Dataset Information

Assessment of Second-Opinion Strategies for Diagnoses of Cutaneous Melanocytic Lesions.

ABSTRACT:

Importance

Histopathologic criteria have limited diagnostic reliability for a range of cutaneous melanocytic lesions.

Objective

To evaluate the association of second-opinion strategies by general pathologists and dermatopathologists with the overall reliability of diagnosis of difficult melanocytic lesions.

Design, setting, and participants

This diagnostic study used samples from the Melanoma Pathology Study, which comprises 240 melanocytic lesion samples selected from a dermatopathology laboratory in Bellevue, Washington, and represents the full spectrum of lesions from common nevi to invasive melanoma. Five sets of 48 samples were evaluated independently by 187 US pathologists from July 15, 2013, through May 23, 2016. Data analysis was performed from April 2016 through November 2017.

Main outcomes and measures

Accuracy of diagnosis, defined as concordance with an expert consensus diagnosis of 3 experienced pathologists, was assessed after applying 10 different second-opinion strategies.

Results

Among the 187 US pathologists examining the 24 lesion samples, 113 were general pathologists (65 men [57.5%]; mean age at survey, 53.7 years [range, 33.0-79.0 years]) and 74 were dermatopathologists (49 men [66.2%]; mean age at survey, 46.4 years [range, 33.0-77.0 years]). Among the 8976 initial case interpretations, physicians desired second opinions for 3899 (43.4%), most often for interpretation of severely dysplastic nevi. The overall misclassification rate was highest when interpretations did not include second opinions and initial reviewers were all general pathologists lacking subspecialty training (52.8%; 95% CI, 51.3%-54.3%). When considering different second opinion strategies, the misclassification of melanocytic lesions was lowest when the first, second, and third consulting reviewers were subspecialty-trained dermatopathologists and when all lesions were subject to second opinions (36.7%; 95% CI, 33.1%-40.7%). When the second opinion strategies were compared with single interpretations without second opinions, the reductions in misclassification rates for some of the strategies were statistically significant, but none of the strategies eliminated diagnostic misclassification. Melanocytic lesions in the middle of the diagnostic spectrum had the highest misclassification rates (eg, moderately or severely dysplastic nevus, Spitz nevus, melanoma in situ, and pathologic stage [p]T1a invasive melanoma). Variability of in situ and thin invasive melanoma was relatively intractable to all examined strategies.

Conclusions and relevance

The results of this study suggest that second opinions rendered by dermatopathologists improve reliability of melanocytic lesion diagnosis. However, discordance among pathologists remained high.

SUBMITTER: Piepkorn MW

PROVIDER: S-EPMC6804025 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Assessment of Second-Opinion Strategies for Diagnoses of Cutaneous Melanocytic Lesions.

Piepkorn Michael W MW Longton Gary M GM Reisch Lisa M LM Elder David E DE Pepe Margaret S MS Kerr Kathleen F KF Tosteson Anna N A ANA Nelson Heidi D HD Knezevich Stevan S Radick Andrea A Shucard Hannah H Onega Tracy T Carney Patricia A PA Elmore Joann G JG Barnhill Raymond L RL

JAMA network open 20191002 10

<h4>Importance</h4>Histopathologic criteria have limited diagnostic reliability for a range of cutaneous melanocytic lesions.<h4>Objective</h4>To evaluate the association of second-opinion strategies by general pathologists and dermatopathologists with the overall reliability of diagnosis of difficult melanocytic lesions.<h4>Design, setting, and participants</h4>This diagnostic study used samples from the Melanoma Pathology Study, which comprises 240 melanocytic lesion samples selected from a de ...[more]

PMID: 31603483

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Project description:BackgroundPrevious studies of second opinions in the diagnosis of melanocytic skin lesions have examined blinded second opinions, which do not reflect usual clinical practice. The current study, conducted in the USA, investigated both blinded and nonblinded second opinions for their impact on diagnostic accuracy.MethodsIn total, 100 melanocytic skin biopsy cases, ranging from benign to invasive melanoma, were interpreted by 74 dermatopathologists. Subsequently, 151 dermatopathologists performed nonblinded second and third reviews. We compared the accuracy of single reviewers, second opinions obtained from independent, blinded reviewers and second opinions obtained from sequential, nonblinded reviewers. Accuracy was defined with respect to a consensus reference diagnosis.ResultsThe mean case-level diagnostic accuracy of single reviewers was 65.3% (95% CI 63.4-67.2%). Second opinions arising from sequential, nonblinded reviewers significantly improved accuracy to 69.9% (95% CI 68.0-71.7%; P < 0.001). Similarly, second opinions arising from blinded reviewers improved upon the accuracy of single reviewers (69.2%; 95% CI 68.0-71.7%). Nonblinded reviewers were more likely than blinded reviewers to give diagnoses in the same diagnostic classes as the first diagnosis. Nonblinded reviewers tended to be more confident when they agreed with previous reviewers, even with inaccurate diagnoses.ConclusionWe found that both blinded and nonblinded second reviewers offered a similar modest improvement in diagnostic accuracy compared with single reviewers. Obtaining second opinions with knowledge of previous reviews tends to generate agreement among reviews, and may generate unwarranted confidence in an inaccurate diagnosis. Combining aspects of both blinded and nonblinded review in practice may leverage the advantages while mitigating the disadvantages of each approach. Specifically, a second pathologist could give an initial diagnosis blinded to the results of the first pathologist, with subsequent nonblinded discussion between the two pathologists if their diagnoses differ.

Project description:Early diagnosis when melanoma is still small and thin is essential for improving mortality and morbidity. However, the diagnosis of small size melanoma might be particularly difficult, not only clinically but also dermoscopically. This study aimed to define clinical and dermatoscopic parameters in the diagnosis of suspicious pigmented cutaneous lesions with a diameter of ≤ 6mm and determine the sensitivity, specificity, positive and negative predictive values as well as the accuracy of each clinical and dermatoscopic criterion. This is a transversal, descriptive and analytical study of dermatoscopic analysis with the gold standard being the pathologic examination obtained from the excisional biopsy of suspicious melanocytic lesions with a diameter of ≤ 6mm. Trunk and limb lesion data from a public health service and a private clinic were prospectively collected from 2011 to 2017 by a unique observer. In total, 481 melanocytic lesions were included, with 73.8% being ≤ 4mm in diameter. Overall, 123 were diagnosed as melanoma, 56.0% in situ and 22.0% as thin melanomas (Breslow index 0.1 to 1.0mm). Melanoma presented symmetry in 53.7% of cases, regular borders in 54.5% and a single color in 60.2%. Regarding evolution, 13.8% of melanomas versus 10.9% of benign lesions (p = 0.116) were new by comparing photos from baseline with photos from the follow-up. The majority of melanomas (65%) were found on the limbs compared to 37.2% of the benign lesions at this location (p<0.001). A multiple logistic regression model adjusted for age, gender and location was created. The independent variables associated with the diagnosis of melanoma ≤ 6mm, adjusted for age, gender and location, were: streaks (adjusted Odds Ratio [aOR] 2.5; 95% CI 1.3-4.7; p = 0.006), and the presence of a structureless area (aOR 2.2, 95% CI 1.2-4.0, p = 0.011). Conversely, a symmetric typical pigment network was a protection variable (aOR 0.4, 95% 0.7-0.9, p = 0.040). In conclusion, dermatoscopic criteria have been identified which help to diagnose cases of small size melanoma. These include streaks and structureless areas that can be taken, particularly in consideration for the diagnosis of this subset of small difficult melanomas.

Project description:Purpose: The aim of this retrospective study was to evaluate the importance of second opinion assessment for diagnostic mammography and sonography in a breast cancer centre. Material and Method: We analysed a total of 374 diagnostic mammographies and sonographies. All patients had previously undergone mammography and sonography examination in different external clinics, and the findings had been classified according to the BI-RADS system. All patients underwent additional sonography investigation in the outpatient department of our university clinic with additional mammography where necessary. The final diagnosis (histological clarification in 316 cases, follow-up in 58 cases) was compared with the BI-RADS classification made by the external clinics and by the university clinic, and the correlation between their findings and the final diagnosis was analysed. Results: The final diagnosis yielded 146 benign lesions and 228 cancers. In 74?% of cases (277/374), the BI-RADS classification of the first assessment corresponded to that of the second assessment. 26/55 lesions (47?%) were upgraded at the second assessment from BI-RADS?3 to BI-RADS?4, and 71/186 findings (38?%) were downgraded at the second assessment from BI-RADS?4 to BI-RADS?3. The correlation between the initial diagnosis made in the external facilities and the final diagnosis was low (kappa: 0.263), but the correlation between the second opinion assessment and the final diagnosis was significantly (p?<?0.001) higher (kappa: 0.765). The second assessment increased the sensitivity from 91?% (208/228) to 99?% (225/228) and the specificity from 32?% (46/146) to 74?% (108/146). 20 additional malignant lesions were only detected at the second assessment; however the second assessment also resulted in 3 additional false-negative findings. Surgical biopsy was prevented in 49 women after the second assessment. Conclusion: An independent second diagnostic evaluation can significantly improve the correlation between BI-RADS classification and the final diagnosis, resulting in a benefit for the patient.

Dataset Information

Assessment of Second-Opinion Strategies for Diagnoses of Cutaneous Melanocytic Lesions.

Importance

Objective

Design, setting, and participants

Main outcomes and measures

Results

Conclusions and relevance

Publications

Assessment of Second-Opinion Strategies for Diagnoses of Cutaneous Melanocytic Lesions.

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