifying interpretation and categorization of the diverse terminology currently extant. Objective To assess an online educational intervention that teaches dermatopathologists to use the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx), a schema collapsing multiple diagnostic terms into 5 classes ranging from benign to invasive melanoma. Methods Practicing dermatopathologists (N = 149) from 40 US states participated in a 2-year educational intervention study (71% response rate). The intervention involved a brief tutorial followed by practice on 28 melanocytic lesions, with the goal of teaching pathologists how to correctly use the MPATH-Dx schema; competence using the MPATH-Dx tool 12-24 months postintervention was assessed. Participants' self-reported confidence using the MPATH-Dx tool was assessed preintervention and postintervention. Results At preintervention, confidence using the MPATH-Dx tool was already high, despite 68% lacking prior familiarity with it, and confidence increased postintervention (P = .0003). During the intervention, participants used the MPATH-Dx tool correctly for 90% of their interpretations; postintervention, participants used the MPATH-Dx tool correctly for 88% of their interpretations. Limitations Future research should examine implementing a standardized pathology assessment schema in actual clinical practice. Conclusion Dermatopathologists can be taught to confidently and competently use the MPATH-Dx schema with a simple educational tutorial followed by practice.
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Barnhill RL, Elder DE, Piepkorn MW, Knezevich SR, Reisch LM, Eguchi MM, Bastian BC, Blokx W, Bosenberg M, Busam KJ, Carr R, Cochran A, Cook MG, Duncan LM, Elenitsas R, de la Fouchardière A, Gerami P, Johansson I, Ko J, Landman G, Lazar AJ, Lowe L, Massi D, Messina J, Mihic-Probst D, Parker DC, Schmidt B, Shea CR, Scolyer RA, Tetzlaff M, Xu X, Yeh I, Zembowicz A, Elmore JG. Revision of the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis Classification Schema for Melanocytic Lesions: A Consensus Statement. JAMA Netw Open 2023; 6:e2250613. [PMID: 36630138 PMCID: PMC10375511 DOI: 10.1001/jamanetworkopen.2022.50613] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE A standardized pathology classification system for melanocytic lesions is needed to aid both pathologists and clinicians in cataloging currently existing diverse terminologies and in the diagnosis and treatment of patients. The Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) has been developed for this purpose. OBJECTIVE To revise the MPATH-Dx version 1.0 classification tool, using feedback from dermatopathologists participating in the National Institutes of Health-funded Reducing Errors in Melanocytic Interpretations (REMI) Study and from members of the International Melanoma Pathology Study Group (IMPSG). EVIDENCE REVIEW Practicing dermatopathologists recruited from 40 US states participated in the 2-year REMI study and provided feedback on the MPATH-Dx version 1.0 tool. Independently, member dermatopathologists participating in an IMPSG workshop dedicated to the MPATH-Dx schema provided additional input for refining the MPATH-Dx tool. A reference panel of 3 dermatopathologists, the original authors of the MPATH-Dx version 1.0 tool, integrated all feedback into an updated and refined MPATH-Dx version 2.0. FINDINGS The new MPATH-Dx version 2.0 schema simplifies the original 5-class hierarchy into 4 classes to improve diagnostic concordance and to provide more explicit guidance in the treatment of patients. This new version also has clearly defined histopathological criteria for classification of classes I and II lesions; has specific provisions for the most frequently encountered low-cumulative sun damage pathway of melanoma progression, as well as other, less common World Health Organization pathways to melanoma; provides guidance for classifying intermediate class II tumors vs melanoma; and recognizes a subset of pT1a melanomas with very low risk and possible eventual reclassification as neoplasms lacking criteria for melanoma. CONCLUSIONS AND RELEVANCE The implementation of the newly revised MPATH-Dx version 2.0 schema into clinical practice is anticipated to provide a robust tool and adjunct for standardized diagnostic reporting of melanocytic lesions and management of patients to the benefit of both health care practitioners and patients.
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Affiliation(s)
- Raymond L Barnhill
- Department of Translational Research, Institut Curie, Unit of Formation and Research of Medicine University of Paris, Paris, France
| | - 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
| | | | - Lisa M Reisch
- Department of Biostatistics, University of Washington School of Medicine, Seattle
| | - Megan M Eguchi
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Boris C Bastian
- Departments of Pathology and Dermatology, University of California, San Francisco
| | - Willeke Blokx
- Department of Pathology, Division Laboratories, Pharmacy and Biomedical Genetics University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcus Bosenberg
- Departments of Dermatology, Pathology, and Immunobiology, Yale School of Medicine, New Haven, Connecticut
| | - Klaus J Busam
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard Carr
- Cellular Pathology, South Warwickshire NHS Trust, Warwick, United Kingdom
| | - Alistair Cochran
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Martin G Cook
- Department of Histopathology, Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Lyn M Duncan
- Pathology Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Rosalie Elenitsas
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Arnaud de la Fouchardière
- Department of Biopathology, Centre Léon Bérard, Lyon, France
- University of Lyon, Université Claude Bernard Lyon 1, National Center for Scientific Research, Mixed Research Unit 5286, National Institute of Health and Medical Research U1052, Cancer Research Centre of Lyon, Lyon, France
| | - Pedram Gerami
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Iva Johansson
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jennifer Ko
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Gilles Landman
- Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Alexander J Lazar
- Departments of Pathology, Dermatology, and Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Lori Lowe
- Departments of Pathology and Dermatology, University of Michigan, Ann Arbor
| | - Daniela Massi
- Section of Pathology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Jane Messina
- Departments of Pathology and Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Daniela Mihic-Probst
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Douglas C Parker
- Departments of Pathology and Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Birgitta Schmidt
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher R Shea
- Department of Dermatology, University of Chicago Medicine, Chicago, Illinois
| | - Richard A Scolyer
- Charles Perkins Centre, The University of Sydney, Sydney, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, Australia
| | - Michael Tetzlaff
- Departments of Pathology and Dermatology, University of California, San Francisco
| | - Xiaowei Xu
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Iwei Yeh
- Departments of Pathology and Dermatology, University of California, San Francisco
| | - Artur Zembowicz
- Tufts University, Boston, Massachusetts
- Lahey Clinic, Burlington, Massachusetts
- Dermatopathology Consultations, Needham, Massachusetts
| | - Joann G Elmore
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
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Eguchi MM, Elder DE, Barnhill RL, Piepkorn MW, Knezevich SR, Elmore JG, Kerr KF. Prognostic modeling of cutaneous melanoma stage I patients using cancer registry data identifies subsets with very-low melanoma mortality. Cancer 2023; 129:89-97. [PMID: 36336975 PMCID: PMC10367581 DOI: 10.1002/cncr.34490] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Evidence exists that escalating melanoma incidence is due in part to overdiagnosis, the diagnosis of lesions that will not lead to symptoms or death. The authors aimed to characterize subsets of melanoma patients with very-low risk of death that may be contributing to overdiagnosis. METHODS Melanoma patients diagnosed in 2010 and 2011 with stage I lesions ≤1.0 mm thick and negative clinical lymph nodes from the Surveillance, Epidemiology, and End Results database were selected. Classification and regression tree and logistic regression models were developed and validated to identify patients with very-low risk of death from melanoma within 7 years. Logistic models were also used to identify patients at higher risk of death among this group of stage I patients. RESULTS Compared to an overall 7-year mortality from melanoma of 2.5% in these patients, a subset comprising 25% had a risk below 1%. Younger age at diagnosis and Clark level II were associated with low risk of death in all models. Breslow thickness below 0.4 mm, absence of mitogenicity, absence of ulceration, and female sex were also associated with lower mortality. A small subset of high-risk patients with >20% risk of death was also identified. CONCLUSION Patients with very-low risk of dying from melanoma within 7 years of diagnosis were identified. Such cases warrant further study and consensus discussion to develop classification criteria, with the potential to be categorized using an alternative term such as "melanocytic neoplasms of low malignant potential." LAY SUMMARY Although melanoma is the most serious skin cancer, most melanoma patients have high chances of survival. There is evidence that some lesions diagnosed as melanoma would never have caused symptoms or death, a phenomenon known as overdiagnosis. In this study, we used cancer registry data to identify a subset of early-stage melanoma patients with almost no melanoma deaths. Using two statistical approaches, we identified patients with <1% risk of dying from melanoma in 7 years. Such patients tended to be younger with minimal invasion into the skin. We also identified a very small patient subset with higher mortality risk.
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Affiliation(s)
- Megan M Eguchi
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, 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, France
- UFR of Medicine University of Paris, Paris, France
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Dermatopathology Northwest, Bellevue, Washington, USA
| | | | - Joann G Elmore
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
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Piepkorn MW, Eguchi MM, Barnhill RL, Elder DE, Kerr KF, Knezevich SR, Elmore JG. Reproducibility of the histopathologic diagnosis of melanoma and related melanocytic lesions: Results from a testing study and a reference guide for providers. JAAD Int 2022; 9:7-10. [PMID: 35996751 PMCID: PMC9391572 DOI: 10.1016/j.jdin.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kerr KF, Eguchi MM, Piepkorn MW, Radick AC, Reisch LM, Shucard HL, Knezevich SR, Barnhill RL, Elder DE, Elmore JG. Dermatopathologist Perceptions of Overdiagnosis of Melanocytic Skin Lesions and Association With Diagnostic Behaviors. JAMA Dermatol 2022; 158:675-679. [PMID: 35442415 PMCID: PMC9021983 DOI: 10.1001/jamadermatol.2022.0489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/04/2022] [Indexed: 12/13/2022]
Abstract
Importance Despite evidence of overdiagnosis of in situ and invasive melanoma, neither the perceptions of practicing dermatopathologists about overdiagnosis nor possible associations between perceptions of overdiagnosis and diagnostic practices have been studied. Objective To examine practicing US dermatopathologists' perceptions of melanoma overdiagnosis as a public health issue, and to associate diagnostic behaviors of dermatopathologists with perceptions of melanoma overdiagnosis. Design, Setting, and Participants This survey study included 115 board-certified and/or fellowship-trained dermatopathologists and their diagnostic interpretations on a set of 18 skin biopsy cases (5 slide sets comprising 90 melanocytic skin lesions). Participants interpreted cases remotely using their own microscopes. Survey invitations occurred during 2018 to 2019, with data collection completed 2021. Data analysis was performed from June to September 2021. Main Outcomes and Measures Agreement vs disagreement that overdiagnosis is a public health issue for atypical nevi, melanoma in situ, and invasive melanoma. Associations between perceptions regarding overdiagnosis and interpretive behavior on study cases. Results Of 115 dermatopathologists, 68% (95% CI, 59%-76%) agreed that overdiagnosis is a public health issue for atypical nevi; 47% (95% CI, 38%-56%) for melanoma in situ; and 35% (95% CI, 26%-43%) for invasive melanoma. Dermatopathologists with more years in practice were significantly less likely to perceive that atypical nevi are overdiagnosed, eg, 46% of dermatopathologists with 20 or more years of experience agreed that atypical nevi are overdiagnosed compared with 93% of dermatopathologists with 1 to 4 years of experience. Compared with other dermatopathologists, those who agreed that all 3 conditions are overdiagnosed were slightly more likely to diagnose study cases as mild to moderately dysplastic nevi (odds ratio, 1.26; 95% CI, 0.97-1.64; P = .08), but the difference was not statistically significant. Dermatopathologists who agreed that invasive melanoma is overdiagnosed did not significantly differ in diagnosing invasive melanoma for study cases compared with those who disagreed (odds ratio, 1.10; 95% CI, 0.86-1.41; P = .44). Conclusions and Relevance In this survey study, about two-thirds of dermatopathologists thought that atypical nevi are overdiagnosed, half thought that melanoma in situ is overdiagnosed, and one-third thought that invasive melanoma is overdiagnosed. No statistically significant associations were found between perceptions about overdiagnosis and interpretive behavior when diagnosing skin biopsy cases.
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Affiliation(s)
| | - Megan M. Eguchi
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | | | - Lisa M. Reisch
- Department of Biostatistics, University of Washington, Seattle
| | | | | | - Raymond L. Barnhill
- Department of Translational Research, Institut Curie, Paris, France
- Paris Sciences and Lettres Research University, Paris, France
- University of Paris UFR of Medicine, Paris, France
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Joann G. Elmore
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine
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Chang OH, Elder DE, Barnhill RL, Piepkorn MW, Eguchi MM, Knezevich SR, Lee AC, Moreno RJ, Kerr KF, Elmore JG. Characterization of multiple diagnostic terms in melanocytic skin lesion pathology reports. J Cutan Pathol 2021; 49:153-162. [PMID: 34487353 PMCID: PMC10367580 DOI: 10.1111/cup.14126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/04/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Histopathologically ambiguous melanocytic lesions lead some pathologists to list multiple diagnostic considerations in the pathology report. The frequency and circumstance of multiple diagnostic considerations remain poorly characterized. METHODS Two hundred and forty skin biopsy samples were interpreted by 187 pathologists (8976 independent diagnoses) and classified according to a diagnostic/treatment stratification (MPATH-Dx). RESULTS Multiple diagnoses in different MPATH-Dx classes were used in n = 1320 (14.7%) interpretations, with 97% of pathologists and 91% of cases having at least one such interpretation. Multiple diagnoses were more common for intermediate risk lesions and are associated with greater subjective difficulty and lower confidence. We estimate that 6% of pathology reports for melanocytic lesions in the United States contain two diagnoses of different MPATH-Dx prognostic classes, and 2% of cases are given two diagnoses with significant treatment implications. CONCLUSIONS Difficult melanocytic diagnoses in skin may necessitate multiple diagnostic considerations; however, as patients increasingly access their health records and retrieve pathology reports (as mandated by US law), uncertainty should be expressed unambiguously.
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Affiliation(s)
- Oliver H Chang
- Department of Laboratory Medicine and Pathology, 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
- Departments of Pathology and Translational Research, Institut Curie, Paris Sciences and Lettres Research University, and Faculty of Medicine University of Paris Descartes, Paris, France
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Dermatopathology Northwest, Bellevue, Washington, USA
| | - Megan M Eguchi
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Annie C Lee
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Raul J Moreno
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Kathleen F Kerr
- 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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10
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Tosteson ANA, Tapp S, Titus LJ, Nelson HD, Longton GM, Bronson M, Pepe M, Carney PA, Onega T, Piepkorn MW, Knezevich SR, Barnhill R, Weinstock MA, Elder DE, Elmore JG. Association of Second-Opinion Strategies in the Histopathologic Diagnosis of Cutaneous Melanocytic Lesions With Diagnostic Accuracy and Population-Level Costs. JAMA Dermatol 2021; 157:1102-1106. [PMID: 34076664 PMCID: PMC8173465 DOI: 10.1001/jamadermatol.2021.1779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/14/2021] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Diagnostic variation among pathologists interpreting cutaneous melanocytic lesions could lead to suboptimal care. OBJECTIVE To estimate the potential association of second-opinion strategies in the histopathologic diagnosis of cutaneous melanocytic lesions with diagnostic accuracy and 1-year population-level costs in the US. DESIGN, SETTING, AND PARTICIPANTS Decision analysis with 1-year time horizon including melanocytic lesion diagnoses available from US pathologists participating in the Melanoma Pathology Study (M-Path) and from the study panel of reference pathologists who classified cases using the MPATH-Dx classification tool. M-Path data collection occurred from July 2013 through March 2015; analyses for the present study were performed between April 2015 and January 2021. EXPOSURES Various second-opinion strategies for interpretation of melanocytic cutaneous lesions. MAIN OUTCOMES AND MEASURES Estimated accuracy of pathologists' diagnoses, defined as concordance with the reference panel diagnoses, and 1-year postbiopsy medical costs under various second-opinion strategies. Expected percentage of concordant diagnoses, including percentages of overinterpretation and underinterpretation, and 1-year costs of medical care per 100 000 in the US population. RESULTS Decision-analytic model parameters were based on diagnostic interpretations for 240 cases by 187 pathologists compared with reference panel diagnoses. Without second opinions, 83.2% of diagnoses in the US were estimated to be accurate-ie, concordant with the reference diagnosis; with overinterpretation (8.0%) or underinterpretation (8.8%), and 16 850 misclassified diagnoses per 100 000 biopsies. Accuracy increased under all second-opinion strategies. Accuracy (87.4% concordance with 3.6% overinterpretation and 9.1% underinterpretation) and cost (an increase of more than $10 million per 100 000 biopsies per year) were highest when second opinions were universal (eg, performed on all biopsies), relative to no second opinions. A selective second-opinion strategy based on pathologists' desire or institutional requirements for a second opinion was most accurate (86.5% concordance; 4.4% overinterpretation; 9.1% underinterpretation) and would reduce costs by more than $1.9 million per 100 000 skin biopsies relative to no second opinions. Improvements in diagnostic accuracy with all second-opinion strategies were associated with reductions in overinterpretation but not underinterpretation. CONCLUSIONS AND RELEVANCE In this decision-analytic model, selective second-opinion strategies for interpretation of melanocytic skin lesions showed the potential to improve diagnostic accuracy and decrease costs relative to no second opinions or universal second opinions.
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Affiliation(s)
- Anna N. A. Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Stephanie Tapp
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Linda J. Titus
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | | | - Gary M. Longton
- Program in Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mackenzie Bronson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Margaret Pepe
- Program in Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Tracy Onega
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Michael W. Piepkorn
- Division of Dermatology, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | | | - Raymond Barnhill
- Departments of Pathology and Translational Research, Institut Curie, Paris, France
- Paris Sciences and Letters Research University, Paris, France
| | | | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Joann G. Elmore
- David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles
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11
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Taylor LA, Eguchi MM, Reisch LM, Radick AC, Shucard H, Kerr KF, Piepkorn MW, Knezevich SR, Elder DE, Barnhill RL, Elmore JG. Histopathologic synoptic reporting of invasive melanoma: How reliable are the data? Cancer 2021; 127:3125-3136. [PMID: 33945628 DOI: 10.1002/cncr.33612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/05/2021] [Accepted: 03/27/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Synoptic reporting is recommended by many guideline committees to encourage the thorough histologic documentation necessary for optimal management of patients with melanoma. METHODS One hundred fifty-one pathologists from 40 US states interpreted 41 invasive melanoma cases. For each synoptic reporting factor, the authors identified cases with "complete agreement" (all participants recorded the same value) versus any disagreement. Pairwise agreement was calculated for each case as the proportion of pairs of responses that agreed, where paired responses were generated by the comparison of each reviewer's response with all others. RESULTS There was complete agreement among all reviewers for 22 of the 41 cases (54%) on Breslow thickness dichotomized at 0.8 mm, with pairwise agreement ranging from 49% to 100% across the 41 cases. There was complete agreement for "no ulceration" in 24 of the 41 cases (59%), with pairwise agreement ranging from 42% to 100%. Tumor transected at base had complete agreement for 26 of the 41 cases (63%), with pairwise agreement ranging from 31% to 100%. Mitotic rate, categorized as 0/mm2 , 1/mm2 , or 2/mm2 , had complete agreement for 17 of the 41 cases (41%), with pairwise agreement ranging from 36% to 100%. Regression saw complete agreement for 14 of 41 cases (34%), with pairwise agreement ranging from 40% to 100%. Lymphovascular invasion, perineural invasion, and microscopic satellites were rarely reported as present. Respectively, these prognostic factors had complete agreement for 32 (78%), 37 (90%), and 18 (44%) of the 41 cases, and the ranges of pairwise agreement were 47% to 100%, 70% to 100%, and 53% to 100%, respectively. CONCLUSIONS These findings alert pathologists and clinicians to the problem of interobserver variability in recording critical prognostic factors. LAY SUMMARY This study addresses variability in the assessment and reporting of critical characteristics of invasive melanomas that are used by clinicians to guide patient care. The authors characterize the diagnostic variability among pathologists and their reporting methods in light of recently updated national guidelines. Results demonstrate considerable variability in the diagnostic reporting of melanoma with regard to the following: Breslow thickness, mitotic rate, ulceration, regression, and microscopic satellites. This work serves to alert pathologists and clinicians to the existence of variability in reporting these prognostic factors.
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Affiliation(s)
- Laura A Taylor
- Division of Dermatology, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Megan M Eguchi
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Lisa M Reisch
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Andrea C Radick
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Hannah Shucard
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington.,Dermatopathology Northwest, Bellevue, Washington
| | | | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raymond L Barnhill
- Department of Pathology, Curie Institute, Paris Sciences and Lettres Research University, Paris, France.,Department of Translational Research, Curie Institute, Paris Sciences and Lettres Research University, Paris, France.,Faculty of Medicine, University of Paris Descartes, Paris, France
| | - Joann G Elmore
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Shucard H, Piepkorn MW, Reisch LM, Kerr KF, Radick AC, Wang PC, Knezevich SR, Barnhill RL, Elder DE, Elmore JG. Dermatopathologists' Experience With and Perceptions of Patient Online Access to Pathologic Test Result Reports. JAMA Dermatol 2020; 156:320-324. [PMID: 31995131 DOI: 10.1001/jamadermatol.2019.4194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Many patients presently have access to their pathologic test result reports via online patient portals, yet little is known about pathologists' perspective on this topic. Objective To examine dermatopathologists' experience and perceptions of patient online access to pathology reports. Design, Setting, and Participants A survey of 160 dermatopathologists currently practicing in the United States who are board certified and/or fellowship trained in dermatopathology was conducted between July 15, 2018, and September 23, 2019. Those who reported interpreting skin biopsies of melanocytic lesions within the previous year and expected to continue interpreting them for the next 2 years were included. Main Outcomes and Measures Dermatopathologists' demographic and clinical characteristics, experiences with patient online access to pathologic test result reports, potential behaviors and reactions to patient online access to those reports, and effects on patients who read their pathologic test result reports online. Results Of the 160 participating dermatopathologists from the 226 eligible for participation (71% response rate), 107 were men (67%); mean (SD) age was 49 (9.7) years (range, 34-77 years). Ninety-one participants (57%) reported that patients have contacted them directly about pathologic test reports they had written. Some participants noted that they would decrease their use of abbreviations and/or specialized terminology (57 [36%]), change the way they describe lesions suspicious for cancer (29 [18%]), and need specialized training in communicating with patients (39 [24%]) if patients were reading their reports. Most respondents perceived that patient understanding would increase (97 [61%]) and the quality of patient-physician communication would increase (98 [61%]) owing to the availability of online reports. Slightly higher proportions perceived increased patient worry (114 [71%]) and confusion (116 [73%]). However, on balance, most participants (114 [71%]) agreed that making pathologic test result reports available to patients online is a good idea. Conclusions and Relevance Dermatopathologists in this survey study perceived both positive and negative consequences of patient online access to pathologic test result reports written by the respondents. Most participants believe that making pathologic test result reports available to patients online is a good idea; however, they also report concerns about patient worry and confusion increasing as a result. Further research regarding best practices and the effect on both patients and clinicians is warranted.
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Affiliation(s)
- Hannah Shucard
- Department of Biostatistics, University of Washington, Seattle
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle.,Dermatopathology Northwest, Bellevue, Washington
| | - Lisa M Reisch
- Department of Biostatistics, University of Washington, Seattle
| | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle
| | - Andrea C Radick
- Department of Biostatistics, University of Washington, Seattle
| | - Pin-Chieh Wang
- David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles
| | | | - Raymond L Barnhill
- Institut Curie, Department of Pathology, Paris Sciences and Lettres Research University, Paris, France.,Faculty of Medicine, University of Paris Descartes, Paris, France
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Joann G Elmore
- David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles
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14
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Reisch LM, Flores MJ, Radick AC, Shucard HL, Kerr KF, Piepkorn MW, Barnhill RL, Elder DE, Knezevich SR, Elmore JG. Malpractice and Patient Safety Concerns. Am J Clin Pathol 2020; 154:700-707. [PMID: 32651589 DOI: 10.1093/ajcp/aqaa088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES "Assurance behaviors," a type of defensive medicine, involve physicians' utilization of additional patient services to avoid adverse legal outcomes. We aim to compare the use of clinical behaviors (such as ordering additional tests, services, and consultations) due to malpractice concerns with the same behaviors due to patient safety concerns. METHODS A national sample of dermatopathologists (n = 160) completed an online survey. RESULTS Participants reported using one or more of five clinical behaviors due to concerns about medical malpractice (95%) and patient safety (99%). Self-reported use of clinical behaviors due to malpractice concerns and patient safety concerns was compared, including ordering additional immunohistochemistry/molecular tests (71% vs 90%, respectively, P < .0001), recommending additional surgical sampling (78% vs 91%, P < .0001), requesting additional slides (81% vs 95%, P < .0001), obtaining second reviews (78% vs 91%, P < .0001), and adding caveats into reports regarding lesion difficulty (85% vs 89%, P > .05). CONCLUSIONS Dermatopathologists use many clinical behaviors both as assurance behaviors and due to patient safety concerns, with a higher proportion reporting patient safety concerns as a motivation for specific behaviors.
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Affiliation(s)
- Lisa M Reisch
- Department of Biostatistics, University of Washington, Seattle
| | | | - Andrea C Radick
- Department of Biostatistics, University of Washington, Seattle
| | | | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, WA
| | - Raymond L Barnhill
- Departments of Pathology and Translational Research, Institut Curie, Paris Sciences and Lettres Research University, and Faculty of Medicine, University of Paris Descartes, Paris, France
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | | | - Joann G Elmore
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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16
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Ferris LK, Rigel DS, Siegel DM, Skelsey MK, Peck GL, Hren C, Gorman C, Frumento T, Jansen B, Yao Z, Rock J, Knezevich SR, Cockerell CJ. Corrigendum: Impact on clinical practice of a non-invasive gene expression melanoma rule-out test: 12-month followup of negative test results and utility data from a large US registry study. Dermatol Online J 2019; 25:13030/qt452297hk. [PMID: 31329399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/15/2019] [Indexed: 06/10/2023] Open
Abstract
The revised version of the article corrected Figure 2. This change appears in the revised online PDF copy of this article.
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Affiliation(s)
- Laura K Ferris
- Department of Dermatology, University of Pittsburgh, Pittsburgh, PA.
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17
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Ferris LK, Rigel DS, Siegel DM, Skelsey MK, Peck GL, Hren C, Gorman C, Frumento T, Jansen B, Yao Z, Rock J, Knezevich SR, Cockerell CJ. Impact on clinical practice of a non-invasive gene expression melanoma rule-out test: 12-month follow-up of negative test results and utility data from a large US registry study. Dermatol Online J 2019; 25:13030/qt61w6h7mn. [PMID: 31220892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 06/09/2023] Open
Abstract
The Pigmented Lesion Assay (PLA, sensitivity 91-95%, specificity 69-91%, negative predictive value ?99%) is a commercially available, non-invasive gene expression test that helps dermatologists guide pigmented lesion management decisions and rule out melanoma. Earlier studies have demonstrated high clinical utility and no missed melanomas in a 3-6-month follow-up period. We undertook the current investigations to provide 12-month follow-up data on PLA(-) tests, and to further confirm utility. A 12-month chart review follow-up of 734 pigmented lesions that had negative PLA results from 5 US dermatology centers was performed. Thirteen of these lesions (1.8%) were biopsied in the follow-up period and submitted for histopathologic review. None of the lesions biopsied had a histopathologic diagnosis of melanoma. The test's utility was studied further in a registry (N=1575, 40 US dermatology offices, 62 participating providers), which demonstrated that 99.9% of PLA(-) lesions were clinically monitored, thereby avoiding a surgical procedure, and 96.5% of all PLA(+) lesions were appropriately biopsied, most commonly with a tangential shave. This long-term follow-up study confirms the PLA's high negative predictive value and high utility in helping guide the management of pigmented lesions to avoid unnecessary surgical procedures.
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Affiliation(s)
- Laura K Ferris
- Department of Dermatology, University of Pittsburgh, Pittsburgh, PA.
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18
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Ferris LK, Rigel DS, Siegel DM, Skelsey MK, Peck GL, Hren C, Gorman C, Frumento T, Jansen B, Yao Z, Rock J, Knezevich SR, Cockerell CJ. Impact on clinical practice of a non-invasive gene expression melanoma rule-out test: 12-month follow-up of negative test results and utility data from a large US registry study. Dermatol Online J 2019. [DOI: 10.5070/d3255044059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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19
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Ferris LK, Rigel DS, Siegel DM, Skelsey MK, Peck GL, Hren C, Gorman C, Frumento T, Jansen B, Yao Z, Rock J, Knezevich SR, Cockerell CJ. Corrigendum: Impact on clinical practice of a non-invasive gene expression melanoma rule-out test: 12-month followup of negative test results and utility data from a large US registry study. Dermatol Online J 2019. [DOI: 10.5070/d3256044511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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20
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Onega T, Barnhill RL, Piepkorn MW, Longton GM, Elder DE, Weinstock MA, Knezevich SR, Reisch LM, Carney PA, Nelson HD, Radick AC, Elmore JG. Accuracy of Digital Pathologic Analysis vs Traditional Microscopy in the Interpretation of Melanocytic Lesions. JAMA Dermatol 2018; 154:1159-1166. [PMID: 30140929 PMCID: PMC6233746 DOI: 10.1001/jamadermatol.2018.2388] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 05/29/2018] [Indexed: 11/14/2022]
Abstract
Importance Use of digital whole-slide imaging (WSI) for dermatopathology in general has been noted to be similar to traditional microscopy (TM); however, concern has been noted that WSI is inferior for interpretation of melanocytic lesions. Since approximately 1 of every 4 skin biopsies is of a melanocytic lesion, the use of WSI requires verification before use in clinical practice. Objective To compare pathologists' accuracy and reproducibility in diagnosing melanocytic lesions using Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) categories when analyzing by TM vs WSI. Design, Setting, and Participants A total of 87 pathologists in community-based and academic settings from 10 US states were randomized with stratification based on clinical experience to interpret in TM format 180 skin biopsy cases of melanocytic lesions, including 90 invasive melanoma, divided into 5 sets of 36 cases (phase 1). The pathologists were then randomized via stratified permuted block randomization with block size 2 to interpret cases in either TM (n = 46) or WSI format (n = 41), with each pathologist interpreting the same 36 cases on 2 separate occasions (phase 2). Diagnoses were categorized as MPATH-Dx categories I through V, with I indicating the least severe and V the most severe. Main Outcomes and Measures Accuracy with respect to a consensus reference diagnosis and the reproducibility of repeated interpretations of the same cases. Results Of the 87 pathologists in the study, 46% (40) were women and the mean (SD) age was 50.7 (10.2) years. Except for class III melanocytic lesions, the diagnostic categories showed no significant differences in diagnostic accuracy between TM and WSI interpretation. Discordance was lower among class III lesions for the TM interpretation arm (51%; 95% CI, 46%-57%) than for the WSI arm (61%; 95% CI, 53%-69%) (P = .05). This difference is likely to have clinical significance, because 6% of TM vs 11% of WSI class III lesions were interpreted as invasive melanoma. Reproducibility was similar between the traditional and digital formats overall (66.4%; 95% CI, 63.3%-69.3%; and 62.7%; 95% CI, 59.5%-65.7%, respectively), and for all classes, although class III showed a nonsignificant lower intraobserver agreement for digital. Significantly more mitotic figures were detected with TM compared with WSI: mean (SD) TM, 6.72 (2.89); WSI, 5.84 (2.56); P = .002. Conclusions and Relevance Interpretive accuracy for melanocytic lesions was similar for WSI and TM slides except for class III lesions. We found no clinically meaningful differences in reproducibility for any of the diagnostic classes.
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Affiliation(s)
- Tracy Onega
- Departments of Medicine and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Raymond L. Barnhill
- Department of Pathology, Institut Curie, Paris Sciences and Lettres Research University, and Faculty of Medicine University of Paris Descartes, Paris, France
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | - Gary M. Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Martin A. Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island
- Departments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island
| | | | - Lisa M. Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Patricia A. Carney
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland
| | - Heidi D. Nelson
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland
- Department of Medicine, School of Medicine, Oregon Health & Science University, Portland
- Providence Cancer Center, Providence Health and Services, Portland, Oregon
| | - Andrea C. Radick
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Carney PA, Frederick PD, Reisch LM, Titus L, Knezevich SR, Weinstock MA, Piepkorn MW, Barnhill RL, Elder DE, Weaver DL, Elmore JG. Complexities of perceived and actual performance in pathology interpretation: A comparison of cutaneous melanocytic skin and breast interpretations. J Cutan Pathol 2018; 45:478-490. [PMID: 29603324 PMCID: PMC6013368 DOI: 10.1111/cup.13147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 02/26/2018] [Accepted: 03/06/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Little is known about how pathologists process differences between actual and perceived interpretations. OBJECTIVE To compare perceived and actual diagnostic agreement before and after educational interventions. METHODS Pathologists interpreted test sets of skin and/or breast specimens that included benign, atypical, in situ and invasive lesions. Interventions involved self-directed learning, one skin and one breast, that showed pathologists how their interpretations compared to a reference diagnoses. Prior to the educational intervention, participants estimated how their interpretations would compare to the reference diagnoses. After the intervention, participants estimated their overall agreement with the reference diagnoses. Perceived and actual agreements were compared. RESULTS For pathologists interpreting skin, mean actual agreement was 52.4% and overall pre- and postinterventional mean perceived agreement was 72.9% vs 54.2%, an overestimated mean difference of 20.5% (95% confidence interval [CI] 17.2% to 24.0%) and 1.8% (95% CI -0.5% to 4.1%), respectively. For pathologists interpreting breast, mean actual agreement was 75.9% and overall pre- and postinterventional mean perceived agreement was 81.4% vs 76.9%, an overestimation of 5.5% (95% CI 3.0% to 8.0%) and 1.0% (95% CI 0.0% to 2.0%), respectively. CONCLUSIONS Pathologists interpreting breast tissue had improved comprehension of their performance after the intervention compared to pathologists interpreting skin lesions.
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Affiliation(s)
- Patricia A. Carney
- Professor of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Paul D. Frederick
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Lisa M. Reisch
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Linda Titus
- Departments of Epidemiology and of Pediatrics, Geisel School of Medicine at Dartmouth, and the Norris Cotton Cancer Center, Lebanon, NH
| | | | - Martin A. Weinstock
- Professor of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Dermatopathology Northwest, Bellevue, WA
| | - Raymond L. Barnhill
- Department of Pathology, Institut Curie, University of Paris Descartes, Paris, France
| | - David E. Elder
- Department of Pathology, University of Pennsylvania, Philadelphia, PA
| | | | - Joann G. Elmore
- Professor of Internal Medicine, University of Washington, Seattle, WA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Elmore JG, Elder DE, Barnhill RL, Knezevich SR, Longton GM, Titus LJ, Weinstock MA, Pepe MS, Nelson HD, Reisch LM, Radick AC, Piepkorn MW. Concordance and Reproducibility of Melanoma Staging According to the 7th vs 8th Edition of the AJCC Cancer Staging Manual. JAMA Netw Open 2018; 1:e180083. [PMID: 30556054 PMCID: PMC6294444 DOI: 10.1001/jamanetworkopen.2018.0083] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The recently updated American Joint Committee on Cancer (AJCC) classification of cancer staging, the AJCC Cancer Staging Manual, 8th edition (AJCC 8), includes revisions to definitions of T1a vs T1b or greater. The Melanoma Pathology Study database affords a comparison,of pathologists' concordance and reproducibility in the microstaging of melanoma according to both the existing 7th edition (AJCC 7) and the new AJCC 8. OBJECTIVE To compare AJCC 7 and AJCC 8 to examine whether changes to the definitions of T1a and T1b or greater are associated with changes in concordance and reproducibility. DESIGN SETTING AND PARTICIPANTS In this diagnostic study conducted as part of the national Melanoma Pathology Study across US states, 187 pathologists interpreting melanocytic skin lesions in practice completed 4342 independent case interpretations of 116 invasive melanoma cases. A consensus reference diagnosis and participating pathologists' interpretations were classified into the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis class IV (T1a) or class V ( T1b) using both the AJCC 7 and AJCC 8 criteria. MAIN OUTCOMES AND MEASURES Concordance with consensus reference diagnosis, interobserver reproducibility, and intraobserver reproducibility. RESULTS For T1a diagnoses, participating pathologists' concordance with the consensus reference diagnosis increased from 44% (95% CI, 41%-48%) to 54% (95% CI, 51%-57%) using AJCC 7 and AJCC 8 criteria, respectively. The concordance for cases of T1b or greater increased from 72% (95% CI, 69%-75%) to 78% (95% CI, 75%-80%). Intraobserver reproducibility of diagnoses also improved, increasing from 59% (95% CI, 56%-63%) to 64% (95% CI, 62%-67%) for T1a invasive melanoma, and from 74% (95% CI, 71%-76%) to 77% (95% CI, 74%-79%) for T1b or greater invasive melanoma cases. CONCLUSIONS AND RELEVANCE Melanoma staging in AJCC 8 shows greater reproducibility and higher concordance with a reference standard. Improved classification of invasive melanoma can be expected after implementation of AJCC 8, suggesting a positive impact on patients. However, despite improvement, concordance and reproducibility remain low.
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Affiliation(s)
- Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Raymond L. Barnhill
- Department of Pathology, Institut Curie, Paris, France
- Paris Sciences and Lettres Research University, Paris, France
- Faculty of Medicine, University of Paris Descartes, Paris, France
| | | | - Gary M. Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Linda J. Titus
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Martin A. Weinstock
- Center for Dermatoepidemiology, Providence Veterans Affair Medical Center, Providence, Rhode Island
- Department of Dermatology, Brown University, Providence, Rhode Island
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Margaret S. Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Heidi D. Nelson
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland
- Department of Medicine, School of Medicine, Oregon Health and Science University, Portland
| | - Lisa M. Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Andrea C. Radick
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Michael W. Piepkorn
- Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
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Zhu VW, Hinduja S, Knezevich SR, Silveira WR, DeLozier CD. A rare case of choroid plexus carcinoma that led to the diagnosis of Lynch syndrome (hereditary nonpolyposis colorectal cancer). Clin Neurol Neurosurg 2017; 158:46-48. [DOI: 10.1016/j.clineuro.2017.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 04/12/2017] [Accepted: 04/15/2017] [Indexed: 10/19/2022]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Titus L, Barnhill RL, Lott JP, Piepkorn MW, Elder DE, Chb MB, Frederick PD, Nelson HD, Carney PA, Knezevich SR, Weinstock MA, Elmore JG. The influence of tumor regression, solar elastosis, and patient age on pathologists' interpretation of melanocytic skin lesions. J Transl Med 2017; 97:187-193. [PMID: 27892931 PMCID: PMC5280085 DOI: 10.1038/labinvest.2016.120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/12/2016] [Accepted: 10/11/2016] [Indexed: 11/09/2022] Open
Abstract
It is not known whether patient age or tumor characteristics such as tumor regression or solar elastosis influence pathologists' interpretation of melanocytic skin lesions (MSLs). We undertook a study to determine the influence of these factors, and to explore pathologist's characteristics associated with the direction of diagnosis. To meet our objective, we designed a cross-sectional survey study of pathologists' clinical practices and perceptions. Pathologists were recruited from diverse practices in 10 states in the United States. We enrolled 207 pathologist participants whose practice included the interpretation of MSLs. Our findings indicated that the majority of pathologists (54.6%) were influenced toward a less severe diagnosis when patients were <30 years of age. Most pathologists were influenced toward a more severe diagnosis when patients were >70 years of age, or by the presence of tumor regression or solar elastosis (58.5%, 71.0%, and 57.0%, respectively). Generally, pathologists with dermatopathology board certification and/or a high caseload of MSLs were more likely to be influenced, whereas those with more years' experience interpreting MSL were less likely to be influenced. Our findings indicate that the interpretation of MSLs is influenced by patient age, tumor regression, and solar elastosis; such influence is associated with dermatopathology training and higher caseload, consistent with expertise and an appreciation of lesion complexity.
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Affiliation(s)
- Linda Titus
- Departments of Epidemiology and of Pediatrics, Geisel School of Medicine at Dartmouth, and the Norris Cotton Cancer Center, Lebanon, NH
| | - Raymond L. Barnhill
- Departments of Pathology, Institut Curie and Faculty of Medicine, University of Paris Descartes, Paris, France
| | | | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Dermatopathology Northwest, Bellevue, WA
| | | | - MB Chb
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Paul D. Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Heidi D. Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR
| | - Patricia A. Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Martin A. Weinstock
- Center for Dermatoepidemiology, VA Medical Center, Providence Department of Dermatology, Rhode Island Hospital; Departments of Dermatology and Epidemiology, Brown University, Providence, RI
| | - Joann G. Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
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Zhao G, Lee KC, Peacock S, Reisch LM, Knezevich SR, Elder DE, Piepkorn MW, Elmore JG, Barnhill RL. The utilization of spitz-related nomenclature in the histological interpretation of cutaneous melanocytic lesions by practicing pathologists: results from the M-Path study. J Cutan Pathol 2017; 44:5-14. [PMID: 27686456 PMCID: PMC5177484 DOI: 10.1111/cup.12826] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/27/2016] [Accepted: 09/25/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spitz nevi, atypical Spitz tumors and spitzoid melanomas ('spitzoid lesions') represent controversial and poorly understood cutaneous melanocytic lesions that are difficult to diagnose histologically. It is unknown how these terms are used by pathologists. METHODS We describe use of Spitz-related terminology using data from the Melanoma Pathology (M-Path) study database comprising pathologists' interpretations of biopsy slides, a nation-wide study evaluating practicing US pathologists' (N = 187) diagnoses of melanocytic lesions (8976 independent diagnostic assessments on 240 total test cases, with 1 slide per case). RESULTS Most pathologists (90%) used the Spitz-related terminology. However, significant variation exists in which specific lesions were diagnosed as spitzoid and in the corresponding treatment recommendations. Recommendations ranged from 'no further treatment' to 'wide excision of 10 mm or greater' with no category capturing more than 50% of responses. For spitzoid melanoma diagnoses, 90% of pathologists recommended excision with ≥10 mm margin. Pathologists report less confidence in diagnosing these lesions compared with other melanocytic proliferations and are more likely to request second opinions and additional clinical information (all p < 0.05). CONCLUSIONS Spitzoid lesions are often not classified in any standardized way, evoke uncertainty in diagnosis by pathologists, and elicit variability in treatment recommendations.
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Affiliation(s)
- Ge Zhao
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA
| | - Kachiu C. Lee
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sue Peacock
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Lisa M. Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | | | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
- Dermatopathology Northwest, Bellevue, WA
| | - Joann G. Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Raymond L. Barnhill
- Department of Pathology, Institut Curie, and Faculty of Medicine, University of Paris Descartes, Paris, France
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lott JP, Elmore JG, Zhao GA, Knezevich SR, Frederick PD, Reisch LM, Chu EY, Cook MG, Duncan LM, Elenitsas R, Gerami P, Landman G, Lowe L, Messina JL, Mihm MC, van den Oord JJ, Rabkin MS, Schmidt B, Shea CR, Yun SJ, Xu GX, Piepkorn MW, Elder DE, Barnhill RL. Evaluation of the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) classification scheme for diagnosis of cutaneous melanocytic neoplasms: Results from the International Melanoma Pathology Study Group. J Am Acad Dermatol 2016; 75:356-63. [PMID: 27189823 DOI: 10.1016/j.jaad.2016.04.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 04/05/2016] [Accepted: 04/13/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pathologists use diverse terminology when interpreting melanocytic neoplasms, potentially compromising quality of care. OBJECTIVE We sought to evaluate the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) scheme, a 5-category classification system for melanocytic lesions. METHODS Participants (n = 16) of the 2013 International Melanoma Pathology Study Group Workshop provided independent case-level diagnoses and treatment suggestions for 48 melanocytic lesions. Individual diagnoses (including, when necessary, least and most severe diagnoses) were mapped to corresponding MPATH-Dx classes. Interrater agreement and correlation between MPATH-Dx categorization and treatment suggestions were evaluated. RESULTS Most participants were board-certified dermatopathologists (n = 15), age 50 years or older (n = 12), male (n = 9), based in the United States (n = 11), and primary academic faculty (n = 14). Overall, participants generated 634 case-level diagnoses with treatment suggestions. Mean weighted kappa coefficients for diagnostic agreement after MPATH-Dx mapping (assuming least and most severe diagnoses, when necessary) were 0.70 (95% confidence interval 0.68-0.71) and 0.72 (95% confidence interval 0.71-0.73), respectively, whereas correlation between MPATH-Dx categorization and treatment suggestions was 0.91. LIMITATIONS This was a small sample size of experienced pathologists in a testing situation. CONCLUSION Varying diagnostic nomenclature can be classified into a concise hierarchy using the MPATH-Dx scheme. Further research is needed to determine whether this classification system can facilitate diagnostic concordance in general pathology practice and improve patient care.
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Affiliation(s)
- Jason P Lott
- Cornell Scott-Hill Health Center, New Haven, Connecticut
| | - Joann G Elmore
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Ge A Zhao
- Division of Dermatology, University of Washington School of Medicine, Seattle, Washington
| | | | - Paul D Frederick
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Lisa M Reisch
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Emily Y Chu
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Martin G Cook
- University of Surrey Division of Clinical Medicine, Surrey, United Kingdom
| | - Lyn M Duncan
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Rosalie Elenitsas
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Pedram Gerami
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gilles Landman
- Department of Pathology, Universidade Federal de São Paulo-Escola Paulista de Medicina, São Paulo, Brazil
| | - Lori Lowe
- Department of Pathology and Dermatology, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
| | - Jane L Messina
- Departments of Anatomic Pathology and Cutaneous Oncology, Moffitt Center, and Department of Pathology and Cell Biology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Martin C Mihm
- Department of Dermatology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joost J van den Oord
- Department of Pathology, University Hospitals Katholieke Universiteit Leuven, Leuven, Belgium
| | | | - Birgitta Schmidt
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher R Shea
- Section of Dermatology, University of Chicago Medicine, Chicago, Illinois
| | - Sook Jung Yun
- Department of Dermatology, Chonnam National University School of Medicine, Gwangju, Korea
| | - George X Xu
- Department of Pathology and Lab Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael W Piepkorn
- Division of Dermatology, University of Washington School of Medicine, Seattle, Washington
| | - David E Elder
- Department of Pathology and Lab Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie and Faculty of Medicine, University of Paris Descartes, Paris, France
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Joselow A, Raugi G, Knezevich SR. Aggressive meningioma presents as innocuous forehead lesion: a case report. Dermatol Online J 2014; 20:13030/qt7tm8t9p0. [PMID: 25419753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 11/14/2014] [Indexed: 06/04/2023] Open
Abstract
Cutaneous meningiomas are very rare neoplasms. In this case report we document a type III (anaplastic meningioma) presenting as a subcutaneous forehead mass. Anaplastic meningiomas arise from the neuraxis. They are biologically aggressive neoplasms that extend into the dermis or subcutaneous tissue via direct extension through the bone.
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Piepkorn MW, Barnhill RL, Elder DE, Knezevich SR, Carney PA, Reisch LM, Elmore JG. The MPATH-Dx reporting schema for melanocytic proliferations and melanoma. J Am Acad Dermatol 2013; 70:131-41. [PMID: 24176521 DOI: 10.1016/j.jaad.2013.07.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 07/12/2013] [Accepted: 07/18/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The histologic diagnosis of melanoma and nevi can be subject to discordance and errors, potentially leading to inappropriate treatment and harm. Diagnostic terminology is not standardized, creating confusion for providers and patients and challenges for investigators. OBJECTIVE We sought to describe the development of a pathology reporting form for more precise research on melanoma and a diagnostic-treatment mapping tool for improved patient care and consistency in treatment. METHODS Three dermatopathologists independently reviewed melanocytic lesions randomly selected from a dermatopathology database. Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) reporting schema evolved from iterative case review and form revision. RESULTS Differences in diagnostic thresholds, interpretation, and nomenclature contributed to development of the MPATH-Dx histology reporting form, which groups lesions by similarities in histogenesis and degrees of atypia. Because preliminary results indicate greater agreement regarding suggested treatments than for specific diagnoses, the diverse terminologies of the MPATH-Dx histology reporting form were stratified by commonalities of treatments in the MPATH-Dx diagnostic-treatment mapping scheme. LIMITATIONS Without transformative advances in diagnostic paradigms, the interpretation of melanocytic lesions frequently remains subjective. CONCLUSIONS The MPATH-Dx diagnostic-treatment mapping scheme could diminish confusion for those receiving reports by categorizing diverse nomenclature into a hierarchy stratified by suggested management interventions.
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Affiliation(s)
- Michael W Piepkorn
- Division of Dermatology, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Dermatopathology Northwest, Bellevue, Washington.
| | - Raymond L Barnhill
- Department of Pathology and Laboratory Medicine, University of California at Los Angeles, Los Angeles, California
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Patricia A Carney
- Department of Family Medicine, Oregon Health Sciences University, Portland, Oregon
| | - Lisa M Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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Eastman KL, Knezevich SR, Raugi GJ. Eruptive seborrheic keratoses associated with adalimumab use. J Dermatol Case Rep 2013; 7:60-3. [PMID: 23858344 DOI: 10.3315/jdcr.2013.1139] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 02/10/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Seborrheic keratoses are common, benign cutaneous growths, however in rare situations they can acutely erupt in large numbers. Eruptive seborrheic keratoses can be associated with internal malignancy (sign of Leser-Trelat), but may also appear in conjunction with inflammatory dermatoses and adverse drug reactions. MAIN OBSERVATION A 71-year-old Caucasian man presented with acute onset of a pruritic, burning papular erythematous rash on his chest, upper extremities and lower extremities after a routine adalimumab injection for rheumatoid arthritis. Two skin biopsies obtained showed findings diagnostic of seborrheic keratoses. Spontaneous resolution of the diffuse eruptive seborrheic keratoses was achieved within 3 months of discontinuing adalimumab therapy. CONCLUSIONS We believe the development of eruptive seborrheic keratoses due to adalimumab therapy is rare, and because our patient responded promptly to discontinuation of the drug we suggest this should be the preferred course of action in future cases.
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Diallo R, Tognon C, Knezevich SR, Sorensen P, Poremba C. Secretory carcinoma of the breast: a genetically defined carcinoma entity. Verh Dtsch Ges Pathol 2003; 87:193-203. [PMID: 16888913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Secretory carcinomas (SBC) are characterized by their characteristic histomorphology and more favorable prognosis compared to invasive ductal carcinoma of usual type (IDC). On this basis, 13 SBCs are evaluated by molecular and immunohistochemical (IH) methods. 13 SBCs and 4 IDCs were analyzed for ETV6-NTRK3 gene fusion by reverse transcriptase-polymerase chain reaction (RT-PCR) and by Fluorescence in situ Hybridization (FISH). 8 of 13 microdissected SBCs with evaluable DNA were evaluated for genetic alterations (GA) by comparative genomic hybridization (CGH). IH included estrogen-receptor (ER), progesterone-receptor (PR), Her-2/neu and Ki-67 (MIB-1) in all 13 cases. Molecular and immunohistochemical results in SBCs were compared with previous data regarding immunohistochemical and molecular characteristics of IDCs. 12 of 13 (92 %) SBC cases, but not IDCs expressed the ETV6-NTRK3 fusion gene which encodes a chimeric tyrosine kinase. Retroviral transfer of ETV6-NTRK3 (EN) into murine mammary epithelial cells resulted in transformed cells that readily formed epithelial tumors in nude mice. CGH revealed an average of 2.0 GAs (range 0-6), including recurrent gains of chromosome 8q and 1q and losses of 22q. Four SBCs were positive for ER and 2 were positive for PR. The mean MIB-1-labeling index was 11.4% (range: <1-34%). Her-2/ neu protein overexpression was detected in 1 case (score 3+). Compared to previous findings in IDCs, SBCs are characterized by the recurrent expression of ETV6-NTRK3 fusion gene, a relatively low number of GAs, low proliferative rate, infrequent Her-2/ neu protein overexpression and a lower rate of steroid hormone receptor expression. These results support the hypothesis that SBCs have immunohistochemical and genetic features that specifically distinguish them from IDCs.
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Affiliation(s)
- R Diallo
- Institut für Pathologie, Heinrich-Heine-Universität, Düsseldorf
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35
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Tognon C, Knezevich SR, Huntsman D, Roskelley CD, Melnyk N, Mathers JA, Becker L, Carneiro F, MacPherson N, Horsman D, Poremba C, Sorensen PHB. Expression of the ETV6-NTRK3 gene fusion as a primary event in human secretory breast carcinoma. Cancer Cell 2002; 2:367-76. [PMID: 12450792 DOI: 10.1016/s1535-6108(02)00180-0] [Citation(s) in RCA: 641] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We report that human secretory breast carcinoma (SBC), a rare subtype of infiltrating ductal carcinoma, expresses the ETV6-NTRK3 gene fusion previously cloned in pediatric mesenchymal cancers. This gene fusion encodes a chimeric tyrosine kinase with potent transforming activity in fibroblasts. ETV6-NTRK3 expression was confirmed in 12 (92%) of 13 SBC cases, but not in other ductal carcinomas. Retroviral transfer of ETV6-NTRK3 (EN) into murine mammary epithelial cells resulted in transformed cells that readily formed tumors in nude mice. Phenotypically, tumors produced glands and expressed epithelial antigens, confirming that EN transformation is compatible with epithelial differentiation. This represents a recurrent chromosomal rearrangement and expression of a dominantly acting oncogene as a primary event in human breast carcinoma.
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MESH Headings
- 3T3 Cells
- Adolescent
- Adult
- Aged
- Animals
- Artificial Gene Fusion
- Breast Neoplasms/genetics
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/genetics
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/pathology
- Child
- Chromosomes, Human, Pair 12
- Chromosomes, Human, Pair 15
- DNA-Binding Proteins/chemistry
- DNA-Binding Proteins/genetics
- DNA-Binding Proteins/metabolism
- Female
- Humans
- Male
- Mice
- Mice, Nude
- Middle Aged
- Proto-Oncogene Proteins c-ets
- Receptor, trkC/chemistry
- Receptor, trkC/genetics
- Receptor, trkC/metabolism
- Recombinant Fusion Proteins/metabolism
- Repressor Proteins/chemistry
- Repressor Proteins/genetics
- Repressor Proteins/metabolism
- Retroviridae/genetics
- Translocation, Genetic
- ETS Translocation Variant 6 Protein
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Affiliation(s)
- Cristina Tognon
- Department of Pathology & Laboratory Medicine, Children's and Women's Health Centre of British Columbia, 950 West 28th Avenue, Vancouver, British Columbia, Canada V5Z4H4
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Alessandri AJ, Knezevich SR, Mathers JA, Schultz KR, Sorensen PH. Absence of t(12;15) associated ETV6-NTRK3 fusion transcripts in pediatric acute leukemias. Med Pediatr Oncol 2001; 37:415-6. [PMID: 11568911 DOI: 10.1002/mpo.1222] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- A J Alessandri
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplantation, University of British Columbia and Children's and Women's Hospital, Vancouver, BC, Canada V5Z 4H4
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Bourgeois JM, Knezevich SR, Mathers JA, Sorensen PH. Molecular detection of the ETV6-NTRK3 gene fusion differentiates congenital fibrosarcoma from other childhood spindle cell tumors. Am J Surg Pathol 2000; 24:937-46. [PMID: 10895816 DOI: 10.1097/00000478-200007000-00005] [Citation(s) in RCA: 236] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Congenital fibrosarcoma (CFS) is a pediatric spindle cell tumor of the soft tissues that usually presents before the age of 2 years. Although these tumors display histologic features of malignancy and frequently recur, they have a relatively good prognosis and only rarely metastasize. CFS must therefore be differentiated from more aggressive spindle cell sarcomas that occur during childhood, particularly adult-type fibrosarcoma (ATFS), which can have an identical morphology. CFS must also be distinguished from benign but cellular fibroblastic lesions of the same age group, including infantile fibromatosis (IFB) and myofibromatosis (MFB). Unfortunately, standard pathologic examination often does not differentiate CFS from these other conditions. The authors recently identified a novel chromosomal translocation in CFS, t(12;15)(p13;q25), which gives rise to an ETV6-NTRK3 gene fusion. They subsequently developed reverse transcription-polymerase chain reaction (RT-PCR) assays that can detect ETV6-NTRK3 fusion transcripts in CFS frozen or paraffin-embedded tumor specimens. To confirm the use of this assay in the differential diagnosis of CFS, they have screened a larger series of childhood pediatric spindle cell lesions for ETV6-NTRK3 gene fusions, including 11 cases of CFS, 13 malignant spindle cell tumors (including ATFS), and 38 benign spindle cell tumors (including IFB and MFB). Of the 11 cases diagnosed as CFS, 10 showed the ETV6-NTRK3 gene fusion, whereas none of the 51 other malignant or benign spindle cell tumors demonstrated this fusion gene. They also compared their RT-PCR findings with those of conventional cytogenetics and with immunohistochemical detection of the ETV6-NTRK3 protein using antisera to NTRK3. They conclude that RT-PCR analysis is superior to these techniques for the detection of the ETV6-NTRK3 gene fusion in pediatric spindle cell tumors, and it is a reliable and specific modality for the diagnosis of CFS.
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Affiliation(s)
- J M Bourgeois
- Department of Pathology and Molecular Medicine, McMaster University Medical Centre, Hamilton, Ontario, Canada
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Wai DH, Knezevich SR, Lucas T, Jansen B, Kay RJ, Sorensen PH. The ETV6-NTRK3 gene fusion encodes a chimeric protein tyrosine kinase that transforms NIH3T3 cells. Oncogene 2000; 19:906-15. [PMID: 10702799 DOI: 10.1038/sj.onc.1203396] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/1999] [Revised: 11/18/1999] [Accepted: 12/08/1999] [Indexed: 11/09/2022]
Abstract
The congenital fibrosarcoma t(12;15)(p13;q25) rearrangement splices the ETV6 (TEL) gene on chromosome 12p13 in frame with the NTRK3 (TRKC) neurotrophin-3 receptor gene on chromosome 15q25. Resultant ETV6-NTRK3 fusion transcripts encode the helix - loop - helix (HLH) dimerization domain of ETV6 fused to the protein tyrosine kinase (PTK) domain of NTRK3. We show here that ETV6-NTRK3 homodimerizes and is capable of forming heterodimers with wild-type ETV6. Moreover, ETV6-NTRK3 has PTK activity and is autophosphorylated on tyrosine residues. To determine if the fusion protein has transforming activity, NIH3T3 cells were infected with recombinant retroviral vectors carrying the full-length ETV6-NTRK3 cDNA. These cells exhibited a transformed phenotype, grew macroscopic colonies in soft agar, and formed tumors in severe combined immunodeficient (SCID) mice. We hypothesize that chimeric proteins mediate transformation by dysregulating NTRK3 signal transduction pathways via ligand-independent dimerization and PTK activation. To test this hypothesis, we expressed a series of ETV6-NTRK3 mutants in NIH3T3 cells and assessed their transformation activities. Deletion of the ETV6 HLH domain abolished dimer formation with either ETV6 or ETV6-NTRK3, and cells expressing this mutant protein were morphologically non-transformed and failed to grow in soft agar. An ATP-binding mutant failed to autophosphorylate and completely lacked transformation activity. Mutants of the three NTRK3 PTK activation-loop tyrosines had variable PTK activity but had limited to absent transformation activity. Of a series of signaling molecules well known to bind to wild-type NTRK3, only phospholipase-Cgamma (PLCgamma) associated with ETV6-NTRK3. However, a PTK active mutant unable to bind PLCgamma did not show defects in transformation activity. Our studies confirm that ETV6-NTRK3 is a transforming protein that requires both an intact dimerization domain and a functional PTK domain for transformation activity. Oncogene (2000) 19, 906 - 915.
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MESH Headings
- 3T3 Cells
- Adaptor Proteins, Signal Transducing
- Animals
- Cell Line, Transformed/enzymology
- Cell Line, Transformed/metabolism
- DNA-Binding Proteins/genetics
- GRB2 Adaptor Protein
- Helix-Loop-Helix Motifs/genetics
- Humans
- Isoenzymes/metabolism
- Mice
- Mice, SCID
- Molecular Sequence Data
- Oncogene Proteins, Fusion/chemistry
- Oncogene Proteins, Fusion/genetics
- Oncogene Proteins, Fusion/metabolism
- Phosphatidylinositol 3-Kinases/metabolism
- Phospholipase C gamma
- Protein Kinases/genetics
- Protein Kinases/metabolism
- Protein-Tyrosine Kinases/genetics
- Protein-Tyrosine Kinases/metabolism
- Proteins/metabolism
- Proto-Oncogene Proteins c-ets
- Receptor, trkC/biosynthesis
- Receptor, trkC/chemistry
- Receptor, trkC/genetics
- Receptor, trkC/metabolism
- Recombinant Fusion Proteins/genetics
- Repressor Proteins
- Transcription Factors/genetics
- Translocation, Genetic
- Type C Phospholipases/metabolism
- src Homology Domains/genetics
- ETS Translocation Variant 6 Protein
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Affiliation(s)
- D H Wai
- Department of Pathology, 4480 Oak St., British Columbia's Children's Hospital, Vancouver, British Columbia V6H 3V4, Canada
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Knezevich SR, Garnett MJ, Pysher TJ, Beckwith JB, Grundy PE, Sorensen PH. ETV6-NTRK3 gene fusions and trisomy 11 establish a histogenetic link between mesoblastic nephroma and congenital fibrosarcoma. Cancer Res 1998; 58:5046-8. [PMID: 9823307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Congenital mesoblastic nephroma (CMN) is an infantile spindle cell tumor of the kidney that is subdivided into "classical" and "cellular" forms based on the degree of cellularity and mitotic activity. The histogenesis of CMN remains obscure, but relationships to other pediatric renal neoplasms have been proposed. However, cellular CMN is virtually identical histologically to congenital fibrosarcoma (CFS), a malignant tumor of fibroblasts in children of the same age group. Moreover, cytogenetic studies have reported common trisomies in CFS and cellular CMN, particularly of chromosome 11. We show here that t(12;15)(p13;q25)-associated ETV6-NTRK3 gene fusions described in CFS are also present in cellular CMN. ETV6-NTRK3 chimeric transcripts were detected in 8 of 9 cellular CMNs and 2 of 2 mixed CMNs. In contrast, all of the four classical CMNs tested were negative, as were cases of Wilms' tumor and clear cell sarcoma of the kidney. Moreover, we found trisomy 11 only in cellular or mixed CMNs with the ETV6-NTRK3 gene fusion. Our studies indicate that classical and cellular CMN have different genetic features and support the concept that cellular CMN is histogenetically related to CFS. They also provide insight into potential mechanisms involved in the transformation of the classical into the cellular form of CMN.
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Affiliation(s)
- S R Knezevich
- Department of Pathology, British Columbia's Children's Hospital, Vancouver, Canada
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Knezevich SR, Hendson G, Mathers JA, Carpenter B, Lopez-Terrada D, Brown KL, Sorensen PH. Absence of detectable EWS/FLI1 expression after therapy-induced neural differentiation in Ewing sarcoma. Hum Pathol 1998; 29:289-94. [PMID: 9496833 DOI: 10.1016/s0046-8177(98)90049-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ewing sarcoma and other peripheral primitive neuroectodermal tumors (pPNETs) display limited neural differentiation and are thought to have a neural crest origin Greater than 95% of these tumors share common t(11;22)(q24;q12) ort(21;22)(q22;q12) chromosomal translocations leading to ES/FLI1 or EWS/ERG gene fusions, respectively. The resulting chimeric oncoproteins seem to function as aberrant transcription factors. However, whether these molecules contribute to the limited neural differentiation observed in pPNETs or actually inhibit differentiation remains unclear. We report a Ewing sarcoma case from the forearm of a 10-year-old girl which expressed EWS/FLI1 fusion transcripts. The tumor was treated with surgery, chemotherapy, and local radiation, but residual tumor was detected within a year as a well-differentiated peripheral neural tumor lacking detectable EWS/FLI1 expression. Further studies suggested that the primary and residual tumors were clonally related. This association between apparent therapy-induced differentiation in Ewing sarcoma and absence of detectable fusion transcripts in the residual tumor provides presumptive evidence that EWS/FLI1 expression may inhibit differentiation in tumour cells.
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MESH Headings
- Bone Neoplasms/metabolism
- Bone Neoplasms/pathology
- Bone Neoplasms/therapy
- Cell Differentiation/drug effects
- Cell Transformation, Neoplastic/metabolism
- Cell Transformation, Neoplastic/pathology
- Child
- Clone Cells
- Combined Modality Therapy
- DNA, Neoplasm/analysis
- Female
- Forearm/pathology
- Fragile X Mental Retardation Protein
- Humans
- Immunoenzyme Techniques
- In Situ Hybridization, Fluorescence
- Neoplasm Proteins/metabolism
- Neoplasm, Residual/genetics
- Neoplasm, Residual/metabolism
- Neoplasm, Residual/pathology
- Nerve Tissue Proteins/metabolism
- Neuroectodermal Tumors, Primitive/metabolism
- Neuroectodermal Tumors, Primitive/pathology
- Neuroectodermal Tumors, Primitive, Peripheral/metabolism
- Neuroectodermal Tumors, Primitive, Peripheral/pathology
- Oncogene Proteins, Fusion/genetics
- Oncogene Proteins, Fusion/metabolism
- Phosphopyruvate Hydratase/metabolism
- Polymerase Chain Reaction
- Proto-Oncogene Protein c-fli-1
- RNA-Binding Protein EWS
- RNA-Binding Proteins
- Sarcoma, Ewing/metabolism
- Sarcoma, Ewing/pathology
- Sarcoma, Ewing/therapy
- Transcription Factors/genetics
- Transcription Factors/metabolism
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Affiliation(s)
- S R Knezevich
- Department of Pathology, BC's Children's Hospital, Vancouver, Canada
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Abstract
Congenital (or infantile) fibrosarcoma (CFS) is a malignant tumour of fibroblasts that occurs in patients aged two years or younger. CFS is unique among human sarcomas in that it has an excellent prognosis and very low metastatic rate. CFS is histologically identical to adult-type fibrosarcoma (ATFS); however, ATFS is an aggressive malignancy of adults and older children that has a poor prognosis. We report a novel recurrent t(12;15)(p13;q25) rearrangement in CFS that may underlie the distinctive biological properties of this tumour. By cloning the chromosome breakpoints, we show that the rearrangement fuses the ETV6 (also known as TEL) gene from 12p13 with the 15q25 NTRK3 neurotrophin-3 receptor gene (also known as TRKC). Analysis of mRNA revealed the expression of ETV6-NTRK3 chimaeric transcripts in all three CFS tumours analysed. These were not detected in ATFS or infantile fibromatosis (IFB), a histologically similar but benign fibroblastic proliferation occurring in the same age-group as CFS. ETV6-NTRK3 fusion transcripts encode the helix-loop-helix (HLH) protein dimerization domain of ETV6 fused to the protein tyrosine kinase (PTK) domain of NTRK3. Our studies indicate that a chimaeric PTK is expressed in CFS and this may contribute to oncogenesis by dysregulation of NTRK3 signal transduction pathways. Moreover, ETV6-NTRK3 gene fusions provide a potential diagnostic marker for CFS.
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MESH Headings
- Adult
- Amino Acid Sequence
- Artificial Gene Fusion
- Base Sequence
- Child
- Chromosome Mapping
- Chromosomes, Human, Pair 12
- Chromosomes, Human, Pair 15
- DNA-Binding Proteins/chemistry
- DNA-Binding Proteins/genetics
- Fibrosarcoma/congenital
- Fibrosarcoma/genetics
- Genetic Markers
- Humans
- In Situ Hybridization, Fluorescence
- Infant
- Infant, Newborn
- Karyotyping
- Molecular Sequence Data
- Nuclear Proteins/genetics
- Polymerase Chain Reaction
- Proto-Oncogene Proteins c-ets
- Receptor Protein-Tyrosine Kinases/chemistry
- Receptor Protein-Tyrosine Kinases/genetics
- Receptor, trkC
- Receptors, Nerve Growth Factor/chemistry
- Receptors, Nerve Growth Factor/genetics
- Repressor Proteins
- Transcription Factors/chemistry
- Transcription Factors/genetics
- Translocation, Genetic
- ETS Translocation Variant 6 Protein
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Affiliation(s)
- S R Knezevich
- Department of Pathology, British Columbia's Children's Hospital, Vancouver, Canada
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