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Does your dermatopathologist recommend treatment suggestions for melanocytic lesions? My two cents (and sense)


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fellowship

My dermatopathology fellowship photo from 1985 at the University of Pennsylvania: Standing Left to Right: Myself, Wallace H. Clark, Jr, and Margaret Freeman (co-fellow); Seated: Bernett Johnson, Jr and Margaret Gray Wood. I learned from the best! While they (the professors) are no longer with us, somehow I hope they know that their lessons still benefit lives decades later.

By Warren R. Heymann, MD
Jan. 5, 2017


The question raised by the title is important for patient care and medicolegal concerns. The format of my commentary will differ from the usual. I have copied the abstract from the article by Lee et al (1) — my comments will appear underlined in italics within the abstract itself. (You should know that I practice medical and pediatric dermatology 75% of the time and dermatopathology 25%.)

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. I did not fill out this survey (We are all inundated with requests for surveys — perhaps I received a request to do so, but cannot recall). In all, 15% and 7% reported never and always including suggestions, respectively. As I tell my patients, it is wise to never say never and never say always. Reasons for offering suggestions included improved care (79%), clarification (68%), and legal liability (39%). These are all legitimate reasons; I was heartened to see that the most important reason was that of improved patient care, although I certainly understand the need for clarification and medical liability issues. Reasons for not offering suggestions included referring physician preference (48%), lack of clinical information (44%), and expertise (29%). As a dermatopathologist, I am happy to comply with the clinicians’ requests, most of the time. Fortunately, we can discuss the situation and reach an agreement on what may be on the report in equivocal cases. Communication between the dermatologist and dermatopathologist prior to signing out the report is optimal in such circumstances (although not always practical). As a dermatologist-dermatopathologist, I usually view my pathology report from the eyes of the clinician. Because of insurance reasons, I only read about half of the specimens sent from our practice. I get most perturbed when I receive re-excision recommendations from outside laboratories on clearly benign lesions, surmising that the main motivation is CYA for medical liability. My personal preference as a clinician is for the pathologist to note that the lesion extends to the margin and not make recommendations, unless the lesion is clearly malignant. 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. When I sign out cases, my reports reflect my clinical perspective — I note that lesions extend to the margins, but I do not tell the clinician what surgical margin to utilize. There are several reasons for not doing so. Aside from the recent literature suggesting that re-excisions of minimally-to-moderately atypical nevi that extend to the margin need not be re-excised (2), I do not want to restrict the clinician regarding therapeutic options. I have had some patients insist on re-excising minimally atypical nevi and others with moderately atypical nevi who are more than happy just to be followed. I recommend re-excison of severely atypical nevi when the interpretation borders on melanoma in situ. When that occurs, I usually opt for a second opinion. What if an elderly patient had melanoma in situ and did not want to undergo surgery? Perhaps, in that circumstance, topical imiquimod would be an option. I trust that the clinicians have a firm grasp of the NCCN guidelines and newer literature about surgical recommendations for melanocytic lesions. I view that more of the clinicians’ responsibility rather than that of the dermatopathologist.

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. Surveys such as this are valuable in understanding current practice. We must understand that accrued opinion (mine included) does not mean that the dermatopathologists’ responses are correct. The fact that there is such variability should serve as an impetus for studying the most effective way of conveying consistent recommendations for optimal patient care.  

1. Lee KC, et al. Variation among pathologists’ treatment suggestions for melanocytic lesions: A survey of pathologists. J Am Acad Dermatol 2017; 76: 121-8.
2. Fleming NH, et al. Reexamining the threshold for reexcision of histologically transected dysplastic nevi. JAMA Dermatology 2016; 152: 1327-34.


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