Integrated Diagnosis of Nevi With Severely Atypical Features and the Impact of Second Opinions by Pathologists

TAKE-HOME MESSAGE

• This single-center retrospective study investigated pathologists' consensus on the histopathologic diagnosis of melanoma and its correlation with dermatoscopic features seen clinically. There was only moderate agreement on atypical melanocytic proliferations among pathologists. The presence of atypical white lines on dermoscopy was associated with the diagnosis of melanoma.
• Certain dermatoscopic features can help dermatologists diagnose melanomas when histologic data are borderline or uncertain.

–  Joshua R. Ortego, MD

Written by

 

 

Jane Grant-Kels MD

Dermatology and dermatopathology are challenging because there are masquerading lesions. In the case of melanocytic lesions, the authors note that there are times we cannot "differentiate between 'atypical melanocytic proliferations' that are just nevi that simulate melanoma and melanomas with nevoid features." Ancillary testing, including molecular analysis, is often not definitive. We, therefore, rely on clinical-dermoscopic-pathologic correlations and second opinions.

Second opinions of atypical melanocytic lesions often result in discordant opinions. In this study, 122 atypical melanocytic lesions were re-reviewed by a second dermatopathologist. A lesion was diagnosed concordantly by both dermatopathologists as melanoma in only 13% of the cases. In contrast, a lesion was diagnosed discordantly as melanoma by only 1 of the 2 dermatopathologists in almost 30% of the lesions! Why is there such discordance? Individual dermatopathologists are influenced by their training, varied personal thresholds to make the diagnosis of melanoma, personal history, and peers. Furthermore, individual dermatopathologists handle their own uncertainty of a diagnosis with varied techniques and phrases that comfortably allow them to communicate their lack of certainty to the referring clinician.

I am a great advocate of dermoscopy and clinical-dermoscopic-pathologic correlation, and this study confirms my opinion. The authors demonstrated that white shiny structures in the form of lines, a polarized dermoscopic feature of fibrosis or regression, are more common in and significantly associated with histologically concordant melanomas. Other dermoscopic melanoma features were not as helpful or significant. The presence of peripheral clods on dermoscopy, an indication of growth, was a reliable clue for melanoma in older patients but not a reliable melanoma clue if patients were younger than 45 years.

Bottom line: Second opinions often confirm that the lesion is difficult to interpret and are not uncommonly discordant from the original sign out. Therefore, correlating clinical appearance of a lesion, dermoscopic features, and dermatopathologic features should be part of the algorithm. When white shiny lines are identified dermoscopically in an atypical melanocytic lesion, melanoma should be strongly considered.

Abstract

BACKGROUND

A subset of melanocytic proliferations is difficult to classify by dermatopathology alone and their management is challenging.

OBJECTIVE

To explore the value of correlation with dermatoscopy and to evaluate the utility of second opinions by additional pathologists.

METHODS

For this single center retrospective study we collected 122 lesions that were diagnosed as atypical melanocytic proliferations, we reviewed dermatoscopy and asked two experienced pathologists to reassess the slides independently.

RESULTS

For the binary decision of nevus versus melanoma the diagnostic consensus among external pathologists was only moderate (kappa 0.43; 95%-CI 0.25-0.61). If ground truth were defined such that both pathologists had to agree on the diagnosis of melanoma, 13.1% of cases would have been diagnosed as melanoma. If one pathologist were sufficient to call it melanoma 29.5% of cases would have been diagnosed as melanoma. In either case, the presence of dermatoscopic white lines was associated with the diagnosis of melanoma. In lesions with peripheral dots and clods, melanoma was not jointly diagnosed by the two pathologists if the patient was younger than 45 years.

CONCLUSIONS

A considerable number of atypical melanocytic proliferations may be diagnosed as melanoma if revised by other pathologists. The presence of white lines on dermatoscopy increases the likelihood of revision toward melanoma. Peripheral clods indicate growth but are not a melanoma clue if patients are younger than 45 years.

Journal of the European Academy of Dermatology and Venereology: JEADV

Integrated Diagnosis of Nevi with Severely Atypical Features and Impact of Second Opinions

J Eur Acad Dermatol Venereol 2023 Feb 24;[EPub Ahead of Print], C Uzundere, BN Akay, AO Heper, SP Clark, P Tschandl, H Kittler 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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