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Histologic Diagnosis of Melanocytic Lesions and Melanoma: Real Challenges
Diagnóstico histológico de lesiones melanocíticas y melanoma: todo un desafío
D. Morgado-Carrasco
, S.S. Ertekin, A. Combalia, L. Ferrandiz
Corresponding author
Unidad de Melanoma, Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, España
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Morgado-Carrasco, S.S. Ertekin, A. Combalia, L. Ferrandiz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Morgado-Carrasco" "email" => array:1 [ 0 => "morgadodaniel8@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "S.S." "apellidos" => "Ertekin" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Combalia" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Ferrandiz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Melanoma, Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, España" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diagnóstico histológico de lesiones melanocíticas y melanoma: todo un desafío" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diagnosis of melanocytic lesions is a complex process that mainly depends on the microscopic evaluation of biopsy samples. Multiple studies have shown low interobserver diagnostic agreement in such cases.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,2</span></a> These studies, however, have largely been small, non-randomized studies or studies that analyzed agreement between experts.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In a recent study, Elmore et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> published the results of the largest study to date to analyze diagnostic concordance in the setting of melanoma and melanocytic proliferations. They studied 187 US pathologists, most of whom (84%) had over 10 years’ experience analyzing melanocytic lesions and 42% of whom were considered an expert in the field. They selected 240 biopsy cases divided into groups of 48. A single hematoxylin-eosin–stained glass slide was available for each case. A reference diagnosis was established by 3 expert pathologists. Each of the participating pathologists was randomly assigned to a set of 48 cases and asked to diagnose them. The researchers grouped their responses using the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) tool,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> which consists of 5 diagnostic classes ranging from low risk to high risk (classes <span class="elsevierStyleSmallCaps">i-v</span> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The same slides were re-evaluated at least 8 months later to check intraobserver concordance. The answers were compared with those given by the other pathologists in the group to evaluate interobserver concordance. These answers were then checked against the consensus reference diagnosis to evaluate observer accuracy.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The results for intraobserver concordance varied according to lesion type. Concordance was highest for class <span class="elsevierStyleSmallCaps">i</span> lesions (76.7%) and class <span class="elsevierStyleSmallCaps">v</span> lesions (82.6%), but was considerably lower (35%-63%) for lesions in the intermediate classes. The results for interobserver concordance were similar (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Observer accuracy also varied significantly by lesion type and was 92% for class <span class="elsevierStyleSmallCaps">i</span> lesions, 25% for class <span class="elsevierStyleSmallCaps">ii</span> lesions, 40% for class <span class="elsevierStyleSmallCaps">iii</span> lesions, 43% for class <span class="elsevierStyleSmallCaps">iv</span> lesions, and 72% for class <span class="elsevierStyleSmallCaps">v</span> lesions. Extrapolation of these results to the level of the population shows a diagnostic error rate of approximately 17.2% (8% for overinterpretation of lesion class and 9.2% for underinterpretation). They also show that based on the reference diagnosis, 16% of class <span class="elsevierStyleSmallCaps">iv</span> or <span class="elsevierStyleSmallCaps">v</span> lesions (invasive melanomas) would be classified as class <span class="elsevierStyleSmallCaps">i</span> or <span class="elsevierStyleSmallCaps">ii</span> lesions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In brief, the study by Elmore et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> shows a low level of diagnostic concordance and accuracy for intermediate-class lesions such as dysplastic nevi, melanomas in situ, and invasive T1a melanomas that could result in over 17% of patients receiving incorrect treatments. Our study has several limitations, including the evaluation of a single glass slide, the nonuse of immunohistochemical staining and molecular assays, and the impossibility of asking for a second opinion. Without these limitations, the concordance and accuracy results may have been better. The results of our study, the largest of its type to date, indicate the need to improve current training systems and enhance the skills of specialists in the diagnosis and staging of melanocytic lesions. They also show the importance of using complementary diagnostic tools. Finally, the importance of adequate clinicopathologic correlation should not be overlooked.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1043228" "palabras" => array:6 [ 0 => "Melanoma" 1 => "Melanocytic proliferations" 2 => "Dysplastic nevus" 3 => "Histology" 4 => "Accuracy" 5 => "Discordance" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Morgado-Carrasco D, Ertekin SS, Combalia A, Ferrandiz L. Diagnóstico histológico de lesiones melanocíticas y melanoma: todo un desafío. Actas Dermosifiliogr. 2018;109:825–826.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abbreviation: MPATH-Dx, Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sources: Elmore et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> Piepkorn et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MPATH-Dx Class \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intraobserver Concordance (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interobserver Concordance (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic Accuracy (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class I No apparent risk for local proliferation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples: Common melanocytic nevus, blue nevus, halo nevus, nevus with mild dysplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class II Low-level risk for local proliferation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples: Typical Spitz nevus, nevus with moderate dysplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class III Higher likelihood of local tumor progression</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples: Spitz tumor, nevus with severe dysplasia, melanoma in situ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class IV High risk of locoregional progression</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples: Invasive T1a melanoma, lentigo maligna melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">V High risk of regional or distant metastasis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Examples: Invasive melanoma<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>T1b, nodular melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1886536.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Main Results from the Study by Elmore et al. (2017).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Discordance of histopathologic parameters in cutaneous melanoma: Clinical implications" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Patrawala" 1 => "A. Maley" 2 => "C. Greskovich" 3 => "L. Stuart" 4 => "D. Parker" 5 => "R. Swerlick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2015.09.008" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 9 | 21 |
| 2024 October | 70 | 39 | 109 |
| 2024 September | 75 | 28 | 103 |
| 2024 August | 93 | 69 | 162 |
| 2024 July | 82 | 42 | 124 |
| 2024 June | 95 | 51 | 146 |
| 2024 May | 63 | 35 | 98 |
| 2024 April | 91 | 44 | 135 |
| 2024 March | 74 | 37 | 111 |
| 2024 February | 68 | 37 | 105 |
| 2024 January | 48 | 34 | 82 |
| 2023 December | 47 | 19 | 66 |
| 2023 November | 61 | 30 | 91 |
| 2023 October | 75 | 29 | 104 |
| 2023 September | 52 | 35 | 87 |
| 2023 August | 44 | 15 | 59 |
| 2023 July | 45 | 42 | 87 |
| 2023 June | 55 | 36 | 91 |
| 2023 May | 52 | 20 | 72 |
| 2023 April | 44 | 26 | 70 |
| 2023 March | 58 | 21 | 79 |
| 2023 February | 53 | 32 | 85 |
| 2023 January | 51 | 38 | 89 |
| 2022 December | 51 | 31 | 82 |
| 2022 November | 31 | 39 | 70 |
| 2022 October | 39 | 28 | 67 |
| 2022 September | 19 | 41 | 60 |
| 2022 August | 54 | 31 | 85 |
| 2022 July | 36 | 39 | 75 |
| 2022 June | 18 | 25 | 43 |
| 2022 May | 47 | 48 | 95 |
| 2022 April | 46 | 28 | 74 |
| 2022 March | 43 | 49 | 92 |
| 2022 February | 34 | 34 | 68 |
| 2022 January | 42 | 41 | 83 |
| 2021 December | 36 | 47 | 83 |
| 2021 November | 54 | 50 | 104 |
| 2021 October | 54 | 60 | 114 |
| 2021 September | 62 | 45 | 107 |
| 2021 August | 54 | 44 | 98 |
| 2021 July | 50 | 42 | 92 |
| 2021 June | 41 | 48 | 89 |
| 2021 May | 47 | 51 | 98 |
| 2021 April | 124 | 72 | 196 |
| 2021 March | 92 | 42 | 134 |
| 2021 February | 72 | 44 | 116 |
| 2021 January | 45 | 42 | 87 |
| 2020 December | 51 | 36 | 87 |
| 2020 November | 40 | 33 | 73 |
| 2020 October | 33 | 26 | 59 |
| 2020 September | 28 | 17 | 45 |
| 2020 August | 24 | 30 | 54 |
| 2020 July | 19 | 23 | 42 |
| 2020 June | 40 | 38 | 78 |
| 2020 May | 26 | 20 | 46 |
| 2020 April | 19 | 15 | 34 |
| 2020 March | 24 | 12 | 36 |
| 2020 February | 4 | 2 | 6 |
| 2019 September | 1 | 2 | 3 |
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