1. Phrasing of pathology report
MANAGEMENT OF ATYPICAL MELANOCYTIC PROLIFERATIONS: A RETROSPECTIVE REVIEW
Jessica Terrell, Lihong Qi, Jiahui Bao, Maxwell Fung, Maija Kiuru
Departments of Dermatology, Pathology, and Public Health Sciences, University of California Davis, Sacramento, California
Our study shows that, healthcare professionals are managing AJMPs primarily with excision at 54.3%.
The way a pathology report is phrased by a dermatopathologist, impacts how the lesion will be managed.
The clinical challenge is the uncertainty in the malignant potential of AJMPs which may lead to more excisions than necessary due to lack of clear guidelines.
It is prudent to begin to define unique genomic features in order to identify novel diagnostic markers for more accurate diagnosis, and better establish the lesions potential for malignancy.
With better diagnostic protocol, clinician guidelines can begin to be established in order to avoid overtreatment, and under treatment.
INTRODUCTION
MATERIALS AND METHODS
RESULTS
SUMMARY & DISCUSSION
Atypical junctional melanocytic proliferations (AJMPs) are melanocytic lesions with features of melanoma in situ (MIS), but do not meet the criteria based on histopathological evaluation.
AJMPs show cytologic atypia, pagetoid growth and other histologic features of MIS but to a variable and lesser degree.1
The malignant potential of AJMPs is unclear, which poses a dilemma for physicians for how best to manage the lesions.2,3,4
Among dermatologists there is a lack of consensus for how best to manage AJMPs, which may lead to over or under treatment5
There is also extensive use of variable language in the pathology reports of similar lesions, adding to the dilemma of management by physicians.3,4
A natural language search for “junctional melanocytic proliferation” was performed
We identified 256 charts from academic and private practices diagnosed by board certified dermatopathologists at UC Davis between January 1, 2014 and December 31, 2014.
Spitz nevi, blue nevi, and re-excisions were excluded
Clinical notes and pathology notes were reviewed for various clinical features and phrasing within pathology reports:
Clinical features:
Age
Gender
Anatomic site
Size of lesion
Pathology report phrasing:
Diagnosis line includes “melanoma in situ”; “sparse” or lacks “atypical”
Favored diagnosis: melanoma in situ, nevus, lentigo, other
Pathology note includes “melanoma in situ”; “pagetoid”; “poor circumscription”; “cytologic atypia”
Note includes recommendation for complete removal
Margin status: involved versus uninvolved
Management
Frequency
Excision
54.3%
Shave biopsy
6.64%
Punch biopsy
5.08%
Mohs
2.73%
Shave removal, shave excision
1.95%
Punch excision
FOLLOW UP; OTHER
27.3%
Table 1: Summary of current management by healthcare providers
5. Improved patient outcomes
1. Define histological features
2. Identify molecular markers
3. Accurate diagnosis and evaluation
4. Clinician guidelines
Phrasing of pathology report
Monitor; unknown
Shave biopsy, removal or excision
Punchy biopsy, excision
Excision; MOHS
Note included melanoma in situ p<0.0001
Yes
17.19%
4.30%
2.73%
47.66% No
10.16%
9.38%
Note includes complete removal recommended (only) p<0.0001
12.92%
0.48%
2.39%
37.80%
9.09%
5.74%
22.49%
Favored diagnosis
p<0.0001
MIS
17.28% 0%
0.55%
44.75%
Nevus
13.36%
3.87%
5.52%
Other
1.10%
6.08%
Diagnosis line includes “sparse” or lacks “atypical” p<0.0001
13.28%
7.03%
6.64%
18.75%
14.06%
1.56%
0.39%
38.28%
AJMP
Mutations/changes
Melanoma ?
REFERENCES
AIMS
Scolyer RA, Mccarthy SW, Elder DE. Frontiers in melanocytic pathology. Pathology. 2004;36(5):385-6.
Elder DE, Xu X. The approach to the patient with a difficult melanocytic lesion. Pathology. 2004;36(5):
Shoo BA, Sagebiel RW, Kashani-sabet M. Discordance in the histopathologic diagnosis of melanoma at a melanoma referral center. J Am Acad Dermatol. 2010;62(5):751-6.
Piepkorn MW, Barnhill RL, Elder DE, et al. The MPATH-Dx reporting schema for melanocytic proliferations and melanoma. J Am Acad Dermatol. 2014;70(1):
Van der rhee JI, Mooi WJ, Kukutsch NA, De snoo FA, Bergman W. Iatrogenic melanoma. Comment on: Melanoma epidemic: a midsummer night's dream?. Br J Dermatol. 2010;162(2):457-8.
The study aims are 1) determining how current healthcare providers are managing AJMPs, and 2) identifying clinical features and phrasing of pathology reports that influence management strategies.
Long term aims are to assist in creating standard guidelines for the management of these lesions by healthcare providers.
STATISTICAL ANALYSIS
Descriptive statistics were obtained
Chi-squared tests or Fisher’s Exact tests (when any cell size < 5) were used to study the associations of phrasing of pathology report with the current management type.
Table 2: Summary of impact of phrasing of pathology report on management