Delayed melanoma diagnosis spurs most lawsuits vs. derms

Adelaide, Australia - When patients and their families learn that a loved one has malignant melanoma, they may question whether the cancer could have been caught earlier, when it was curable.

Lab use critical Appropriate use of the laboratory is key, according to Dr. Glusac, associate professor of pathology and dermatology at Yale University School of Medicine, New Haven, Conn. "Most important is making sure that, whenever possible, you remove the lesion entirely - not just part of it," he says. When that is not possible, it is important to alert the histopathologist to the partial nature of the biopsy and give an estimate of the percentage of it that has been supplied. Secondly, sending the specimen to a laboratory with certified and experienced dermatopathologists will result in more accurate results.

There remains substantial inter-observer variation in how to interpret the most challenging melanocytic lesions, according to Dr. Glusac. He notes that a study headed by Evan Farmer, M.D., involving 37 challenging mela-nocytic lesions interpreted by eight expert histopathologists, found at least one discrepant diagnosis in two-thirds of such cases.

Even more worrisome is inter-observer variation in interpreting difficult melanocytic lesions of children. He describes a study led by Raymond Barnhill, M.D., in which 10 pathologists interpreted 30 such cases, finding that several lesions interpreted as Spitz nevi or atypical Spitz tumors were, in fact, melanomas, some proving fatal.

Interestingly, Dr. Glusac estimates that although less than 1 percent of randomly selected lesions would likely be misdiagnosed, with increased sampling of pigmented lesions, even a small percentage is concerning. Lawsuits settled in the defendant's favor can be extremely costly because melanoma contributes to more lost years of life per fatal case than any other common malignancy except leukemia. Reducing morbidity and mortality requires early detection, appropriate treatment and careful long-term monitoring.

Documentation is key On pathology requisition slips, it is important that dermatologists document all relevant information for the histopathologist so that the most accurate diagnosis can be made, Dr. Glusac points out. This includes size of lesion, percentage of lesion sampled, appearance of lesion, duration and change, unusual foci, and light and dark spots.

"It's not just a lab test," he says.

For histopathologists, ways to reduce mistakes include obtaining pertinent patient history, ordering recuts and obtaining outside expert opinions. As soon as any mistake is identified, it should be noted in the medical record and the patient's dermatologist should be contacted. These are not surefire ways of avoiding malpractice suits, according to Dr. Glusac, but they can aid in prompt and accurate diagnosis and protect dermatologists and other histopathologists from costly litigation.