title: Agreement of dermatopathologists in the evaluation of clinically difficult melanocytic lesions: how golden is the 'gold standard'?
abstract: BACKGROUND
  The 'gold standard' for the diagnosis of melanocytic lesions is dermatopathology. Although most of the diagnostic criteria are clearly defined, the interpretation of histopathology slides may be subject to interobserver variability.
  
  
  OBJECTIVE
  The aim of this study was to determine the variability among dermatopathologists in the interpretation of clinically difficult melanocytic lesions.
  
  
  METHODS
  This study used the database of MelaFind®, a computer-vision system for the diagnosis of melanoma. All lesions were surgically removed and sent for independent evaluation by four dermatopathologists. Agreement was calculated using kappa statistics.
  
  
  RESULTS
  A total of 1,249 pigmented melanocytic lesions were included. There was a substantial agreement among expert dermatopathologists: two-category kappa was 0.80 (melanoma vs. non-melanoma) and three-category kappa was 0.62 (malignant vs. borderline vs. benign melanocytic lesions). The agreement was significantly greater for patients ≥40 years (three-category kappa = 0.67) than for younger patients (kappa = 0.49). In addition, the agreement was significantly lower for patients with atypical mole syndrome (AMS) (kappa = 0.31) than for patients without AMS (kappa = 0.76).
  
  
  CONCLUSIONS
  The data were limited by the inclusion/exclusion criteria of the MelaFind® study. This might represent a selection bias. The agreement was evaluated using kappa statistics. This is a standard method for evaluating agreement among pathologists, but might be considered controversial by some statisticians.
  
  
  CONCLUSIONS
  Expert dermatopathologists have a high level of agreement when diagnosing clinically difficult melanocytic lesions. However, even among expert dermatopathologists, the current 'gold standard' is not perfect. Our results indicate that lesions from younger patients and patients with AMS may be more problematic for the dermatopathologists, suggesting that improved diagnostic criteria are needed for such patients.
authors.affiliation: Department of Dermatology, University Hospital Zürich, Zürich, Switzerland. ralph.braun@usz.ch
authors.forename: R P
authors.initials: RP
authors.lastname: Braun
authors.forename: D
authors.initials: D
authors.lastname: Gutkowicz-Krusin
authors.forename: H
authors.initials: H
authors.lastname: Rabinovitz
authors.forename: A
authors.initials: A
authors.lastname: Cognetta
authors.forename: R
authors.initials: R
authors.lastname: Hofmann-Wellenhof
authors.forename: V
authors.initials: V
authors.lastname: Ahlgrimm-Siess
authors.forename: D
authors.initials: D
authors.lastname: Polsky
authors.forename: M
authors.initials: M
authors.lastname: Oliviero
authors.forename: I
authors.initials: I
authors.lastname: Kolm
authors.forename: P
authors.initials: P
authors.lastname: Googe
authors.forename: R
authors.initials: R
authors.lastname: King
authors.forename: V G
authors.initials: VG
authors.lastname: Prieto
authors.forename: L
authors.initials: L
authors.lastname: French
authors.forename: A
authors.initials: A
authors.lastname: Marghoob
authors.forename: M
authors.initials: M
authors.lastname: Mihm
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008545:Melanoma / Q000473:pathology*; D008875:Middle Aged; D015588:Observer Variation; D015203:Reproducibility of Results; D012878:Skin Neoplasms / Q000473:pathology*; D013223:Statistics as Topic; D055815:Young Adult