Vol. 119 No. 6 June 2015
EDITORIAL
Second opinion reporting in head and neck pathology: perspective on Mullin et al. Pathologists, on whose diagnosis a patient’s definitive management is predicated, are keenly aware of the importance of minimizing diagnostic discrepancies. Nevertheless, studies from several countries have consistently identified significant diagnostic discrepancies in 10% or more of pathology specimens that are subjected to specialist review. Similar discrepancies have been reported following reinterpretation of radiologic material from patients with cancer, with discrepancies resulting in changes in prognosis or therapy in 3% to 9% of cases.1 These reported rates would be expected to vary, depending on the complexity of the condition being assessed, the anatomic site from which the biopsy specimen was obtained, and the individual pathologist’s level of experience and familiarity with the specific entity being interpreted. This is further influenced by the criteria selected by individual investigators to categorize these discrepancies and, of course, by interobserver variation; since “a second opinion is an opinion, indeed, and not a fact.”2 In this issue of Oral Surgery Oral Medicine Oral Pathology Oral Radiology, Mullin et al.3 retrospectively compared original diagnoses to the second opinion diagnoses of specialist oral and maxillofacial pathologists in 566 consecutive referrals. Not entirely unexpectedly, the authors identified diagnostic errors that were likely to have had a substantial influence on clinical management and possible outcome in 10% of the cases reviewed. Discrepancies with the potential to affect clinical management or outcome were noted in 15% of biopsies, and differences in interpretation of minimal clinical significance were identified in an additional 25% of cases. These are important findings, providing evidence of the benefits of secondary review of biopsy specimens from the head and neck area. This study also provides interesting information as to the nature of cases received in consultation, which predominantly comprised salivary gland neoplasms (30%), odontogenic cysts and tumors (23%), and benign fibro-osseous lesions of the jaws (7%), specimens that are, for the most part, unique to the craniofacial structures. So, what are the implications of these findings? Since the head and neck area is a high risk for diagnostic errors,4 the fact that the rates of clinically significant diagnostic differences were not even higher than
reported reflects very favorably on the diagnostic acumen of general pathologists in the United Kingdom. Additionally, both pathologist and nonpathologist clinicians have long recognized the value of expert second opinion, to the extent that this is formally codified into the professional conduct guidelines of many health care professions.5,6 As a result, many, if not the vast majority, of hospitals already mandate the routine review of outside pathology slides for patients referred for definitive treatment.7 Arguably, then, the more critical concern is the scenario of underdiagnosis, as “noncritical” diagnoses are commonly not reviewed unless a recurrence of the lesion is noted. What is encouraging is that in this study, malignant lesions were misclassified as benign in only 4% of cases. Although a misdiagnose rate of 4 cases out of 100 is, by no means, an acceptable false-negative rate, this may in part be an overestimation, as it is unclear how many of these consultations were requested by the outside pathologist prior to rendering a definitive diagnosis, after recognizing a potential diagnostic pitfall. Therefore, although a prima facie “common sense” case can be made for the benefit of regular review of biopsy specimens from the jaws and salivary glands by specialist pathologists with advanced training in oral and maxillofacial pathology, head and neck pathology, or both, the need for additional data in support of this argument is evident. Additionally, these findings must not be interpreted as implying the diagnostic superiority of practitioners from one specialty over those of another. Indeed, the study reported similar rates of diagnostic discrepancy among biopsy specimens submitted from outside specialists in oral and maxillofacial pathology. The authors offer a plausible explanation (“It is likely that these were among the most challenging” cases), although the strength of this hypothesis cannot be gauged from the data presented. This study offers some valuable insight into the potential benefits of expert second review of head and neck biopsies, but it also gives rise to a number of uncertainties. How best to further reduce the rate of false-negative diagnoses remains an unanswered question. Certainly, stratifying high-risk lesions (e.g., jaw lesions not intimately associated with a tooth root) for expert review would be one approach. But, again, more evidence is needed to quantify these risk stratifications, 599
EDITORIAL 600 Edwards
as the present study does not provide a breakdown of the diagnostic categories most commonly associated with diagnostic disparities. Perhaps, as molecular and genomic profiling of excised tissue further enhances our diagnostic decision making with respect to both classification of lesions and preferred treatment approaches, the need for expert consultation may diminish. But, again, it is equally, if not even more, likely that these developments will, instead, increase the need for specialist review, albeit by one with expertise beyond traditional histopathologic interpretation. But irrespective of the ultimate impact of molecular tissue profiling on the diagnostic process, this study emphasizes that, currently, second-opinion specialist consultation remains a critical element in providing our patients with the highest level of diagnostic accuracy achievable.
Paul C. Edwards, MSc, DDS Section Editor, Oral and Maxillofacial Pathology Department of Oral Pathology Medicine and Radiology Indiana University School of Dentistry
OOOO June 2015
Indianapolis IN, USA http://dx.doi.org/10.1016/j.oooo.2015.01.002
REFERENCES 1. Tilleman EH, Phoa SS, Van Delden OM, et al. Reinterpretation of radiological imaging in patients referred to a tertiary referral centre with a suspected pancreatic or hepatobiliary malignancy: impact on treatment strategy. Eur Radiol. 2003;13:1095-1099. 2. Mellinka VA, Henzen-Logmansb SC, Bongaertsc AH, Ooijend BV, Rodenburge CJ, Wiggers T. Discrepancy between second and first opinion in surgical oncological patients. EJSO. 2006;32:108-112. 3. Mullin MH, Brierley DJ, Speight PM. Second opinion reporting in head and neck pathology; the pattern of referrals and impact on final diagnosis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:656-660. 4. Kronza JD, Westra WH. The role of second opinion pathology in the management of lesions of the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2005;13:81-84. 5. American Dental Association. http://www.ada.org/en/about-theada/principles-of-ethics-code-of-professional-conduct/nonmaleficence. Accessed Jan 7, 2014. 6. American Dental Association. http://www.ama-assn.org/ama/pub/ physician-resources/medical-ethics/code-medical-ethics/opinion 8041.page. Accessed Jan 7, 2014. 7. [No authors listed]. Recommendations on quality control and quality assurance in surgical pathology and autopsy pathology. The association of directors of anatomic and surgical pathology. Mod Pathol. 1992;5:567-568.
EDITORIAL
Second opinion reporting in head and neck pathology: perspective on Mullin et al. Pathologists, on whose diagnosis a patient’s definitive management is predicated, are keenly aware of the importance of minimizing diagnostic discrepancies. Nevertheless, studies from several countries have consistently identified significant diagnostic discrepancies in 10% or more of pathology specimens that are subjected to specialist review. Similar discrepancies have been reported following reinterpretation of radiologic material from patients with cancer, with discrepancies resulting in changes in prognosis or therapy in 3% to 9% of cases.1 These reported rates would be expected to vary, depending on the complexity of the condition being assessed, the anatomic site from which the biopsy specimen was obtained, and the individual pathologist’s level of experience and familiarity with the specific entity being interpreted. This is further influenced by the criteria selected by individual investigators to categorize these discrepancies and, of course, by interobserver variation; since “a second opinion is an opinion, indeed, and not a fact.”2 In this issue of Oral Surgery Oral Medicine Oral Pathology Oral Radiology, Mullin et al.3 retrospectively compared original diagnoses to the second opinion diagnoses of specialist oral and maxillofacial pathologists in 566 consecutive referrals. Not entirely unexpectedly, the authors identified diagnostic errors that were likely to have had a substantial influence on clinical management and possible outcome in 10% of the cases reviewed. Discrepancies with the potential to affect clinical management or outcome were noted in 15% of biopsies, and differences in interpretation of minimal clinical significance were identified in an additional 25% of cases. These are important findings, providing evidence of the benefits of secondary review of biopsy specimens from the head and neck area. This study also provides interesting information as to the nature of cases received in consultation, which predominantly comprised salivary gland neoplasms (30%), odontogenic cysts and tumors (23%), and benign fibro-osseous lesions of the jaws (7%), specimens that are, for the most part, unique to the craniofacial structures. So, what are the implications of these findings? Since the head and neck area is a high risk for diagnostic errors,4 the fact that the rates of clinically significant diagnostic differences were not even higher than
reported reflects very favorably on the diagnostic acumen of general pathologists in the United Kingdom. Additionally, both pathologist and nonpathologist clinicians have long recognized the value of expert second opinion, to the extent that this is formally codified into the professional conduct guidelines of many health care professions.5,6 As a result, many, if not the vast majority, of hospitals already mandate the routine review of outside pathology slides for patients referred for definitive treatment.7 Arguably, then, the more critical concern is the scenario of underdiagnosis, as “noncritical” diagnoses are commonly not reviewed unless a recurrence of the lesion is noted. What is encouraging is that in this study, malignant lesions were misclassified as benign in only 4% of cases. Although a misdiagnose rate of 4 cases out of 100 is, by no means, an acceptable false-negative rate, this may in part be an overestimation, as it is unclear how many of these consultations were requested by the outside pathologist prior to rendering a definitive diagnosis, after recognizing a potential diagnostic pitfall. Therefore, although a prima facie “common sense” case can be made for the benefit of regular review of biopsy specimens from the jaws and salivary glands by specialist pathologists with advanced training in oral and maxillofacial pathology, head and neck pathology, or both, the need for additional data in support of this argument is evident. Additionally, these findings must not be interpreted as implying the diagnostic superiority of practitioners from one specialty over those of another. Indeed, the study reported similar rates of diagnostic discrepancy among biopsy specimens submitted from outside specialists in oral and maxillofacial pathology. The authors offer a plausible explanation (“It is likely that these were among the most challenging” cases), although the strength of this hypothesis cannot be gauged from the data presented. This study offers some valuable insight into the potential benefits of expert second review of head and neck biopsies, but it also gives rise to a number of uncertainties. How best to further reduce the rate of false-negative diagnoses remains an unanswered question. Certainly, stratifying high-risk lesions (e.g., jaw lesions not intimately associated with a tooth root) for expert review would be one approach. But, again, more evidence is needed to quantify these risk stratifications, 599
EDITORIAL 600 Edwards
as the present study does not provide a breakdown of the diagnostic categories most commonly associated with diagnostic disparities. Perhaps, as molecular and genomic profiling of excised tissue further enhances our diagnostic decision making with respect to both classification of lesions and preferred treatment approaches, the need for expert consultation may diminish. But, again, it is equally, if not even more, likely that these developments will, instead, increase the need for specialist review, albeit by one with expertise beyond traditional histopathologic interpretation. But irrespective of the ultimate impact of molecular tissue profiling on the diagnostic process, this study emphasizes that, currently, second-opinion specialist consultation remains a critical element in providing our patients with the highest level of diagnostic accuracy achievable.
Paul C. Edwards, MSc, DDS Section Editor, Oral and Maxillofacial Pathology Department of Oral Pathology Medicine and Radiology Indiana University School of Dentistry
OOOO June 2015
Indianapolis IN, USA http://dx.doi.org/10.1016/j.oooo.2015.01.002
REFERENCES 1. Tilleman EH, Phoa SS, Van Delden OM, et al. Reinterpretation of radiological imaging in patients referred to a tertiary referral centre with a suspected pancreatic or hepatobiliary malignancy: impact on treatment strategy. Eur Radiol. 2003;13:1095-1099. 2. Mellinka VA, Henzen-Logmansb SC, Bongaertsc AH, Ooijend BV, Rodenburge CJ, Wiggers T. Discrepancy between second and first opinion in surgical oncological patients. EJSO. 2006;32:108-112. 3. Mullin MH, Brierley DJ, Speight PM. Second opinion reporting in head and neck pathology; the pattern of referrals and impact on final diagnosis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:656-660. 4. Kronza JD, Westra WH. The role of second opinion pathology in the management of lesions of the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2005;13:81-84. 5. American Dental Association. http://www.ada.org/en/about-theada/principles-of-ethics-code-of-professional-conduct/nonmaleficence. Accessed Jan 7, 2014. 6. American Dental Association. http://www.ama-assn.org/ama/pub/ physician-resources/medical-ethics/code-medical-ethics/opinion 8041.page. Accessed Jan 7, 2014. 7. [No authors listed]. Recommendations on quality control and quality assurance in surgical pathology and autopsy pathology. The association of directors of anatomic and surgical pathology. Mod Pathol. 1992;5:567-568.
